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Taking care of the ticker
As people living with HIV get older and live longer, they become vulnerable to all the complications of ageing — including cardiovascular disease. Cardiovascular disease (CVD) is an umbrella term that refers to conditions that can negatively affect heart health. The main types of CVD in Australia are coronary heart disease, stroke and heart failure.
Several large international studies have shown that people with HIV are one-and-a-half to two times more at risk of CVD than HIV-negative people. Indeed, CVD is now perhaps one of the most common causes of death for people with HIV. As awareness of the increasing problem of cardiovascular disease has grown, many doctors now have an important secondary goal in HIV management: to try to reduce the risk of CVD in people with HIV.
While trying to understand that might be driving this elevated risk, researchers have reached a number of conclusions. Firstly, changes in blood lipids (fats) are associated with antiretroviral treatments, increasing the risk of cardiovascular disease. This risk has been well studied and doctors are now able to keep patients off these drugs if necessary.
Secondly, many of the risks associated with CVD in the general population — such as smoking, elevated cholesterol or hypertension (high blood pressure) — are more widespread among people with HIV. Thirdly, HIV itself seems to play a role in elevating cardiovascular risk. It is clear from studies that, when compared to people on HIV treatment, those who are not have an increased risk of heart disease.
Even among people on treatment, the prospect of CVD is still elevated. The reasons for this are not entirely clear but some researchers have speculated that even very low levels of viral activity — below what can be detected — may induce an inflammatory immune response that, over many years, can exacerbate such conditions as hardening of the arteries. However, trials have found that antiretroviral treatment generally protects against cardiovascular disease with more heart attacks recorded among those who delayed or stopped treatment than those who started and stayed on treatment.
There are two main categories for major risks of CVD: those we can’t control and those we can. Among those factors out of our control are genetics; some families are just more predisposed toward CVD than others. Both gender and age also strongly influence heart health. Generally, men have a greater risk of CVD than women, and at an earlier age. For men, risk begins to increase from 45-plus, women 55-plus.
The risks that we can control are abdominal obesity, elevated cholesterol, hypertension, diabetes, smoking and depression. This seems like a daunting list, but the fact we can act to reduce these risk factors is good news.
Carrying extra weight around the gut is more of a risk for CVD than carrying it elsewhere. Unfortunately, this is a particular problem for men, who typically put on abdominal weight as they age. It’s recommended that men try to keep their waist circumference below 94cm and women below 80cm. Another way to think about weight is using the Body Mass Index (BMI) which should be between 18 and 25.
If your cholesterol is high, there are a number of strategies available. A healthy diet low in saturated fats is a good start and fish oil capsules have also shown to be a benefit. For some people, drugs called statins may be prescribed to lower cholesterol.
Blood pressure, when elevated, places stress on the heart, and the arteries that supply blood to the heart. Over time, this increases the risk of heart attack. Reducing salt in your diet is a good way to start controlling blood pressure as is maintaining a healthy weight, taking regular exercise and limiting alcohol consumption. If these things don’t lead to a reduction then medications are available.
Diabetes is intolerance to sugar in the blood and is diagnosed through a blood test. Diabetes can be managed through various lifestyle measures including healthy eating, weight control and smoking cessation. In more serious cases insulin therapy may be recommended.
Smoking is a major risk for CVD and can also exacerbate many of the other risk factors already mentioned. The benefits of quitting are widely known and support is available to quit from doctors and HIV organisations.
Psycho-social factors such as depression are now recognised as independent risks for CVD. Allowing depression to go untreated can be both emotionally and physically damaging. A combination of counselling and antidepressant medication seems to work best for most people with depression. Talk to your doctor about the options.
In looking at these different risks and thinking about how to address them it’s important to know one thing: cardiovascular risks multiply one another, they don’t just add to each other. That means that if you have three or more risks your total risk of CVD is exponentially higher than if you only have one. That’s the bad news; the better news is that by addressing one or two factors you’ll significantly reduce your total risk.
What works for most people and tends to be sustainable are small regular steps in the right direction rather than dramatic diets or extreme exercise regimes. Likewise with smoking, using nicotine replacement therapy for several months is more likely to succeed than going cold turkey. Last but not least, if you are over 40 make sure you get a CVD risk assessment from your doctor. Knowing your level of risk is the first step towards reducing cardiovascular disease.