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Insomnia as an Independent Predictor of Incident Cardiovascular Disease in HIV

Data From the Veterans Aging Cohort Study

Polanka, Brittanny M., MSa; Kundu, Suman, DSc, MScb; So-Armah, Kaku A., PhDc; Freiberg, Matthew S., MD, MScb; Gupta, Samir K., MDd; Bedimo, Roger J., MD, MSe; Budoff, Matthew J., MDf; Butt, Adeel A., MD, MSg,h,i,j; Chang, Chung-Chou H., PhDk; Gottlieb, Stephen S., MDl; Marconi, Vincent C., MDm,n,o; Womack, Julie A., PhD, CNM, FNP-BCp,q; Stewart, Jesse C., PhDa

JAIDS Journal of Acquired Immune Deficiency Syndromes: May 1, 2019 - Volume 81 - Issue 1 - p 110–117
doi: 10.1097/QAI.0000000000001981
Clinical Science

Background: Insomnia is associated with increased cardiovascular disease (CVD) risk in the general population and is highly prevalent in people with HIV. The CVD risk conferred by insomnia in the HIV population is unknown.

Methods: Using the Veterans Aging Cohort Study Survey Cohort, insomnia symptoms were measured and dummy coded with the item, “Difficulty falling or staying asleep?” (5-point scale from no difficulty to bothers a lot). Incident CVD event ICD-9 codes (acute myocardial infarction, stroke, or coronary artery revascularization) were identified with the Department of Veterans Affairs (VA) and Medicare administrative data and VA fee-for-service data. Those with baseline CVD were excluded.

Results: HIV-infected (N = 3108) veterans had a median follow-up time of 10.8 years, during which 267 CVD events occurred. Compared to HIV-infected veterans with no difficulty falling or staying asleep, HIV-infected veterans bothered a lot by insomnia symptoms had an increased risk of incident CVD after adjusting for demographics [hazard ratio (HR) = 1.64, 95% confidence interval (CI): 1.16 to 2.31, P = 0.005], CVD risk factors (HR = 1.62, 95% CI: 1.14 to 2.30, P = 0.007), additional potential confounders (hepatitis C infection, renal disease, anemia, alcohol use, and cocaine use; HR = 1.70, 95% CI: 1.19 to 2.43, P = 0.003), and HIV-specific factors (HIV-1 RNA, CD4+ T-cell count, and antiretroviral therapy; HR = 1.66, 95% CI: 1.16 to 2.37, P = 0.005). Additional adjustment for nonbenzodiazepine sleep medication (HR = 1.62, 95% CI: 1.13 to 2.32, P = 0.009) did not attenuate the association; however, it fell short of significance at P < 0.01 after adjustment for depressive symptoms (HR = 1.51, 95% CI: 0.98 to 2.32, P = 0.060) or antidepressant medication (HR = 1.51, 95% CI: 1.04 to 2.19, P = 0.031).

Conclusions: Highly bothersome insomnia symptoms were significantly associated with incident CVD in HIV-infected veterans, suggesting that insomnia may be a novel, modifiable risk factor for CVD in HIV.

aDepartment of Psychology, Indiana University-Purdue University Indianapolis (IUPUI), Indianapolis, IN;

bDivision of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN;

cDivision of General Internal Medicine, Boston University School of Medicine, Boston, MA;

dDivision of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN;

eDivision of Infectious Diseases, VA North Texas Healthcare System, Dallas, TX;

fLos Angeles Biomedical Research Institute, Torrance, CA;

gVA Pittsburgh Healthcare System, Pittsburgh, PA;

hWeill Cornell Medical College, Doha, Qatar;

iWeill Cornell Medical College, New York, NY;

jHamad Medical Corp, Doha, Qatar;

kDepartment of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA;

lDepartment of Medicine, University of Maryland School of Medicine and Baltimore VAMC, Baltimore, MD;

mDivision of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA;

nAtlanta VA Medical Center, Atlanta, GA;

oDepartment of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA;

pVA Connecticut Healthcare System, West Haven, CT; and

qYale University School of Nursing, West Haven, CT.

Correspondence to: Jesse C. Stewart, PhD, Department of Psychology, Indiana University-Purdue University Indianapolis (IUPUI), 402 N. Blackford Street, LD 100E, Indianapolis, IN 46202 (e-mail:

S.K.G. reports funding from the National Institutes of Health, Indiana University, and Gilead Sciences; advisory board fees from Gilead Sciences and GlaxoSmithKline/ViiV; and travel support to present data at scientific conferences from Gilead Sciences and Bristol‐Myers Squibb. M.J.B. reports funding from the National Institutes of Health and General Electric. A.A.B. reports funding from Gilead, and Merck. J.C.S. reports funding from the National Institutes of Health and Indiana University. The Veterans Aging Cohort Study was funded by grant U10AA13566 from the National Institute on Alcohol Abuse and Alcoholism and Veterans Health Administration Public Health Strategic Health Core Group. This analysis was funded in part by grant R01HL126557 from the National Institutes of Health.

Oral presentation presented at the 76th annual meeting of the American Psychosomatic Society; March 7–10, 2018; Louisville, Kentucky.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the Department of Veterans Affairs or the National Institutes of Health. The remaining authors have no funding or conflicts of interest to disclose.

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Received June 26, 2018

Accepted December 27, 2018

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