Cerebrovascular Ischemic Events in HIV-1-Infected Patients Receiving Highly Active Antiretroviral Therapy: Incidence and Risk Factors

Abstract

Background: Stroke risk is increased in AIDS patients, and highly active antiretroviral therapy (HAART) may accelerate atherosclerosis, but little is known about the incidence and risk factors for ischemic stroke in patients under HAART. We have studied the incidence, types of stroke and possible risk factors for cerebrovascular ischemic events in a large cohort of HIV-1-infected patients treated with HAART. Methods: We conducted a retrospective review of ischemic strokes and transient ischemic attacks occurring in a cohort of HIV-1-infected patients treated with HAART from 1996 to 2008. As a control group, consecutive unselected patients from the same cohort were included. Patients and controls were compared for demographic, clinical and laboratory variables, including vascular risk factors, data on HIV infection and duration of HAART. Variables with significant differences were included in a backward logistic regression model. Results: Twenty-seven cerebrovascular ischemic events occurred in 25 patients, with an incidence of 189 events (166 strokes) per 100,000 patients/year. Independent factors associated with cerebrovascular events were: history of high alcohol intake (OR 7.13, 95% CI 1.69–30.11; p = 0.007), a previous diagnosis of AIDS (OR 6.61, 95% CI 2.03–21.51; p = 0.002) and fewer months under HAART (OR 0.97, 95% CI 0.96–0.99; p < 0.001). Six patients (24%) had large artery atherosclerosis: they had a similar HAART duration to controls. Conclusions: Stroke incidence is high in patients with HIV-1 infection treated with HAART. Duration of HAART exerted a global protective effect for cerebrovascular ischemic events, and our results do not support a major role in large artery atherosclerosis stroke. High alcohol intake is a major risk factor for stroke in these patients.

Incidence and Clinical Features of Cerebrovascular Disease Among HIV-Infected Adults in the Southeastern United States

“…In Europe, HIV-infected adults have a slightly lower CVE incidence than we recorded, consistent with lower rates seen in the general population of Europe compared to the US. 14,[25][26][27] Among HIV-infected populations in the US, two studies reported somewhat higher incidence rates than seen in our cohort. The Veterans Aging Cohort Study (VACS) reported a stroke rate of 2.93 per 1,000 person-years in HIV monoinfected and 6.99 per 1,000 person-years in HIV/HCV coinfected patients.…”

Revised and Updated Recommendations for the Establishment of Primary Stroke Centers

“…113 We support HIV testing in accordance with the Centers for Disease Control and Prevention guidelines based on the high prevalence of HIV, its importance as a public health matter, and the relationship between HIV and cerebrovascular disease. 114,115 A blood or urine test for drug toxicology is also suggested based on the high prevalence of drug abuse and the association between illicit drug use and stroke. 116,117 A letter of support from the laboratory director(s) should be provided along with written documentation that the testing noted can be completed within the recommended time period.…”

Elevated rates of intracerebral hemorrhage in individuals from a US clinical care HIV cohort

“…5,6,33,38,39 Similar to our finding that a CD4 count ,200 3 10 6 cells/L was associated with higher ICH risk, we previously found a higher CD4 count decreased the hazard of ischemic stroke, although this did not reach statistical significance. 5 Furthermore, ART use, for which there is mixed evidence in relation to stroke risk, 5,6,9,38 was associated with a lower, but not statistically significant, hazard of ICH (table 5). These findings suggest that more advanced or less wellcontrolled HIV infection may contribute to increased cerebrovascular risk.…”

“…[1][2][3][4][5][6][7] Several studies pointing to an elevated risk of cerebrovascular disease in HIV-infected individuals have focused on ischemic stroke and excluded intracranial hemorrhage. 5,8,9 Whereas ischemic stroke and cardiovascular disease often coexist and share a similar risk profile and underlying mechanism, the association between HIV and intracerebral hemorrhage (ICH), which has mechanisms distinct from ischemic stroke, is less clear. We examined the association of HIV with the risk of ICH by comparing the incidence of ICH in HIV-infected and uninfected individuals in a large US clinical care cohort.…”