HIV Infection Itself May Not Be Associated with Subclinical Coronary Artery Disease among African Americans without Cardiovascular Symptoms

BACKGROUND:

The key objectives of this study were to examine whether HIV infection itself is associated with subclinical coronary atherosclerosis and the potential contributions of cocaine use and antiretroviral therapies (ARTs) to subclinical coronary artery disease (CAD) in HIV-infected persons.

METHODS AND RESULTS:

Between June 2004 and February 2015, 1429 African American (AA) adults with/without HIV infection in Baltimore, Maryland, were enrolled in an observational study of the effects of HIV infection, exposure to ART, and cocaine use on subclinical CAD. The prevalence of subclinical coronary atherosclerosis was 30.0% in HIV-uninfected and 33.7% in HIV-infected (P=0.17). Stratified analyses revealed that compared to HIV-uninfected, HIV-infected ART naïve were at significantly lower risk for subclinical coronary atherosclerosis, whereas HIV-infected long-term ART users (≥36 months) were at significantly higher risk. Thus, an overall nonsignificant association between subclinical coronary atherosclerosis and HIV was found. Furthermore, compared to those who were ART naïve, long-term ART users (≥36 months) were at significantly higher risk for subclinical coronary atherosclerosis in chronic cocaine users, but not in those who never used cocaine. Cocaine use was independently associated with subclinical coronary atherosclerosis.

CONCLUSIONS:

Overall, HIV infection, per se, was not associated with subclinical coronary atherosclerosis in this population. Cocaine use was prevalent in both HIV-infected and -uninfected individuals and itself was associated with subclinical disease. In addition, cocaine significantly elevated the risk for ART-associated subclinical coronary atherosclerosis. Treating cocaine addiction must be a high priority for managing HIV disease and preventing HIV/ART-associated subclinical and clinical CAD in individuals with HIV infection.

Below:  Prevalences of subclinical CAD by HIV serostatus

Below:  Unadjusted prevalence estimates of subclinical CAD by the 2013 ACC/AHA cardiovascular risk profile quintile

Below:  Associations between HIV infection and presence of coronary stenosis by duration of ART use

Full article at:   http://goo.gl/iwwLdK

By:  Lai H1, Moore R2, Celentano DD3, Gerstenblith G2, Treisman G4, Keruly JC2, Kickler T5, Li J5, Chen S5, Lai S6, Fishman EK1.

• 1Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD.
• 2Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD.
• 3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
• 4Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD.
• 5Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD.
• 6Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD slai@jhmi.edu. 
• J Am Heart Assoc. 2016 Mar 24;5(3). pii: e002529. doi: 10.1161/JAHA.115.002529.

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Custody and Prison Deaths Autopsied in Istanbul between 2010 and 2012

The occurred death of a convict in prison, police custody cell or in a hospital always attracts public attention and can be considered as a complex phenomenon. 

The aim of this study is to evaluate the data obtained from autopsies performed to the custody and prison deaths in Istanbul and to discuss the possible solutions by comparing with the literature. It is also aimed to discuss the postponement of the sentence and presidential amnesty facts in Turkey. 

Deaths of inmates, which occurred in hospitals, prisons, prison medical rooms, police vans and police custody cells between 2010 and 2012 in Istanbul, Turkey were included in the study. Totally 125 cases were found and 98.4% of them were male. Natural deaths accounted for a great majority of deaths (83.2%). The most common natural cause was cardiovascular diseases. Unnatural deaths accounted for 15.2% of the deaths. Death reason cannot be determined for 1.6% of the cases. More than half of the cases (56%) were died at the hospital, 34.4% were died at the prison, 4% of them at the police van, 3.2% were died under police custody and 2.4% were died at the prison medical room. Moreover, twelve of these cases had applied to Third Specialization Board previously for postponement of the sentence or Presidential amnesty. Totally five of these cases found suitable for postponement of the sentence. 

Prison conditions should be improved, prisoners with chronic diseases should be examined periodically and if appropriate their sentences should be postponed until they heal.

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By:  Ünal V1, Özgün Ünal E2, Çetinkaya Z3, İmalı M4, Gürler S5, Koç S6.

