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Predictors of Ischemic and Hemorrhagic Strokes Among People Living With HIV: The D:A:D International Prospective Multicohort Study.
EClinicalMedicine 2019; 13:91-100E

Abstract

Background

Hypertension is a stronger predictor of hemorrhagic than ischemic strokes in the general population. We aimed to identify whether hypertension or other risk factors, including HIV-related factors, differ in their associations with stroke subtypes in people living with HIV (PLWHIV).

Methods

HIV-1-positive individuals from the Data collection on Adverse events of anti-HIV Drugs (D:A:D) study were followed from the time of first blood pressure (BP) measurement after 1/1/1999 or study entry until the first of a validated stroke, 6 months after last follow-up or 1/2/2014. Stroke events were centrally validated using standardized criteria. Hypertension was defined as one systolic BP ≥ 140 mm Hg and/or diastolic BP ≥ 90 mm Hg. Poisson and Cox proportional hazards regression models determined associations of established cerebro/cardiovascular disease and HIV-related risk factors with stroke and tested whether these differed by stroke subtype.

Findings

590 strokes (83 hemorrhagic, 296 ischemic, 211 unknown) occurred over 339,979 person-years (PYRS) (incidence rate/1000 PYRS 1.74 [95% confidence interval (CI) 1.60-1.88]). Common predictors of both hemorrhagic and ischemic strokes were hypertension (relative hazard 3.55 [95% CI 2.29-5.50] and 2.24 [1.77-2.84] respectively) and older age (1.28 [1.17-1.39] and 1.19 [1.12-1.25]). Male gender (1.62 [1.14-2.31] and 0.60 [0.35-0.91]), previous cardiovascular events (4.03 [2.91-5.57] and 1.44 [0.66-3.16]) and smoking (1.90 [1.41-2.56] and 1.08 [0.68-1.71]) were stronger predictors of ischemic then hemorrhagic strokes, whereas hypertension, hepatitis C (1.32 [0.72-2.40] and 0.46 [0.30-0.70]) and estimated glomerular filtration rate < 60 mL/min/1.72 m3 (4.80 [2.47-9.36] and 1.04 [0.67-1.60]) were stronger predictors of hemorrhagic than ischemic strokes. A CD4 count < 200 cells/μL was associated with an increased risk of hemorrhagic stroke only.

Interpretation

Risk factors for stroke may differ by subtype in PLWHIV, emphasizing the importance of further research to increase the precision of stroke risk estimation.

Authors+Show Affiliations

Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Denmark.Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Denmark.Institute for Global Health, UCL, London, United Kingdom.Division of Infectious Diseases, Saint Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium.The Kirby Institute, UNSW Australia, Sydney, Australia.Institute for Global Health, UCL, London, United Kingdom.Amsterdam University Medical Center (location AMC), Dept. of Global Health and Div. of Infectious Diseases, University of Amsterdam, Amsterdam, the Netherlands. HIV Monitoring Foundation, Amsterdam, the Netherlands.Dipartimento di Scienze della Salute, Clinica di Malattie Infettive e Tropicali, Azienda Ospedaliera-Polo Universitario San Paolo, Milan, Italy.Institute for Global Health, UCL, London, United Kingdom.Department of Public Health, Nice University Hospital, Nice, France.Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Denmark.Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Switzerland.Université de Bordeaux, ISPED, INSERM U1219, CHU de Bordeaux, Bordeaux, France.ICAP-Columbia University, Harlem Hospital, New York, USA.Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Denmark.Institute for Global Health, UCL, London, United Kingdom.No affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

