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HIV and coronary heart disease: time for a better understanding
Franck Boccara1, Sylvie Lang, Catherine Meuleman
1Department of Cardiology, Saint Antoine Hospital, University of Paris, Paris, France. franck.boccara@sat.aphp.fr
Insights
HIV patients face increased coronary heart disease risk due to longer lifespans and complex factors like inflammation and antiretroviral drugs. Current risk scores underestimate this danger, necessitating new prevention strategies for this high-risk group.
Area of Science:
- Cardiology
- Infectious Diseases
- Public Health
Background:
- Cardiovascular disease, especially coronary heart disease (CHD), is a growing concern in individuals with human immunodeficiency virus (HIV).
- Antiretroviral therapies have increased patient lifespan, leading to a higher observed risk of myocardial infarction in HIV-infected populations compared to the general population.
- The accelerated atherosclerosis in HIV is multifactorial, involving traditional risk factors, uncontrolled viral replication, and antiretroviral drug exposure, contributing to lipid and glucose disturbances.
Purpose of the Study:
- To highlight the complex pathophysiology of accelerated atherosclerosis in HIV-infected patients.
- To emphasize the inadequacy of current cardiovascular risk assessment tools for the HIV population.
- To advocate for revised prevention strategies, including earlier screening and novel risk assessment tools, for coronary heart disease in HIV patients.
Main Methods:
- Review of existing literature on cardiovascular disease in HIV-infected individuals.
- Analysis of the multifactorial pathophysiology of atherosclerosis in this population.
- Comparison of traditional cardiovascular risk scores with the specific risks in HIV patients.
Main Results:
- HIV patients exhibit an increased risk of myocardial infarction, even with effective antiretroviral therapy, due to chronic inflammation and immune activation.
- Traditional cardiovascular risk factors are overrepresented in the HIV population and interact with viral factors and medications.
- Current cardiovascular risk scores underestimate the actual risk in HIV patients, particularly younger individuals (<45 years), failing to account for novel risk factors.
Conclusions:
- Physicians must proactively prevent coronary heart disease in HIV patients using adapted strategies.
- There is a critical need for new risk assessment tools that incorporate HIV-specific factors like chronic inflammation and immune activation.
- Further studies are required to determine the efficacy of intensive primary prevention strategies in this vulnerable population.
Abstract:
Cardiovascular disease, and particularly coronary heart disease, is an emerging area of concern in the HIV population. Since the advent of efficient antiretroviral therapies and the consequent longer patient life span, an increased risk for myocardial infarction has been observed in HIV-infected patients compared with the general population in Western countries. The pathophysiology of this accelerated atherosclerotic process is complex and multifactorial. Traditional cardiovascular risk factors-overrepresented in the HIV population-associated with uncontrolled viral replication and exposure to antiretroviral drugs (per se or through lipid and glucose disturbances) could promote acute ischemic events. Thus, despite successful antiviral therapy, numerous studies suggest a role of chronic inflammation, together with immune activation, that could lead to vascular dysfunction and atherothrombosis. It is time for physicians to prevent coronary heart disease in this high-risk population through the use of tools employed in the general population. Moreover, the lower median age at which acute coronary syndromes occur in HIV-infected patients should shift prevention to include patients <45 years of age. Available cardiovascular risk scores in the general population usually fail to screen young patients at risk for myocardial infarction. Moreover, the novel vascular risk factors identified in HIV-related atherosclerosis, such as chronic inflammation, immune activation, and some antiretroviral agents, are not taken into account in the available risk scores, leading to underestimation of cardiovascular risk in the HIV population. Cardiovascular prevention in HIV-infected patients is a challenge for both cardiologists and physicians involved in HIV care. We require new tools to assess this higher risk and studies to determine whether intensive primary prevention is warranted.
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