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ART and Asymptomatic Ischemic Heart Disease in HIV-infected Adults: A Cross-sectional Analysis of Patients Enrolling in the SMART Trial
Andrew Carr*1, B Grund2, J Neuhaus2, W El-Sadr3, G Grandits2, C Gibert4, J Neaton2, R Prineas5, and on behalf of the SMART Study Investigators
1St Vincent's Hosp, Sydney, Australia; 2Univ of Minnesota, Minneapolis, US; 3Harlem Hosp, Columbia Univ, New York, NY, US; 4VAMC, Washington, DC, US; and 5EPICARE, Winston-Salem, NC, US
Background: Combination ART is associated with an increased risk of symptomatic
myocardial infarction; the effect of individual drug classes is unknown. Also,
it is not known whether ART or any ART class affects the risk of asymptomatic ischemic
heart disease.
Methods: We
evaluated baseline, resting, 12-lead electrocardiograms (ECG) for ischemic
heart disease (Q-waves or ST depression) from HIV+ adults enrolled
in SMART (all with CD4 counts >350 cells/µL) with no known ischemic heart
disease. ECG recording was standardized and were centrally analyzed, excluding
poor quality ECG. Analysis was by logistic regression, sequentially adjusted
for demographics (age, sex, race, location, likely mode of infection), clinical
history (prior AIDS, hepatitis C, alcohol abuse, current smoking, body mass
index, and antihypertensive therapy), ART type and duration, and lastly metabolic
risk factors (prior diabetes; cholesterol ≥240 mg/dL,
low HDL (high-density lipoprotein) cholesterol, triglycerides ≥200 mg/dL, and current lipid-lowering therapy).
Results: The
analysis includes the first 2874 participants (mean age 46 years) with
acceptable ECG and no symptoms of prior ischemic heart disease: 777 (27%) were female, 1005 (35%) black, 1182
(41%) smokers, 219 (8%) diabetic; and 559 (20%) were receiving antihypertensive
therapy and 450 (16%), lipid-lowering therapy. Only 150 (5%) participants were
ART-naïve. Mean ART duration was 6 years. ECG evidence of ischemic heart
disease was detected in 296 (10%) participants: Q-waves (n
= 178; 6%); ST depression (n = 130; 5%),
and increased from 7% in those <40 years to 15% in those >60 years. Prevalence
was similar in men and women. Two variables were independently associated with
ECG evidence of ischemic heart disease: age (OR 2.3, 95%CI 1.4 to 3.6 for patients
with age ³60 vs <40 years; p <0.005) and current antihypertensive therapy (OR 1.5, 95%CI
1.1 to 2.0; p = 0.01). Diabetes was
significant in the univariate, but not the multivariate, analysis (OR 1.5, CI
0.9 to 2.3, p = 0.09). No other
parameter, including total ART, non-nucleoside analogue, and protease inhibitor
durations, was statistically significant.
Conclusions: ECG evidence of asymptomatic ischemic heart disease is common in this
large, diverse cohort of HIV+ adults with CD4+ counts >350
cells/µL and mostly influenced by age and hypertension.
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