Cardiovascular and cerebrovascular events in patients treated for human immunodeficiency virus infection

Nevirapine and efavirenz elicit different changes in lipid profiles in antiretroviral-therapy-naive patients infected with HIV-1

BACKGROUND

Patients infected with HIV-1 initiating antiretroviral therapy (ART) containing a non-nucleoside reverse transcriptase inhibitor (NNRTI) show presumably fewer atherogenic lipid changes than those initiating most ARTs containing a protease inhibitor. We analysed whether lipid changes differed between the two most commonly used NNRTIs, nevirapine (NVP) and efavirenz (EFV).

METHODS AND FINDINGS

Prospective analysis of lipids and lipoproteins was performed in patients enrolled in the NVP and EFV treatment groups of the 2NN study who remained on allocated treatment during 48 wk of follow-up. Patients were allocated to NVP (n = 417), or EFV (n = 289) in combination with stavudine and lamivudine. The primary endpoint was percentage change over 48 wk in high-density lipoprotein cholesterol (HDL-c), total cholesterol (TC), TC:HDL-c ratio, non-HDL-c, low-density lipoprotein cholesterol, and triglycerides. The increase of HDL-c was significantly larger for patients receiving NVP (42.5%) than for patients receiving EFV (33.7%; p = 0.036), while the increase in TC was lower (26.9% and 31.1%, respectively; p = 0.073), resulting in a decrease of the TC:HDL-c ratio for patients receiving NVP (-4.1%) and an increase for patients receiving EFV (+5.9%; p < 0.001). The increase of non-HDL-c was smaller for patients receiving NVP (24.7%) than for patients receiving EFV (33.6%; p = 0.007), as were the increases of triglycerides (20.1% and 49.0%, respectively; p < 0.001) and low-density lipoprotein cholesterol (35.0% and 40.0%, respectively; p = 0.378). These differences remained, or even increased, after adjusting for changes in HIV-1 RNA and CD4+ cell levels, indicating an effect of the drugs on lipids over and above that which may be explained by suppression of HIV-1 infection. The increases in HDL-c were of the same order of magnitude as those seen with the use of the investigational HDL-c-increasing drugs.

CONCLUSION

NVP-containing ART shows larger increases in HDL-c and decreases in TC:HDL-c ratio than an EFV-containing regimen. Based on these findings, protease-inhibitor-sparing regimens based on non-nucleoside reverse transcriptase inhibitor, particularly those containing NVP, may be expected to result in a reduced risk of coronary heart disease.

Thrombotic complications in patients infected with HIV in the era of highly active antiretroviral therapy: a case series

BACKGROUND

Recent reports suggest that patients infected with human immunodeficiency virus (HIV) may have an increased risk of developing thrombosis, but the etiology, risk factors, and clinical course remain largely undefined, with few descriptive case series.

METHODS

We identified 30 patients from an HIV outpatient clinic (treatment population, 650 persons) who had had a total of 43 venous or arterial thromboses during 1996-2002. Data pertaining to demographic characteristics, medical history, thrombosis presentation, and clinical outcomes were abstracted from patient medical records.

RESULTS

The median patient age at the time of thrombosis was 43 years. Although the presence of persistent antibody to phospholipids was the most common abnormal finding in the laboratory, evaluation of thrombophilia, cases of low levels of proteins C and S and antithrombin III, and elevated levels of factor VIII and homocysteine were also identified. Seventy-seven percent of the patients smoked cigarettes, 57% had dyslipidemia, and 43% had a malignancy (most commonly Kaposi sarcoma). Although the Centers for Disease Control and Prevention (CDC) classification for 16 patients (53%) was C3, most showed evidence of immune reconstitution (median CD4 cell count, 290 cells/ mu L) and control of the virus (median HIV load, 2290 copies/mL). Lower extremity, deep vein thrombosis and pulmonary emboli accounted for 66% of all thrombotic events. The median time to diagnosis of thrombosis was 1 day (range, 3 h to 3 weeks).