• 1The Council of Forensic Medicine, Bahcelievler, Istanbul 34196, Turkey. Electronic address: volkanunal75@yahoo.com.
• 2The Council of Forensic Medicine, Bahcelievler, Istanbul 34196, Turkey. Electronic address: unalesra@yahoo.com.
• 3The Council of Forensic Medicine, Bahcelievler, Istanbul 34196, Turkey. Electronic address: drzafer03@hotmail.com.
• 4The Council of Forensic Medicine, Bahcelievler, Istanbul 34196, Turkey. Electronic address: muratimali@msn.com.
• 5The Council of Forensic Medicine, Bahcelievler, Istanbul 34196, Turkey. Electronic address: selcukgurler@gmail.com.
• 6Department of Forensic Medicine, Istanbul University, Cerrahpaşa Medical Faculty, Istanbul, Turkey. Electronic address: sermetkoc@istanbul.edu.tr.
• J Forensic Leg Med. 2016 Jan 12;39:16-21. doi: 10.1016/j.jflm.2016.01.009. 

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High Prevalence of Metabolic Syndrome and Cardiovascular Disease Risk among People with HIV on Stable ART in Southwestern Uganda

The objectives of this study were to determine the epidemiology and correlates of cardiovascular disease (CVD) risk among Ugandans on first-line antiretroviral therapy (ART). 

We conducted a cross-sectional study at an HIV clinic in southwestern Uganda. We enrolled adult patients on non-nucleoside-based ART regimens for a minimum of 2 years. We collected anthropometric and clinical measurements, smoking history, and blood for fasting lipid profile and blood sugar (FBS). 

Outcomes of interest were

1. presence of metabolic syndrome (at least two of: FBS >100 mg/dL, blood pressure of ≥130/85 mmHg, triglycerides ≥150 mg/dL, HDL <40 mg/DL, or waist circumference ≥94 cm in males or ≥80 cm in females); and 
2. a Framingham score correlating to >5% 10-year CVD risk. 

Of the 250 participants enrolled, metabolic syndrome was detected in 145/250 (58%) of participants (62% in females and 50% in males). Forty-three participants (17%) had a Framingham risk correlating to a 5% or greater risk for CVD within 10 years (26% in males and 13% in females). In multivariate analyses, being female (AOR 3.13; 95% CI: 1.0-9.70; p = 0.04) and over 40 years of age (AOR 1.78; 95% CI: 1.00-3.17; p = 0.05) was independently associated with having metabolic syndrome. 

We found no independent risk factors for a Framingham risk score 10-year risk exceeding 5%, or associations between ART regimen and CVD risk profiles. We conclude that metabolic abnormalities are common among patients on first-line ART in rural Uganda, and appear to be more common in women than men.

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By:   Muyanja D1, Muzoora C1, Muyingo A1, Muyindike W2, Siedner MJ3,4.

• 1 Department of Internal Medicine, Mbarara University of Science and Technology , Mbarara, Uganda .
• 2 Department of Internal Medicine, Mbarara Regional Referral Hospital , Mbarara, Uganda .
• 3 Department of Infectious Disease and Center for Global Health, Massachusetts General Hospital , Boston, Massachusetts.
• 4 Harvard Medical School , Boston, Massachusetts.

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Assessment of Cardiovascular Risk Factors in People with HIV Infection Treated with ART in Rural South Africa

Background

The risk of cardiovascular diseases (CVD) in human immunodeficiency virus (HIV) infected people on antiretroviral therapy (ART) from some rural parts of Africa is not well known. We assessed CVD risk factors, the estimated 5-year Data collection on adverse effects of anti-HIV drugs (DA.) risk score and the 10-year Framingham risk score in persons with HIV infection on ART in a rural area in South Africa.

Methods

A cross-sectional study in which the data on demographic, lifestyle, and chronic disease were collected using the World Health Organization Stepwise approach to surveillance questionnaire. Biochemical parameters were tested using standard biochemical methods. CD4 counts were performed using PIMA analyser and viral load was tested using the branched deoxyribonucleic acid technique. Student t test and Chi square test were used on continuous and categorical variables respectively. Bivariate and multivariate logistic regression were used to analyze predictors of CVD risk factors. Estimates of 5 and 10-year CVD risk were calculated using online tools. The Cohen’s kappa coefficient was used to assess the agreement between CVD risk equations.

Results

The mean age of participants was 44.8 ± 11.8 years; 79.9 % were females. Most of the participants (85 %) had an undetectable viral load and a mean CD4 count of 462 ± 235 cell/mm³. The most common CVD risk factors were low high density lipoprotein cholesterol (HDL-C) (43.8 %), hypercholesterolaemia (33.2 %) and a high Apolipoprotein (Apo) B/ApoA ratio (45.4 %).Using the Framingham equation, 6.7 % of participants had a moderate to high 10-year CVD risk while the DAD risk equation showed that 31.1 % of participants had a moderate to high 5-year CVD risk. Most participants had a low CVD risk by both risk equations. The level of agreement between the two risk equations was 73.8 % (k = 0.23; 95 % CI 0.10–0.35; p value 0.001).

