Predicting the risk of cardiovascular disease in HIV-infected patients: the data collection on adverse effects of anti-HIV drugs study

Changes in metabolic, inflammatory and coagulation biomarkers after HIV seroconversion--the Health in Men (HIM) Biomarker Substudy

BACKGROUND

Biomarkers of inflammation, coagulation, lipids and vitamin D have been associated with cardiovascular and mortality risk in HIV-infected individuals. Scarce data exist on changes in these markers from pre- to post-HIV seroconversion.

METHODS

The study participants were drawn from the Health in Men Study, which recruited HIV-negative homosexual men. Participants with incident HIV infection (n=26) were compared with HIV-negative controls (n=52) matched on age at enrolment, date of visit and reported intravenous drug use. Levels of metabolic (lipids and vitamin D), inflammatory (C-reactive protein and interleukin-6) and coagulation (D-dimer and fibrinogen) biomarkers were measured at pre- and post-HIV seroconversion visits and corresponding visits for controls. Random-effect models were used to compare changes in markers between cases and controls.

RESULTS

The median gap between pre- and post-seroconversion or matched first and second visits in controls was 12 months. HIV seroconversion was associated with decline in high density lipoprotein (HDL-C; difference in mean change between cases and controls -0.14 mmol/l; 95% CI -0.22, -0.01; P=0.035). There were no significant differences in changes in other lipids, markers of inflammation, coagulation or vitamin D.

CONCLUSIONS

Decline in HDL-C seems to be the main proatherogenic change within 1-1.5 years after HIV seroconversion. HIV seroconversion was not associated with profound changes in other lipids, or markers of inflammation, coagulation and vitamin D. Longitudinal assessment of these markers in comparable population needs further assessment.

Predicting the short-term risk of diabetes in HIV-positive patients: the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study

Introduction

HIV-positive patients receiving combination antiretroviral therapy (cART) frequently experience metabolic complications such as dyslipidemia and insulin resistance, as well as lipodystrophy, increasing the risk of cardiovascular disease (CVD) and diabetes mellitus (DM). Rates of DM and other glucose-associated disorders among HIV-positive patients have been reported to range between 2 and 14%, and in an ageing HIV-positive population, the prevalence of DM is expected to continue to increase. This study aims to develop a model to predict the short-term (six-month) risk of DM in HIV-positive populations and to compare the existing models developed in the general population.

Methods

All patients recruited to the Data Collection on Adverse events of Anti-HIV Drugs (D:A:D) study with follow-up data, without prior DM, myocardial infarction or other CVD events and with a complete DM risk factor profile were included. Conventional risk factors identified in the general population as well as key HIV-related factors were assessed using Poisson-regression methods. Expected probabilities of DM events were also determined based on the Framingham Offspring Study DM equation. The D:A:D and Framingham equations were then assessed using an internal-external validation process; area under the receiver operating characteristic (AUROC) curve and predicted DM events were determined.

Results

Of 33,308 patients, 16,632 (50%) patients were included, with 376 cases of new onset DM during 89,469 person-years (PY). Factors predictive of DM included higher glucose, body mass index (BMI) and triglyceride levels, and older age. Among HIV-related factors, recent CD4 counts of<200 cells/µL and lipodystrophy were predictive of new onset DM. The mean performance of the D:A:D and Framingham equations yielded AUROC of 0.894 (95% CI: 0.849, 0.940) and 0.877 (95% CI: 0.823, 0.932), respectively. The Framingham equation over-predicted DM events compared to D:A:D for lower glucose and lower triglycerides, and for BMI levels below 25 kg/m².

Conclusions

The D:A:D equation performed well in predicting the short-term onset of DM in the validation dataset and for specific subgroups provided better estimates of DM risk than the Framingham.

Underutilization of aspirin for primary prevention of cardiovascular disease among HIV-infected patients

BACKGROUND

Individuals infected with human immunodeficiency virus (HIV) are at increased risk for cardiovascular disease (CVD) events compared with uninfected persons. However, little is known about HIV provider practices regarding aspirin (ASA) for primary prevention of CVD.

METHODS

A cross-sectional study was conducted among patients attending the University of Alabama at Birmingham 1917 HIV Clinic during 2010 to determine the proportion receiving ASA for primary prevention of CVD and identify factors associated with ASA prescription. Ten-year risk for CVD events was calculated for men aged 45-79 and women aged 55-79. The 2009 US Preventive Services Task Force (USPSTF) guidelines were used to determine those qualifying for primary CVD prevention.

