Antiretroviral Drugs and the Risk of Myocardial Infarction

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Abstract
We agree with the Perspective article by Hughes and Williams (April 26 issue)1 that a more detailed presentation of data from the well-conducted Data Collection on Adverse Effects of Anti-HIV Drugs (DAD) Study Group collaboration2 may help to disentangle several variables that potentially affect the risk of myocardial infarction among persons infected with human immunodeficiency virus type 1 (HIV-1). First, data on the nadir CD4+ lymphocyte count, but not the recent CD4+ count, were presented in relation to the risk of myocardial infarction. Inflammation may trigger an acute myocardial infarction by activating prothrombotic mechanisms, and the patient's immune status at the time of the myocardial infarction is most relevant in this regard. Moreover, inflammation increases markedly with the onset of clinical AIDS.3 Therefore, threshold models relating a low CD4+ count (i.e., <200 cells per cubic millimeter) with myocardial infarction may be more biologically plausible than linear models.