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Association of Syndemic Unhealthy Alcohol Use, Smoking, and Depressive Symptoms on Incident Cardiovascular Disease among Veterans With and Without HIV-Infection

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Abstract

Unhealthy alcohol use, smoking, and depressive symptoms are risk factors for cardiovascular disease (CVD). Little is known about their co-occurrence – termed a syndemic, defined as the synergistic effect of two or more conditions—on CVD risk in people with HIV (PWH). We used data from 5621 CVD-free participants (51% PWH) in the Veteran’s Aging Cohort Study-8, a prospective, observational study of veterans followed from 2002 to 2014 to assess the association between this syndemic and incident CVD by HIV status. Diagnostic codes identified cases of CVD (acute myocardial infarction, stroke, heart failure, peripheral artery disease, and coronary revascularization). Validated measures of alcohol use, smoking, and depressive symptoms were used. Baseline number of syndemic conditions was categorized (0, 1, ≥ 2 conditions). Multivariable Cox Proportional Hazards regressions estimated risk of the syndemic (≥ 2 conditions) on incident CVD by HIV-status. There were 1149 cases of incident CVD (52% PWH) during the follow-up (median 10.1 years). Of the total sample, 64% met our syndemic definition. The syndemic was associated with greater risk for incident CVD among PWH (Hazard Ratio [HR] 1.87 [1.47–2.38], p < 0.001) and HIV-negative veterans (HR 1.70 [1.35–2.13], p < 0.001), compared to HIV-negative with zero conditions. Among those with the syndemic, CVD risk was not statistically significantly higher among PWH vs. HIV-negative (HR 1.10 [0.89, 1.37], p = .38). Given the high prevalence of this syndemic combined with excess risk of CVD, these findings support linked-screening and treatment efforts.

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Availability of Data and Material

VACS codebooks are available online at https://medicine.yale.edu/intmed/vacs/. Data and code used for the current manuscript is available upon request and approval from the VACS Executive Committee.

Code Availability

SAS code pertaining to the current manuscript is available upon request.

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Acknowledgements

We would like to thank the participants of the Veterans Aging Cohort Study.

Funding

This work is supported by The National Heart, Lung, and Blood Institute (K12HL143956 to M.F., N.C.); The National Institute on Alcohol Abuse and Alcoholism (K01AA029042 to N.C.); ViTAL: The Vanderbilt Center for Tobacco, Addiction and Lifestyle (to H.T., M.F., N.C.); V-CREATE: Vanderbilt Clinical Cardiovascular Outcomes Research and Trials Evaluation (to M.F., H.T., N.C.); The Veterans Aging Cohort Study was funded by the National Institute on Alcohol Abuse and Alcoholism U24-AA020794, U01-AA020790, U01-AA02201, and U10-AA013566. The Funders had no involvement in the conduct, collection, analysis, or interpretation of the data, nor the preparation, review, or approval of the manuscript.

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Authors and Affiliations

  1. Department of Medicine, Vanderbilt University Medical Center, 2525 West End Avenue, Office 315, Nashville, TN, 37203, USA

    Natalie E. Chichetto, Suman Kundu, Matthew S. Freiberg, John R. Koethe & Hilary A. Tindle

  2. Geriatric Research Education and Clinical Centers (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA

    Matthew S. Freiberg & Hilary A. Tindle

  3. VA Pittsburgh Healthcare System, Pittsburgh, PA, USA

    Adeel A. Butt

  4. Department of Medicine, Weill-Cornell Medical College, Doha, USA

    Adeel A. Butt

  5. Hamad Medical Corporation, Doha, Qatar

    Adeel A. Butt

  6. Health Care Policy, and Aging Research and School of Social Work, Institute for Health, Rutgers University, New Brunswick, NJ, USA

    Stephen Crystal

  7. Department of Medicine, Boston University School of Medicine, Boston, MA, USA

    Kaku A. So-Armah

  8. Department of Epidemiology, Colleges of Public Health and Health Professions and Medicine, University of Florida, Gainesville, FL, USA

    Robert L. Cook

  9. Department of Population Health, New York University School of Medicine, New York, NY, USA

    R. Scott Braithwaite & Maria Khan

  10. Schools of Medicine and Public Health, Yale University, New Haven, CT, USA

    Amy C. Justice, David A. Fiellin & Julie R. Gaither

  11. Veterans Affairs Connecticut Healthcare System, New Haven, CT, USA

    Amy C. Justice

  12. National Institute On Alcohol Abuse and Alcoholism, Bethesda, MD, USA

    Kendall J. Bryant

  13. Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, KY, USA

    Shirish S. Barve

  14. Department of Medicine, University of Washington, Seattle, WA, USA

    Kristina Crothers

  15. Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA

    Roger J. Bedimo

  16. Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CT, USA

    Alberta Warner

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  1. Natalie E. Chichetto
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  2. Suman Kundu
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  8. Robert L. Cook
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  9. R. Scott Braithwaite
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on behalf of the Veterans Aging Cohort Study

Contributions

All authors contributed to the concept and design of the analyses. N.C., S.K., M.F., and H.T. let the analytic plan and final data analyses. N.C., S.K., M.F., H.T., and JK led the initial drafting of the manuscript and interpretation of results. All authors were responsible for critical review and revisions to the analyses and interpretation of results. Any expressed views do not represent those of the US Government.

Corresponding author

Correspondence to Natalie E. Chichetto.

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Conflicts of Interest

The authors have no conflicts of interest to report.

Ethical Approval

Approval of the Veterans Aging Cohort Study (VACS) was obtained from the institutional review board of the Yale School of Medicine. The following analyses were approved by the institutional review board of Vanderbilt University Medical Center.

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All participants gave written informed consent to participate in the VACS-8 survey cohort.

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Chichetto, N.E., Kundu, S., Freiberg, M.S. et al. Association of Syndemic Unhealthy Alcohol Use, Smoking, and Depressive Symptoms on Incident Cardiovascular Disease among Veterans With and Without HIV-Infection. AIDS Behav 25, 2852–2862 (2021). https://doi.org/10.1007/s10461-021-03327-4

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