1. Aging and Cardiovascular Disease Marek Smieja, MD PhD FRCPC

2. Atherosclerosis and Cardiovascular Disease

3. Cardiovascular Disease Heart attack (myocardial infarction) –Death, bypass surgery or coronary angioplasty –Heart failure, recurrent angina Stroke –Death –Disability: weakness, sensory, speech Renal: dialysis or transplant Peripheral vascular disease –Gangrene, infections –Impotence

4. Heart Attacks increase with Age Incidence / 1000 PY/ 95% CI Events PYFU 0 2 2 15 55 80 80 75 53 34 25 24 445 275 2322 7408 18012 32551 30991 18600 12209 7583 4024 1916 1413 137310 Age group <2020-2425-29 30-3450-5435-3940-4445-4955-5960-64 D:A:D study: Friis-Møller et al, NEJM, 2007 Adjusted* relative rate: 1.32 (32%) / 5 years = 1.06 (6%) / year >7065-69

5. Predicting Risk of Heart Disease Age Male Smoking Cholesterol Blood pressure Diabetes

6. *Framingham equation Law et al, HIV Medicine, 2006 Observed and Predicted Heart Attack Rates Copenhagen Risk Score underpredicted by 40%

7. …and now for the good news “Age as a modifiable risk factor” –Allen Sniderman –Years of risk factor acting, not age per se –Smoking, cholesterol, blood pressure damage arteries –Almost NO progression of disease in absence of risk factors

8. Smoking and Heart Attacks Cui Qu (poster): 60% smokers vs. 20% Ontario Continue smoking: 3.0 X (90% lifelong!) Former smoking: 1.8 X-DAD study Heavy smoking (>40 cig/day): 9.0 X Second-hand smoking: –1-3 hours/day: 1.24 X –>3 hours/day: 1.62 X-InterHeart Scotland smoking ban (NEJM 2008): –17% decrease in MI (versus 3% in England) –21% never smokers, 19% former smokers

9. Cholesterol and Heart Attacks Total cholesterol, LDL (“bad”) cholesterol –Mediterranean Diet –Statins slow atherosclerosis, prevent heart attacks HDL (“good”) cholesterol protective –Lifestyle: smoking cessation, exercise –Drugs not very effective or even harmful Statin drugs most effective –No effect of Vitamin C, E, beta-carotene, B6/B12/folate, fish oils?

10. Developing Canadian Evidence-Based Guidelines on Cardiovascular Risk in HIV Marek Smieja Astha Ramaiya Greg Bondy Unrestricted educational grants from: Abbott, Astra-Zeneca, BI, BMS, Gilead, GSK, Merck, Pfizer, Tibotec, CIHR

11. Participants Marek Smieja Astha Ramaiya Greg Bondy Jacques Genest Allan Sniderman Jean-Guy Baril Julian Falutz Marianne Harris Sean Hosein Mona Loutfy Anita Rachlis Linda Robinson

12. Canadian Guidelines Summary Smieja et al, CAHR 2008 (B-II)1. HIV is a weak cardiac risk factor (B-II) (A-II)2. Smoking main cause (A-II) (B-II(C-II)3. HAART: PI (B-II) > NRTI (C-II) > NNRTI (B-II) –Starting & stopping HAART (B-II) (B-II) (C-II)4. Screening-Framingham (B-II) + time on HAART (C-II) (A-I),(B-I)5. Treatment-statins (A-I), switching (B-I) (A-I) smoking cessation meds (A-I)

13. Solutions to Aging & Heart Disease: S&M Stop Smoking –Avoid all smoking including passive smoking Start Statins –Best data on large benefit, low risks Switch HIV therapies –Maximize viral load suppression, –Minimize lipid abnormalities Stress management Slim Sweat: (s)exercise & Mediterranean diet