Conclusion

CVD risk factors were common among this rural population on ART. The high proportion of participants with a moderate to high CVD risk, observed with the DAD risk equation, clearly represents a considerable health burden that can possibly be reduced by increasing educational programs on CVD prevention for people on ART. There is however a need to develop and evaluate a race/ethnicity-specific CVD risk estimation tool for HIV infected Africans.

Full article at:   http://goo.gl/s1jSoK

By:   Felistas Mashinya, Marianne Alberts, Jean-Pierre Van geertruyden and Robert Colebunders

• Department of Medical Science, Public Health and Health Promotion, School of Health Care Sciences, Faculty of Health Sciences, University of Limpopo
• Department of Medical Science, Public Health and Health Promotion, School of Health Care Sciences, Faculty of Health Sciences, University of Limpopo
• International Health Unit, Department of Epidemiology and Social Medicine, Faculty of Medicine, Antwerp University
• International Health Unit, Department of Epidemiology and Social Medicine, Faculty of Medicine, Antwerp University

  

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Use of Abacavir & Risk of Cardiovascular Disease among HIV-Infected Individuals

Evidence is conflicting about the association of abacavir use and cardiovascular disease (CVD) among HIV-infected individuals. Prior studies may have been biased by the preferential initiation or continuation of abacavir in patients with renal dysfunction.

We conducted a cohort study in Kaiser Permanente California during 1998-2011, following HIV-infected adults initiating antiretroviral therapy (ART) until the earliest of CVD (i.e., coronary heart disease or ischemic stroke), health plan disenrollment, death, or end of study. We used inverse probability weighting to fit marginal structural models to estimate hazard ratios (HRs) for CVD comparing regimens with and without abacavir. Propensity score models included demographics, HIV-specific factors, and CVD risk factors, including alcohol/drug use, smoking, overweight/obesity, diabetes, lipid-lowering and hypertension therapy, and renal dysfunction (i.e., estimated glomerular filtration rate <60 mL/min/1.73 m2).

Among 8154 subjects, 178 had ≥1 CVD event, with 24/704 (3.4%) in the abacavir group and 154/7450 (2.1%) in the group initiating regimens without abacavir. Abacavir users had more renal dysfunction at ART initiation (7.0% vs. 3.3%, P<0.001). Compared with patients initiating regimens without abacavir, abacavir users had a 2.2-fold higher risk of CVD in intention-to-treat analysis, a 2.7-fold higher risk when remaining on their initial regimens for ≥1 year, and a 2.1-fold higher risk in per-protocol analysis.

Abacavir was associated with an over two-fold increased risk of CVD, which was not explained by renal dysfunction or other CVD risk factors.

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By: Marcus JL1, Neugebauer RS, Leyden WA, Chao CR, Xu L, Quesenberry CP Jr, Klein DB, Towner WJ, Horberg MA, Silverberg MJ.

• 1Kaiser Permanente Northern California, Oakland, CA 2Kaiser Permanente Southern California, Pasadena, CA 3Kaiser Permanente Northern California, Hayward, CA 4Kaiser Permanente Southern California, Los Angeles, CA 5Kaiser Permanente Mid-Atlantic States, Rockville, MD.

 

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High Blood Pressure & Related Factors among Individuals at High Risk for HIV/Sexually Transmitted Infections

Data from a social network-based human immunodeficiency virus (HIV)/sexually transmitted infection (STI) prevention study with a total of 330 men and women at high risk for HIV/STIs were used to examine the relationships between substance use, depressive symptoms, general health, cardiovascular disease risk factors, sociodemographic characteristics, and systolic/diastolic blood pressure (SBP/DBP). 

Approximately 60% of the participants had prehypertension to stage 2 hypertension. In the base model, older patients (P<.0001), men (P=.003), and patients with poorer self-reported health (P=.029) were significantly associated with high SBP, whereas older age (P<.001) and higher body mass index (P<.001) were significantly associated with higher DBP. 

After adjusting for the base model, high frequency of alcohol drinking and high frequency of binge drinking remained significant for high SBP and DBP. 

These data suggest that future cardiovascular disease programs should target moderate alcohol consumption to improve blood pressure among individuals at high risk for HIV/STIs.

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By: Nam S1, Whittemore R1, Jeon S2, Davey-Rothwell MA3, Latkin C3,4.

• 1Division of Primary Care, Yale School of Nursing, Orange, CT.
• 2Division of Acute Care/Health Systems, Yale School of Nursing, Orange, CT.
• 3Department of Health, Behavior and Society, Johns Hopkins School of Public Health, Baltimore, MD.
• 4Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.  