RESULTS

Among 397 patients who qualified to receive ASA (mean age, 52.2 years, 94% male, 36% African American), only 66 (17%) were prescribed ASA. In multivariable logistic regression analysis, diabetes mellitus (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.28-5.27), hyperlipidemia (OR, 3.42; 95% CI, 1.55-7.56), and current smoking (OR, 1.87; 95% CI, 1.03-3.41) were significantly associated with ASA prescription. Odds of ASA prescription more than doubled for each additional CVD-related comorbidity present among hypertension, diabetes, hyperlipidemia, and smoking (OR, 2.13, 95% CI, 1.51-2.99).

CONCLUSIONS

In this HIV-infected cohort, fewer than 1 in 5 patients in need received ASA for primary CVD prevention. Escalating likelihood of ASA prescription with increasing CVD-related comorbidity count suggests that providers may be influenced more by co-occurrence of these diagnoses than by USPSTF guidelines. In the absence of HIV-specific guidelines, interventions to improve HIV provider awareness of and adherence to existing general population guidelines on CVD risk reduction are needed.

Reclassification of risk of death with the knowledge of D-dimer in a cohort of treated HIV-infected individuals

OBJECTIVE

To evaluate the change in categories of risk of death by adding D-dimer to conventional mortality risk factors.

DESIGN

Cohort study.

METHODS

Data on HIV-infected participants receiving standard combination antiretroviral therapy in two clinical trials (Evaluation of Subcutaneous Proleukin in a Randomized International Trial and Strategic Management of antiretroviral therapy), who had baseline D-dimer measured, were randomly split into two equal training and a validation datasets. A multivariable survival model was built using the training dataset and included only conventional mortality risk factors measured at baseline. D-dimer was added to create the comparison model. The level of reclassification of mortality risk, for those with at least 5-years of follow-up, was then assessed by tabulating mortality risk defined as low (≤2% predicted rate), moderate (2-5%) or high (>5%). Reclassification analyses were then repeated on the validation dataset.

RESULTS

The analysis population at baseline had a mean age of 43 years, median CD4(+) cell count of 535 cells/μl (IQR: 420-712), and 83% had HIV RNA of at least 500 copies/ml. In the training dataset (n=1946, 8939 person-years), there were 83 deaths at a rate of 0.93 per 100 person-years. Addition of D-dimer to the reference model resulted in 6% or fewer (P>0.05) being correctly reassigned, either up or down, to a new risk category, in both, training and validation datasets. The integrated discrimination improvement in training and validation datasets was 0.60% (P=0.084) and 0.45% (P=0.168), respectively.

CONCLUSION

In this relatively well population, at the given risk cutoffs, D-dimer appeared to only modestly improve the discernment of risk. Risk reclassification provides a method for assessing the clinical utility of biomarkers in HIV cohort studies.

HIV and aging: state of knowledge and areas of critical need for research. A report to the NIH Office of AIDS Research by the HIV and Aging Working Group

HIV risk behaviors, susceptibility to HIV acquisition, progression of disease after infection, and response to antiretroviral therapy all vary by age. In those living with HIV, current effective treatment has increased the median life expectancy to >70 years of age. Biologic, medical, individual, social, and societal issues change as one ages with HIV infection, but there has been only a small amount of research in this field. Therefore, the Office of AIDS Research of the National Institutes of Health commissioned a working group to develop an outline of the current state of knowledge and areas of critical need for research in HIV and Aging; the working groups' findings and recommendations are summarized in this report. Key overarching themes identified by the group included the following: multimorbidity, polypharmacy, and the need to emphasize maintenance of function; the complexity of assessing HIV versus treatment effects versus aging versus concurrent disease; the inter-related mechanisms of immune senescence, inflammation, and hypercoagulability; the utility of multivariable indices for predicting outcomes; a need to emphasize human studies to account for complexity; and a required focus on issues of community support, caregivers, and systems infrastructure. Critical resources are needed to enact this research agenda and include expanded review panel expertise in aging, functional measures, and multimorbidity, and facilitated use and continued funding to allow long-term follow-up of cohorts aging with HIV.

