Risk Factors

Increased coronary heart disease (CHD) rates among HIV-infected patients may be associated with traditional risk factors, and non-traditional factors such as body composition changes (loss of subcutaneous fat and/or accumulation of visceral fat), inflammation, direct effects of the virus on the vasculature and direct effects of specific antiretroviral (ARV) drugs.1 Traditional cardiovascular (CV) risk factors may be more common in people living with HIV (PLWHIV) versus HIV-negative people.2

Traditional CV risk factors include:

  • dyslipidaemia, including hypertriglyceridaemia and hypercholesterolaemia1,3
  • smoking1,3,4
  • premature menopause in women3
  • family history3
  • diabetes mellitus,3 insulin resistance and impaired glucose tolerance1
  • age (>45 years)1,3 
  • hypertension4

Data suggest that increasing the duration of ARV therapy, particularly protease inhibitors (PIs), increases the risk of myocardial infarction (MI) in PLWHIV.5

  • Use of non-nucleoside reverse transcriptase inhibitors (NNRTIs) and PIs (alone and particularly in combination) is associated with a lipid profile known to increase the risk of coronary heart disease (CHD), particularly among older patients with suppressed HIV replication and normalized CD4 cell counts6
  • In recent years, the D:A:D study suggested a link between abacavir and increased risk of MI.7 However, the majority of recent randomized-controlled data, cohort analyses that control for known risk factors, and mechanistic data have not supported an association between abacavir and increased risk of MI.8,9 It should be noted that these studies were not prospectively designed to measure risk of MI
  • When looking at data regarding MI risk, health care providers should take into consideration all data - RCTs, cohorts, and biomarker studies - and recognize the advantages and limitations of each

In one study assessing 10-year predicted CHD risk in HIV-infected men and women, the identified risk factors included:10

  • HIV-related factors associated with CHD risk:11
    • use of highly active ARV therapy (HAART) (CHD risk was lower in HAART-naïve individuals)
    • use of PI-based regimens (non-PI-based HAART and former HAART users had a lower risk of CHD)
    • history of AIDS
       
  • non-HIV related factors associated with CHD risk:10
    • low income
    • overweight and obese individuals
    • alcohol consumption
    • gender (women were less likely than men to have CHD risk)

In a study of 78 HIV-infected men, the following traditional and non-traditional risk factors were significantly associated with atherosclerotic plaque burden:11

  • Framingham score
  • total cholesterol
  • •ow-density lipoprotein levels
  • CD4/CD8 cell ratio
  • monocyte chemo-attractant protein 1 levels


Nearly all PLWHIV who developed acute coronary syndromes (ACS) in one study had traditional coronary risk factors.12 In another study, PLWHIV who developed ACS compared with HIV-negative ACS patients:13

  • were younger, more likely to be male, current smokers and to have low HDL cholesterol levels
  • had lower thrombolysis in MI (TIMI) risk scores and were more likely to have single-vessel disease
  • had unexpectedly high restenosis rates after percutaneous coronary intervention

Prevention strategies recommended for coronary artery disease (CAD), and that may be applied to people living with HIV, are based on lifestyle modifications.





References

  1. 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. 
  2. Baker JV, Lundgren JD. Cardiovascular implications from untreated human immunodeficiency virus infection. Eur Heart J. 2011;32:945–951.  
  3. Passalaris JD, Sepkowitz KA, Glesby MJ. Coronary artery disease and human immunodeficiency virus infection. Clin Infect Dis. 2000;31:787–797.
  4. Hsue PY, Hunt PW, Schnell A, et al. Role of viral replication, antiretroviral therapy, and immunodeficiency in HIV-associated atherosclerosis. AIDS. 2009;23(9):1059–1067. 
  5. Boccara F. Cardiovascular complications and atherosclerotic manifestations in the HIV-infected population: type, incidence and associated risk factors. AIDS. 2008;22(Suppl 3):S19-26. 
  6. Friis-Møller N, Weber R, Reiss P, et al; DAD study group. Cardiovascular disease risk factors in HIV patients--association with antiretroviral therapy. Results from the DAD study. AIDS. 2003;17:1179-1193. 
  7. The SMART/INSIGHT and the D:A:D Study Groups. Use of nucleoside reverse transcriptase inhibitors and risk of myocardial infarction in HIV-infected patients. AIDS. 2008;22(14): F17-24.
  8. Cruciani M, Zanichelli V, Serpelloni G, et al. ABACAVIR use and cardiovascular disease events: a meta-analysis of published and unpublished data. AIDS. 2011 Jun 29. [Epub ahead of print].
  9. Ribaudo HJ, Benson CA, Zheng Y, et al. No risk of myocardial infarction associated with initial antiretroviral treatment containing abacavir: short and long-term results from ACTG A5001/ALLRT. Clin Infect Dis. 2011;1;52(7):929-940.
  10. Kaplan RC, Kingsley LA, Sharrett AR, et al. Ten-year predicted coronary heart disease risk in HIV-infected men and women. Clin Infect Dis. 2007;45(8):1074–1081.
  11. 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.  
  12. Ambrose JA, Gould RB, Kurian DC, et al. Frequency of and outcome of acute coronary syndromes in patients with human immunodeficiency virus infection. Am J Cardiol. 2003;92:301–303. 
  13. Hsue PY, Giri K, Erickson S, et al. Clinical features of acute coronary syndromes in patients with human immunodeficiency virus infection. Circulation. 2004;109:316–319.