Abstract
IMPORTANCE: Persons with human immunodeficiency virus (HIV) that is treated with antiretroviral therapy have improved longevity but face an elevated risk of myocardial infarction (MI) due to common MI risk factors and HIV-specific factors. Despite these elevated MI rates, optimal methods to predict MI risks for HIV-infected persons remain unclear. OBJECTIVE: To determine the extent to which existing and de novo estimation tools predict MI in a multicenter HIV cohort with rigorous MI adjudication. DESIGN, SETTING, AND PARTICIPANTS: We evaluated the performance of standard of care and 2 new data-derived MI risk estimation models in 5 Centers for AIDS Research Network of Integrated Clinical Systems sites across the United States where a multicenter clinical prospective cohort of 19 829 HIV-infected adults received care in inpatient and outpatient settings since 1995. The new risk estimation models were validated in a separate cohort from the derivation cohort. EXPOSURES: Traditional cardiovascular risk factors, HIV viral load, CD4 lymphocyte count, statin use, antihypertensive use, and antiretroviral medication use were used to calculate predicted event rates. MAIN OUTCOMES AND MEASURES: We observed MI rates over the course of follow-up that were scaled to 10 years using the Greenwood-Nam-D’Agostino Kaplan-Meier approach to account for dropout and loss to follow-up before 10 years. RESULTS: Of the 11 288 patients with complete baseline data, 6904 were white and 9250 were men. Myocardial infarction rates were higher among black men (6.9 per 1000 person-years) and black women (7.2 per 1000 person-years) than white men (4.4 per 1000 person-years) and white women (3.3 per 1000 person-years), older participants (7.5 vs 2.2 MI per 1000 person-years for adults 40 years and older vs < 40 years old at study entry, respectively), and participants who were not virally suppressed (6.3 vs 4.7 per 1000 person-years for participants with and without detectable viral load, respectively). The 2013 Pooled Cohort Equations, which predict composite rates of MI and stroke, adequately discriminated MI risk (Harrell C statistic = 0.75; 95% CI, 0.71-0.78). Two data-derived models incorporating HIV-specific covariates exhibited weak calibration in a validation sample and did not discriminate risk any better (Harrell C statistic = 0.72; 95% CI, 0.67-0.78 and 0.73; 95% CI, 0.68-0.79) than the Pooled Cohort Equations. The Pooled Cohort Equations were moderately calibrated in the Centers for AIDS Research Network of Clinical Systems but predicted consistently lower MI rates. CONCLUSIONS AND RELEVANCE: The Pooled Cohort Equations discriminated MI risk and were moderately calibrated in this multicenter HIV cohort. Adding HIV-specific factors did not improve model performance. As HIV-infected cohorts capture and assess MI and stroke outcomes, researchers should revisit the performance of risk estimation tools.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 155-162 |
| Number of pages | 8 |
| Journal | JAMA cardiology |
| Volume | 2 |
| Issue number | 2 |
| DOIs | |
| State | Published - Feb 2017 |
Funding
completed and submitted the ICMJE Form for the Disclosure of Potential Conflict of Interest. Dr Delaney reports receiving grant R01HL126538 from the National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute during the conduct of the study. Drs Heckbert, Matthews, and Moore report grant support from the NIH during the conduct of the study. Dr Budoff reports grant support from the NIH during the conduct of the study and from General Electric outside of the submitted work. Dr Saag reports grant support from the NIH/National Institute of Allergy and Infectious Diseases (NIAID)/Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) (R24) during the conduct of the study; grants from Gilead Sciences, Merck, Janssen, Bristol-Myers Squibb, and ViiV Healthcare paid to his institution for other work; and consulting fees from Gilead Sciences, Merck, and Bristol-Myers Squibb for services as a scientific advisor. Dr Enron reports grant support from the NIH during the conduct of the study and grants and personal fees from Gilead Sciences, Janssen, Bristol-Myers Squibb, and Viiv Healthcare and personal fees from Merck outside of the submitted work. Dr Crane reports grant support from the NIH during the conduct of the study and a grant from the NIH and the Patient-Centered Outcomes Research Center outside of the submitted work. No other disclosures were reported. Funding/Support: This study was supported by several grants from the NIH (CNICS R24 AI067039, CNICS MI supplement R24S AI067039, National Heart, Lung, and Blood Institute R01 HL126538, University of Washington Center for AIDS Research NIAID grant P30 AI027757, and Third Coast Center for AIDS Research NIAID grant P30AI117943). The study was also supported by grant 16FTF31200010 from the American Heart Association.
ASJC Scopus subject areas
- Cardiology and Cardiovascular Medicine
