Abstract
Background: Cardiovascular events (CVEs) have emerged as an important cause of morbimortality in people living with HIV/AIDS (PLHA). We aimed to investigate factors associated with incident CVE and compare the observed incidence with the predicted CVE risk by three different equations. Methods: Among the 649 active participants of the INI-ELSA cohort, we analysed data of 644 individuals free of CVE at baseline examinations. We used Cox regression models to study factors associated with CVE and to assess the equation's performance we compared the observed incidence with the overall 5-year predicted risks. Results: Over a median follow-up of 6.26-years (interquartile range [IQR] 6.01-6.47), there were 18 CVE, four deaths. Overall, 57.92% were male, median age was 43.4 years (35.82-50.73), most were on cART (88.65%). Participants who had CVE were older, had poorer renal function, higher proportion of dyslipidemia and higher levels of systolic blood pressure and triglycerides. The observed CVE rate was 2.90% (1.60-4.90%) whereas their overall cardiovascular disease (CVD) risk differed depending on which score was used: 0.91 (0.42-20), 1.16 (0.38-2.78) and 1.68 (0.60-3.87), according to Framingham, ASCVD and DAD, respectively. In the multivariable Cox analysis black race, smoking 10+ packs years, dyslipidemia, current CD4 cell count x101, cumulative viral load and time on NNRTI were independent predictors of CVE. Conclusion: Both traditional and HIV-related factors were associated with incident CVE. Risk scores were inconsistent in classifying patients who had CVE as high risk, indicating that validation studies are required to improve risk assessment of PLHA in Brazil.
Highlights
In the last decades HIV infection and its related complications remained as the major causes of death in people living with HIV/AIDS (PLHA), mounting data suggest that cardiovascular disease (CVD) have emerged as important causes of morbimortality in PLHA, after the introduction of combined antiretroviral therapy
The most widely used in clinical practice, the Framingham risk score (FRS), was the first to demonstrate the ability to predict sex-specific 10-year CVD risk using a set of variables obtained from a Caucasian population, using a mathematical model [9]
Our results suggest that FRS could be underestimating cardiovascular events (CVE) risk in PLHA in Brazil, as the predicted 5-year absolute CVD risk was the lowest amongst the three equations that have been evaluated and models that take into account exposure to individual combined antiretroviral therapy (cART) regimens and immune activation could more accurately predict CVE occurrence
Summary
In the last decades HIV infection and its related complications remained as the major causes of death in people living with HIV/AIDS (PLHA), mounting data suggest that cardiovascular disease (CVD) have emerged as important causes of morbimortality in PLHA, after the introduction of combined antiretroviral therapy (cART).The etiology seems to be multifactorial; the main components of traditional CVD risk factors for the development of CVD are increasingly present in PLHA, as recent epidemiologic studies showed higher rates of diabetes, smoking and hypertension in PLHA when compared to the general population [1,2,3,4]. Traditional risk factors do not fully explain the increased CVD risk, whether HIV infection is itself a risk factor by promoting immune activation and inflammation is not totally clear yet Notwithstanding, it is of uppermost importance for clinicians to correctly recognize high-risk patients in order to initiate preventive interventions to control modifiable risk factors. The most widely used in clinical practice, the Framingham risk score (FRS), was the first to demonstrate the ability to predict sex-specific 10-year CVD risk using a set of variables obtained from a Caucasian population, using a mathematical model [9] Since it has been further validated for use in different populations, provided that adjustments are made for demographic variation and the underlying CVD rates [10, 11]. Risk scores were inconsistent in classifying patients who had CVE as high risk, indicating that validation studies are required to improve risk assessment of PLHA in Brazil
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