Aware of the Heart
Reports about the heart, one pill a day, and more were highlighted when ICAAC, the leading conference on infectious diseases and antimicrobial agents convened in San Francisco. For more conference information, go to icaac.org.
People with HIV may develop heart disease earlier than HIV-negative individuals and they may also have a greater risk of dying from it, reported two separate research teams.
"[Our] study was done to evaluate whether or not HIV-positive patients were receiving the same consideration for cardiovascular disease by their health care providers as HIV-negative patients," Charles Hicks, M.D., of Duke University, wrote in a statement summarizing his team's findings. "We hypothesized that if they were not, then coronary disease would be diagnosed later in the disease process -- often after having already suffered a heart attack or developing unstable angina (impending heart attack) -- rather than through earlier evaluation of chest pain or other symptoms.
"This is in fact what was found," he continued. "54% of HIV-positive patients did not have coronary catheterization until the time of an acute coronary event, as compared to 34% of controls. Since the current quality of HIV treatment now allows most HIV-infected patients to live into old age, and given the concern that HIV itself and/or the medications used to treat it may increase cardiovascular risk, failure to aggressively treat cardiac risk factors and to identify heart disease early could have significant consequences for the growing population of HIV-infected persons."
His team looked at first-time cardiac catheterization, or cath (insertion of a catheter, or tube, into a chamber or vessel of the heart, for either diagnostic or treatment purposes), in patients with unstable angina (chest pain) or suspected coronary artery disease (CAD).
The HIV patients were an average of 49 years old. This made it very difficult for the team to put together an age-matched control group for comparison purposes, because few HIV-negative individuals had a cath done around that age.
These patients, whether HIV-positive or negative, were already in stable care, with at least three medical visits in the previous year, "so we felt it wasn't an access to care issue so much as failure to recognize the risk factors in HIV and the fact that the higher proportion of HIV patients with cardiovascular disease weren't recognized until a coronary event was about to happen or already underway," said Dr. Hicks.
The good news was that once CAD was diagnosed, HIV-positive patients received the same care as HIV-negative ones, such as bypass surgery or getting a stent. The patients came from Duke University and the University of North Carolina at Chapel Hill.
Daniel D. Pearce, M.D., of Loma Linda University in Loma Linda, California, reported a higher rate of death for heart attack patients who had HIV compared to those who were HIV-negative. His team looked at the Nationwide Inpatient Sample, a huge national database on hospitalized people.
"We found the hazard ratio of dying was 1.83 times greater if you have HIV," said Dr. Pearce. (A hazard ratio of 1.0 would be an equal risk between the two groups. A hazard ratio of 1.83 represents an 83% higher risk.)
Furthermore, 4% of the HIV-positive heart attack patients died vs. 2% of the HIV-negative ones.
Unlike Dr. Hicks' team, Dr. Pearce's group found inequality in the way people with HIV were treated. They were significantly less likely to get typical heart attack medications and procedures. The team looked at patients hospitalized for at least a day.
Dr. Pearce agreed with Dr. Hicks when he said that medical providers should be aware of these differences found in the HIV-positive population, an issue long raised by specialists. He noted various biological dysfunctions promoting heart disease which have been found in HIV-positive people, saying research looking at what causes these problems needs to continue.
There could be other concerns, as well.
"It could be a bias on the doctor's part," he continued, "like we had a bias against women and we weren't treating women correctly, or it just could be some systemic thing or that HIV or the medications are causing them to be sicker and they won't qualify for the intervention."
He said the findings raise the question of having an echocardiogram earlier for HIV-positive patients or considering aspirin therapy for them, and Dr. Hicks urged medical providers to start considering heart disease in HIV-positive patients with chest discomfort. "Because the patients are young, we may not think of cardiovascular disease," he said.
"We don't want people to have the procedure after they've already had injury to their heart," he added.
You can see a panel presentation with the two men, along with Kristy Kaiser, M.D., of Georgetown University (who worked in Dr. Hicks' study) at here.
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