869    

Background:  Coronary heart disease (CHD) and myocardial infarction (MI) rates have been shown to be higher in HIV⁺ than in HIV^– patients. Some studies associate ART with increased risk of MI, but mechanisms of CHD risk in HIV patients remain to be understood. As new knowledge and therapies become available, CHD and MI risk management in HIV patients is evolving.

Methods:  We continue to monitor hospitalizations for new CHD (ICD9 410-414, including MI) among HIV⁺ male members of Kaiser Permanente Northern California and among HIV^– male members. Ongoing prospective follow-up of HIV⁺ men now extends through June 30, 2004. Age-adjusted CHD and MI rates for ages 35 to 64 were calculated overall for HIV⁺ and HIV^–men and by protease inhibitor (PI) exposure. HIV⁺ person-years of follow-up were assigned to pre- or no-PI exposure or PI exposure; patients could contribute person-years to both exposure categories. Use of ART associated with elevated lipids (notably stavudine and some PI), and use of “lipid friendly” ART (e.g., atazanavir, nevirapine), as well as use of lipid-lowering therapies was examined.

Results:  In the 8.5-year observation period, 5134 HIV⁺ patients contributed 23,792 person-years of follow-up (median 4.5), including 10,230 person-years of non-PI follow-up and 13,562 person-years of PI follow-up. There were 125 CHD events (76 MI); 282,000 person-years of HIV follow-up were examined. Age-adjusted CHD and MI rates among HIV⁺ continue to be twice that of HIV^– (CHD 6.3 vs 2.9 events per 1000 person-years, p < 0.0001; MI 3.8 vs 2.2, p < 0.003). Among HIV⁺ exposed to PI, median PI exposure was 4.2 years. Among HIV⁺, CHD and MI rates among PI-exposed patients were not statistically different from PI-unexposed patients (CHD 7.1 vs 5.2 events per 1000 person-years, p = 0.17; MI 4.4 vs 3.1, p = 0.19, respectively). The crude MI rate among PI-exposed patients in 1999 was 3.4 per 1000 PY (6 MI per 1770 person-years) and was 3.8 per 1000 person-years (7 MI per1847 person-years) in 2003. The percentage of ART-treated patients who were on a stavudine-containing regimen dropped from 48% in 2001 (third quarter) to 19% in 2004 (third quarter) (p < 0.0001); percentage of PI-treated patients on an ATV-containing regimen rose from 0% in 2003 (second quarter) to 24% in 2004 (third quarter) (p < 0.0001); percentage of PI-treated patients also taking lipid-lowering therapies rose from 1% in 1997 (fourth quarter) to 22% in 2004 (third quarter) (p < 0.0001).

Conclusions:  CHD and MI rates continue to be higher among HIV⁺ males than HIV^–; CHD/MI risk management is warranted. Despite advancing age and cumulating exposure to ART, crude PI MI rates have risen only modestly. Changes in practice could be slowing the progression/incidence of CHD/MI. Continued monitoring of CHD/MI among HIV⁺ patients is needed.

Keywords: HIV; CHD; Antiretroviral therapy