Review
Cardiovascular disease in patients with chronic human immunodeficiency virus infection

https://doi.org/10.1016/j.ijcard.2014.04.155Get rights and content

Abstract

In 2012, the United Nations estimated that globally, 34 million people were living with human immunodeficiency virus (HIV) infection at the end of 2011.

About 6.5% of AIDS-related mortality is attributable to cardiovascular disease. HIV related cardiovascular disease is diverse. In this review we explore the different disease states associated with HIV such as cardiomyopathy, coronary artery disease, dyslipidemia, electrocardiographic abnormalities, prolonged QT interval and sudden death. The pathophysiology of these numerous diseases is complex and multifactorial. Current management of these patients is challenging due to multiple drug–drug interactions and side effects. However, the approach to prevention is quite familiar, taking on the same rules that apply for any patient to minimize cardiovascular disease risk. The challenges are many, therefore for HIV patients who present after a cardiovascular event, or for prevention of cardiovascular disease, the concept of a heart team is essential, where cardiovascular specialists and the HIV care team work side by side to ensure safety of medications (avoid drug interactions) and to institute a goal directed prevention plan of care.

Introduction

In 2012, the United Nations (UN) estimated that globally, 34 million people were living with human immunodeficiency virus (HIV) infection at the end of 2011. The same report estimated that 1.7 million people died from acquired immunodeficiency syndrome (AIDS)-related causes worldwide. This represents a 24% decline in AIDS-related mortality compared with 2005 (when 2.3 million deaths occurred) [1] About 6.5% of AIDS-related mortality is attributable to cardiovascular disease [2].

In the United States, over half of all HIV-infected individuals will be over the age of 50 years by 2015 [3]. It is evident that advancing age, resulting from prolonged life expectancy, and a higher prevalence of traditional risk factors remain important contributors to cardiovascular disease (CVD) risk in these patients. However, HIV-specific factors are also pro-atherogenic, both as a consequence of antiretroviral drug toxicity and HIV infection itself perhaps due to inflammation and immune dysfunction [4]. Immune dysfunction, activation of lymphocytes, and inflammation are hallmarks of HIV infection that may play a pivotal role in the development of early CVD [5]. In fact, literature suggests that patients with chronic inflammatory diseases are at increased risk for the development of CVD [6]. In this particular group of patients atherosclerosis is the most common cardiac abnormality, although lesions of the valves, myocardium and pericarditis may all occur [7].

The purpose of this review is to explore the cardiovascular disease states induced by HIV infection and its therapy such as HIV-related cardiomyopathy, conduction system disease, and coronary heart disease.

Section snippets

Coronary artery disease

In several cohorts, the mean age at which MI occurred in HIV infected patients was lower than 50 years of age, [8], far less than that reported in the general population. However, the median age of the HIV population is also far less than that of the general population, leading to a younger age at diagnosis of MI [9]. It is evident that patients infected with HIV are at higher risk for CAD compared with the age-matched general population [10]. Several studies have suggested that among patients

Antiretroviral therapies for HIV

It has now been over 25 years since the approval of zidovudine (AZT) as the first antiretroviral agent for HIV. Since that time, there have been dramatic advances in the efficacy, tolerability, potency, and availability of highly active antiretroviral therapy (HAART). Now, combination antiretroviral therapy (cART) with multiple agents has become the standard of care for HIV infected individuals [58], [59]. Current classes of antiretroviral agents are as follows: nucleoside reverse transcriptase

References (79)

  • D.G. Blanchard et al.

    Reversibility of cardiac abnormalities in human immunodeficiency virus (HIV)-infected individuals: a serial echocardiographic study

    J Am Coll Cardiol

    (1991)
  • D.B. Sims et al.

    Human immunodeficiency virus infection and left ventricular assist devices: a case series

    J Heart Lung Transplant

    (2011)
  • N. Uriel et al.

    Heart transplantation in human immunodeficiency virus-positive patients

    J Heart Lung Transplant

    (2009)
  • O. Wever-Pinzon et al.

    Inotropic contractile reserve can risk-stratify patients with HIV cardiomyopathy: a dobutamine stress echocardiography study

    JACC Cardiovasc Imaging

    (2011)
  • R.S. Crow et al.

    Prognostic associations of Minnesota Code serial electrocardiographic change classification with coronary heart disease mortality in the Multiple Risk Factor Intervention Trial

    Am J Cardiol

    (1997)
  • E.Z. Soliman et al.

    Prevalence and prognostic significance of ECG abnormalities in HIV-infected patients: results from the Strategies for Management of Antiretroviral Therapy study

    J Electrocardiol

    (2011)
  • S.S. Chugh et al.

    Current burden of sudden cardiac death: multiple source surveillance versus retrospective death certificate-based review in a large U.S. community

    J Am Coll Cardiol

    (2004)
  • Z.H. Tseng et al.

    Sudden cardiac death in patients with human immunodeficiency virus infection

    J Am Coll Cardiol

    (2012)
  • G. Iacobellis et al.