Cardiovascular risk estimation in 2012: lessons learned and applicability to the HIV population

Cardiovascular disease (CVD) risk assessment tools such as the Framingham Risk Functions, often called Framingham Risk Scores, are common in the evaluation of the CVD risk among individuals in the general population. These functions are multivariate risk algorithms that combine data on CVD risk factors, such as sex, age, systolic blood pressure, total cholesterol level, high-density lipoprotein cholesterol level, smoking behavior, and diabetes status, to produce an estimate (or risk) of developing CVD or a component of it (such as coronary heart disease, stroke, peripheral vascular disease, and heart failure) over a fixed period (eg, the next 10 years). These estimates of CVD risk are often major inputs in recommending drug treatments, such as agents to reduce cholesterol level. The Framingham Risk Functions are valid in diverse populations, at times requiring a calibration adjustment for proper applicability. With the realization that individuals with human immunodeficiency virus (HIV) infection often have elevated CVD risk factors, the evaluation of CVD risk for these individuals becomes a serious concern. Researchers have recently developed new CVD risk functions specifically for HIV-infected patients and have also examined the extension of existing Framingham Risk Functions to the HIV-infected population. This article first reviews briefly the Framingham Study and risk functions, covering their objectives, their components, evaluation of their performance, and transportability and validity on non-Framingham populations. It then reviews the development of CVD risk functions for HIV-infected individuals and comments on the usefulness of extending the Framingham risk equation to the HIV-infected population and the need to develop more-specific risk prediction equations uniquely tailored to this population.

Diagnosis of subclinical atherosclerosis in HIV-infected patients: higher accuracy of the D:A:D risk equation over Framingham and SCORE algorithms

AIMS

While the detection of subclinical atherosclerosis may provide an opportunity for the prevention of cardiovascular disease (CVD), which currently is a leading cause of death in HIV-infected subjects, its diagnosis is a clinical challenge. We aimed to compare the agreement and diagnostic performance of Framingham, SCORE and D:A:D equations for the recognition of subclinical atherosclerosis in HIV patients and to adjust the D:A:D equation using HIV and CVD variables.

METHODS AND RESULTS

Atherosclerosis was evaluated in 203 HIV-infected individuals by measuring the carotid intima-media thickness (IMT). The CVD risk was calculated using the Framingham, SCORE and D:A:D risk equations. Framingham, SCORE and D:A:D equations showed a low agreement with the IMT (Kappa: 0.219, 0.298, 0.244, respectively; p = 0.743) and a moderate predictive performance, (area under the curve [AUC] = 0.686, 0.665 and 0.716, respectively; p = 0.048), with the D:A:D equation being the most accurate. Atherosclerosis was demonstrated in a significant proportion of subjects with low predicted CVD risk by all three algorithms (16.3%, 17.2%, 17.2%, respectively; p = 0.743). In patients with an estimated low CVD risk atherosclerosis was associated with older age (p = 0.012) and low CD4 counts (p = 0.021). A model was developed to adjust the D:A:D equation; a significant increase in accuracy was obtained when CD4 counts and low-grade albuminuria were included (AUC = 0.772; p < 0.001).

CONCLUSION

The D:A:D equation overperforms Framingham and SCORE in HIV patients. However, all three equations underestimate the presence of subclinical atherosclerosis in this population. The accuracy of the D:A:D equation improves when CD4 counts and low-grade albuminuria are incorporated into the equation.

HIV replication and immune status are independent predictors of the risk of myocardial infarction in HIV-infected individuals

BACKGROUND

Individuals infected by human immunodeficiency virus (HIV) have a higher risk of cardiovascular disease than the general population. The specific effects of virological and immunological parameters on the risk of myocardial infarction (MI) in HIV-infected individuals are debated.

METHODS

We conducted a nested case-control study within the French Hospital Database on HIV. Case patients (n = 289) were patients who, between January 2000 and December 2006, had a prospectively recorded and validated first MI. Up to 5 HIV-infected controls (n = 884) matched for age, sex, and clinical center were selected, at random with replacement, among patients with no history of MI. Conditional logistic regression models were used to identify predictors of the risk of MI.

RESULTS

Plasma HIV-1 RNA levels >50 copies/mL, a low CD4 T-cell nadir, and a high CD8 T-cell count were independently associated with an increased risk of MI, with respective odds ratios of 1.51 (95% confidence interval, 1.09-2.10), 0.90 (.83-.97) per log(2) unit, and 1.48 (1.01-2.18) for the highest tertile of CD8 T-cell counts (>1150 cells/mm(3)) compared with the lowest (≤760 cells/mm(3)).

