Cardiovascular Disease, Smoking Cessation, and HIV
Cardiovascular Disease, Smoking Cessation, and HIV
Objectives The aim of the study was to estimate the rates of cardiovascular disease (CVD) events after stopping smoking in patients with HIV infection.
Methods Patients who reported smoking status and no previous CVD prior to enrolment in the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study were included in this study. Smoking status is collected at each visit as current smoker (yes/no) and ever smoker (yes/no). Time since stopping smoking was calculated for persons who had reported current smoking during follow-up and no current smoking subsequently. Endpoints were: myocardial infarction (MI); coronary heart disease (CHD: MI plus invasive coronary artery procedure or death from other CHD); CVD (CHD plus carotid artery endarterectomy or stroke); and all-cause mortality. Event rates were calculated for never, previous and current smokers, and smokers who stopped during follow-up. Incidence rate ratios (IRRs) were determined using Poisson regression adjusted for age, sex, cohort, calendar year, family history of CVD, diabetes, lipids, blood pressure and antiretroviral treatment.
Results A total of 27 136 patients had smoking status reported, with totals of 432, 600, 746 and 1902 MI, CHD, CVD and mortality events, respectively. The adjusted IRR of CVD in patients who stopped smoking during follow-up decreased from 2.32 within the first year of stopping to 1.49 after >3 years compared with those who never smoked. Similar trends were observed for the MI and CHD endpoints. Reductions in risk were less pronounced for all-cause mortality.
Conclusion The risk of CVD events in HIV-positive patients decreased with increasing time since stopping smoking. Smoking cessation efforts should be a priority in the management of HIV-positive patients.
Rates of cigarette smoking are high across most HIV-infected populations in developed countries. Studies have reported at least a two-to-threefold increased rate compared with the general population, with 40–70% of HIV-positive patients reporting current smoking. Smoking has been independently associated with morbidity and mortality in HIV-positive patients; comorbid conditions include bacterial pneumonia, pulmonary disease, lung cancer and cardiovascular disease (CVD). The contribution of smoking to the risk of myocardial infarctions (MIs) has also been shown to be considerably greater than other CVD risk factors. The Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study demonstrated a twofold increased risk of MIs among current and previous smokers compared with nonsmokers. For other cardiovascular risk factors, the risk of MIs was increased by 16% per doubling in triglycerides, 20% per unit increase in total cholesterol, and 25% for patients with hypertension and diabetes.
In the era of effective combination antiretroviral therapy (cART), the effect of smoking on morbidity in HIV-positive patients remains a concern, as HIV-positive patients are living longer and are at increased risk for many smoking-associated non-AIDS-defining illnesses including CVD, pulmonary disease and non-AIDS-related malignancies [7,15,18–20]. Despite this, HIV-positive patients continue to smoke. Several reasons have been suggested, including social conditions, polysubstance abuse, psychiatric comorbidities, physical and mental distress, poor access to smoking cessation interventions and poor adherence to such treatments, as well as the negative perception of long-term survival among HIV-positive patients.
The health benefits of stopping cigarette smoking in the general population are substantial and widely documented. The risk of coronary heart disease (CHD) and mortality is considerably reduced within the first 2 years of stopping smoking, and in some studies has been shown to return to levels observed in nonsmokers within 5 years. Whether HIV-positive patients also benefit from stopping smoking in terms of cardiovascular and mortality risk has not previously been investigated, although recent data have demonstrated a reduced risk of bacterial pneumonia after at least 1 year of having ceased smoking. If similar evidence observed in the general HIV-negative population could be demonstrated in HIV-positive populations, then this may provide an additional incentive to stop smoking. The D:A:D study is a large international prospective cohort study with detailed follow-up information on incident CVD and smoking status. Our objective was to estimate the rates of CVD events and mortality after smoking cessation in HIV-positive patients participating in the D:A:D study.
Abstract and Introduction
Abstract
Objectives The aim of the study was to estimate the rates of cardiovascular disease (CVD) events after stopping smoking in patients with HIV infection.
Methods Patients who reported smoking status and no previous CVD prior to enrolment in the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study were included in this study. Smoking status is collected at each visit as current smoker (yes/no) and ever smoker (yes/no). Time since stopping smoking was calculated for persons who had reported current smoking during follow-up and no current smoking subsequently. Endpoints were: myocardial infarction (MI); coronary heart disease (CHD: MI plus invasive coronary artery procedure or death from other CHD); CVD (CHD plus carotid artery endarterectomy or stroke); and all-cause mortality. Event rates were calculated for never, previous and current smokers, and smokers who stopped during follow-up. Incidence rate ratios (IRRs) were determined using Poisson regression adjusted for age, sex, cohort, calendar year, family history of CVD, diabetes, lipids, blood pressure and antiretroviral treatment.
Results A total of 27 136 patients had smoking status reported, with totals of 432, 600, 746 and 1902 MI, CHD, CVD and mortality events, respectively. The adjusted IRR of CVD in patients who stopped smoking during follow-up decreased from 2.32 within the first year of stopping to 1.49 after >3 years compared with those who never smoked. Similar trends were observed for the MI and CHD endpoints. Reductions in risk were less pronounced for all-cause mortality.
Conclusion The risk of CVD events in HIV-positive patients decreased with increasing time since stopping smoking. Smoking cessation efforts should be a priority in the management of HIV-positive patients.
Introduction
Rates of cigarette smoking are high across most HIV-infected populations in developed countries. Studies have reported at least a two-to-threefold increased rate compared with the general population, with 40–70% of HIV-positive patients reporting current smoking. Smoking has been independently associated with morbidity and mortality in HIV-positive patients; comorbid conditions include bacterial pneumonia, pulmonary disease, lung cancer and cardiovascular disease (CVD). The contribution of smoking to the risk of myocardial infarctions (MIs) has also been shown to be considerably greater than other CVD risk factors. The Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study demonstrated a twofold increased risk of MIs among current and previous smokers compared with nonsmokers. For other cardiovascular risk factors, the risk of MIs was increased by 16% per doubling in triglycerides, 20% per unit increase in total cholesterol, and 25% for patients with hypertension and diabetes.
In the era of effective combination antiretroviral therapy (cART), the effect of smoking on morbidity in HIV-positive patients remains a concern, as HIV-positive patients are living longer and are at increased risk for many smoking-associated non-AIDS-defining illnesses including CVD, pulmonary disease and non-AIDS-related malignancies [7,15,18–20]. Despite this, HIV-positive patients continue to smoke. Several reasons have been suggested, including social conditions, polysubstance abuse, psychiatric comorbidities, physical and mental distress, poor access to smoking cessation interventions and poor adherence to such treatments, as well as the negative perception of long-term survival among HIV-positive patients.
The health benefits of stopping cigarette smoking in the general population are substantial and widely documented. The risk of coronary heart disease (CHD) and mortality is considerably reduced within the first 2 years of stopping smoking, and in some studies has been shown to return to levels observed in nonsmokers within 5 years. Whether HIV-positive patients also benefit from stopping smoking in terms of cardiovascular and mortality risk has not previously been investigated, although recent data have demonstrated a reduced risk of bacterial pneumonia after at least 1 year of having ceased smoking. If similar evidence observed in the general HIV-negative population could be demonstrated in HIV-positive populations, then this may provide an additional incentive to stop smoking. The D:A:D study is a large international prospective cohort study with detailed follow-up information on incident CVD and smoking status. Our objective was to estimate the rates of CVD events and mortality after smoking cessation in HIV-positive patients participating in the D:A:D study.