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Cardiovascular Health Knowledge & Preventive Practices in People Living with HIV in Kenya

Traditional cardiovascular disease (CVD) risk factors contribute to increase risk of CVD in people living with HIV (PLWH). Of all world regions, sub-Saharan Africa has the highest prevalence of HIV yet little is known about PLWH’s CVD knowledge and self- perceived risk for coronary heart disease (CHD). In this study, we assessed PLWH’s knowledge, perception and attitude towards cardiovascular diseases and their prevention.

We conducted a cross-sectional study in the largest HIV care program in western Kenya. Trained research assistants used validated questionnaires to assess CVD risk patterns. We used logistic regression analysis to identify associations between knowledge with demographic variables, HIV disease characteristics, and individuals CVD risk patterns.

There were 300 participants in the study; median age (IQR) was 40 (33–46) years and 64 % women. The prevalence of dyslipidemia, overweight and obesity were 70 %, 33 % and 8 %, respectively. Participant’s knowledge of risk factors was low with a mean (SD) score of 1.3 (1.3) out of possible 10. Most (77.7 %) could not identify any warning signs for heart attack. Higher education was a strong predictor of CVD risk knowledge (6.72, 95 % CI 1.98-22.84, P < 0.0001). Self-risk perception towards CHD was low (31 %) and majority had inappropriate attitude towards CVD risk reduction.

Despite a high burden of cardiovascular risk factors, PLWH in Kenya lack CVD knowledge and do not perceived themselves at risk for CHD. These results emphasis the need for behavior changes interventions to address the stigma and promote positive health behaviors among the high risk HIV population in Kenya.

Below:  Prevalence of selected CVD risk factors in the study population. All (n = 300) participants were included. Current smokers are those who have responded “yes” to smoking. Alcohol use was defined by intake of at least one drink within the previous month. Central obesity was defined as waist circumference of ≥80 cm (women) and ≥90 cm (men). BMI (kg/m 2 ) definition are; overweight 25.0-29.9 and obesity ≥ 30.0. *P <0.05, **P < 0.001

Below:  CVD risk factors as identified by participants

Below:  Heart attack warning signs as identified by participants

Full article at: http://goo.gl/o176p3

By: Tecla M. Temu^12*, Nicholas Kirui¹⁴, Celestine Wanjalla⁵, Alfred M. Ndungu⁶, Jemima H. Kamano¹³⁴, Thomas S. Inui¹³⁴⁷ and Gerald S. Bloomfield⁸

¹Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya

²Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA

³AMPATH Partnership, Eldoret, Kenya

⁴Division of Medicine, Moi Teaching and Referral Hospital, Eldoret, Kenya

⁵Department of Medicine, Vanderbilt University, Nashville, TN, USA

⁶Department of Statistics, North Dakota State University, Fargo, ND, USA

⁷Department of Medicine, Indiana University, Indianapolis, USA

⁸Department of Medicine, Duke Clinical Research Institute and Duke Global Health Institute, Duke University, Durham, NC, USA

   

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Missed Opportunities to Address Cardiovascular Disease Risk Factors amongst Adults Attending an Urban HIV Clinic in South Africa

We assessed cardiovascular disease (CVD) risk factor prevalence and risk stratification amongst adults on antiretroviral therapy in South Africa. Of the 175 patients screened, 37.8% had high blood pressure (HBP), 15.4% were current smokers, 10.4% had elevated cholesterol, and 4.1% had diabetes, but very few (3.6%) had a 10-year CVD risk >10%. One-third of those with HBP, 40% of those with diabetes, and two-thirds of those with high cholesterol had not previously been diagnosed. Although participants were adherent with chronic HIV care, screening for and management of CVDRF were suboptimal, representing a missed opportunity to reduce non-AIDS morbidity and mortality.

Below:  Results for the 110 participants eligible for stratification, superimposed on the WHO/ISH risk stratification charts for the AFR-E region

Full article at: http://goo.gl/1ZLSyR

By: 

Miriam Rabkin, Wafaa M. El-Sadr

ICAP at Columbia, Columbia University Mailman School of Public Health, New York, New York, United States of America

Miriam Rabkin, Wafaa M. El-Sadr

Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, United States of America

Miriam Rabkin, Wafaa M. El-Sadr

Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, United States of America

Anthony Mutiti

ICAP in South Africa, Pretoria, South Africa

Christine Chung

ICAP in Malawi, Lilongwe, Malawi

Yuan Zhang, Ying Wei

Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York, United States of America

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