People living with HIV who smoke have a risk almost three times more likely to have a heart attack than smoking HIV-negative, according to published online Dutch data before it is published on paper in Clinical Infectious Diseases (Clinical Infectious Diseases). The study suggests that smoking spearheads the number of attacks the heart watchesof in people living with HIV in rich scenarios resources with other factors being less important.
At the same time, a major supplier of health care in California reported a drop in the incidence of heart attacks in people living with HIV in recent years with rates now equivalent to HIV-negative people. They attribute the change not only the cessation of smoking, but also better monitoring of cardiovascular risks, greater use of drugs to reduce and prevent cholesterol and early initiation of therapy antiretroviral.
Cardiovascular disease and heart attacks
In an era of effective antiretroviral therapy, focus on medical care for many people living with HIV has changed through the co-morbidity management and health conditions that are associated with aging such as cardiovascular disease.
Several observational studies reported an increase of the 1.5 2 times the risk of heart attack (myocardial infarction) among people living with HIV, compared to people who do not have HIV. Around one in ten deaths of people living with HIV are due to heart attacks and other cardiovascular diseases. The underlying causes of this are a matter of scientific debate. Having HIV directly causes chronic inflammation and changes in cholesterol and other lipids that can accelerate the cardiovascular disease. Some researchers suggest that specific antiretroviral drugs can contribute to these processes. Genetic factors, accelerated aging in people with HIV and high blood pressure also have been proposed as potential factors.
But behavioral and social factors are also likely to be well part of it. More importantly, smoking rates tend to be considerably high in people with
HIV than in the general population. In addition, differences in socioeconomic status, ethnicity, alcohol consumption and the use of recreational drugs have been observed among groups of people HIV-positive and HIV-negative. While researchers try to measure factors such as these and the take into consideration when comparing the risk of heart attack in HIV-positive and HIV-negative individuals, this process is inevitably inaccurate and Incompleteo.
An increased risk for smokers in Denmark
To better understand the link between HIV infection, smoking and the risk of heart attack, Line Rasmussen and his colleagues compared data in HIV-positive patients 3.251 living in Denmark and 13.004 the general population in Copenhagen, grouped by age and gender.
Specifically, the researchers wanted to find out if smoking has a greater impact on the risk of heart attack among smokers living with HIV than among HIV-negative smokers. They also aimed to estimate the extent to which smoking may explain the increased risk of heart attack among people living with HIV.
Data were collected between 1995 and 2013. People who had injected drugs in their lifetime were excluded from the analysis.
Smoking rates were much higher among people living with HIV:
- 47% currently smoked, compared to 19% in the general population.
- 19% were former smokers, compared to 34% in the general population.
- 34% had never smoked, compared to 46% in the general population.
The proportion of people with HIV who came to suffer a heart attack (2.9%) was considerably higher than in the general population (1.0%)
The researchers analyzed the risk of heart attack according to the fact whether the person smoked:
- Smokers usual living with HIV had a risk almost three times higher heart attack compared to smokers in the general population of the same age and gender: the proportion of incident rate was 2.83 (95% confidence interval in 0.75 - 4.24).
- Ex-smokers living with HIV had a risk almost twice: 1.78 incident aspect ratio (95% confidence interval in 0.75 - 4.24)
But people living with HIV who had never smoked not a big risk of heart attack than non-smokers in the general population of the same age and gender: the proportion of incident rate was 1.01.
The latest findings were not observed in other studies typically found that people living with HIV have a higher risk of heart attack, even if they do not smoke.
Data were analyzed otherwise, only looking for people living with HIV and taking individuals who had never smoked as the comparison group. Habitual smokers were statistically significant six times greater risk of having a heart attack (aspect ratio of 6.06 incident) and former smokers had more than double the risk (2.64 incident aspect ratio).
The Dutch data, however suggest that the main reason for the increase in heart attack rates in people with HIV is smoking. Not only smoking is more prevalent in this group as it also has a great physiological impact than in people without HIV.