CONCLUSIONS

Patients in this series were characterized by a relatively young age at the time of thrombosis, a predominance of elevated levels of lipids, a history of malignancy, and an advanced CDC HIV classification but not by a low CD4 cell count or an elevated HIV load.

Cardiovascular implications of HIV-associated dyslipidemic lipodystrophy

The emergence of a new metabolic syndrome in patients with HIV infection, termed "HIV-associated dyslipidemic lipodystrophy" (HADL), is characterized by central fat redistribution, severe dyslipidemia, and insulin resistance and predisposes to an increased risk of cardiovascular disease. The factors promoting the development of cardiovascular disease in this condition are not well understood and may involve contributions from antiretroviral drugs and components of the HIV virus, as well as inflammatory cytokines, leading to accelerated lipolysis, dyslipidemia, lipotoxic insulin resistance, and vascular inflammation. In this article, we review HADL in terms of metabolic, molecular, and cytokine derangements leading to cardiovascular disease.

Metabolic complications associated with the use of highly active antiretroviral therapy in HIV-1-infected adults

The availability of highly active antiretroviral therapy (HAART) has resulted in dramatic declines in morbidity and mortality in patients infected with human immunodeficiency virus-1 (HIV-1). However, the success of HAART has been tempered by the recognition of adverse metabolic effects clearly associated with its use. These "metabolic complications" include dyslipidemia, changes in body fat distribution, insulin resistance and glucose intolerance, metabolic bone disease, and lactic acidosis. Guidelines to assist clinicians in the management of these complications have been put forth by various organizations, including the International AIDS Society, the HIV Medicine Association of the Infectious Disease Society of America, and the Adult AIDS Clinical Trials Group.

The Problems Faced When Assessing the Prevalence and Incidence of Antiretroviral-Related Toxicities

Although the dramatic effect of highly active antiretroviral therapy (HAART) in reducing morbidity and mortality must not be underestimated, it is also important to consider the incidence and prevalence of HAART-related toxicities. Although several studies have investigated HAART-related toxicities, there has been great variety between them in the reported incidence and prevalence rates of these toxicities. Various factors, including whether the study type was a clinical trial or an observational study, the definition of the toxicity endpoints, the demographic characteristics of the study populations and the effect of calendar year on analyses, may all influence the rates observed. We investigated the possible explanations for the differences in the incidence and prevalence rates of HAART-related toxicities between studies, focussing on metabolic and hepatotoxic disorders.

Antiretroviral therapy, fat redistribution and hyperlipidaemia in HIV-infected children in Europe

OBJECTIVES

To estimate prevalence of body fat redistribution and dyslipidaemia in HIV-infected children and to assess associated risk factors, ultimately to inform the definition of lipodystrophy in children.

DESIGN

Cross-sectional observational study.

METHODS

During a 2-3 month period, 477 HIV-infected children aged >or= 3 years (median 9.78; range, 3-18) in 30 paediatric HIV clinics were assessed at their first visit. Sociodemographic, clinical and immunological data were recorded and the presence or absence of clinical signs of fat redistribution (peripheral lipoatrophy and central lipohypertrophy) determined according to an agreed protocol. Laboratory indicators of lipid/glucose metabolism were recorded for all children in 18 centres.

RESULTS

Prevalence was 26.0% [95% confidence interval (CI), 22.1-30.2] for any fat redistribution, 8.81% (95% CI, 6.42-11.7) for central lipohypertrophy, 7.55% (95% CI, 5.34-10.3) for peripheral lipoatrophy and 9.64% (95% CI, 7.15-12.7) for the combined subtype (more than one sign of each). Independent predictors of fat redistribution included Centers for Disease Control and Prevention class C disease, female gender, ever used versus never use of protease inhibitors and of stavudine. Increasing time since initiation of antiretroviral therapy was associated with increased severity of fat redistribution. In the metabolic assessment subgroup, 27% (95% CI, 21.6-32.7) of children had hypercholesterolaemia and 21% (95% CI, 16.4-26.6) hypertriglyceridaemia; however, significantly more children had fat redistribution in this subgroup than overall (31%).

