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At the Heart of Longevity Cardiovascular Health

At the Heart of Longevity Cardiovascular Health

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At the Heart of Longevity Cardiovascular Health

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  1. At the Heart of LongevityCardiovascular Health A goodheadand a goodheart are always a formidablecombination Nelson Mandela Founder of The Elders (www.theelders.org) Peter Reiss Director HIV Monitoring Foundation Professor of Medicine Department of Global Health &Division of InfectiousDiseases Amsterdam Institutefor Global Health and Development AcademicMedical Center, University of Amsterdam

  2. Disclosures • Unrestrictedscientificgrant support tomyinsitutionfor • investigator-initiated research fromGilead Sciences, • ViiV, Janssen Pharmaceutica, Merck and • Bristol Myers Squibb • Honoraria paidtomyinstitutionfor DSMB participation • andscientificadvisory board participationfrom • Janssen PharmaceuticaandGilead Sciences

  3. Case • 52 yearold man knownwith HIV for > 15 years. • HIV well controlledwithcARTfor 10+ years; CD4 450/mm3 • ART: history of long-term d4T use; currently on TDF+3TC+EFV • BMI 27 kg/m2; BP 150/100 mmHg; creatinine clearance 55 ml/min • Presents withincreasingly frequent episodes of chestpain • Evaluation: Dx: angina pectoris as result of coronaryarterydisease

  4. Whatmaybecontributingtothisman’scoronaryarterydisease? • Beingoverweight • His HIV infection • His hypertension • His prior d4T use • His reducedrenalfunction • Each of the above

  5. Age-related chronic diseases rise exponentially with age INCIDENCE Age Age is the largest single risk factor

  6. Osteoporosis & Fragility fractures Cardiovascular disease Non-Aids cancers Diabetes mellitus Neurocognitive decline Frailty Chronic obstructive pulmonary disease Chronic kidney disease Chronic liver disease

  7. Comorbidity in relation to age

  8. Comorbiditydistribution *

  9. Increased age-related complications on ART Mean AMI events per 1000 person years Increased risk of AMI in HIV compared to HIV uninfected HR = 1.48 (CI = 1.27 – 1.72) Further increase HR if CD4<200 or HIV RNA>500 N=82,459; Veterans Ageing Cohort Study Virtual Cohort Frieberg et al., JAMA Internal Med 2013

  10. More Co-morbidityrelatedtoworseQoL

  11. Proportion reporting to be 100% unfit-to-work by age category among working age cohort participants HIV-positivity, older age and experiencing ≥ 3 age-associated non-communicable co-morbidities, each were independently associated with higher levels of non-participation in paid work I. Stolte et. al. NCHIV 2012; Poster 46

  12. Chronic disease drivers, known and suspected Clinical Chronic Co-morbidity ART Toxicity Persistent Inflammation in treated HIV disease Lifestyle (smoking etc.) Many chronic diseases of ageing are more common in those with HIV, even after adjustment for ART use and lifestyle factors Deeks SG, et al. BMJ 2009; 338:a3172

  13. Control HIV Axial Image F Coronal Image Representative18F- FDG PET Images S.Subramanian et al JAMA 2012;308:379-86 and S. Grinspoon CROI 2012

  14. Proportionof deaths attributed to AIDS fell over time Largely explained by increases in CD4+ cell counts Proportionof deaths attributed to non-AIDS causes increased over time non-AIDS ̶ defining malignancies now the leading cause in this category Rateof death attributed to cardiovascular or liver disease declined over time possibly suggesting improved management and care Rateof death attributed to non-AIDS malignancy remained stable over time D:A:D: Changes in Causes of Death Over Time 1999-2011 32% 34% 1999-2000 (N = 255) 8% 16% 10% AIDS related Liver related CVD related NADM Other/unknown 22% 2009-2011 (N = 548) 39% 9% 10% 20% AIDS related Liver-related CVD related NADM Other/unknown Weber R, C. Smith et al. IAC2012. Abstract THAB0304.

  15. Whatadvicewouldyougivetoourpatient? • Looseweightandexerciseregularly • Stop smoking • Discontinue cART • Change currentcART treatment • 1. and 2 of the above

  16. AgehIV Study Team Academic Medical Center P. Reiss (PI) F.W. Wit M. van der Valk J. Schouten K. Kooij B.C. Elsenga A. Henderiks Public Health Service Amsterdam M. Prins (co-PI) I.G. Stolte M. Martens J. Berkel S. Moll A. van Roosmalen G.R. Visser HIV Monitoring Foundation F. de Wolf S. Zaheri Y.M. Ruijs L. Gras A. Kesselring Amsterdam Institute of Global Health and Development M. Heidenrijk R. Meester F. Janssen Financial support: The Netherlands Organisationfor Health Research and Development (ZonMW) grant nr. 300020007 & Stichting AIDS Fonds grant nr. 2009063 Additionalunconditionalgrantsfrom: GileadSciences ViiVHealthcare Janssen Pharmaceuticals Merck & Co Bristol Myers Squibb