Sepsis and the use of stimulant drugs are important causes of heart attacks in people living with HIV according to a US study published in the Journal of Acquired Immunodeficiency Syndromes. Heart attacks with such causes, rather than attacks caused by hardening of the arteries, predominated in young people living with HIV who had a heart attack.
But the study also showed that even younger people living with HIV had heart attacks due to arterial disease and that there were high rates of heart attacks due to sepsis / drug use and to hardening in the elderly.
Dr. Heidi Crane of the University of Washington, Seattle, and co-investigators conducted the research.
The results of the study are important because heart disease is an increasingly important cause of serious illness and death in people living with HIV. In addition, there are several types of heart attacks, each with different underlying causes. Treatment strategies depend on the type of heart attack.
Type 1 heart attacks are caused by arterial disease, particularly the buildup of cholesterol-related deposits or plaques in the arteries. The instability of these plaques can cause arterial blockages, obstructing the blood supply to the heart, resulting in a heart attack.
In contrast, the causes of type 2 heart attack include sepsis (a severe reaction to an infection), cocaine use, and hypoxia (low levels of oxygen).
Risk factors for both types of heart attack are common in people with HIV. Lifestyle factors such as diet and the use of certain antiretroviral drugs can cause cholesterol to rise. But recreational drug use rates are also high among people living with HIV, and the use of unsterile injecting equipment increases the risk of infections.
In the general population, type 1 heart attacks predominate. But Dr. Crane’s research team has already shown that people with HIV have a different heart attack profile, with about half of the attacks classified as type 2. They found that there is a greater risk of death after a type 2 heart attack.
They wanted to dig deeper into this research and see if the type of heart attack in people living with HIV differed by age. They hypothesized that the causes associated with type 2 heart attack would mean that it is predominant in young people. But investigators also hypothesized that type 1 heart attacks would also occur in young PLHIV at a measurable rate.
Their research involved adults who received specialized HIV care in six US cities between 2000 and 2019. Potential heart attacks have been identified from medical records. Two doctors looked at each case to determine the type of heart attack. The incidence of each type was calculated as a function of age (in decades).
The total study population consisted of 28,741 PLHIV. Of these, 875 had a heart attack. Their median age was 51, 79% were men, 50% were African Americans, and 79% were on ART. The median CD4 cell count at the time of the heart attack was 355.
Just over half (53%) of heart attacks were type 1, the remaining 47% were type 2 events.
People with a type 1 heart attack were more likely than those with a type 2 event to be aged 40 and over, male (85% vs. 72%), Caucasian (49% vs. 26%, on statins (49% vs. 25%), on ART (84% vs. 72%) and have higher total and LDL (or “bad”) cholesterol levels. The mean CD4 cell count also differed depending on the type of myocardial infarction (type 1, 423 vs type 2, 253).
Type 1 attacks have occurred in people living with HIV of all ages, including those under 30 (one event in 2,254 people, rate 0.31 per 1,000 person-years). Their frequency increased with age, with the incidence in people aged 70 and over reaching 9 cases per 1000 person-years of follow-up.
Type 2 events were observed in all age groups (five events in those under 30, rate 1.31 per 1000 person-years) and their frequency also increased with age (five events among the 573 people aged 70 and over, incidence 8.88 per 1000 person-years).
However, type 1 events were more common than type 2 events in people aged 50 to 69 years, while type 2 events were more common in those under 40 years old. 2 in those under 30 was significantly higher (IRR = 10.0; 95% CI, 2.43-88.24, p
Common causes of type 2 events were sepsis (36%), use of cocaine or other stimulant drugs (11%), and respiratory failure (10%).
“These results show that type 1 myocardial infarction and type 2 myocardial infarction represent distinct clinical entities and require different prevention and treatment approaches,” commented the authors. “One of the main conclusions of this study is that people living with HIV with type 2 myocardial infarction were younger than those with type 1 myocardial infarction.”
“Common causes of type 2 events were sepsis, use of cocaine or other stimulant drugs, and respiratory failure.”
They note that this contrasts with the general population where type 2 events are rare and usually occur in the elderly. Dr Crane and colleagues suggest this discrepancy was likely due to the high frequency of sepsis-related heart attacks they observed. In the general population, this accounts for 10% of type 2 events, but among people living with HIV, it was the most common risk factor for a heart attack of this type, present in 27% to 50% of individuals (according to age).
“We have found that among people living with HIV, type 1 myocardial infarction occurs in adults of all ages. Type 2 myocardial infarctions accounted for almost half of all myocardial infarctions… and occurred at a higher rate… until the age of 40, ”the investigators conclude. “A better understanding of these important comorbidities, who is affected, when and why, is needed to better understand the underlying mechanisms and intervene successfully to improve the long-term outcomes of older PLHIV as the population of care continues. to grow old.