HIV Infection and the Risk of Acute Myocardial Infarction HIV Infection and the Risk of AMI

Freiberg MS, Chang CH, Kuller LH, et al. — Mon, 22 Apr 2013 00:00:00 GMT

Importance

Whether people infected with human immunodeficiency virus (HIV) are at an increased risk of acute myocardial infarction (AMI) compared with uninfected people is not clear. Without demographically and behaviorally similar uninfected comparators and without uniformly measured clinical data on risk factors and fatal and nonfatal AMI events, any potential association between HIV status and AMI may be confounded.

Objective

To investigate whether HIV is associated with an increased risk of AMI after adjustment for all standard Framingham risk factors among a large cohort of HIV-positive and demographically and behaviorally similar (ie, similar prevalence of smoking, alcohol, and cocaine use) uninfected veterans in care.

Design and Setting

Participants in the Veterans Aging Cohort Study Virtual Cohort from April 1, 2003, through December 31, 2009.

Participants

After eliminating those with baseline cardiovascular disease, we analyzed data on HIV status, age, sex, race/ethnicity, hypertension, diabetes mellitus, dyslipidemia, smoking, hepatitis C infection, body mass index, renal disease, anemia, substance use, CD4 cell count, HIV-1 RNA, antiretroviral therapy, and incidence of AMI.

Main Outcome Measure

Acute myocardial infarction.

Results

We analyzed data on 82 459 participants. During a median follow-up of 5.9 years, there were 871 AMI events. Across 3 decades of age, the mean (95% CI) AMI events per 1000 person-years was consistently and significantly higher for HIV-positive compared with uninfected veterans: for those aged 40 to 49 years, 2.0 (1.6-2.4) vs 1.5 (1.3-1.7); for those aged 50 to 59 years, 3.9 (3.3-4.5) vs 2.2 (1.9-2.5); and for those aged 60 to 69 years, 5.0 (3.8-6.7) vs 3.3 (2.6-4.2) (P < .05 for all). After adjusting for Framingham risk factors, comorbidities, and substance use, HIV-positive veterans had an increased risk of incident AMI compared with uninfected veterans (hazard ratio, 1.48; 95% CI, 1.27-1.72). An excess risk remained among those achieving an HIV-1 RNA level less than 500 copies/mL compared with uninfected veterans in time-updated analyses (hazard ratio, 1.39; 95% CI, 1.17-1.66).

Conclusions and Relevance

Infection with HIV is associated with a 50% increased risk of AMI beyond that explained by recognized risk factors.

Complexity Science and the Readmission Dilemma Comment on “Potentially Avoidable 30-Day Hospital Readmissions in Medical Patients” and “Association of Self-reported Hospital Discharge Handoffs With 30-Day Readmissions” Complexity Science and the Readmission Dilemma

Marks E. — Mon, 22 Apr 2013 00:00:00 GMT

The increasing proliferation of articles dealing with hospital readmission is in no small part a response to the recommendations in the 2007 Medicare Payment Advisory Commission report to Congress (http:// www.medpac.gov/documents/Jun07_ EntireReport.pdf). These recommendations became the basis for the Hospital Readmissions Reduction Program in the Affordable Care Act altering the criteria for hospital payment reimbursement. Enforcement of these criteria by the Centers for Medicare & Medicaid Services reduces Medicare payments to hospitals that exceed preset all-cause readmission rates. As health care policy and aspects of care delivery are increasingly influenced by reimbursement, it is important to ensure that the attenuation of the overall health care financial burden is accomplished by research-driven improvements in the quality and safety of care that minimize the potential for unintended outcomes.

JAMA Internal Medicine: Myocardial Infarction Topic Collection

HIV Infection and the Risk of Acute Myocardial Infarction HIV Infection and the Risk of AMI

Complexity Science and the Readmission Dilemma Comment on “Potentially Avoidable 30-Day Hospital Readmissions in Medical Patients” and “Association of Self-reported Hospital Discharge Handoffs With 30-Day Readmissions” Complexity Science and the Readmission Dilemma