title: Baseline, Time-Updated, and Cumulative HIV Care Metrics for Predicting Acute Myocardial Infarction and All-Cause Mortality.
abstract: BACKGROUND
  After adjustment for cardiovascular risk factors and despite higher mortality, those with human immunodeficiency virus (HIV+) have a greater risk of acute myocardial infarction (AMI) than uninfected individuals.
  
  
  METHODS
  We included HIV+ individuals who started combination antiretroviral therapy (cART) in the Veterans Aging Cohort Study (VACS) from 1996 to 2012. We fit multivariable proportional hazards models for baseline, time-updated and cumulative measures of HIV-1 RNA, CD4 counts, and the VACS Index. We used the trapezoidal rule to build the following cumulative measures: viremia copy-years, CD4-years, and VACS Index score-years, captured 180 days after cART initiation until AMI, death, last clinic visit, or 30 September 2012. The primary outcomes were incident AMI (Medicaid, Medicare, and Veterans Affairs International Classification of Diseases-9 codes) and death.
  
  
  RESULTS
  A total of 8168 HIV+ individuals (53 861 person-years) were analyzed with 196 incident AMIs and 1710 deaths. Controlling for known cardiovascular risk factors, 6 of the 9 metrics predicted AMI and all metrics predicted mortality. Time-updated VACS Index had the lowest Akaike information criterion among all models for both outcomes. A time-updated VACS Index score of 55+ was associated with a hazard ratio (HR) of 3.31 (95% confidence interval [CI], 2.11-5.20) for AMI and a HR of 31.77 (95% CI, 26.17-38.57) for mortality.
  
  
  CONCLUSIONS
  Time-updated VACS Index provided better AMI and mortality prediction than CD4 count and HIV-1 RNA, suggesting that current health determines risk more accurately than prior history and that risk assessment can be improved by biomarkers of organ injury.
authors.affiliation: School of Medicine.|Rollins School of Public Health, Emory University.
authors.forename: Jorge L
authors.initials: JL
authors.lastname: Salinas
authors.affiliation: Atlanta Veterans Affairs Medical Center, Georgia.|West Haven Veterans Administration Medical Center.|Yale University Schools of Medicine and Public Health, New Haven, Connecticut.
authors.forename: Christopher
authors.initials: C
authors.lastname: Rentsch
authors.affiliation: School of Medicine.|Rollins School of Public Health, Emory University.|Atlanta Veterans Affairs Medical Center, Georgia.
authors.forename: Vincent C
authors.initials: VC
authors.lastname: Marconi
authors.affiliation: West Haven Veterans Administration Medical Center.|Yale University Schools of Medicine and Public Health, New Haven, Connecticut.
authors.forename: Janet
authors.initials: J
authors.lastname: Tate
authors.affiliation: Veterans Affairs Greater Los Angeles Health Care System and David Geffen School of Medicine at University of California-Los Angeles, California.
authors.forename: Matthew
authors.initials: M
authors.lastname: Budoff
authors.affiliation: University of Pittsburgh School of Medicine and VA Pittsburgh Healthcare System, Pennsylvania.|Weill Cornell Medical College, Doha, Qatar and New York City.|Hamad Healthcare Quality Institute, Hamad Medical Corporation, Doha, Qatar.
authors.forename: Adeel A
authors.initials: AA
authors.lastname: Butt
authors.affiliation: Vanderbilt University, Nashville, Tennessee.
authors.forename: Matthew S
authors.initials: MS
authors.lastname: Freiberg
authors.affiliation: Wasington DC VA Medical Center and George Washington University School of Medicine, Washington D.C.
authors.forename: Cynthia L
authors.initials: CL
authors.lastname: Gibert
authors.affiliation: Veterans Affairs Greater Los Angeles Health Care System and David Geffen School of Medicine at University of California-Los Angeles, California.
authors.forename: Matthew Bidwell
authors.initials: MB
authors.lastname: Goetz
authors.affiliation: Veterans Affairs Greater Los Angeles Health Care System and David Geffen School of Medicine at University of California-Los Angeles, California.
authors.forename: David
authors.initials: D
authors.lastname: Leaf
authors.affiliation: Infectious Diseases Section, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, Texas.
authors.forename: Maria C
authors.initials: MC
authors.lastname: Rodriguez-Barradas
authors.affiliation: West Haven Veterans Administration Medical Center.|Yale University Schools of Medicine and Public Health, New Haven, Connecticut.
authors.forename: Amy C
authors.initials: AC
authors.lastname: Justice
authors.affiliation: School of Medicine.|Atlanta Veterans Affairs Medical Center, Georgia.
authors.forename: David
authors.initials: D
authors.lastname: Rimland
mesh_terms: D000328:Adult; D000368:Aged; D000375:Aging; D015415:Biomarkers; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy / Q000821:virology; D015497:HIV-1 / Q000302:isolation & purification; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology* / Q000401:mortality* / Q000821:virology; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D014481:United States; D014728:Veterans / Q000706:statistics & numerical data; D014766:Viremia
chemical_list: D015415:Biomarkers
keywords: HIV; VACS Index; acute myocardial infarction; mortality