CONCLUSIONS

Independently of cardiovascular risk factors and antiretroviral therapy, HIV replication, a low CD4 T-cell nadir and a high current CD8 T-cell count are associated with an increased risk of MI in HIV-infected individuals. This suggests new paths for interventions to diminish the risk of MI in HIV-infected patients.

Differences in lipid measurements by antiretroviral regimen exposure in cohorts from Asia and australia

We explored the mean differences in routinely measured lipids (total cholesterol, triglycerides, and high-density lipoprotein cholesterol) according to exposure to different combination antiretroviral regimens in Asian (n = 2051) and Australian (predominantly Caucasian, n = 794) cohorts. The regimen was defined as at least 3 antiretroviral drugs with at least 2 nucleoside-reverse transcriptases (NRTIs) and either of at least one protease inhibitor (PI) or non-nucleoside-reverse transcriptases (NNRTIs). We categorised cART regimens as: NRTIs as tenofovir based or not; NNRTIs as nevirapine or efavirenz (but not both); and PI as atazanavir based or not. We found that the impact of various antiretroviral regimens on lipids in Asian and Australian cohorts was only different by cohort for total cholesterol (P for interaction between regimen and cohort: <0.001) but not in case of other lipids (P for interaction: >0.05). The differences in total cholesterol were however small and unlikely to be of clinical significance. Overall, tenofovir with nevirapine or atazanavir was associated with the most favorable lipids, while the PI regimens without tenofovir and atazanavir were associated with least favorable lipids. We conclude that the impact of various ART regimens on lipids is largely similar in Asian and Australian cohorts and that the newer drugs such as tenofovir and atazanavir are likely to provide similar benefit in terms of lipid profiles in both populations.

Antihypertensive Drugs in Patients Treated with Antiretroviral

Objective:

To review the literature for information regarding pharmacokinetic interactions between antiretrovirals and antihypertensive agents, evaluate the clinical significance of these interactions, and analyze the effect of antihypertensive drugs on the metabolic complications frequently observed in HIV-infected patients to emphasize the advantages and inconveniences of every class of antihypertensive drugs in association with antiretrovirals.

Data Sources:

A literature search was conducted via PubMed and MEDLINE (1950-November 2011) using the search terms drug interactions, cytochrome P450, names of antiretrovirals, names of commonly prescribed antihypertensive drugs, pharmacokinetics, and metabolic complications. Reference citations from relevant publications, manufacturers’ product information, and www.HIV-druginteracttons.org were also reviewed.

Study Selection And Data Extractions:

All articles with an English abstract identified through the data search were examined. Of these, pharmacologic reviews, studies, and case reports were evaluated.

Data Synthesis:

Antihypertensive drugs interact with several antiretroviral drugs, non nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (Pls) in particular. Pharmacokinetic interactions are less expected with diuretics, jî-blockers excreted by the kidney, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs) other than losartan and irbesartan. Calcium channel blockers (CCBs) are metabolized by CYP3A4, with the potential for interaction with NNRTIs and Pls. Because CCBs do not adversely affect glucose or lipid metabolism or renal function, they may be preferred in patients with such complications. ACE inhibitors and ARBs may exert favorable effects on glucose homeostasis. In addition, they may significantly reduce protein excretion and further slow the progression of renal disease.

Conclusions:

The choice of antihypertensive drugs in HIV-infected patients is complex and must take into account the metabolic pathways of antiretroviral drugs and antihypertensive drugs with the potential of pharmacokinetic interactions, as well as the effect of antihypertensive drugs on some biological parameters.

Cardiovascular disease in patients with HIV

The introduction of combination antiretroviral therapy (cART) has substantially decreased mortality among the HIV-infected population. In this setting, cardiovascular disease (CVD) has become a leading cause of morbidity and mortality. Compared with the general population, higher rates of myocardial infarction as well as a high prevalence of subclinical coronary atherosclerosis have been found in the HIV-infected population. It has been suggested that in HIV-infected patients, the atherosclerotic burden is not based solely on traditional cardiovascular risk factors. The interplay of other mechanisms such as chronic inflammation, effects of cART or immune activation after initiation of cART may predispose to accelerated and increased risk of CVD. Effective treatment are available today to reduce CVD in at-risk patients, and therefore early detection of subclinical coronary atherosclerosis is important. However, the mechanisms behind the development of CVD in HIV-infected patients may limit the usefulness of the traditional noninvasive screening tools for CVD used in the general population. This review will focus on the different plausible mechanisms behind the increased risk of CVD and the noninvasive methods by which atherosclerosis may be assessed in the HIV-infected population.