Researchers estimate that 72% of heart attacks in people living with HIV were attributed to smoking - considerably higher than the 24% in the general population. If the usual smokers living with HIV could quit smoking and had the risk of former smokers, the total number of heart attacks in people with HIV would fall to 42%.
Discussing research in a comment added, M. John Gill and Dominque Costagliola question whether the majority of heart attacks are caused by smoking alone. They suspect that some of the behavioral and social differences in study participants may not have been completely captured by the survey. In addition, they believe that lipid abnormalities, chronic inflammation and the choice of antiretrovirals may also contribute to cardiovascular disease.
However, they say it is quite clear that smoking remains the dominant cause of heart attacks in people living with HIV. The study should encourage doctors to prioritize their work in smoking cessation.
"Grab every opportunity for the help in the care of HIV to focus our efforts to reduce the high rates of smoking offers the greatest potential to reduce rates of MI [myocardial infarction]," they say. "Encouragement and support for our patients in their efforts to quit smoking offers immense benefits to health."
Fewer heart attacks in California
Published simultaneously in Clinical Infectious Diseases is a program of the report on health care managed by Kaiser Permanente, which provides care to six million Californians. As previously reported by aidsmap, if the risk of heart attack by its HIV-positive limbs was twice that of 1996-99 (risk ratio 1.8, 95% confidence in 1.3-2.6) HIV-negative members, it has steadily fallen since then. In 2010 - 2011, there was no increased risk of heart attack for members living with HIV (1.0 proportion rate, 95% confidence in 0.7 - 1.4 interval).
The data comes from a comparison of 24.768 individuals living with HIV and 257.600 individuals who do not have HIV, with data collected from the 1996 2011.
In recent years the significant marker Framingham risk for cardiovascular diseases has decreased slightly for members with HIV than for members without HIV, with better results for some risk factors (such as total cholesterol), but poorer outcomes for others (such like high blood pressure). If 45% of people living with HIV had smoked at least once in life, 31% of HIV-negative people also did.
Moreover, there was a dramatic increase in the use of medicines for cholesterol and other drugs to lower lipids for HIV-positive patients during the study period - from 5.5 to 31.5%.
"In our scenario integrated care to patients with insurance, these results can be explained by access to care, and efforts to reduce risk of widespread DC [cardiovascular disease], such as the implementation of health reminders that appear during all the records of clinic visits, including reminders of cholesterol monitoring and blood pressure, diabetes monitoring, and smoking cessation, "the researcher writes.
An additional explanation offered by researchers is the transformation in the use of antiretroviral therapy in people living with HIV from 1996. Drugs that have less association with cardiovascular diseases are now more likely to be used. In addition, patients begin treatment as soon CD4 and has higher cell count, avoiding the immunodeficiency is associated with chronic inflammation and cardiovascular disease.
"Our findings lend support to the concept that the increased risk of MI [myocardial infarction] to patients with HIV is largely reversible with continued emphasis in primary prevention in combination with early initiation of ART to preserve immune function," the author concludes.Tradução: Rodrigo S. Pellegrini An observation from the Editor-in-Chief of Seropositive.Org: If the arguments above did not interest you in thinking that you had stopped smoking, I invite you to invest (...) another five minutes in the wise words of a man whom I seriously, I would say very seriously, under the devastating and fatal consequences of the ill-fated (habit) habit of consuming tobacco (...)
|Full name||Sandra Brito Bréa|
|Birth & Standardization||May 11 de 1952 Rio de Janeiro, RJ|
|Death||May 4 de 2000 (47 years) Rio de Janeiro, RJ|
Editor's Notes: The links below point to studies in English.Rasmussen LD et al. Myocardial infarction Among HIV-infected Individuals Danish: Population attributable fractions associated with smoking. Clinical Infectious Diseases, 2015. Gill MJ & Costagliola D. Myocardial Infarction in HIV infected persons: Time to focus on the silent elephant in the room? Clinical Infectious Diseases, 2015. Klein DB et al. Declining Relative Risk for Myocardial Infarction Among HIV-Positive Compared with HIV-Negative Individuals with Access to Care. Clinical Infectious Diseases, 2015.
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