CROI 2017 Abstract e-Book

Abstract eBook

Poster and Themed Discussion Abstracts

346 THE ROLE OF PRESTROKE IMMUNE STATUS IN STROKE MECHANISMS IN HIV+ INDIVIDUALS Jose Gutierrez 1 , Camilla Ingrid Hatleberg 2 , Henry W. Evans 1 , Michael T. Yin 1 1 Columbia Univ, New York, NY, USA, 2 CHIP, Copenhagen, Denmark Background: Autopsy studies from HIV+ individuals suggest an association between intracranial atherosclerosis with lower nadir CD4 but higher CD4 count at the time of death. It is unknown whether the same association applies to HIV+ individuals with ischemic stroke. Methods: A retrospective chart review of inpatient admissions for ICD-9 defined ischemic stroke in HIV+ individuals from 2002-2016 at a tertiary care center was performed. Stroke mechanisms were ascertained based on radiographic and clinical presentation, and adjudicated by examining the diagnostic results by pre-defined criteria. The prevalence of vascular risk factors, use of antiretroviral drugs (ARVs), nadir CD4 and absolute CD4 counts (cells/mm3) at the time of stroke were captured. Logistic regressions were used to calculate the odds ratios (OR) and 95% confidence intervals (CIs) adjusting for age, sex, ethnicity, vascular risk factors and ARVs. Results: Among 115 cases of stroke, the median age was 52 ± 12 years, and 64%were men. The distribution of stroke mechanisms were 26% intracranial atherosclerosis, 12% small artery disease, 14% infectious, 8% cardioembolic, 31% cryptogenic, and 9% other etiologies. The median nadir CD4-count was 154 (IQR 22-300), and 351 (IQR 103-546) at the time of stroke, and 53%were on ARVs. At the time of stroke; infectious etiologies were less common with increasing CD4 counts (OR 0.44 per each 50 cells/mm3 , 95%CI 0.70- 0.99) while intracranial atherosclerosis stroke were more common with vascular risk factors (OR 1.5, 95%CI 1.00-2.18) and higher CD4 counts (OR 1.08, 95%CI 1.00-1.18). Statistical interaction was found between lower nadir CD4-count and greater absolute gain in CD4 count at the time of stroke (P=0.01) for stroke due to intracranial atherosclerosis. Among individuals with nadir CD4 counts < 200, but absolute CD4 counts gains > 200 from nadir to the time of stroke, intracranial atherosclerosis was the more common stroke mechanism (OR 4.44, 95%CI 1.31-15.07). Conclusion: In one of the largest studies of HIV+ individuals focused on ischemic stroke mechanisms, intracranial atherosclerosis was the most frequent stroke mechanisms among those with lower nadir CD4 counts but higher CD4 counts at the time of stroke. Determining the association between pre-stroke immune status and stroke mechanisms may allow a targeted approach to stroke prevention. 347 TYPES OF ISCHEMIC STROKES AMONG HIV-INFECTED INDIVIDUALS ACROSS THE UNITED STATES Heidi M. Crane 1 , Robin M. Nance 1 , Felicia C. Chow 2 , Christina Marra 3 , Joseph Zunt 1 , Emily Ho 1 , Richard D. Moore 4 , Daniel Drozd 1 , Mari Kitahata 1 , David Tirschwell 1 1 Univ of Washington, Seattle, WA, USA, 2 Univ of California San Francisco, San Francisco, CA, USA, 3 HarborviewMed Cntr, Seattle, WA, USA, 4 The Johns Hopkins Univ, Baltimore, MD, USA Background: Most of the evidence for an increased risk of cardiovascular disease (CVD) in HIV is from studies of myocardial infarction. Estimates of stroke risk are less well- defined, in part because of the lack of a standard approach to identifying stroke in HIV. We developed a protocol to identify and validate stroke type (ischemic vs. hemorrhagic), ischemic sub-types, etiologies and risk factors including CNS infection and illicit drug use to address questions specific to HIV. Methods: Using comprehensive diagnosis and procedure codes, we first identified potential stroke events at 5 sites in CNICS, a US multisite clinical cohort of HIV-infected individuals receiving longitudinal care. Sites then assembled de-identified packets of provider notes and neuroimaging results for each potential event. Two neurologists reviewed each packet, followed by a 3rd if discrepancies occurred. Each neurologist identified stroke type, subtype and whether the stroke was associated with infection or illicit drug use. We compared demographic and clinical characteristics, including those related to HIV and CVD risk, by ischemic stroke subtype. Results: Among 20,973 HIV-infected individuals, 312 had a stroke, 253 (81%) of which were ischemic. Of these, 41% occurred in the setting of illicit drug use or infection. Ischemic stroke subtypes included large vessel atheroembolic (23%); cardioembolic (30%); small vessel (31%); and other/unknown (15%). Those with cardioembolic strokes were younger (21% vs. 8%<40 years, p<0.01) and more likely to be associated with illicit drug use or CNS infection (50% vs. 27%, p<0.01) compared with individuals with small vessel strokes. Small vessel strokes were associated with use of antihypertensive medications, higher systolic blood pressure (mean 138 vs. 129 or 130mmHg, p=0.02), and higher total cholesterol (mean 196 vs. 168 or 183 mg/dL, p=0.03) compared to those with cardioembolic or atheroembolic stroke respectively. Conclusion: Ischemic stroke, particularly small vessel and cardioembolic subtypes are most common in HIV. A high proportion of ischemic and particularly cardioembolic strokes were related to illicit drug use or infection. Those with small vessel strokes had a more severe CVD risk profile. Rigorous stroke type and subtype definitions allowed for clear elucidation of traditional and non-traditional risk factors associated with stroke types which will better inform interventions designed to improve clinical management and reduce risk.

Poster and Themed Discussion Abstracts

CROI 2017 136