Coronary Artery Calcification in Hemophilia A

Objective—

Ischemic heart disease mortality is lower in hemophilia patients than in the general male population. As coagulation plays a role in the inflammatory pathways involved in atherogenesis, we investigated whether the clotting factor deficiency protects hemophilia patients from developing atherosclerosis.

Methods and Results—

Coronary artery calcification, measured with multidetector-row computed tomography, was compared between 42 men, ≥59 years, with severe or moderate hemophilia A, and 613 nonhemophilic men from the Rotterdam Study, a prospective population-based study. None of the study subjects were HIV infected or had a history of cardiovascular disease. Coronary artery calcification was quantified by calculating the Agatston score and calcification mass. Data were analyzed using linear regression. Mean difference (β) of the natural log–transformed Agatston score between men with and without hemophilia was 0.141 (95% CI −0.602 to 0.885, P =0.709). Results did not change after adjustment for age, body mass index, hypercholesterolemia, hypertension, and use of antidiabetic medication (β=0.525, 95% CI −0.202 to 1.252, P =0.157). Comparable results were found for calcification mass.

Conclusion—

The extent of coronary artery atherosclerosis is comparable between elderly men with and without hemophilia. Results from this study underline the importance of screening and treating atherosclerosis risk factors in hemophilia patients.

HIV infection, aging and cardiovascular disease: epidemiology and prevention

In the developed world, HIV infection is now well managed with very effective and less toxic antiretroviral treatment. HIV-positive patients therefore are living longer, but are now faced by challenges associated with aging. Several non-AIDS associated morbidities are increased in this population, including cardiovascular disease (CVD). It is suggested that CVD occurs earlier among HIV-positive patients compared with HIV-negative patients, and at a higher rate. Several factors have been proposed to contribute to this. First, the traditional CVD risk factors are highly prevalent in this population. High rates of smoking, dyslipidaemia and a family history of CVD have been reported. This population is also aging, with estimates of more than 25% of HIV-positive patients in the developed world being over the age of 50. Antiretroviral treatment, both through its effect on lipids and through other, sometimes less well understood, mechanisms, has been linked to increased CVD risk. HIV infection, especially untreated, is a further contributing factor to increased CVD risk in HIV-positive patients. As the HIV-positive population continues to age, the risk of CVD will continue to increase. Guidelines for the management and prevention of CVD risk have been developed, and are largely modelled on those used in the general population. However, the data currently suggest that these interventions, such as the use of lipid-lowering medications and smoking cessation programs, remain quite low. A better understanding the mechanisms of CVD risk in this aging population and further efforts in improving uptake of prevention strategies will remain an important research area.

Impact of immunodepression and moderate alcohol consumption on coronary and other arterial disease events in an 11-year cohort of HIV-infected patients on antiretroviral therapy

OBJECTIVE

To investigate the relationship between response to antiretroviral therapy (ART), alcohol use and occurrence of a major coronary or other arterial disease event (CADE) in HIV-infected individuals.

DESIGN

A cohort study. A Cox model was used to identify the correlates of a first occurrence of a major CADE.

SETTING

The French ANRS CO8 APROCO-COPILOTE cohort was set up in 1997 to study clinical progression and patient-reported outcomes (PRO) after initiating a protease inhibitor-containing ART. Clinical data were retrieved from medical records. Self-administered questionnaires collected data on PRO and behaviours, including alcohol use.

PARTICIPANTS

Metabolic data were only available for a subgroup (n=675) of the study group (n=1154).

MAIN OUTCOME MEASURES

Major coronary or other arterial disease first event.

RESULTS

Over the 11-year follow-up, 49 major CADE were observed, with an incidence rate (95% CI)=0.75(0.57 to 0.99) per 100 person-years. Immunodepression (CD4 cell count <200 cells/mm(3)) was associated with an increased risk of CADE (adjusted HR (95% CI)=2.52(1.15 to 5.48)) after adjustment for female gender (0.25(0.08 to 0.83)), age (1.07(1.04 to 1.10)) and smoking>20 cigarettes/day (4.19(2.17 to 8.11)). Moreover, individuals with moderate alcohol consumption (≤4(3) alcohol units (AU)/day for men(women)) had a lower risk of CADE (0.38(0.20 to 0.71)) than alcohol abstainers, although the risk for those drinking>4(3) AU/day for men(women) was not significantly different from this latter group. These associations remained valid after adjustment for metabolic disorders. No significant association with exposure to any specific antiretroviral was detected.

