Abstract
BackgroundPersons with human immunodeficiency virus (HIV) have higher risks for myocardial infarction (MI) than the general population. This is driven in part by higher type 2 MI (T2MI, due to coronary supply-demand mismatch) rates among persons with HIV (PWH). In the general population, T2MI has higher mortality than type 1 MI (T1MI, spontaneous and generally due to plaque rupture and thrombosis). PWH have a greater burden of comorbidities and may therefore have an even greater excess risk for complication and death in the setting of T2MI. However, mortality patterns after T1MI and T2MI in HIV are unknown.MethodsWe analyzed mortality after MI among PWH enrolled in the multicenter, US-based Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort (N = 28,186). Incident MIs occurring between January 1, 1996, and December 31, 2014, were centrally adjudicated and classified as T1MI or T2MI. We first compared mortality following T1MI vs. T2MI among PWH. Cox survival analyses and Bayesian model averaging were then used to evaluate pre-MI covariates associated with mortality following T1MI and T2MI.ResultsAmong the 596 out of 28,186 PWH who experienced MI (2.1%; 293 T1MI and 303 T2MI), mortality rates were significantly greater after T2MI (22.2/100 person-years; 1-, 3-, and 5-year mortality 39%, 52%, and 62%) than T1MI (8.2/100 person-years; 1-, 3-, and 5-year mortality 15%, 22%, and 30%). Significant mortality predictors after T1MI were higher HIV viral load, renal dysfunction, and older age. Significant predictors of mortality after T2MI were low body-mass index (BMI) and detectable HIV viral load.ConclusionsMortality is high following MI for PWH and substantially greater after T2MI than T1MI. Predictors of death after MI differed by type of MI, reinforcing the different clinical scenarios associated with each MI type and the importance of considering MI types separately.
Highlights
Persons with human immunodeficiency virus (HIV) have higher risks for myocardial infarction (MI) than the general population
Among participants with Type 1 myocardial infarction (T1MI), those who died during follow-up were significantly older and had significantly higher HIV viral loads, lower CD4 counts, and lower body-mass index (BMI) prior to MI than participants who did not die during follow-up (Table 2)
We found that post-MI mortality rates for persons with HIV (PWH) are elevated in general and elevated after Type 2 myocardial infarction (T2MI), in a diverse, multi-center cohort of over 28,000 PWH with rigorous MI adjudication
Summary
Persons with human immunodeficiency virus (HIV) have higher risks for myocardial infarction (MI) than the general population. This is driven in part by higher type 2 MI (T2MI, due to coronary supply-demand mismatch) rates among persons with HIV (PWH). Type 2 MIs (T2MIs), which are secondary to myocardial supply/demand mismatch rather than primary plaque rupture or thrombosis [11], account for as many as half of HIV-associated MIs [9] but a lower [12] (though increasing [13]) proportion of MIs in the general population. A recent single-center retrospective study in the general population found that 1year mortality after T1MI was 12.4% vs 34.9% for T2MI [21] This difference was driven in large part by non-cardiovascular causes of death following T2MI. T2MI may be a important prognostic marker among PWH, who tend to have a greater chronic disease burden, prognosis after T1MI and T2MI has not been studied among PWH
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