Exploring the issue of heart attack in HIV

• As people with HIV live longer the risk for some other health issues increases
• A 10-year California study has found that HIV more than doubles the risk for heart attack
• Heart attacks are not inevitable—many steps can be taken to reduce risks

Thanks to effective HIV treatment (ART), many people with HIV can have near-normal life expectancy in Canada and other high-income countries. As HIV-positive people live longer, they become susceptible to many of the issues associated with aging that also affect the health of HIV-negative people.

In California

As part of a study, a team of researchers at the University of California in San Francisco (UCSF) has been monitoring the health of nearly 19 million residents of California, of whom about 44,000 were people with HIV. The study collected health-related information for a decade and researchers focused on the issue of heart attacks that occurred outside of a hospital. The researchers found that regardless of the underlying risk factors for a heart attack (obesity, smoking and so on), HIV-positive people had a 2.5-fold greater risk of having a heart attack than HIV-negative people.

The researchers stated that the risk for a heart attack was “disproportionally” distributed among the following sub-populations: “younger people, women, and those with high blood pressure, chronic heart failure and chronic kidney disease.”

The researchers encouraged physicians to be aware of these conditions among their HIV-positive patients and to screen them for potential issues that can intensify the risk for heart attack.

Study details

The research team gathered and analyzed health-related information from databases in California. All participants were at least 21 years old and entered the study between January 1, 2005 and June 30, 2015.

The average profile of HIV-positive people upon study entry was as follows:

• age – 45 years
• 84% men, 26% women
• major ethno-racial groups: White – 50%; Black – 24%; Hispanic – 21%; Asian – 3%

The researchers also collected data on factors that increased the risk for a heart attack, which were distributed as follows:

• high blood pressure – 15%
• tobacco smoking – 11%
• type 2 diabetes – 9%
• problematic drug use – 7%
• coronary artery disease – 3%
• chronic kidney disease – 3%
• congestive heart failure – 2%
• problematic alcohol use – 2%
• abnormal heart rhythm – 1%
• obesity – 1%

Note that the researchers did not collect information on HIV-specific issues such as CD4+ cell counts, viral load and HIV medication history.

Results

The researchers found that a total of 133,983 heart attacks occurred—676 were in HIV-positive people.

After considering many factors—including age, gender, race, income, smoking, substance use and so on—statistical analysis revealed that HIV infection was associated with an almost 2.5-fold increased risk for a heart attack. The researchers stated that HIV’s impact on heart attack risk was greater than “any other risk factor.”

The researchers also found that the increased risk for heart attacks among HIV-positive people was “significantly higher” among the following sub-populations:

• younger people
• women
• people with high blood pressure
• people with heart failure
• people with chronic kidney disease

Other studies

A smaller 109-person study in San Francisco that was published earlier this year used data collected from autopsies, medical records and interviews with first responders and family members. That study explored causes of death among people initially presumed to have died from heart attack. The researchers found that sudden death due to undisclosed substance use was more common among HIV-positive people than among HIV-negative people (34% vs. 13%).

A study in Spain spanning two decades (1997 to 2018) found that hospitalizations for cardiovascular disease more than doubled (from 12% to 28%) among 500,000 instances of hospitalizations in people with HIV. This study did not provide details about heart attacks and associated risk factors.

The San Francisco and Spanish studies underscore cardiovascular disease as a major cause of illness in people with HIV.

Back to the larger California study

It is plausible that some of the deaths in the UCSF study were also due to undisclosed substance use. However, it is still likely that most heart attacks among people with HIV in this study were related to the presence of this virus.

HIV infection is associated with an excess of two immunologically related features— inflammation and immune activation. Taking ART and achieving and maintaining an undetectable viral load help to greatly reduce the level of these immunological issues. However, ART does not normalize excessive inflammation and immune activation.

Scientists have known that excess inflammation contributes to an increased risk for cardiovascular and other health issues in both HIV-positive and HIV-negative people. Researchers have been conducting clinical trials to significantly reduce the risk of heart attack and associated issues in HIV-negative people. However, most of these trials have not been able to show sustained suppression of excess immunological activation and inflammation or they showed only a modest reduction.   

Statins

Drugs such as atorvastatin (Lipitor) and rosuvastatin (Crestor) are used to help reduce cholesterol levels, and in HIV-negative people these drugs can reduce the risk for serious cardiovascular disease. Small studies have found that these drugs can sometimes reduce inflammation in HIV-positive people. Recent studies from the U.S. have found that not all HIV-positive people at risk for cardiovascular disease are being prescribed statins.

Unfortunately, there was no information on the use of statins by HIV-positive people in the UCSF study.

An international trial called Reprieve is underway. This study is testing a daily dose of a statin called pitavastatin vs. placebo. Reprieve has recruited more than 7,700 HIV-positive people.

Heart attacks are not inevitable

The California researchers hope that their study will increase physicians’ awareness of the link between HIV and cardiovascular disease, particularly among people with the following additional risk factors:

• high blood pressure
• heart failure
• chronic kidney disease

The researchers encouraged physicians to screen their patients for cardiovascular disease and provide interventions to reduce the risk of heart attack in their patients.

Heart attacks are not inevitable. Below are some resources that offer suggestions for reducing some of the risks for a heart attack.

Resources

HIV and cardiovascular disease – CATIE

Prévention des maladies cardiovasculaires – l’Institut de Cardiologie de Montréal

Heart attack – Public Health Agency of Canada

For professionals: Heart diseases and conditions – Government of Canada

Heart & Stroke – Heart and Stroke Foundation

Quitting smoking: Deciding to quit – Government of Canada

Reprieve Study

—Sean R. Hosein

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