www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 20 At the Heart of Longevity Cardiovascular Health A good head and a good heart are always a formidable combination Nelson Mandela Founder of The Elders (www.theelders.org) Peter Reiss Director HIV Monitoring Foundation Professor of Medicine Department of Global Health &Division of Infectious Diseases Amsterdam Institute for Global Health and Development Academic Medical Center, University of Amsterdam
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www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
At the Heart of LongevityCardiovascular Health
A good head and a good heart are always a formidable combination
Nelson MandelaFounder of The Elders (www.theelders.org)
Peter ReissDirector HIV Monitoring Foundation
Professor of Medicine
Department of Global Health &Division of Infectious DiseasesAmsterdam Institute for Global Health and DevelopmentAcademic Medical Center, University of Amsterdam
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Disclosures
• Unrestricted scientific grant support to my insitution for investigator-initiated research fromGilead Sciences, ViiV, Janssen Pharmaceutica, Merck and
Bristol Myers Squibb
• Honoraria paid to my institution for DSMB participation and scientific advisory board participation from Janssen Pharmaceutica and Gilead Sciences
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Case• 52 year old man known with HIV for > 15 years.• HIV well controlled with cART for 10+ years; CD4
450/mm3
• ART: history of long-term d4T use; currently on TDF+3TC+EFV
• Presents with increasingly frequent episodes of chest pain
• Evaluation: Dx: angina pectoris as result of coronary artery disease
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
What may be contributing to this man’s coronary artery disease?
1. Being overweight
2. His HIV infection
3. His hypertension
4. His prior d4T use
5. His reduced renal function
6. Each of the above
Age-related chronic diseasesrise exponentially with age
Age
INCIDENCE
Age is the largest single risk factor
Chronic liver disease
Neurocognitive decline
Non-Aids cancers
Chronic kidney disease
Osteoporosis &Fragility fractures
Cardiovasculardisease
FrailtyDiabetes mellitus
Chronic obstructivepulmonary disease
Comorbidity in relation to age
Comorbidity distribution
*
Increased age-related complications on ART
Frieberg et al., JAMA Internal Med 2013
Increased risk of AMI in HIV compared to HIV uninfectedHR = 1.48 (CI = 1.27 – 1.72)
Further increase HR if CD4<200 or HIV RNA>500
Mea
n A
MI
even
ts p
er 1
000
pers
on y
ears
40-49 years 50-59 years 60-69 years0
1
2
3
4
5
6
2
3.9
5
1.52.2
3.3
HIV+ HIV-
N=82,459; Veterans Ageing Cohort Study Virtual Cohort
0
20
40
60
80
100
hiv-infected hiv-uninfected
mean score on physical funtioning
no comorbidity
1 co morbidity
2 co morbidities
3 or more co morb
More Co-morbidity related to worse QoL
Proportion reporting to be 100% unfit-to-work by age category among working age cohort participants
I. Stolte et. al. NCHIV 2012; Poster 46
HIV-positivity, older age and experiencing ≥ 3 age-associatednon-communicable co-morbidities, each were independently associated with higher levels of non-participation in paid work
0
10
20
30
40
hiv+ hiv-
%
45-50
51-55
56-60
61-65
Chronic disease drivers, known and suspected
Many chronic diseases of ageing are more common in those with HIV, even after adjustment for ART use and lifestyle factors
ART Toxicity
Lifestyle (smoking etc.)
ClinicalChronic
Co-morbidityPersistent Inflammation
in treatedHIV disease
Deeks SG, et al. BMJ 2009; 338:a3172
Control HIV
Axial Image
Coronal Image
F
Representative 18F- FDG PET Images
S.Subramanian et al JAMA 2012;308:379-86and S. Grinspoon CROI 2012
Proportion of deaths attributed to AIDS fell over time
Largely explained by increases in CD4+ cell counts
Proportion of deaths attributed to non-AIDS causes increased over time
non-AIDS K defining malignancies now the leading cause in this category
Rate of death attributed to cardiovascular or liver disease declined over time
possibly suggesting improved management and care
Rate of death attributed to non-AIDS malignancy remained stable over time
D:A:D: Changes in Causes of Death Over Time 1999-2011
1999-2000(N = 255)
2009-2011(N = 548)
Weber R, C. Smith et al. IAC2012. Abstract THAB0304.
34%
16%10%8%
32%
AIDS related Liver relatedCVD related NADMOther/unknown
22%
9%
10%20%
39%
AIDS related Liver-relatedCVD related NADMOther/unknown
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
What advice would you give to our patient?
1. Loose weight and exercise regularly
2. Stop smoking
3. Discontinue cART
4. Change current cART treatment
5. 1. and 2 of the above
AgehIV Study Team
Academic Medical Center
P. Reiss (PI) F.W. WitM. van der Valk J. Schouten K. KooijB.C. Elsenga A. Henderiks
Public Health Service Amsterdam
M. Prins (co-PI)I.G. StolteM. Martens J. BerkelS. MollA. van RoosmalenG.R. Visser
HIV Monitoring Foundation
F. de Wolf S. Zaheri Y.M. Ruijs L. GrasA. Kesselring
Amsterdam Institute of Global Health and Development
M. HeidenrijkR. Meester F. Janssen
Financial support:The Netherlands Organisation for Health Research and Development (ZonMW) grant nr. 300020007 & Stichting AIDS Fonds grant nr. 2009063Additional unconditional grants from: Gilead SciencesViiV HealthcareJanssen PharmaceuticalsMerck & CoBristol Myers Squibb
