CHA2DS2-VASc Score, Warfarin Use, and Risk for Thromboembolic Events Among HIV-Infected Persons With Atrial Fibrillation

Chau, Katherine H.; Scherzer, Rebecca; Grünfeld, Carl; Hsue, Priscilla Y.; Shlipak, Michael G.

doi:10.1097/qai.0000000000001470

Cited by 11 publications

(12 citation statements)

References 43 publications

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“…27 Furthermore, even when atrial fibrillation could be detected, treatment with warfarin did not consistently prevent new episodes of stroke, suggesting additional underlying pathomechanisms. 40 Contrary to other reports, our cohort did not contain any strokes within the first six months after starting ART, which has been attributed to an immune reconstitution inflammatory syndrome. 41 Through various mechanisms, the intake of ART appears to pose an independent vascular risk.…”

Section: Discussioncontrasting

confidence: 83%

Ischemic stroke in human immunodeficiency virus-positive patients: An increasingly age-related comorbidity?

Schaefer

Stephan

Foerch

et al. 2020

European Stroke Journal

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Introduction The global incidence of ischemic stroke among patients with human immunodeficiency virus is increasing. The aim of this controlled case analysis was to study patient characteristics, stroke etiologies, and risk factors in human immunodeficiency virus-positive patients in a medical system with easy access to antiretroviral therapies. Patients and methods We conducted a retrospective, observational study of human immunodeficiency virus-positive patients treated in our stroke unit and outpatient clinic in Germany between 2012 and 2018. A control group of all patients treated for acute ischemic stroke in 2018 was used to elicit possible differences in stroke localization, etiology, and distribution of risk factors. Results Out of 3615 patients with an acute ischemic stroke, 24 (0.7%) were newly or previously diagnosed as human immunodeficiency virus-positive. Strokes in this cohort were caused by large-vessel disease (37.5%), small-vessel disease (20.8%), cryptogenic-embolism (20.8%), vasculitis (16.7%), and cardio-embolism (4.2%). Large-vessel disease-related strokes were more often located in the posterior circulation (77.8%). Compared to the control group, cardio-embolic strokes were less and vasculitis and large-vessel disease more frequent. Human immunodeficiency virus-positive patients were younger at stroke onset (53.7 ± 12.8 vs. 70.2 ± 14.6 years, p = 0.05). Discussion Although the prevalence of human immunodeficiency virus-infection among patients treated for acute ischemic strokes appears low, this collective merits special attention due to a high burden of potentially modifiable risk factors and vasculitis. Conclusion Compared to previous studies, age at stroke onset was one of the highest, supporting the hypothesis that as antiretroviral therapy increases the life expectancy of people living with HIV/AIDS, they will be increasingly affected by cardiovascular disease. Human immunodeficiency virus-related cerebral vasculitis was associated with high mortality (75%).

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Section: Discussioncontrasting

confidence: 83%

Ischemic stroke in human immunodeficiency virus-positive patients: An increasingly age-related comorbidity?

Schaefer

Stephan

Foerch

et al. 2020

European Stroke Journal

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“…Recent analyses using Veterans Affairs HIV Clinical Case Registry [39] suggest that CHADS2VASc score was not a strong predictor of thromboembolic events in this subgroup. Furthermore, they found that warfarin therapy was actually associated with more thromboembolic events, even after adjusting for CHADS2VASc score (HR 2.2 [95% CI 1.1–4.7, p = 0.04].…”

Section: Cardiac Arrhythmiamentioning

confidence: 99%

HIV Infection and Risk of Cardiovascular Diseases Beyond Coronary Artery Disease

Barnes

Lacson

Bahrami

2017

Curr Atheroscler Rep

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Purpose of Review Cardiovascular disease (CVD) increasingly afflicts people living with HIV (PLWH) in the contemporary era of antiretroviral therapy (ART). Coronary artery disease (CAD) is the most widely studied cardiovascular problem in PLWH; however, less is known about other clinically relevant subtypes of CVD such as heart failure (HF), cerebrovascular disease, sudden cardiac death, pericardial diseases, and pulmonary hypertension. This paper reviews evidence of other subtypes of CVD as emerging issues in the post-ART era. Recent Findings Recent studies have shown that PLWH have higher risk of HF as well as subclinical impairment of left ventricular (LV) mechanics (systolic and diastolic dysfunction) and myocardial abnormalities (fibrosis and steatosis). The underlying mechanisms, however, are not well-understood. A few studies have also shown higher rates of atrial fibrillation and sudden cardiac death in PLWH. Ischemic stroke is the most common stroke type in the post-ART era, with underlying mechanisms like those identified in CAD: chronic inflammation and associated vasculopathy. Studies of great vessels (carotid artery and aorta) and peripheral arterial disease show heterogeneous results. Small subclinical pericardial effusions are common in PLWH in post-ART era. Pulmonary hypertension continues to be an underdiagnosed and potentially fatal complication of HIV infection. Summary PLWH remain at higher risk for all types of CVD including heart failure, stroke, and arrhythmias in the post-ART era. Chronic inflammation may play an important role in this increased risk. More studies are needed to further elucidate the extent of non-coronary CVD in PLWH and the underlying mechanisms for them.

