Among adults with HIV infection, cardiovascular disease accounted for a growing proportion of all deaths over the past 15 years in a nationwide U.S. study.1 In contrast, cardiovascular disease accounted for a decreasing (but still large) proportion of all deaths in the general population of the United States.
As people with HIV infection live longer thanks to antiretroviral therapy, they are more likely to acquire age-related diseases like cardiovascular disease (heart disease) and certain cancers. Research shows growing rates of cardiovascular disease in HIV groups compared with HIV-negative people. Reasons for higher rates of cardiovascular disease in people with HIV than in the general population include (1) high rates of heart disease risk factors like smoking and diabetes in people with HIV, (2) side effects from certain antiretroviral drugs, and (3) inflammation caused by HIV even when antiretroviral therapy makes the viral load undetectable.
Despite a growing understanding of cardiovascular disease in people with HIV, researchers had never analyzed patterns of death caused by cardiovascular disease in HIV-positive people across the entire United States. To fill this need, a group of HIV heart disease experts set out to explore rates of cardiovascular death in people with HIV. Specifically, they wanted to learn what proportion of all deaths in U.S. adults with HIV are caused by cardiovascular disease, how that proportion changed over time, and how that proportion compared with rates in other U.S. groups without HIV.
The researchers collected information on causes of death in all U.S. adults at least 25 years old from an online database created by the Centers for Disease Control and Prevention (CDC). This database lists causes of death gathered from death certificates as well as basic information like age, gender, and race of each person who died. The database also indicates which individuals have HIV infection.
The research team recorded the proportion of all deaths caused by cardiovascular disease in three groups (1) people with HIV infection, (2) the general population, and (3) people with inflammatory polyarthropathy (arthritis and related conditions that cause inflammation). The researchers included inflammatory polyarthropathy because HIV infection is also an inflammatory disease and they wanted to compare death rates in people with HIV-related inflammation and non-HIV inflammation.
The analysis included all deaths in the United States from 1999 through 2013 among people 25 years old or older at the time of death. Within the three groups listed in the preceding paragraph, the researchers analyzed death rates by gender (male or female) and by race or ethnicity (black, white, or Hispanic). They used standard statistical methods to determine trends in cardiovascular death rates in these groups from 1999 through 2013.
The study analyzed 140,661 HIV-positive people who died of any cause, including 4104 who died of cardiovascular disease. In the general population, 18.2 million died of any cause, including 6.1 million who died of cardiovascular disease.
Total deaths among people with HIV fell from 15,739 in 1999 to 8660 in 2013. But cardiovascular deaths rose from 307 in 1999 to 400 in 2013. Thus in people with HIV the proportion of all deaths caused by cardiovascular disease climbed from 1.95% in 1999 to 4.6% in 2013, more than a 2-fold increase (Figure 1). Cardiovascular disease accounted for a much higher proportion of all deaths in the general population across the study period. But the proportion of all deaths caused by cardiovascular disease in the general population fell from about 40% in 1999 to about 30% in 2013 (Figure 1). In the group with inflammatory polyarthropathy, the proportion of all deaths caused by cardiovascular disease also fell from about 40% in 1999 to about 30% in 2013.
Figure 1. From 1999 through 2013 in a nationwide U.S. study, the proportion of all deaths caused by cardiovascular disease rose from under 2% to above 4% among people with HIV. Over the same years, the proportion of all deaths caused by cardiovascular disease in the general U.S. population fell from about 40% to about 30%. (Credit: Teresa B. Southwell)
From 1999 through 2013, the cardiovascular death rate in people with HIV rose significantly in white men, black men, Hispanic men, and black women -- but not in white women or Hispanic women. In this context, a "significant" increase in proportion of deaths means the increase probably cannot be explained by chance.
Then the researchers looked only at ischemic heart disease, which is heart disease caused by narrowing heart arteries, including angina and myocardial infarction (heart attack). Among people with HIV infection, the proportion of all deaths caused by ischemic heart disease rose from 0.8% in 1999 to 2.5% in 2013, more than a 3-fold increase. In the general population, the proportion of all deaths caused by ischemic heart disease fell from 22.8% in 1999 to 14.6% in 2013.
This analysis of all deaths in the United States from 1999 through 2013 among people 25 or older found that the proportion of deaths caused by cardiovascular disease fell in the general population while rising in people with HIV infection. The 15-year drop in the proportion of cardiovascular deaths in the general population probably reflects a growing awareness of heart disease risk in the United States and lifestyle changes (like more exercise and less smoking) that prevent cardiovascular disease and death. However, cardiovascular disease remains the leading cause of death in the United States, followed by cancer and lung disease.2
In the general population, cardiovascular disease caused about 40% of all deaths in 1999 and about 30% in 2013. In contrast, cardiovascular disease caused a much lower proportion of all deaths among people with HIV, but that proportion rose from about 2% in 1999 to more than 4% in 2013. Cardiovascular disease probably causes a lower proportion of deaths in people with HIV than in the general population because people with HIV still face substantial threats from deadly diseases like AIDS illnesses, non-AIDS cancers, and non-AIDS infections.
But the growing proportion of deaths from cardiovascular disease in people with HIV provides a strong reminder that heart attacks, strokes, and other cardiovascular diseases pose a growing threat to HIV-positive individuals. People with HIV should be aware of heart disease risk factors, many of which can be avoided or changed (Table 1). The most important thing anyone can do to avoid heart disease is to avoid smoking or quit smoking.
|Table 1. Factors That Raise the Risk of Heart Disease|
|Changeable Conditions||Changeable Behaviors||Unchangeable Factors|
Source: Centers for Disease Control and Prevention. Heart disease. Heart disease risk factors.
|Physical Activity by HIV Group Tied to Heart Markers and Inflammation|
|3D Scans Show Thickening Arteries in HIV-Positive Group With Low Classic Heart Risk|
|Higher CD4/CD8 Ratio Tied to Lower Risk of Coronary Artery Disease|
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