as one of the most important risk factors for heart attack in an analysis of 29,515
people with HIV receiving care in North America, presented by Keri Althoff of
Johns Hopkins University, Baltimore. The study set out to determine what
proportion of heart attacks in the population of people with HIV were
attributable to various risk factors.
These included, on the one hand, the
well-established risk factors: smoking, high cholesterol, treated hypertension,
diabetes, body mass index (BMI) of 30 or above and stage 4 chronic kidney disease.
The analysis also looked at the contribution of HIV-specific risk factors: CD4
count below 200, lack of viral suppression, an AIDS diagnosis, and HCV
cohort study recorded 347 heart attacks among participants during a median
follow-up period of 3.5 years.
The prevalence of
smoking in the cohort was extremely high: 75% in people who did not experience
a heart attack, and 84% in those who did. Smokers were 80% more likely to have
a heart attack than never-smokers – similar to the risk of heart attack seen in
people with stage 4 kidney disease, diabetes or a current CD4 count below 200.
But this degree of risk was dwarfed by the risks attached to hypertension.
People with high blood pressure, even though it was being treated, were four
times more likely to have a heart attack than people without, and people with a
BMI of 30 or above and elevated cholesterol were three times more likely to
have a heart attack than those without elevated cholesterol. Surprisingly, high
cholesterol in the absence of obesity was not associated with an increased risk
of heart attack.
contribution of these risk factors to the total number of heart attacks, three
stood out. If everyone stopped smoking 38% of all heart attacks would be
avoided. If everyone had normal cholesterol, 43% of heart attacks would be
avoided, and if everyone had normal blood pressure, 41% of heart attacks would
be avoided. In comparison, changing risk factors associated with HIV would have
a much smaller effect on the total number of heart attacks.
Keri Althoff drew
the attention of delegates to previous research from the same cohort study,
which found that stopping smoking would make the single greatest contribution
to cutting cancer diagnoses in people with HIV. Controlling cholesterol would
have greatest impact on end-stage kidney disease and on heart attack.
of the burden of cardiovascular disease among people with HIV in the
Netherlands between 2015 and 2030 found that smoking cessation and cholesterol and
hypertension management would result in far greater reductions in
cardiovascular events than HIV-related interventions such as earlier diagnosis
and treatment or avoiding antiretrovirals with known cardiovascular risks.
presented by Rosan van Zoest of Amsterdam Institute for Global Health and
Development, used data from the Netherlands ATHENA cohort and the D:A:D study
to simulate cardiovascular disease over time. The model predicts that the
annual incidence of cardiovascular events will increase by 55% between 2015 and
2030, and that improving the rate of smoking cessation would reduce the number
of heart attacks by 6-13% each year. However, the model makes the ambitious
assumption that it will be possible to achieve cessation rates of 50% or 100%.
In clinical settings, smoking cessation rates are much lower.
the findings suggest the need for a much greater emphasis on smoking cessation
in people with HIV, as well as a greater emphasis on management of cholesterol
and hypertension. All these interventions will require greater input from
primary care physicians in settings where these interventions are chiefly delivered
by general practitioners, and greater focus on non-HIV health care in settings
where HIV care is delivered by specialist providers.