With Lives Often Extended by HAART, Cardiovascular Disease Has Become a Concern

by Chael Needle

LifeGuide

[Treatment Horizons]

At the Ninth European AIDS Conference last October, results from a managed care database study showed that cardiovascular disease is a leading cause among HIV/AIDS patients for hospital admissions. The study?s lead author, Dr. Carl Fichtenbaum, Associate Professor of Clinical Medicine and Director of Infectious Diseases Center at the University of Cincinnati, qualifies this: ?It?s [only] one hospital cohort and it?s a group of people who had insurance, and were taking [antiretroviral] medications.?

Eighty-one percent of the study?s participants were male; median age was forty-five years. Seventy-one percent had exposure to protease inhibitors. He continues: ?If you were to look at a cohort of people without insurance in this country, and who were not regularly taking medications, this would not apply to them. This is the circumstance of people who had access to medications. Infection was still the leading cause of why they were in the hospital, but of the non-infectious causes, heart attacks, or heart disease itself, was the leading cause.?

Cardiovascular disease outpaced conditions related to renal disease, hepatotoxicity, and opportunistic infections. Funded by Boehringer Ingelheim, the study is part of a general interest in cardiovascular complications and other problems.

According to Dr. Fichtenbaum, cardiovascular disease most often refers to heart attacks?blockages of arteries and blood vessels that feed the heart that can result in a heart attack, heart failure, or a rhythm disturbance in the heart that can cause people to suddenly become unconscious and die. He adds that we shouldn?t forget that the same types of build-ups can occur in the blood vessels in the brain, and which can lead to strokes.

One explanation for the prevalence of heart disease among this population is that, says Dr. Fichtenbaum, it is ?merely a marker: People who take antiretroviral therapy might have been already destined to have heart disease, and the fact is that they?re living long enough to reach their destiny.?

What about antiretroviral therapy as the culprit? Dr. Fichtenbaum thinks this explanation needs further research, though he did cite a recent European study published in The New England Journal of Medicine where longer exposure to HAART in general was shown to be associated with a higher risk of having a heart attack. The leading theory, he says, is that ?these medications can potentially cause cholesterol and triglyceride problems, so people are more likely to develop atherosclerotic plaques, or fat build-up inside their arteries.? Others have proposed that these medications can cause damage to the walls of blood vessels, which makes it more likely for plaques to develop, or that there may be some interplay with HIV, ?which  itself causes some inflammation throughout the body, and some of the changes may make people more susceptible to these kinds of problems.? Though there are some animal-model studies which draw a connection between medications and an increased risk of heart disease, and at least one human study implicates protease inhibitors, Dr. Fichtenbaum thinks it is much too early to determine which medications, if any, are implicated in an increased risk for heart disease.

How then might patients incorporate this information about cardiovascular disease into their treatment plans? ?Every decision should always be individualized to the patient. You can?t take the results of any study and directly apply them to somebody willy-nilly,? says Dr. Fichtenbaum. Instead one might look at the established risks for cardiovascular disease: a family history of heart attacks, especially at early ages, or if a patient has high blood pressure, diabetes, and/or smokes. ?I would address these types of problems very aggressively: encourage my patient not to smoke; try to control their blood pressure; control their diabetes.? If this patient had to go on treatment for HIV, he says he ?would try to choose a treatment plan that would cause the least amount of changes in cholesterol and triglyceride [levels] to avoid the potential risk of them having more problems. I would try and use different medication combinations which would most likely give you fewer changes, in the short-term, in cholesterol and triglycerides than others. Whether that means anything in the long run for patients I think is anybody?s guess. In the absence of information, if you have equal choices in terms of the potency of treatment for HIV, why not choose something that?s less harmful for that patient? My first choice is always to choose a treatment plan for HIV that?s going to work for that patient to save their life. Without effective treatment for HIV, patients aren?t going to live.?

Chael Needle wrote about patients? antiretroviral therapy preferences and trade-offs in the November issue.

December 2003