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Patterns of Cardiovascular Mortality for HIV-Infected Adults in the United States: 1999 to 2013
Published by Anton POZNAK

Updated: 15 June, 2016

Feinstein MJ et al. Am J Cardiol. 2016 Jan 15;117(2):214-20.

With widespread availability and the use of ART, patients with HIV in the United States are living long enough to experience non-AIDS-defining illnesses. HIV is associated with an increased risk for cardiovascular disease (CVD) because of traditional CVD risk factors, residual virally mediated inflammation despite HIV treatment, and side effects of ART. No United States population-wide studies have evaluated patterns of CVD mortality for HIV-infected subjects.

The central hypothesis of this study was that the proportionate mortality from CVD (CVD mortality/ total mortality) in the HIV-infected population increased from 1999 to 2013. Authors used the CDC Wide-Ranging Online Data for Epidemiologic Research (WONDER) online database of the United States public health data to assess proportionate CVD mortality from 1999 to 2013 in the HIV-infected, general, and inflammatory polyarthropathy populations; the inflammatory polyarthropathy population was included as a positive control group. WONDER provides data on death certificates of US residents, which include underlying causes of death, up to 20 additional multiple causes, and demographic and geographic data. Death certificates of all in-hospital and out-of-hospital deaths of US residents are captured. The primary outcome for the study was change in proportionate CVD mortality from 1999 to 2013. Only adults aged 25 years and older at the time of death were included for analysis. Assessment was as follows : selection of “diseases of the circulatory system” (ICD-10 codes I00 to I99) as the underlying cause of death, then selection of all causes of death (all ICD-10 codes) as the underlying cause of death, and subsequently division of the number of CVD deaths by all causes of death to determine proportionate mortality, stratified by gender according to race and/or ethnic groups. Secondary analysis was done by subtypes of CVD deaths, including stroke, MI, arrhythmias, and heart failure. Linear regression models were used to assess within-group trends in proportionate CVD mortality from 1999 to 2013; slope ( ß ) was used to assess trends over time (change in proportionate mortality per year), with a p value <0.05 indicating statistical significance.

Total mortality in the HIV-infected population decreased from 15,739 in 1999 to 8,660 in 2013; however, CVD mortality increased from 307 to 400 during the same period. Compared with the general population, HIV-infected subjects dying from CVD were more likely to be men, black, younger, urban-dwelling, and to have died in a medical facility. Among HIV-infected persons dying from any cause, those dying from CVD tended to be older.
Proportionate CVD mortality for the HIV-infected population increased significantly from 1999 (1.95%) to 2013 (4.62%) (p <0.0001); this pattern was consistent across races, particularly for men (p <0.0001), less for women (p = 0.0028).
In contrast, proportionate CVD mortality decreased for the general and inflammatory polyarthropathy populations from 1999 to 2013, from 40% to 30% approximatively.
In a sensitivity analysis, proportionate mortality due to ischemic heart disease (mortality due to ischemic heart disease/overall mortality) increased threefold in the HIV-infected population, from 0.8% in 1999 to 2.5% in 2013 but decreased in the general population, from 22.8% in 1999 to 14.6% in 2013.

In conclusion, CVD has become an increasingly common cause of death in HIV-infected subjects since 1999, proportionate CVD mortality increasing more than twofold between 1999 and 2013; understanding evolving mortality risks in the HIV-infected population is essential to inform routine clinical care of HIV-infected subjects as well as CVD prevention and treatment.