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Original Investigation
April 22, 2013

HIV Infection and the Risk of Acute Myocardial Infarction

Author Affiliations

Author Affiliations: University of Pittsburgh School of Medicine (Drs Freiberg, Chang, Kraemer, and Butt) and Graduate School of Public Health (Drs Freiberg, Chang, Kuller, and Doebler and Mr Armah), Pittsburgh, Pennsylvania; Veterans Affairs (VA) Connecticut Health Care System, West Haven Veterans Administration Medical Center, West Haven (Mss Skanderson and McGinnis and Drs Sico and Justice), and Yale University School of Medicine, New Haven (Drs Sico and Justice), Connecticut; VA Puget Sound Health Care System (Dr Lowy) and the University of Washington School of Public Health (Dr Lowy) and School of Medicine (Drs Crothers and Crane), Seattle; David Geffen School of Medicine, UCLA (University of California, Los Angeles) (Drs Bidwell Goetz and Leaf), the VA Greater Los Angeles Health Care System (Drs Bidwell Goetz, Leaf, and Warner), and the Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute (Dr Budoff), Los Angeles; University of Maryland School of Medicine (Drs Oursler, Gottlieb, and Gottdiener) and the Baltimore VA Health Care System (Dr Oursler), Baltimore, and the National Institute on Alcohol Abuse and Alcoholism, Bethesda (Dr Bryant), Maryland; Emory University School of Medicine and Atlanta VA Medical Center, Atlanta, Georgia (Dr Rimland); Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, Texas (Dr Rodriguez Barradas); James J. Peters VA Medical Center, Bronx, and Mount Sinai School of Medicine, New York (Dr Brown), New York; George Washington University School of Medicine and the Washington, DC, VA Medical Center (Dr Gibert), Washington, DC; University of Vermont College of Medicine, Burlington (Dr Tracy); and University of South Carolina Arnold School of Public Health, Columbia (Ms Watson).

JAMA Intern Med. 2013;173(8):614-622. doi:10.1001/jamainternmed.2013.3728

Importance Whether people infected with human immunodeficiency virus (HIV) are at an increased risk of acute myocardial infarction (AMI) compared with uninfected people is not clear. Without demographically and behaviorally similar uninfected comparators and without uniformly measured clinical data on risk factors and fatal and nonfatal AMI events, any potential association between HIV status and AMI may be confounded.

Objective To investigate whether HIV is associated with an increased risk of AMI after adjustment for all standard Framingham risk factors among a large cohort of HIV-positive and demographically and behaviorally similar (ie, similar prevalence of smoking, alcohol, and cocaine use) uninfected veterans in care.

Design and Setting Participants in the Veterans Aging Cohort Study Virtual Cohort from April 1, 2003, through December 31, 2009.

Participants After eliminating those with baseline cardiovascular disease, we analyzed data on HIV status, age, sex, race/ethnicity, hypertension, diabetes mellitus, dyslipidemia, smoking, hepatitis C infection, body mass index, renal disease, anemia, substance use, CD4 cell count, HIV-1 RNA, antiretroviral therapy, and incidence of AMI.

Main Outcome Measure Acute myocardial infarction.

Results We analyzed data on 82 459 participants. During a median follow-up of 5.9 years, there were 871 AMI events. Across 3 decades of age, the mean (95% CI) AMI events per 1000 person-years was consistently and significantly higher for HIV-positive compared with uninfected veterans: for those aged 40 to 49 years, 2.0 (1.6-2.4) vs 1.5 (1.3-1.7); for those aged 50 to 59 years, 3.9 (3.3-4.5) vs 2.2 (1.9-2.5); and for those aged 60 to 69 years, 5.0 (3.8-6.7) vs 3.3 (2.6-4.2) (P < .05 for all). After adjusting for Framingham risk factors, comorbidities, and substance use, HIV-positive veterans had an increased risk of incident AMI compared with uninfected veterans (hazard ratio, 1.48; 95% CI, 1.27-1.72). An excess risk remained among those achieving an HIV-1 RNA level less than 500 copies/mL compared with uninfected veterans in time-updated analyses (hazard ratio, 1.39; 95% CI, 1.17-1.66).

Conclusions and Relevance Infection with HIV is associated with a 50% increased risk of AMI beyond that explained by recognized risk factors.