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Baseline, Time-Updated, and Cumulative HIV Care Metrics for Predicting Acute Myocardial Infarction and All-Cause
Jorge L Salinas1,2, Christopher Rentsch3,4,5, Vincent C Marconi1,2,3
1School of Medicine.
Insights
Individuals with HIV have a higher risk of heart attack. The VACS Index, reflecting current health, better predicts heart attack and death risk than past measures like CD4 count or HIV viral load.
Area of Science:
- Cardiology
- Infectious Diseases
- Public Health
Background:
- Individuals with human immunodeficiency virus (HIV) face elevated risks for acute myocardial infarction (AMI) compared to uninfected individuals.
- This increased risk persists even after accounting for traditional cardiovascular risk factors and despite higher mortality rates in the HIV+ population.
Purpose of the Study:
- To evaluate the predictive performance of various HIV-related metrics for incident acute myocardial infarction (AMI) and mortality.
- To compare the predictive accuracy of baseline, time-updated, and cumulative measures of HIV-1 RNA, CD4 counts, and the Veterans Aging Cohort Study (VACS) Index.
Main Methods:
- Analysis of 8168 HIV+ individuals from the Veterans Aging Cohort Study (VACS) initiating combination antiretroviral therapy (cART) between 1996 and 2012.
- Utilized multivariable proportional hazards models with baseline, time-updated, and cumulative measures (viremia copy-years, CD4-years, VACS Index score-years) of HIV disease markers.
- Incident AMI and death were primary outcomes, identified through ICD-9 codes and vital status records.
Main Results:
- Among 8168 HIV+ individuals, 196 incident AMIs and 1710 deaths were recorded.
- Six of nine assessed metrics predicted AMI, and all predicted mortality, after controlling for cardiovascular risk factors.
- A time-updated VACS Index score of 55+ demonstrated a significantly elevated hazard ratio for both AMI (3.31) and mortality (31.77).
Conclusions:
- The time-updated VACS Index demonstrated superior predictive capability for AMI and mortality compared to CD4 count and HIV-1 RNA.
- Current health status, as indicated by the VACS Index, appears to be a more accurate determinant of risk than historical disease markers.
- These findings suggest that incorporating biomarkers of organ injury into risk assessment models can improve prediction for HIV+ individuals.
Background:
After adjustment for cardiovascular risk factors and despite higher mortality, those with human immunodeficiency virus (HIV+) have a greater risk of acute myocardial infarction (AMI) than uninfected individuals.
Methods:
We included HIV+ individuals who started combination antiretroviral therapy (cART) in the Veterans Aging Cohort Study (VACS) from 1996 to 2012. We fit multivariable proportional hazards models for baseline, time-updated and cumulative measures of HIV-1 RNA, CD4 counts, and the VACS Index. We used the trapezoidal rule to build the following cumulative measures: viremia copy-years, CD4-years, and VACS Index score-years, captured 180 days after cART initiation until AMI, death, last clinic visit, or 30 September 2012. The primary outcomes were incident AMI (Medicaid, Medicare, and Veterans Affairs International Classification of Diseases-9 codes) and death.
Results:
A total of 8168 HIV+ individuals (53 861 person-years) were analyzed with 196 incident AMIs and 1710 deaths. Controlling for known cardiovascular risk factors, 6 of the 9 metrics predicted AMI and all metrics predicted mortality. Time-updated VACS Index had the lowest Akaike information criterion among all models for both outcomes. A time-updated VACS Index score of 55+ was associated with a hazard ratio (HR) of 3.31 (95% confidence interval [CI], 2.11-5.20) for AMI and a HR of 31.77 (95% CI, 26.17-38.57) for mortality.
Conclusions:
Time-updated VACS Index provided better AMI and mortality prediction than CD4 count and HIV-1 RNA, suggesting that current health determines risk more accurately than prior history and that risk assessment can be improved by biomarkers of organ injury.
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