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Coronary Events in HIV-Infected Patients

HIV infection is considered yet another cardiovascular risk factor (CVRF), particularly associated with immunosuppression. In addition, HIV-infected patients have a higher prevalence of CVRF than in the general population. The clinical importance of all this is the result of increase in the incidence of cardiovascular events in these patients. However, few data are available in Spain relating to coronary events (CEs) in patients with HIV infection. The aim, therefore, of this study was to estimate the incidence of CEs in HIV-infected patients on outpatient followup and to determine the associated characteristics. We undertook a cross-sectional, multicenter study involving outpatients seen between March 2007 and August 2007 at 5 hospitals. All the patients completed a questionnaire about CVRF and were asked about any prior cardiovascular event. Information was checked from the clinical histories of the patients. Coronary events included any acute coronary syndrome, acute myocardial infarction, placement of a coronary stent, or coronary surgery. The statistical analysis was done with SPSS 17.0 (SPSS, Chicago, Illinois). Continuous variables are expressed as medians (interquartile range [IQR]) and the categorical variables as numbers (percentages). A multivariate analysis was done to seek factors potentially associated with CEs. The study was designed and carried out in accordance with the principles of the Declaration of Helsinki and approved by the Research Ethics Committee of the Hospital Virgen de la Victoria, Málaga. The study included 1155 patients, with a mean follow-up of 11 422 patient-years. Of the 40 cardiovascular events recorded, 29 were CEs, representing an incidence of 2.53 events per 1000 patient-years. Table 1 shows the patients with and without CEs. The CEs were associated with older age (odds ratio [OR] 1.8; 95% confidence interval [CI], 1.78-1.96; P < .009), hypertension (OR 4.9; 95% CI, 1.7-4.9; P < .005), and a family history of ischemic heart disease (OR 4.7; 95% CI, 1.7-13; P < .006). The estimated incidence of CEs in our study was higher than the estimates reported for the general population in the meta-analysis of Medrano, which found an incidence of CEs of 1.3 to 2.1 per 1000 patient-years for men aged 25 to 74 and 0.29 to 0.61 for women of the same age. However, it is lower than that found in such cohort studies as Manresa (5 events per 1000 person-years) or ZACARIS-I (Zaragoza Cardiovascular Risk factors Study-I; 6.4 and 4.0 events per 1000 person-years in men and women, respectively), though it should be noted that both cohorts were labeled high risk. The reported incidence of CEs in HIV-infected patients ranges from 3.5 to 11.1 per 1000 patient-years. These variations are due to the different methods used in the various studies and the different types and end points considered. All these studies include mostly AngloSaxon patients, who usually have a greater incidence of CEs than Spanish people, as well as having a slightly older mean age. Our study, despite the limitations associated with a cross-sectional design (no inclusion of patients who are lost or dead), approximates to the true situation in our area regarding the incidence of cardiovascular events and the type of patient affected in this population. Thus, the patients with CEs in our series were older and had a greater prevalence of certain traditional CVRF, such as hypertension or a family history of ischemic heart disease. No differences were seen in other traditional CVRF like smoking, which is probably due to the very high prevalence of smokers among the whole cohort, and dyslipidemia, which is also quite frequent in our patients. Though the incidence of CEs in our study was slightly higher than that in the general Spanish population, the fact that it was a young cohort with a high prevalence of CVRF, some much more common than in the general population, suggests that in the coming years cardiovascular events, and particularly CEs, will become frequent in HIV-infected patients. Just as in the general population, prevention strategies should be designed and action should be taken on modifiable factors in order to stem, as far as possible, the foreseeable growth in cardiovascular diseases in HIV-infected patients.