Review ArticleCoronary artery disease in patients with human immunodeficiency virus infection
Introduction
Globally, an estimated 36.7 million people were living with human immunodeficiency virus (HIV) in 2015.1 The Joint United Nations Programme on HIV/Acquired Immune Deficiency Syndrome (AIDS), UNAIDS, estimated that in 2015 about 1.2 million people were living with HIV (PLWH) in the United States with 39,000 new HIV infections that year.2 The increased life expectancy of PLWH in developed countries has been largely attributed to better access to combination antiretroviral therapy (ART)3 that has reduced AIDS related mortality and morbidity. However in PLWH, deaths and morbidity due to non-AIDS defining illnesses have been on the rise. Farahani et al. estimated that the pooled non-AIDS causes of death in PLWH in high income countries were 53 percent, and a significant number of this was from cardiovascular disease (CVD), non-AIDS malignancies and liver disease.4 In this review, we will describe in detail the pathogenesis and manifestations of cardiovascular disease that occur in PLWH, as well as a brief review of non-invasive modalities for prognosticating CAD.
Section snippets
HIV and atherosclerosis
CVD is emerging as a major public health concern in PLWH. Atherosclerosis is consistently higher among the HIV-positive population, with or without treatment, than among the HIV-negative population. Subclinical markers of atherosclerosis, such as carotid, femoral and iliac intima-thickness are greater and progress earlier in the HIV-positive population.5, 6, 7 The factors linked to atherosclerosis in PLWH are both traditional (age, diabetes mellitus, smoking, dyslipidemia, inflammation and
HIV and coronary artery disease (CAD)
The association of CAD and HIV has been well recognized for years. An increased prevalence of CAD in this high risk group may be due to various complex interactions between the virus, host and treatment. In this section of the review, we will focus on the epidemiological evidences linking HIV to CAD. We will discuss the cardiovascular effects of ART, interactions of ART with drugs used in the treatment of CAD and the current revascularization practices in HIV-positive individuals.
HIV infection
Clinical presentation and outcomes of CAD and acute coronary syndrome (ACS)
Several observational studies have evaluated the clinical presentation of CAD in HIV patients. One of the earlier studies evaluating ACS in persons with HIV showed that the HIV group was 10 years younger and had low blood pressure, lower HDL, and a lower Thrombolysis in Myocardial Infarction (TIMI) score compared with the uninfected group.98 A meta-analysis demonstrated that the most common presentation was ST-segment elevation myocardial infarction (STEMI), comprising of 57% of the CAD related
CAD in HIV-infected women
Women represent almost 25% of PLWH. Thus, it is important to understand their risk of CAD to optimize adequate prevention, screening and treatment.111 Studies have demonstrated that the relative risk of MI was greater in women with HIV (2.7-3) as compared to men (1.4) when compared with uninfected controls.43,112 The median age at the first event was significantly lower in HIV-infected women as compared with uninfected women (49.3 years versus 52.1 years) 112. Women have a higher prevalence of
Exercise tolerance testing
Exercise tolerance testing is widely used as a diagnostic test in the initial evaluation of patients with symptoms suggestive of myocardial ischemia and in persons with previously recognized coronary heart disease. The treadmill exercise electrocardiogram test is one of the most commonly used and least expensive test which has a mean sensitivity of 68% and specificity of 77%, respectively for detecting angiographically significant coronary artery disease.114 The utility of exercise testing as a
Conclusion
HIV and CAD are both global health issues which pose a significant burden to the medical community. With better and more tolerant ART, the life expectancy of HIV-positive individuals has increased. In the past 2 decades we have better understood the mechanisms that link HIV to CAD. However, we need more research to be able to target specific pathways that play crucial roles in the pathogenesis of atherosclerosis and CAD in HIV-infected individuals. Drug-drug interactions and adverse effects of
Disclosures
None of the authors have any disclosures and conflicts of interest pertinent to this topic.
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