CONCLUSIONS

In the long term, absence of immunodepression and moderate alcohol consumption remain associated with a lower risk of a major CADE. Combined interventions to reduce CADE-risk-related behaviours including adherence counselling for assuring long-term immunological response to ART in HIV-infected individuals are now a clinical and public health priority.

An inducible cell-cell fusion system with integrated ability to measure the efficiency and specificity of HIV-1 entry inhibitors

HIV-1 envelope glycoproteins (Envs) mediate virus entry by fusing the viral and target cell membranes, a multi-step process that represents an attractive target for inhibition. Entry inhibitors with broad-range activity against diverse isolates of HIV-1 may be extremely useful as lead compounds for the development of therapies or prophylactic microbicides. To facilitate the identification of such inhibitors, we have constructed a cell-cell fusion system capable of simultaneously monitoring inhibition efficiency and specificity. In this system, effector cells stably express a tetracycline-controlled transactivator (tTA) that enables tightly inducible expression of both HIV-1 Env and the Renilla luciferase (R-Luc) reporter protein. Target cells express the HIV-1 receptors, CD4 and CCR5, and carry the firefly luciferase (F-Luc) reporter gene under the control of a tTA-responsive promoter. Thus, Env-mediated fusion of these two cell types allows the tTA to diffuse to the target cell and activate the expression of the F-Luc protein. The efficiency with which an inhibitor blocks cell-cell fusion is measured by a decrease in the F-Luc activity, while the specificity of the inhibitor is evaluated by its effect on the R-Luc activity. The system exhibited a high dynamic range and high Z'-factor values. The assay was validated with a reference panel of inhibitors that target different steps in HIV-1 entry, yielding inhibitory concentrations comparable to published virus inhibition data. Our system is suitable for large-scale screening of chemical libraries and can also be used for detailed characterization of inhibitory and cytotoxic properties of known entry inhibitors.

Management of the metabolic effects of HIV and HIV drugs

Morphologic and metabolic abnormalities, including subcutaneous adipose tissue wasting, central adipose tissue accumulation, dyslipidemia and disorders of glucose metabolism are common among HIV-infected patients receiving highly active antiretroviral therapy (HAART) and contribute to the risk of cardiovascular disease in this population. The pathogenesis of these disorders is due to complicated interactions between effects of chronic HIV infection, HAART medications and patient factors, including genetic susceptibility. HAART has transformed HIV into a chronic condition for many patients and as a result the majority of HIV-infected patients in many areas of the developed world will soon be aged ≥50 years. Given that metabolic and cardiovascular diseases increase with aging, knowledge of the optimal management of these conditions is essential for practitioners caring for HIV-infected patients, including endocrine subspecialists. This Review highlights the clinical management of these disorders, focusing on the latest evidence regarding the efficacy of treatment strategies, newly available medications and potential interactions between HAART medications and medications used to treat metabolic disorders.

Rates of cardiovascular disease following smoking cessation in patients with HIV infection: results from the D:A:D study(*)

OBJECTIVES

The aim of the study was to estimate the rates of cardiovascular disease (CVD) events after stopping smoking in patients with HIV infection.

METHODS

Patients who reported smoking status and no previous CVD prior to enrolment in the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study were included in this study. Smoking status is collected at each visit as current smoker (yes/no) and ever smoker (yes/no). Time since stopping smoking was calculated for persons who had reported current smoking during follow-up and no current smoking subsequently. Endpoints were: myocardial infarction (MI); coronary heart disease (CHD: MI plus invasive coronary artery procedure or death from other CHD); CVD (CHD plus carotid artery endarterectomy or stroke); and all-cause mortality. Event rates were calculated for never, previous and current smokers, and smokers who stopped during follow-up. Incidence rate ratios (IRRs) were determined using Poisson regression adjusted for age, sex, cohort, calendar year, family history of CVD, diabetes, lipids, blood pressure and antiretroviral treatment.

RESULTS

A total of 27 136 patients had smoking status reported, with totals of 432, 600, 746 and 1902 MI, CHD, CVD and mortality events, respectively. The adjusted IRR of CVD in patients who stopped smoking during follow-up decreased from 2.32 within the first year of stopping to 1.49 after >3 years compared with those who never smoked. Similar trends were observed for the MI and CHD endpoints. Reductions in risk were less pronounced for all-cause mortality.

