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Arterial disease in patients with human immunodeficiency virus infection: what has imaging taught us?
James H Stein1, Judith S Currier2, Priscilla Y Hsue3
1University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin.
Insights
Advances in HIV treatment mean longer lives, but cardiovascular disease (CVD) risk remains a concern. Imaging studies confirm HIV infection increases CVD risk, likely due to persistent inflammation and immune issues.
Area of Science:
- Cardiovascular Imaging
- Infectious Diseases
- Immunology
Background:
- Antiretroviral therapy (ART) allows longer lifespans for individuals with human immunodeficiency virus (HIV).
- Non-HIV-related diseases, particularly cardiovascular disease (CVD), are now leading causes of mortality in this population.
- Observational studies indicate an elevated CVD risk in HIV-infected patients on ART, but underlying mechanisms require further elucidation.
Purpose of the Study:
- To critically review the role of medical imaging in understanding arterial disease, atherosclerosis, and CVD risk in HIV-infected individuals.
- To synthesize findings from various imaging modalities regarding HIV and CVD.
- To explore potential research and therapeutic targets for mitigating CVD risk in HIV.
Main Methods:
- Review of studies utilizing carotid ultrasound, coronary computed tomographic angiography, and aortic positron emission tomography.
- Analysis of brachial artery reactivity testing and coronary artery calcium scoring in HIV-infected cohorts.
- Synthesis of findings from observational studies on CVD outcomes and subclinical atherosclerosis markers.
Main Results:
- Carotid ultrasound, coronary CT angiography, and aortic PET findings align with observational data, suggesting HIV infection is linked to increased CVD risk.
- Studies using carotid intima-media thickness indicate a moderate CVD risk increase associated with HIV serostatus.
- Brachial artery reactivity testing has been valuable for understanding HIV-related arterial pathophysiology and treatment effects.
- Aortic PET is effective for assessing arterial inflammation; coronary artery calcium has not been a useful marker in this population.
- Persistent inflammation and immune dysregulation are hypothesized contributors to elevated CVD risk in treated, suppressed HIV patients.
Conclusions:
- Medical imaging supports the association between HIV infection and increased CVD risk.
- Persistent inflammation and immune dysregulation are plausible drivers of heightened CVD risk in HIV-infected individuals, even with effective treatment.
- Further research is needed to clarify the specific roles of ART and to address methodological limitations in current imaging studies.
Abstract:
With advances in antiretroviral therapy (ART), individuals with human immunodeficiency virus (HIV) infection are living longer and increasingly die of non-HIV-related diseases, such as cardiovascular disease (CVD). Several observational studies suggest that HIV-infected patients on ART are at increased risk of CVD; however, the precise mechanisms underlying the association between HIV infection and CVD risk are uncertain. Atherosclerosis and arterial disease in HIV-infected individuals is a multifactorial process with several potential targets for research and therapeutic intervention. This paper critically reviews the contributions of imaging to our understanding of arterial disease, atherosclerosis, and CVD risk in HIV-infected individuals. In general, the findings of studies using carotid ultrasound, coronary computed tomographic angiography, and aortic positron emission tomography agree with those from observational studies of CVD events and suggest that HIV infection is associated with an increased risk of CVD. Observational studies of CVD outcomes and studies using carotid intima-media thickness suggest that there is a moderate increase in CVD risk related to HIV serostatus. Less can be said about the role of ART and specific ART therapies in CVD risk, mainly because imaging studies have had serious methodological limitations that diminish their generalizability. Brachial artery reactivity testing has been especially useful for elucidating the arterial pathophysiology of HIV infection and its treatments, as well as the arterial effects of interventions for treating HIV and dyslipidemia. Aortic positron emission tomography has been especially useful for evaluating arterial inflammation. Coronary artery calcium has not proven to be a useful marker of subclinical atherosclerosis in HIV-infected individuals. Imaging studies support the intriguing hypothesis that persistent inflammation and immune dysregulation contribute to increased CVD risk among treated and suppressed patients with HIV infection.
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