Oliveira Raquel de Vasconcellos Carvalhaes de, Shimakura Silvia Emiko, Campos Dayse Pereira, Hökerberg Yara Hahr Marques, Victoriano Flaviana Pavan, Ribeiro Sayonara, Veloso Valdiléa G, Grinsztejn Beatriz, Carvalho Marilia Sá
a Instituto Nacional de Infectologia Evandro Chagas , Fundação Oswaldo Cruz , Rio de Janeiro , Brazil.
b Setor de Ciências Exatas , Universidade Federal do Paraná , Curitiba , Brazil.
AIDS Care. 2018 May;30(5):551-559. doi: 10.1080/09540121.2017.1391984. Epub 2017 Oct 23.
The use of highly active antiretroviral therapy has resulted in changes of comorbidity profile in people living with HIV (PLHIV), increasing non-AIDS-related events. The occurrence of cardiovascular events is greater in PLHIV, but the mechanism responsible for it is still controversial. This article aimed to investigate factors associated with the progression to cardiovascular events in PLHIV using HAART. A 15-years cohort study with 1135 PLHIV was conducted in Rio de Janeiro-Brazil. Clinical progression was stratified in five states: No comorbidities (s), arterial hypertension (s), lipid abnormalities (s), hypertension and lipid abnormalities (s) and major cardiovascular events (stroke, coronary artery disease, thrombosis or death) (s). Semi-Markov models evaluated the effects of cardiovascular traditional factors, treatment and clinical covariates on transitions between these states. Hazard Ratios (HR) and 95% confidence intervals (CI) were provided. In addition to traditional factors (age, sex, educational level and skin color), the development of one comorbidity (lipid abnormalities or hypertension) increased in patients with low nadir CD4 (<50 cells/mm), (HR = 1.59, CI 1.11-2.28 and 1.36, CI 1.11-1.66, respectively). The risk to experience a second comorbidity (s→s) increased 75% with low nadir CD4. Age was the only factor that increased the risk of major cardiovascular events once having lipid abnormalities with or without hypertension (s,s→s). The prolonged use of certain antiretroviral drugs (abacavir, didanosine, ritonavir, lopinavir, amprenavir and fosamprenavir) increased the risk of direct transition (s→s) to major cardiovascular events (HR = 5.29, CI 1.16-24.05). This analysis suggests that prolonged use of certain antiretroviral drugs led directly to major cardiovascular events, while low nadir CD4 only affected the occurrence of lipid abnormalities and hypertension. Management strategies, including rational use of complex exams (such as, computed-tomography angiography), statins and antihypertensives, should be developed based on the distinct roles of antiretroviral use and of HIV infection itself on the progression to cardiovascular events.
高效抗逆转录病毒疗法的使用已导致艾滋病毒感染者（PLHIV）的合并症情况发生变化，非艾滋病相关事件有所增加。PLHIV发生心血管事件的几率更高，但其背后的机制仍存在争议。本文旨在研究使用高效抗逆转录病毒疗法（HAART）的PLHIV发生心血管事件进展的相关因素。在巴西里约热内卢对1135名PLHIV进行了一项为期15年的队列研究。临床进展分为五个状态：无合并症（s）、动脉高血压（s）、血脂异常（s）、高血压和血脂异常（s）以及重大心血管事件（中风、冠状动脉疾病、血栓形成或死亡）（s）。半马尔可夫模型评估了心血管传统因素、治疗和临床协变量对这些状态之间转变的影响。提供了风险比（HR）和95%置信区间（CI）。除了传统因素（年龄、性别、教育水平和肤色）外，低最低点CD4（<50个细胞/mm）的患者发生一种合并症（血脂异常或高血压）的几率增加（HR分别为1.59，CI为1.11 - 2.28和1.36，CI为1.11 - 1.66）。最低点CD4低时，发生第二种合并症（s→s）的风险增加75%。年龄是唯一一个在有或无高血压的血脂异常（s，s→s）情况下增加重大心血管事件风险的因素。某些抗逆转录病毒药物（阿巴卡韦、去羟肌苷、利托那韦、洛匹那韦、安普那韦和福沙普那韦）的长期使用增加了直接转变（s→s）为重大心血管事件的风险（HR = 5.29，CI为1.16 - 24.05）。该分析表明，某些抗逆转录病毒药物的长期使用直接导致重大心血管事件，而最低点CD4低仅影响血脂异常和高血压的发生。应基于抗逆转录病毒药物使用和HIV感染本身在心血管事件进展中的不同作用，制定包括合理使用复杂检查（如计算机断层血管造影）、他汀类药物和抗高血压药物在内的管理策略。