CONCLUSION

The risk of CVD events in HIV-positive patients decreased with increasing time since stopping smoking. Smoking cessation efforts should be a priority in the management of HIV-positive patients.

Management of dyslipidemia in HIV-infected patients

Antiretroviral therapy has dramatically increased survival for HIV-infected individuals. As this population lives longer, coronary heart disease has become an important comorbid condition. Dyslipidemia in HIV-infected individuals is a complex condition, with multiple contributing factors including the HIV virus itself, individual genetic characteristics and antiretroviral therapy-induced metabolic changes. Effective management of dyslipidemia in this population is essential to reduce cardiovascular risk but presents multiple challenges due to interactions between antiretroviral therapy agents and lipid-lowering medications.

Cardiovascular risk assessment for persons living with HIV

Systematic assessment of cardiovascular risk among persons living with HIV (PLWH) has become more important as HIV survival has increased. Since the advent of effective antiretroviral therapy (ART), PLWH often enjoy life expectancies equal to those of the general population. PLWH then share the same comorbidities as the general population, with some increased risks due to HIV and ART. One comorbidity, cardiovascular disease, is the leading cause of death in the United States. As the current population of PLWH ages, reducing cardiovascular risk will become even more important. Before cardiovascular risk reduction can take place, providers must first know the patient's risks. This paper describes the importance of cardiovascular risk assessment for PLWH based on current literature and presents findings from a quality-improvement (QI) initiative designed to implement systematic cardiovascular assessment using the Framingham Risk (FR) for PLWH in an infectious-disease practice.

Regional fat deposition and cardiovascular risk in HIV infection: the FRAM study

HIV-infected individuals are at increased risk for cardiovascular disease (CVD) and lipodystrophy, but the relationship between regional adipose tissue (AT) depots and CVD risk is not well described. We determined regional AT volumes and CVD risk in an analysis of 586 HIV-infected and 280 control FRAM study subjects using whole-body magnetic resonance imaging (MRI) and the Framingham Risk Score (FRS). Median FRS and FRS >10% were higher in HIV than control men (4.7% vs. 3.7%, p=0.0002; 16% vs. 4%, p<0.0001). HIV and control women had similarly low FRS (1.1% vs. 1.2%, p=0.91). In controls, total AT and all regional AT depots showed strong positive correlations with FRS (p<0.001) in men and weaker positive correlations in women. Greater visceral AT (VAT) and lower leg subcutaneous AT (SAT) volumes were associated with elevated FRS in HIV subjects with a trend for upper trunk SAT. Controls in the lowest quartile of leg SAT had the lowest FRS (1.5%), whereas HIV with similarly low leg SAT had the highest FRS (4.0%, p<0.001 vs. controls). Increased VAT is associated with CVD risk, but the risk is higher in HIV-infected individuals relative to controls at every level of VAT. Peripheral lipoatrophy (as measured by leg SAT) is associated with striking increased CVD risk in HIV-infected patients even after controlling for VAT, whereas low leg SAT is associated with low CVD risk in controls.

The metabolic syndrome in HIV

The metabolic syndrome (MS) is a term used to describe the clustering of risk factors for cardiovascular disease (CVD), including elevated triglyceride (TG), low high density lipoprotein cholesterol (HDL), hypertension, hyperglycemia/ insulin resistance and intra-abdominal obesity. This paper discusses why the prevalence of MS in the setting of HIV has been reported to range from 7-45% and how antiretroviral drugs might contribute to the development of MS. The MS has been reported to be a 'CVD risk enhancer', and much debate is ongoing on the independent risk of CVD associated with the MS. Based on a limited number of studies on MS in HIV with clinical end-points, there is no data to support that the MS is independently associated with an increased risk of CVD.

Cardiovascular risk assessment in persons with HIV infection in the developing world: comparing three risk equations in a cohort of HIV-infected Thais

OBJECTIVE

There is growing concern regarding cardiovascular disease in HIV-infected individuals in developing countries such as Thailand. We evaluated the 10-year risk of coronary heart disease (CHD) in a Thai HIV-infected cohort using three cardiovascular risk equations, and assessed the level of agreement among their predictions.

METHODS

We carried out a cross-sectional analysis of data on 785 Thai subjects followed prospectively in the HIV Netherlands Australia Thailand Collaboration (HIV-NAT) cohort study from 1996 to 2009. Cardiovascular risk factor history, along with relevant laboratory and clinical data, was collected at follow-up clinic visits. Ten-year risks of CHD were calculated using the Framingham, Ramathibodi-Electricity Generating Authority of Thailand (Rama-EGAT) and Data Collection on Adverse Effects of Anti-HIV Drugs (D:A:D) risk equations.

