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Cardiovascular Complications of HIV

Cardiovascular Complications of HIV. Mark Boyd MD, FRACP The Kirby Institute for infection and immunity in society 7 th IAS Conference Kuala Lumpur, Malaysia 03 July 2013. Cardiovascular Complications of HIV. Conflicts of interest G rants Honoraria AbbVie AbbVie

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Cardiovascular Complications of HIV

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  1. Cardiovascular Complications of HIV Mark Boyd MD, FRACP The Kirby Institute for infection and immunity in society 7th IAS Conference Kuala Lumpur, Malaysia 03 July 2013

  2. Cardiovascular Complications of HIV Conflicts of interest GrantsHonoraria AbbVie AbbVie Gilead Sciences Boehringer-Ingelheim Merck Bristol Myers Squibb Janssen-Cilag Merck

  3. Cardiovascular Complications of HIV Outline • Epidemiology • Risk factors • host • virus-host • ART • Prevention • Key messages • Conclusions

  4. Cardiovascular Complications of HIV Outline • Epidemiology • Risk factors • host • virus-host • ART • Prevention • Key messages • Conclusions

  5. Myocardial Infarction rates in HIV+ versus HIV- Mean MI rate = 11 v 7 per 1000 person years RR=1.7 Triant J, et al. ClinEndocrinolMetab. 2007.

  6. Cardiovascular Complications Outline • Epidemiology • Risk factors • host • virus-host • ART • Prevention • Key messages • Conclusions

  7. Risk factors CVD HIV+ vs HIV- HIV-neg men HIV-pos men HIV-neg women HIV-pos. women Dyslipidaemia Smoking Insulin resistance Kaplan R, et al. CID 2007.

  8. Comorbidity distribution Schouten J et al. World AIDS Conference July 2012; updated May 2013 (personal communication, Reiss P) *

  9. Cardiovascular Complications Outline • Epidemiology • Risk factors • host • virus-host • ART • Prevention • Key messages • Conclusions

  10. ► Favours DC SMART - major CVD, hepatic or renal disease Relative risk (95% CI) No. of patients with events Endpoints 1.7 Major CVD, hepatic or renal disease 104 1.6 CVD, fatal or non-fatal 79 Hepatic disease, fatal or non-fatal 17 1.4 Renal disease, fatal or non-fatal 11 4.5 Favours VS ► El-Sadr W, et al. SMART. NEJM 2006

  11. Cardiovascular complications of HIV SMART: risk of death strongly associated with IL-6 & D-dimer biomarker levels at study entry Kuller L, et al. PLoS Med 2008

  12. Untreated HIV infection and CVD pathogenesis: a proposed model Baker J and Lundgren J. Eur Heart J 2011

  13. Cardiovascular Complications Outline • Epidemiology • Risk factors • host • virus-host • ART • Prevention • Key messages • Conclusions

  14. Cardiovascular complications of HIV • ART and myocardial infarction MI incidence according to duration of ART exposure Friis-Moller N, et al. D:A:D. NEJM 2003.

  15. Cardiovascular complications of HIV • MI risk disease by ARV exposure in D:A:D ART exposure and MI risk in D:A:D Worm S, et al. D:A:D. JID 2012.

  16. Untreated HIV infection and CVD pathogenesis: a proposed model Baker J and Lundgren J. Eur Heart J 2011

  17. Treated HIV infection and CVD pathogenesis: a proposed model Insulin resistance ART Baker J and Lundgren Eur Heart J. 2011

  18. Cardiovascular Complications Outline • Epidemiology • Risk factors • host • virus-host • ART • Prevention • Key messages • Conclusions

  19. Stop Smoking Myocardial Infarction 5 - 1 - Baseline status Stopped smoking during follow-up Never smoked Previous Current < 1 yr 1-2 yrs 2-3 yrs 3+ yrs 0.5 - • Adjusted for: age, sex, cohort, calendar year, antiretroviral treatment, family history of CVD, diabetes, and time-updated lipids and blood pressure assessments D:A:D study group. HIV Med 2011.

  20. Cardiovascular disease in HIV Prevention: monitor and modify risks CVD hazard in D:A:D* Reduce sysBP 10 mmHg Reduce TC 1 mmol/L Stop smoking *relative to 40 y.o. HIV+ male Petoumenos K for D:A:D . 20th CROI 2013.

  21. Control dyslipidaemia: use TDF Gallant J, et al. GS 934 study. JAMA 2004;292:191-201.

  22. CVD complications of HIV Prevention: adopt a healthy lifestyle Score 0 Score 2 Score 3 & 4 Probability of CHD according to health score Ahmed H et al. MESA. Am J Epi 2013.

  23. CVD complications of HIV Prevention: adopt a healthy lifestyle Score 3 & 4 Score 2 Score 1 Score 0 Probability of death according to health score Ahmed A, et al. MESA. Am J Epi 2013.

  24. Cardiovascular Complications Outline • Epidemiology • Risk factors • host • virus-host • ART • Prevention • Key messages • Conclusions

  25. CVD complications of HIV: key messages ART saves lives Walker S, et al. DART. Lancet 2009.

  26. CVD complications of HIV: key messages The risk of death from AMI ismuch less than the risk of dying from untreated HIV-infection Law M et al. HIV Med 2003.

  27. CVD complications of HIV: key messages Monitor and treat modifiable risk factors • Stop smoking • Monitor& treat hypertension • Monitor & treat dyslipidaemia and diabetes • Encourage healthy weight, diet and exercise • Monitor and treat HIV-infection • according to guidelines • there is no evidence to support use of specific ART regimens for PLHIV with high-risk for CVD

  28. Cardiovascular Complications Outline • Epidemiology • Risk factors • host • virus-host • ART • Prevention • Key messages • Conclusions

  29. Cardiovascular Complications of HIV Conclusions • Cardiovascular disease pathogenesis in HIV is complex • While HIV factors may add to complexity, conventional risk factors are prominent • Risks can be monitored and modified • Primary prevention is key in low-, middle- and high-income settings

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