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“…Whether HIV‐1 infection should probably be regarded to as an additional stroke risk factor beyond the CHA 2 DS 2 ‐VASc score is uncertain, although such patients are clearly at high risk. In one study involving 914 HIV‐1 patients with AF (free from events at baseline) the event rate of thromboembolic events (including pulmonary embolism, peripheral embolism and ischaemic stroke) ranged from 5.4% per 1000 person‐years for CHA 2 DS 2 ‐VASc score of 0, to 9.3% and 8.1% for score of 1 and ≥2, respectively . Of note, none of the single components of the CHA 2 DS 2 VASC score was associated to thromboembolic risk in this cohort and most patients scored 0 for ‘age’ due to the low mean age of the study cohort.…”

Section: Discussionmentioning

confidence: 86%

“…A recent study from the Veterans Affairs HIV Clinical Case Registry including 914 patients with HIV‐1 and AF confirmed a high thromboembolic risk in this setting . Thus, the rate of events according to a CHA 2 DS 2 ‐VASc score of 0, 1 and ≥2 was 5.4, 9.3 and 8.1 per 1000 person‐years, respectively . Furthermore, warfarin did not show a significant association with reduced rate of thromboembolic events raising concerns about the optimal thromboprophylaxis for HIV‐1 infected persons with AF.…”

Section: Managing Drug–drug Interactions In Patients With Hiv‐1 and Amentioning

confidence: 93%

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Atrial fibrillation and human immunodeficiency virus type‐1 infection: a systematic review. Implications for anticoagulant and antiarrhythmic therapy

Pastori

Mezzaroma

Pignatelli

et al. 2019

Brit J Clinical Pharma

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The prevalence and incidence of atrial fibrillation/flutter (AF/AFL) in patients with human immunodeficiency virus type-1 (HIV-1) infection have been poorly investigated. We performed a systematic review using PubMed and Cochrane Database of Systematic Reviews, and screening of references, searching for clinical studies reporting on the association between HIV-1 infection and AF/AFL. We also summarized the main interactions of antiretroviral agents with antithrombotic and antiarrhythmic drugs. We found a prevalence of AF/AFL ranging from 2.0% to 5.13% in patients with HIV-1, with an incidence rate of 3.6/1000 personyears. Low CD4+ count (<200-250 cells ml À1 ) and high viral load were predictors of AF/AFL. Regarding drugs interactions, nucleoside reverse transcriptase inhibitors, integrase inhibitor and maraviroc have the lowest interactions with oral anticoagulants. Among anticoagulants, dabigatran presents the most favourable profile. Most of antiarrhythmic drugs interact with protease inhibitors, with beta blockers and diltiazem having fewer interactions. The few studies available suggest a non-negligible prevalence of AF/AFL in patients with HIV-1 infection. Awareness of potential interactions with anticoagulation and antiarrhythmic drugs is needed to offer optimal management in this population. CVD, even in treated HIV-1 patients [3]. Moreover, low CD4+ T cell count and/or failure to restore normal CD4+ T cell British Journal of Clinical PharmacologyBr J Clin Pharmacol (2019) 85 508-515 508

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CHA2DS2-VASc Score, Warfarin Use, and Risk for Thromboembolic Events Among HIV-Infected Persons With Atrial Fibrillation

Cited by 11 publications

References 43 publications

Ischemic stroke in human immunodeficiency virus-positive patients: An increasingly age-related comorbidity?

Ischemic stroke in human immunodeficiency virus-positive patients: An increasingly age-related comorbidity?

HIV Infection and Risk of Cardiovascular Diseases Beyond Coronary Artery Disease

Atrial fibrillation and human immunodeficiency virus type‐1 infection: a systematic review. Implications for anticoagulant and antiarrhythmic therapy

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