RESULTS

The mean age of the patients was 41.0 years; 55% of the subjects were male. The mean duration of antiretroviral therapy was 7.7 years. The prevalence of cardiovascular risk factors was low, with the most common risk factor being low high-density lipoprotein (HDL) (36.3%). The prevalence of high cardiovascular risk scores (defined as 10-year risk of CHD≥10%) was also low: 9.9, 2.1 and 0.8%, by the Framingham, Rama-EGAT and D:A:D scoring systems, respectively. Only eight subjects (1.0%) had a history of CHD. Bland-Altman plots showed that the Framingham equation predicted a higher risk of CVD compared with the Rama-EGAT and D:A:D equations, which agreed relatively well.

CONCLUSION

The predicted cardiovascular risk in this HIV-infected Thai cohort was relatively low. The agreement among the Rama-EGAT and D:A:D risk scores suggests that both equations may be appropriate estimators of cardiovascular risk in this population.

Soluble biomarkers and morbidity and mortality among people infected with HIV: summary of published reports from 1997 to 2010

PURPOSE OF REVIEW

Published articles from 1997 through May 2010 that reported findings on the relationship of soluble biomarkers with clinical outcomes among people infected with HIV were identified, and studies that examined the incremental value (over that of CD4 cell count and HIV RNA level) that biomarkers had for predicting clinical outcomes were summarized.

RECENT FINDINGS

Over 1500 articles were identified on MEDLINE databases that met selected medical subject heading terms. Thirty-eight met criteria for inclusion in the review. Fifteen of the articles were published since 2008. Most evaluated biomarkers reflecting inflammation and immune activation. For 25 studies, the relationship between the biomarker and all-cause mortality was evaluated. Samples stored in specimen repositories were used for many studies, and those that did not usually focused on biomarkers that are measured as part of routine care. Eight of the reports utilized a case-control design and most of these were nested within a cohort study or a clinical trial.

SUMMARY

Establishing the relationship between a biomarker and a clinical outcome is an important step in biomarker evaluation. To advance research on biomarkers relevant to people with HIV, large studies with long follow-up, carefully documented clinical events, and specimen repositories will be needed.

Accelerated coronary atherosclerosis after execution of percutaneous coronary intervention in patient with HIV/HCV coinfection: case report and review of the literature

Highly active antiretroviral therapy has greatly reduced AIDS-related morbidity and mortality; however, its widespread use has been associated with a marked rise in the frequency of cardiovascular diseases in patients with HIV. Moreover, HIV infection is associated with accelerated coronary atherosclerosis and vasculopathy, although the mechanisms underlying these findings have not been determined. We describe the case of a 45-year-old woman with HIV/HCV coinfection, irritable bowel syndrome, and accelerated progression of coronary atherosclerosis after execution of percutaneous coronary intervention (PCI). In this case, the rapidity of progression of atherosclerosis seems linked principally to chronic inflammation and excess immune activation that can depend by a concourse of factors (chronic C hepatitis, irritable bowel syndrome, PCI execution) not directly associated with traditional risk factors. Caregivers following HIV-infected patients should be aware of the increased risk of accelerated atherogenesis in these subjects, principally in case of presence of causes of intense immune activation.

Premature onset of cardiovascular disease in HIV-infected individuals: the drugs and the virus

Life expectancy in HIV-infected individuals has been greatly enhanced through immunologic restoration and virologic suppression resulting from antiretroviral therapy. Current clinical HIV care in Western countries focuses on treatment of drug toxicities and prevention of comorbidities. These non-AIDS HIV-related comorbidities, such as cardiovascular disease, occur even in individuals with virologic suppression and manifest at an earlier age than when normally presenting in the general population. While traditional risk factors are present in many HIV-infected individuals who develop cardiovascular disease, the additional roles of HIV-related chronic inflammation and immune activation as well as chronic HIV viremia may be significant. This review provides current evidence for the contributions of the virus, in terms of both chronic viremia and its contribution via chronic low-level inflammation, immune activation, premature immune senescence and dyslipidemia, to the pathogenesis of HIV-related cardiovascular disease, and balances this against the propensity of specific antiretroviral therapies to cause cardiovascular disease, in particular through altered cholesterol metabolism.