    Relation of subepicardial adipose tissue to carotid intima-media thickness in patients with human immunodeficiency virus

    Am J Cardiol

    (2007)
  • S.I. Rennard et al.

    Smoking cessation

    Clin Chest Med

    (2014)
  • UNAIDS report on the global AIDS epidemic

  • Causes of death in HIV-1-infected patients treated with antiretroviral therapy, 1996–2006: collaborative analysis of 13 HIV cohort studies

    Clin Infect Dis

    (2010)
  • R.B. Effros et al.

    Aging and infectious diseases: workshop on HIV infection and aging: what is known and future research directions

    Clin Infect Dis

    (2008)
  • M. Saves et al.

    Risk factors for coronary heart disease in patients treated for human immunodeficiency virus infection compared with the general population

    Clin Infect Dis

    (2003)
  • L.H. Kuller et al.

    Inflammatory and coagulation biomarkers and mortality in patients with HIV infection

    PLoS Med

    (2008)
  • L. ao et al.

    Roles of the chemokine system in development of obesity, insulin resistance and cardiovascular disease

    J Immunol Res.

    (2014)
  • R.O.G.-C.M. Escarcega et al.

    Accelerated Atherosclerosis in systemic lupus erythematosus: perspectives towards decreasing cardiovascular morbidity and mortality

    Lupus

    (2009)
  • R.C. Kaplan et al.

    Ten-year predicted coronary heart disease risk in HIV-infected men and women

    Clin Infect Dis

    (2007)
  • M. Baekken et al.

    Hypertension in an urban HIV-positive population compared with the general population: influence of combination antiretroviral therapy

    J Hypertens

    (2008)
  • J. Capeau

    From lipodystrophy and insulin resistance to metabolic syndrome: HIV infection, treatment and aging

    Curr Opin HIV AIDS

    (2007)
  • C. Gazzaruso et al.

    Hypertension among HIV patients: prevalence and relationships to insulin resistance and metabolic syndrome

    J Hypertens

    (2003)
  • S.K. Grinspoon

    Metabolic syndrome and cardiovascular disease in patients with human immunodeficiency virus

    Am J Med

    (2005)
  • M. Rotger et al.

    Contribution of genetic background, traditional risk factors, and HIV-related factors to coronary artery disease events in HIV-positive persons

    Clin Infect Dis

    (2013)
  • F. D'Ascenzo et al.

    Acute coronary syndromes in human immunodeficiency virus patients: a meta-analysis investigating adverse event rates and the role of antiretroviral therapy

    Eur Heart J

    (2012)
  • F. Boccara et al.

    Acute coronary syndrome in human immunodeficiency virus-infected patients: characteristics and 1 year prognosis

    Eur Heart J

    (2011)
  • M.V. Zanni et al.

    Increased coronary atherosclerotic plaque vulnerability by coronary computed tomography angiography in HIV-infected men

    AIDS

    (2013)
  • K.V. Fitch et al.

    Increased coronary artery calcium score and noncalcified plaque among HIV-infected men: relationship to metabolic syndrome and cardiac risk parameters

    J Acquir Immune Defic Syndr

    (2010)
  • K.E. Wellen et al.

    Inflammation, stress, and diabetes

    J Clin Invest

    (2005)
  • G. Barbaro

    Cardiovascular manifestations of HIV infection

    Circulation

    (2002)
  • Cited by (25)

    • Cardiovascular risk in HIV-infected individuals: A comparison of three risk prediction algorithms

      2019, Revista Portuguesa de Cardiologia
      Citation Excerpt :

      Traditional risk factors such as smoking, which are particularly prevalent in this population, contribute to this increased risk.1,2,6,11–16 Other factors include substance abuse6 and changes in lipid profile1,8,12,15,17 and glucose metabolism, with increased insulin resistance and/or impaired insulin secretion.8,18 HIV infection itself, as well as inflammation and antiretroviral therapy (ART), are further contributing factors in this population.11

    • Effect of aspirin treatment on abacavir-associated platelet hyperreactivity in HIV-infected patients

      2018, International Journal of Cardiology
      Citation Excerpt :

      Nevertheless, recent follow-up reports re-analysing the large D:A:D study have confirmed a consistent increase of the risk of MI associated with ABC use [9,10], and other recent studies have concluded that cumulative exposure to ABC increases cardiovascular ischemic events [11,12]. Therefore, although the overall available evidence on the association of ABC with MI can not be considered as conclusive [13], most treatment guidelines warrant caution in the prescription of this drug in patients with a high cardiovascular risk [14]. Given that the enhanced cardiovascular risk associated with ABC use involves principally MI, a disease condition in the pathogenesis of which platelets play a central role [15], it appears precociously (within 6 months) and is rapidly reversible upon drug suspension [16,17], it seems likely that its mechanism may be linked to a drug-induced enhancement of platelet-dependent coronary thrombus formation rather than to accelerated atherosclerosis.

    View all citing articles on Scopus
    View full text