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Control of Lipids and Diabetes-But
Not BP-Cuts Cardio Risk With HIV
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CROI 2021, Conference on Retroviruses and Opportunistic Infections, March 6-10, 2021
Mark Mascolini
HIV-positive people with good control of lipids and diabetes (HbA1c) had the same cardiovascular disease (CVD) risk as HIV-negative people in a large matched comparison by the Kaiser Permanente Northern California group [1]. But people with HIV and good blood pressure (BP) control had a 35% higher CVD risk than the HIV-negative comparison group. And HIV-positive people with poor blood pressure control had almost a doubled CVD risk.
Several studies over the past decade establish a higher CVD risk in people with than without HIV infection. Because the impact of risk factor control on higher CVD rates with HIV remains inadequately studied, the Kaiser Permanente Northern California group performed this analysis.
The study focused on measures of hypertension control (systolic/diastolic blood pressure below 140/90 mm Hg), lipid control (LDL cholesterol below 130 mg/dL, total cholesterol below 200 mg/dL, triglycerides below 150 mg/dL), and diabetes control (HbA1c below 6.5%). The outcome of interest was the disease management index (DMI), a metric that reflects how effectively a condition is managed by considering both time and level of control [2].
The analysis involved 8285 HIV-positive adults who were Kaiser members in 2013-2017 and a comparison group of 170,517 HIV-negative Kaiser members matched to the HIV group by age, sex, and race or ethnicity. The researchers excluded people who already had CVD (coronary heart disease or ischemic stroke) when they entered the study period. Measuring continuous DMIs for systolic and diastolic blood pressure, LDL cholesterol, total cholesterol, triglycerides, and HbA1c, the researchers assessed the association of HIV status on DMIs by generalized estimating equation. They used Cox proportional hazards regression to determine the association of HIV status on CVD by level of risk factor control.
Age averaged 47 in the HIV group and 48 in HIV-negative controls. Respective proportions of men were 91% and 90%, whites 53% and 53%, blacks 15% and 17%, and Hispanics 18% and 18%. Proportions with a Charlson comorbidity index at or above 2 were 11% with HIV and 8% without HIV. Respective proportions with depression were 32% and 12% and current smokers 11% and 9%.
The HIV-positive and negative groups did not differ in DMIs for diastolic or systolic blood pressure, LDL cholesterol, or total cholesterol. The HIV group had worse triglyceride control as measured by DMI (78% vs 86%) but better HbA1c control (73% vs 65%).
In people with no history of hypertension, abnormal lipids, or diabetes, those with HIV had a 26% higher CVD risk (hazard ratio [HR] 1.26) than those without HIV. Among people with good hypertension control (DMI 100%), those with HIV had a 35% higher CVD risk (HR 1.35). And among those with poor hypertension control (DMI 80%), people with HIV had almost a doubled CVD risk (HR 1.91). There was a trend toward higher CVD risk with versus without HIV in people with poor triglyceride control (DMI 80%): HR 1.31 but confidence interval crosses 1.0. A similar trend to higher CVD risk with versus without HIV could be seen in people with poor HbA1c control (DMI 80%): HR 1.24 but confidence interval crosses 1.0.
The Kaiser team concluded that tight control of lipids and the diabetes marker HbA1c "can help reduce the CVD burden in people with HIV." They underlined the worrisome CVD risk with HIV in people with poor blood pressure control and even with good blood pressure control. They endorsed further research to see whether a more aggressive blood pressure target for people with HIV, such as 130/80 mm Hg as in the latest ACC/AHA guidelines [3], would help them trim cardiovascular risk.
The researchers noted their analysis did not consider potential confounders like diet and exercise, and they cautioned the findings may not apply to women (only about 10% of their study group) or uninsured people. Use of an unfamiliar clinical care tool, the disease management index (DMI), could frustrate readers without the time to explore this metric [2].
References
1. Silverberg MJ, Levine-Hall T, Anderson A, et al. Prevention of cardiovascular disease in persons with and without HIV. CROI 2021, Conference on Retroviruses and Opportunistic Infections, March 6-10, 2021. Abstract 97.
2. William AE, Vogt TM. Using IT to Improve the quality of cardiovascular disease (CVD) prevention and management. Grant Final Report: Grant ID: 5R18HS017016.
https://digital.ahrq.gov/sites/default/files/docs/publication/r18hs017016-williams-final-report-2010.pdf
3. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018;138:e484-e594. doi: 10.1161/CIR.0000000000000596.
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