Elsevier

Thrombosis Research

Volume 134, Issue 3, September 2014, Pages 558-564
Thrombosis Research

Regular Article
Prognostic Indicators for Recurrent Thrombotic Events in HIV-infected Patients with Acute Coronary Syndromes: Use of Registry Data From 12 sites in Europe, South Africa and the United States

https://doi.org/10.1016/j.thromres.2014.05.037Get rights and content

Abstract

Aims

Limited data are available on prognostic indicators for HIV patients presenting with ACS.

Methods and results

Data on consecutive patients with HIV infection receiving standard highly active antiretroviral therapy (HAART) presenting with ACS between January 2001 and September 2012 were collected. Cardiac death and myocardial infarction (MI) were the primary end-points. 10,050 patients with ACS were screened, and among them a total of 201 patients (179 [89%] males and a median age of 53 [47-62] years) were included, 48% of them admitted for ST-elevation myocardial infarction and 14% having left ventricular systolic dysfunction (LVSD) at discharge. CD4 + counts less than 200 cells/mm3 were reported in 18 patients (9%), and 136 patients (67%) were treated with nucleoside-reverse transcriptase inhibitors (NRTI). After a median of 24 months (10–41), 30 patients (15%) died, 12 (6%) for cardiac reasons, 20 (10%) suffered a MI, 29 (15%) a subsequent revascularization, and 7 (3%) a stent thrombosis. Other than LVSD (hazard ratio = 6.4 [95% confidence interval [CI]: 1.6-26: p = 0.009]), the only other independent predictor of cardiac death was not being treated with NRTI (hazard ratio = 9.9 [95% CI: 2.1-46: p = 0.03); a CD4 cell count < 200 cells/mm3 was the only predictor of MI (hazard ratio = 5.9 [95% CI: 1.4-25: p = 0.016]).

Conclusions

HIV patients presenting with ACS are at significantly increased risk for cardiac death if not treated with NRTI, and at significantly increased risk of MI if their CD4 cell count is < 200 cells/mm3, suggesting that the stage of HIV disease (and lack of NRTI treatment) may contribute to cardiovascular instability.

Introduction

Antiretroviral therapy (ART) dramatically increases life expectancy for patients with human immunodeficiency virus (HIV) [1], such that their long term outlook appears to be similar to that of general population in the highly active antiretroviral therapy (HAART) era [2]. The shift from an acute to a chronic condition leads subjects with HIV to exposition to the long-term detrimental effects of both disease progression and antiretroviral therapy [3], [4].

Heart disease represents one of the most important causes of morbidity and mortality for these patients [4], [5]. Before the introduction of HAART, clinically significant cardiomyopathy mainly related to myocarditis was already reported in up to 10% of patients [6], [7], [8], [9]. In the HAART era, increased and persistent arterial inflammation leading to aggressive atherosclerosis [10] was demonstrated, most likely related to a complex (and not yet thoroughly clarified) relationship between coronary HIV infection, immune-mediated response and adverse risk factor profile [11].

The high risk of cerebro- and cardiovascular events (CV) [12], [13] and especially acute coronary syndromes (ACS) represents the clinical consequence of these pathological processes. Most of the evidence on HIV and ACS, however, derives from small studies [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], not performed in the contemporary era, and with a subspecialty focus, thus limiting a comprehensive clinical evaluation of these patients.

We thus designed the Percutaneous coronary intervention and surgical revascularization in HIV Database (PHD) study whose aim was to investigate the outcome of HIV-positive patients treated as in contemporary practice.

Section snippets

Design, Patients and Treatments

The PHD study was a retrospective registry conducted at 12 sites in Europe and USA. All consecutive HIV-positive patients presenting with ACS between January 2001 and September 2012 were enrolled, irrespectively of their management by percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or medical therapy. International guidelines on ACS were used to diagnose and classify ACS [23], [24], distinguishing ST-elevation myocardial infarction (STEMI), non-ST-elevation

Results

10,050 patients with ACS were screened, and among them a total of 201 (2.0%) fulfilled the inclusion criteria (see Fig. 1). 179 (89%) were men, with median age of 53 (47-62) years (Table 1). Traditional CV risk factors were highly prevalent, with 98 patients (48%) reporting hypertension, and 36 patients (18%) diabetes mellitus. HAART was started 1.4 ± 1.0 years before the ACS current T CD4 + cell count was 651 ± 510 cells/mm3, with 17% of patients not being fully suppressed that is with a high viral

Discussion

To the best of our knowledge, this is the largest study with HIV-positive patients presenting with ACS in the contemporary era.

The main findings are: a) this population presents with a high prevalence of high-.risk clinical features and of subsequent thrombotic events; b) CD4 cell count < 200 cells/mm3 and not being treated with NRTI represents a powerful predictor of cardiac prognosis.

HIV patients are exposed to higher rates of recurrence of ischemic events, particularly if presenting with a

Disclosures

None.

Conflict of Interests

None.

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