Key considerations for people living with HIV

Cardiac involvement in people with HIV/AIDS is relatively common and includes diseases such as coronary artery disease (CAD), also known as coronary heart disease (CHD).1 CAD underlies many of the manifestations of cardiovascular (CV) disease including:2

  • Atherosclerosis
  • Coronary artery disease
  • Myocardial ischemia
  • Coronary thrombosis
  • Myocardial infarction
  • Arrhythmia and loss of muscle
  • Remodeling
  • Ventricular dilation
  • Congestive heart failure
  • End stage heart disease

 

  • The European Society for Cardiology (ESC) highlights that the clinical presentations of ischemic heart disease include silent ischemia, stable angina pectoris, unstable angina, myocardial infarction (MI), heart failure and sudden death.3 Unstable CAD, also known as the acute coronary syndromes (ACS), includes a number of conditions from unstable angina to transmural MI.4
  • CAD involves two distinct processes: gradual luminal narrowing slowly over decades (atherosclerosis), and complete/partial coronary occlusion (thrombosis, vasospasm, or both) that occurs rapidly in a sudden and unpredictable way.3
    • Generally, atherosclerosis predominates in chronic stable angina, whereas thrombosis is the critical component of lesions responsible for ACS.3

Information in this website covers aspects of CAD, including chronic stable angina and ACS. As there is currently no separate specific guidance on the management of CAD in people living with HIV (PLWHIV), the information is not specific to the HIV population and predominantly relates to management in the general population.



HIV is viewed as a potential risk factor for CAD.1 Studies have shown a higher incidence of CAD in PLWHIV compared with non-infected people,5,6 though comparisons may be limited due to difficulties in selecting an appropriate control group.7

  • Increased hospitalization rates for CHD in HIV-infected patients have been demonstrated.6
  • In addition, atherosclerosis, which causes CAD, is known to occur in PLWHIV more frequently than in HIV-negative subjects.8,9
  • Investigation of subclinical atherosclerosis in young asymptomatic men with long standing HIV-infection showed a higher prevalence of coronary atherosclerosis in HIV-infected versus non-infected men (59% versus 34%, p=0.02).10
    • In addition, 6.5% of this study population demonstrated evidence of obstructive CAD (>70% luminal narrowing), compared with 0% of controls.
       
  • In a small study of PLWHIV who died due to AIDS, 35% of HIV-infected patients had luminal narrowing of ≥75% in at least one coronary artery, compared with 16% of HIV-negative controls.11
    • compared with controls, HIV-infected patients had three times greater odds of stenosis ≥75%, after controlling for age and sex differences.11
       
  • An increase in vascular age, as measured by the amount of coronary artery calcium (CAC), has been demonstrated in mid-aged patients (mean age 48 years) with stable HIV-infection receiving antiretroviral therapy.12
  • In this study, increased vascular age was found to be frequent among HIV-infected patients and appeared to be associated with an increased CD4+ cell count.

Several hypotheses have been proposed regarding the pathophysiology of atherosclerotic CAD in PLWHIV receiving highly active anti-retroviral therapy (HAART). Refer to the section on Causes of CAD for more information. 


For information on CV disease prevention refer to the main CV disease page of this website, where a downloadable document on prevention is available. 



Dyslipidemia will be covered as a separate medical condition within this website (upcoming); refer to this or to guidelines from the Infectious Disease Society of America (IDSA).



References

  1. Khunnawat C, Mukerji S, Havlichek D Jr, Touma R, Abela GS. Cardiovascular manifestations in human immunodeficiency virus-infected patients. Am J Cardiol. 2008; 102:635–642.
  2. Dzau V, Braunwald E. Resolved and unresolved issues in the prevention and treatment of coronary artery disease: a workshop consensus statement. Am Heart J. 1991; 121:1244–263.
  3. European Society of Cardiology Full Guidelines and Pocket Guidelines on Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation (2007). Accessed 3 May 2011.
  4. Scottish Intercollegiate Guidelines Network. Guideline 93: Acute Coronary Syndromes.
  5. Boccara F, Cohen A. Coronary artery disease and stroke in HIV-infected patients: prevention and pharmacological therapy. Adv Cardiol. 2003; 40:163–184.
  6. Klein D, Hurley LB, Quesenberry CP Jr, Sidney S. Do protease inhibitors increase the risk for coronary heart disease in patients with HIV-1 infection? J Acquir Immune Defic Syndr. 2002; 30:471–477.
  7. Grinspoon SK, Grunfeld C, Kotler DP, et al. State of the science conference: Initiative to decrease cardiovascular risk and increase quality of care for patients living with HIV/AIDS: executive summary. Circulation. 2008; 118:198–210.
  8. Grunfeld C, Delaney JA, Wanke C, et al. Preclinical atherosclerosis due to HIV infection: carotid intima-medial thickness measurements from the FRAM study. AIDS. 2009; 23:1841–1849.
  9. Hulten E, Mitchell J, Scally J, Gibbs B, Villines TC. HIV positivity, protease inhibitor exposure and subclinical atherosclerosis: a systematic review and meta-analysis of observational studies. Heart. 2009; 95:1826–1835.
  10. Lo J, Abbara S, Shturman L, et al. Increased prevalence of subclinical coronary atherosclerosis detected by coronary computed tomography angiography in HIV-infected men. AIDS. 2010; 24:243–253.
  11. Micheletti RG, Fishbein GA, Fishbein MC, et al. Coronary atherosclerotic lesions in human immunodeficiency virus-infected patients: a histopathologic study. Cardiovasc Pathol. 2009; 18:28–36.
  12. Guaraldi G, Zona S, Alexopoulos N, et al. Coronary aging in HIV-infected patients. Clin Infect Dis. 2009; 49:1756–1762.