As people with HIV are living longer, new concerns are cropping up, such as a risk for heart attack up to two times greater than for people without the AIDS-causing virus, a new study reports.
Those increased odds are seen even in people whose virus has been suppressed to undetectable levels in the blood with antiretroviral drugs, the researchers said.
There are several reasons for this higher risk, said lead researcher Dr. Matthew Feinstein, a cardiology fellow at Northwestern University Feinberg School of Medicine in Chicago.
“A key factor appears to be chronic HIV-associated inflammation that persists even when there is no detectable virus in the blood,” he said.
Feinstein explained that the heart disease and stroke risk is higher “because the virus maintains a reservoir in the body’s tissues, driving a chronic inflammatory and immune response that can lead to the development of inflammatory plaque and ultimately heart attacks and strokes.”
Furthermore, plaque buildup happens 10 to 15 years earlier in HIV patients than in people without the infection, Feinstein said.
“The ability to predict heart attack and stroke risk is essential,” he said. But he added that the best way to do that isn’t yet clear, and that’s where the new study comes in.
The study included more than 11,000 people receiving HIV care at one of five sites in the United States. The researchers compared the rates of heart attacks in the general population with the rates of heart attacks seen among these HIV patients. They also looked at how two heart disease risk estimator tools fared in the HIV population.
The researchers said these tools were helpful in people with HIV, but not as accurate at assessing heart attack risk as they hoped. As the HIV population continues to grow older, the researchers suggest that studies should reassess these risk estimators with new information to increase their ability to predict someone at risk of a heart attack.
If the risk can be accurately predicted, then patients can be treated with drugs that lower the risk, including drugs to reduce blood pressure and cholesterol, Feinstein said.
“When people have higher risks of heart attack or stroke, the potential benefit from one of these medications is greater and can justify the possible side effects of the medications,” he said. “But we still have some work to do in order to figure out how to best predict heart disease risk in the setting of HIV,” Feinstein said.
The report was published online Dec. 21 in the journal JAMA Cardiology.
According to Feinstein, an estimated 1.2 million Americans have HIV, as do about 35 million around the world.
Dr. Michael Horberg is director of HIV/AIDS at Kaiser Permanente and immediate past chair of the HIV Medicine Association in Washington, D.C. “As people are living longer with HIV, the higher risk of heart attack is something we are becoming aware of among HIV patients,” he said.
As these patients live longer, they start to get a lot of serious diseases, including heart disease, Horberg said. “HIV itself accounts for some of this, but historically there are more smokers among HIV-infected folks, which also increases the odds of developing heart disease,” he said.
Race may also play a role, he said. “In the United States, HIV is a disease of the minority populations, who can be at greater risk for heart disease,” Horberg said.
A clinical trial is under way at Northwestern Medicine to evaluate how well common medications for heart disease — such as cholesterol-lowering statins — work to prevent heart disease in the HIV-infected population, according to the researchers.
The key to reducing the risk of heart attacks among HIV-positive patients is similar to the advice given to everyone, Horberg said.
“Treating HIV to get your viral load as low as possible and your immune system as strong as possible is number one,” he said. “Two, stop smoking and exercise more.”
“These were things early on in the [AIDS] epidemic that we didn’t talk about because life expectancy wasn’t that great. But now that it is, these are things you’ve got to talk about,” Horberg said. “You’ve got to talk about treating high cholesterol, high blood pressure and diabetes and obesity.”
Doctors are becoming more aware that as HIV-positive patients live longer, they need the same care and advice about conditions other than HIV, he said. “All those things your doctor would have told patients who are HIV-negative apply, and are maybe even more important among our HIV-positive population,” he added.
For more information on HIV/AIDS, visit the U.S. Centers for Disease Control and Prevention.