Correspondence
Cardiovascular Disease and HIV Infection
N Engl J Med 2003; 349:1869-1870November 6, 2003
- Article
To the Editor:
We read with interest the work of Bozzette et al. (Feb. 20 issue),1 who describe reduced rates of cardiovascular events among patients with human immunodeficiency virus (HIV) infection in the era of highly active antiretroviral therapy (HAART). This finding, however, contrasts with the results of studies showing that the rates of cardiovascular events among persons with HIV infection increase with the duration of exposure to HAART regimens containing protease inhibitors.2-5
The mean period of exposure to HAART of 15 months in this cohort (which is below the threshold of exposure to protease inhibitors suggested by others) and the low proportion of patients (roughly 3 percent) who were exposed to protease inhibitors for 48 months or more severely limits the study's relevance regarding long-term exposure to protease inhibitors. Ascertainment of events among patients who sought care outside the Veterans Affairs system may not have been comprehensive. Also, the relatively early stage of disease at diagnosis (suggesting a shorter duration of chronic infection, with chronic infection itself a possible cardiovascular risk factor) and the low prevalence of traditional risk factors appear to be unique to this cohort.
We do agree with the authors that the rates of cardiovascular disease among HIV-infected persons are not currently high enough to offset the reductions in HIV-related morbidity and mortality afforded by HAART-era therapies, and we encourage appropriate risk-reduction strategies.
5 ReferencesDaniel Klein, M.D.
Leo B. Hurley, M.P.H.
Stephen Sidney, M.D.
Kaiser Permanente Medical Care Program, Oakland, CA 94612
daniel.klein@kp. org 1
Bozzette SA ,Ake CF ,Tam HK ,Chang SW ,Louis TA . Cardiovascular and cerebrovascular events in patients treated for human immunodeficiency virus infection. N Engl J Med 2003;348:702-710
Full Text | Web of Science | Medline2
Mary-Krause M, Cotte L, Partisani M, et al. Impact of treatment with protease inhibitor on myocardial infarction occurrence in HIV infected men. In: Abstracts of the Eighth Conference on Retroviruses and Opportunistic Infections, Chicago, February 4–8, 2001:241. abstract.
3
Holmberg SD ,Moorman AC ,Williamson JM , et al. Protease inhibitors and cardiovascular outcomes in patients with HIV-1. Lancet 2002;360:1747-1748
CrossRef | Web of Science | Medline4
Friis-Møller N, Weber R, D'Arminio Monforte A. Exposure to HAART is associated with an increased risk of myocardial infarction: the D:A:D Study. In: Abstracts of the 10th Conference on Retroviruses and Opportunistic Infections, Boston, February 10–14, 2003:103. abstract.
5
Klein D, Hurley L, Quesenberry C Jr, Sidney S. Hospitalizations for coronary heart disease and myocardial infarction among men with HIV-1 infection: additional follow-up. In: Abstracts of the 10th Conference on Retroviruses and Opportunistic Infections, Boston, February 10–14, 2003:326. abstract.
Author/Editor Response
Our investigation, which was an outcome study, clearly showed that antiretroviral therapy has a benefit that is enormous relative to the risk of cardiovascular or cerebrovascular disease (Figure 1Figure 1
Rates of Death and of Death or Admission for Cardiovascular or Cerebrovascular Disease.). Some clinical studies have suggested that HAART has only a small effect or no effect on this risk, but these studies had a small number of events or short follow-up or failed to correct for selection or the amount of drug exposure.1-5 Our conclusions were no different for the approximately 1000 patients treated with protease inhibitors for 48 months or more. Ascertainment may have affected the point estimates but probably did not change over time in a way that would attenuate a putative drug effect. Furthermore, we obtained similar results from national death-index data.We reported the stage of disease at first presentation and the treatment for risk factors, accounting for the appearance of an atypically healthy population. We found that traditional risk factors increased risk. We join Klein and colleagues in encouraging risk reductions when appropriate. We also look forward to analyses of our outcome and clinical-study data bases and those of others as they mature.
5 ReferencesSam A. Bozzette, M.D., Ph.D.
San Diego Veterans Affairs Medical Center, San Diego, CA 92161
sbozzette@ucsd.edu Thomas A. Louis, Ph.D.
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 212051
Holmberg SD ,Moorman AC ,Williamson JM , et al. Protease inhibitors and cardiovascular outcomes in patients with HIV-1. Lancet 2002;360:1747-1748
CrossRef | Web of Science | Medline2
Friis-Møller N, Weber R, D'Arminio Monforte A. Exposure to HAART is associated with an increased risk of myocardial infarction: the D:A:D Study. In: Abstracts of the 10th Conference on Retroviruses and Opportunistic Infections, Boston, February 10–14, 2003:103. abstract.
3
Iloeje U, Yuan Y, Tuomari A, L'Italien G, Mauskopf J, Moore R. Protease inhibitors may increase risk of cardiovascular disease in HIV-infected patients. In: Abstracts of the 10th Conference on Retroviruses and Opportunistic Infections, Boston, February 10–14, 2003. abstract.
4
Klein D, Hurley L, Quesenberry C Jr, Sidney S. Hospitalizations for coronary heart disease and myocardial infarction among men with HIV-1 infection: additional follow-up. In: Abstracts of the 10th Conference on Retroviruses and Opportunistic Infections, Boston, February 10–14, 2003:326. abstract.
5
Currier J ,Taylor A ,Boyd F , et al. Coronary heart disease in HIV-infected individuals. J Acquir Immune Defic Syndr 2003;33:506-512
CrossRef | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Clive R. Pullinger, Bradley E. Aouizerat, Caryl Gay, Traci Coggins, Irina Movsesyan, Harvey Davis, John P. Kane, Carmen Portillo, Kathryn A. Lee. (2010) Metabolic Abnormalities and Coronary Heart Disease Risk in Human Immunodeficiency Virus–Infected Adults. Metabolic Syndrome and Related Disorders 8:3, 279-286
CrossRef