31517266

Citation

Hatleberg, Camilla Ingrid, et al. "Predictors of Ischemic and Hemorrhagic Strokes Among People Living With HIV: the D:A:D International Prospective Multicohort Study." EClinicalMedicine, vol. 13, 2019, pp. 91-100.
Hatleberg CI, Ryom L, Kamara D, et al. Predictors of Ischemic and Hemorrhagic Strokes Among People Living With HIV: The D:A:D International Prospective Multicohort Study. EClinicalMedicine. 2019;13:91-100.
Hatleberg, C. I., Ryom, L., Kamara, D., De Wit, S., Law, M., Phillips, A., ... Sabin, C. (2019). Predictors of Ischemic and Hemorrhagic Strokes Among People Living With HIV: The D:A:D International Prospective Multicohort Study. EClinicalMedicine, 13, pp. 91-100. doi:10.1016/j.eclinm.2019.07.008.
Hatleberg CI, et al. Predictors of Ischemic and Hemorrhagic Strokes Among People Living With HIV: the D:A:D International Prospective Multicohort Study. EClinicalMedicine. 2019;13:91-100. PubMed PMID: 31517266.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Predictors of Ischemic and Hemorrhagic Strokes Among People Living With HIV: The D:A:D International Prospective Multicohort Study. AU - Hatleberg,Camilla Ingrid, AU - Ryom,Lene, AU - Kamara,David, AU - De Wit,Stephane, AU - Law,Matthew, AU - Phillips,Andrew, AU - Reiss,Peter, AU - D'Arminio Monforte,Antonella, AU - Mocroft,Amanda, AU - Pradier,Christian, AU - Kirk,Ole, AU - Kovari,Helen, AU - Bonnet,Fabrice, AU - El-Sadr,Wafaa, AU - Lundgren,Jens D, AU - Sabin,Caroline, AU - ,, Y1 - 2019/08/11/ PY - 2017/12/07/received PY - 2019/06/25/revised PY - 2019/07/18/accepted PY - 2019/9/14/entrez PY - 2019/9/14/pubmed PY - 2019/9/14/medline KW - Cerebrovascular disease KW - HIV KW - Hemorrhagic stroke KW - Ischemic stroke KW - Risk factors KW - Stratified risk prediction KW - Stroke SP - 91 EP - 100 JF - EClinicalMedicine JO - EClinicalMedicine VL - 13 N2 - Background: Hypertension is a stronger predictor of hemorrhagic than ischemic strokes in the general population. We aimed to identify whether hypertension or other risk factors, including HIV-related factors, differ in their associations with stroke subtypes in people living with HIV (PLWHIV). Methods: HIV-1-positive individuals from the Data collection on Adverse events of anti-HIV Drugs (D:A:D) study were followed from the time of first blood pressure (BP) measurement after 1/1/1999 or study entry until the first of a validated stroke, 6 months after last follow-up or 1/2/2014. Stroke events were centrally validated using standardized criteria. Hypertension was defined as one systolic BP ≥ 140 mm Hg and/or diastolic BP ≥ 90 mm Hg. Poisson and Cox proportional hazards regression models determined associations of established cerebro/cardiovascular disease and HIV-related risk factors with stroke and tested whether these differed by stroke subtype. Findings: 590 strokes (83 hemorrhagic, 296 ischemic, 211 unknown) occurred over 339,979 person-years (PYRS) (incidence rate/1000 PYRS 1.74 [95% confidence interval (CI) 1.60-1.88]). Common predictors of both hemorrhagic and ischemic strokes were hypertension (relative hazard 3.55 [95% CI 2.29-5.50] and 2.24 [1.77-2.84] respectively) and older age (1.28 [1.17-1.39] and 1.19 [1.12-1.25]). Male gender (1.62 [1.14-2.31] and 0.60 [0.35-0.91]), previous cardiovascular events (4.03 [2.91-5.57] and 1.44 [0.66-3.16]) and smoking (1.90 [1.41-2.56] and 1.08 [0.68-1.71]) were stronger predictors of ischemic then hemorrhagic strokes, whereas hypertension, hepatitis C (1.32 [0.72-2.40] and 0.46 [0.30-0.70]) and estimated glomerular filtration rate < 60 mL/min/1.72 m3 (4.80 [2.47-9.36] and 1.04 [0.67-1.60]) were stronger predictors of hemorrhagic than ischemic strokes. A CD4 count < 200 cells/μL was associated with an increased risk of hemorrhagic stroke only. Interpretation: Risk factors for stroke may differ by subtype in PLWHIV, emphasizing the importance of further research to increase the precision of stroke risk estimation. SN - 2589-5370 UR - https://www.unboundmedicine.com/medline/citation/31517266/Predictors_of_Ischemic_and_Hemorrhagic_Strokes_Among_People_Living_With_HIV:_The_D:A:D_International_Prospective_Multicohort_Study L2 - https://linkinghub.elsevier.com/retrieve/pii/S2589-5370(19)30123-3 DB - PRIME DP - Unbound Medicine ER -