People with HIV have an increasing risk of heart attacks as they age, and this risk increases if they also have the hepatitis C virus (HCV), according to new research published in the Journal of the American Heart Association. The good news is that managing traditional cardiovascular risk factors, keeping HIV under control, and getting treatment for hepatitis C can reduce the risk.
Because people with HIV live longer thanks to effective treatment, they are more likely to develop age-related conditions such as cardiovascular disease (CVD). A large body of research has shown that HIV-positive people are at greater risk for a variety of cardiovascular problems, including atherosclerosis (build-up of cholesterol and other material in the arteries), coronary artery disease (blockage of the arteries supplying the heart muscle) . ), heart failure and heart attacks (myocardial infarction).
HIV and hepatitis C virus share some common transmission routes, and many people live with both viruses (known as co-infection). Hepatitis C can now be easily cured with direct-acting antivirals, but a significant proportion of people with HCV do not know their status and have not been treated.
Hepatitis C is also associated with cardiovascular problems, but the combined impact of HIV and HCV is not well understood. Keri Althoff, PhD, MPH, of the Johns Hopkins Bloomberg School of Public Health, and colleagues wanted to determine whether HIV/HCV co-infection increases the risk of type 1 myocardial infarction — the type of heart attack caused by coronary artery disease — and whether the risk differs by age.
“In part because of the inflammation from the chronic immune activation of two viral infections, we hypothesized that people with HIV and hepatitis C would have a higher risk of heart attack as they age compared to people with HIV alone,” Althoff said in a US News report. of the Heart Foundation.
The researchers analyzed data from 2000 to 2017 from 23,361 HIV-positive North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) participants who had started antiretroviral treatment for HIV. More than 80% were male, about half were white, and they were between 40 and 79 years old (median 45) when they participated in NA-ACCORD. One in five study participants (4,677) also had hepatitis C. Data from participants with HIV/HCV co-infection were not included after they started hepatitis C treatment.
Over a median follow-up period of approximately four years, the researchers compared the incidence of heart attacks in the HIV-only and HIV/HCV co-infection groups, both overall and at each decade of age.
During follow-up, there were 314 type 1 myocardial infarctions in people with HIV alone and 89 in people with HIV/HCV co-infection, representing 1.7% versus 1.9%, respectively.
Overall, having hepatitis C was not significantly associated with a higher risk of heart attack. While the risk of type 1 myocardial infarction in people with HIV alone increased by 30% per decade, it increased by 85% for people with both HIV and HCV.
Looking beyond HCV status, the researchers confirmed that traditional cardiovascular risk factors, including smoking, high blood pressure and type 2 diabetes, were associated with a greater chance of having a heart attack. In addition, HIV-related factors, including low CD4 counts, a history of AIDS-defining diseases, and use of protease inhibitors, have also been linked to a higher risk of heart attack.
“[T]he risks [type 1 myocardial infarction] with increasing age was greater in those with HCV compared to those without, and HCV status should be considered when assessing CVD risk in older people with HIV,” the researchers concluded. “A better understanding of the complex interplay of factors influencing cardiovascular risk as people living with HIV age, their long-term care and well-being will improve.”
“Several mechanisms may be involved in the increased risk of heart attack in co-infected patients,” said lead study author Raynell Lang, MD, MSc, of the University of Calgary in Canada. “A contributing factor may be the inflammation associated with having two chronic viral infections. Also, there may be differences in cardiovascular disease risk factors and non-medical factors affecting health in people with HIV and hepatitis C who have a play a role in the increased risk.”
More than half of people living with HIV in the United States are now 50 years of age or older. As people with HIV age, reducing the risk of CVD is “a primary therapeutic goal,” the researchers wrote. People with both HIV and HCV are at greater risk for cardiovascular problems, “emphasizing the importance of maintaining antiretroviral therapy, promoting CVD risk-lowering strategies, and initiating treatment of their HCV to reduce the chronic inflammation of which believed to contribute to this risk.”
Effective and well-tolerated HCV treatment was unavailable for several years of the study period, so the researchers were unable to evaluate the effect of treated hepatitis C on cardiovascular risk in people with HIV. Several studies have shown that HCV clearance is associated with reduced CVD events, but there is little data on people with HIV/HCV co-infection. “This will be an important question to answer in future studies,” Lang said.
In addition to treating HIV and hepatitis C, people aging with HIV can take other steps to reduce their risk of heart disease, including quitting smoking, eating a balanced diet, exercising, maintaining a healthy weight, and, if appropriate, taking of drugs such as statins (currently being studied in the REPRIEVE study). Regular checkups, including blood pressure, blood sugar and cholesterol levels, can provide early warning signs of heart problems when they are easier to treat.
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