CONCLUSIONS

Approximately a quarter of children and adolescents could be taken to have signs of lipodystrophy, with clinical presentation and risk factors similar to those described in adults.

Illness Representation and Smoking Behavior: a Focus Group Study of HIV-Positive Men

Focus group interviews were conducted with 13 men living with HIV (mean age = 44.7) to explore their beliefs about cigarette smoking and HIV. Interview data were audiotaped, transcribed verbatim, and systematically analyzed using inductive techniques. Participants believed cigarette smoking provides a number of benefits to persons living with HIV. Although participants acknowledged that smoking has disadvantages, smokers generally discounted health risks, noting how it improves their sense of well-being and reasoning that they would not live long enough to suffer its consequences. Although smoking is a risk factor for HIV-related morbidity and mortality, rates of smoking are high among men living with HIV. Research completed with other population groups finds beliefs are significant in explaining variance in smoking behavior change. Smoking-cessation programs targeting HIV-positive men may be more successful if illness-specific belief systems are taken into account. Additional study is warranted to substantiate the effectiveness of this approach.

Management of Dyslipidaemia in HIV-Infected Patients Receiving Antiretroviral Therapy

Dyslipidaemia associated with the treatment of HIV infection, particularly with the use of protease inhibitors (PIs), can raise cholesterol and triglyceride (TG) levels to the thresholds indicated for intervention. Recent evidence from epidemiological studies has shown that there are correlations between antiretroviral drug use and increased risks for, and incidences of, cardiovascular disease, including myocardial infarction and coronary heart disease. The primary goals of dyslipidaemia therapy for HIV patients are reductions of both low-density lipoprotein cholesterol (LDL-C) and markedly elevated TG levels. Dietary strategies and exercise programs may be tried, although these have shown inconsistent results. The two options for drug therapy are switching anti-retroviral agents and using lipid-lowering drugs. Each approach is associated with advantages and limitations, and the need to maintain viral suppression must be balanced with the need to treat abnormal lipid levels. Most drug switches replace the PI component with drugs from another antiretroviral class. Selection of drug therapy for lipid lowering depends on the type of dyslipidaemia predominating and the potential for drug interactions. The use of the statins pravastatin and atorvastatin is recommended for the treatment of patients with elevated LDL-C levels and gemfibrozil or fenofibrate for patients with elevated TG concentrations. Development of new PIs with more favourable effects on the lipid profile should be of benefit.

Risk of diabetes in HIV infected veterans pre- and post-HAART and the role of HCV coinfection

We examined the association of hepatitis C virus (HCV) infection with diabetes in veterans infected with human immunodeficiency virus (HIV) before and after the institution of highly active antiretroviral therapy (HAART). The role of age, race, liver disease, alcohol, and drug diagnoses upon the risk of diabetes was also determined. Male veterans with HIV who entered care between 1992 and 2001 were identified from the Veterans Affairs (VA) administrative database. Demographic and disease data were extracted. Kaplan-Meier curves were plotted to determine the incidence of diabetes. Unadjusted and adjusted hazards ratios for diabetes were determined using Cox regression method. A total of 26,988 veterans were studied. In multivariate Cox regression analysis, factors associated with a diagnosis of diabetes included increasing age (HR, 1.44 per 10-year increase in age; 95% CI, 1.39-1.49), minority race (African American: HR, 1.35; 95% CI, 1.24-1.48; Hispanic: HR, 1.63; 95% CI, 1.43-1.86), and care in the HAART era (HR, 2.35; 95% CI, 2.01-2.75). There was a significant interaction between care in the HAART era and HCV infection, with HCV infection being associated with a significant risk of diabetes in the HAART era (HR, 1.39; 95% CI, 1.27-1.53) but not in the pre-HAART era (HR, 1.01; 95% CI, 0.75-1.36). In conclusion, HIV-infected veterans in the HAART era are at a higher risk for diabetes compared with those in the pre-HAART era. HCV coinfection is associated with a significantly higher risk of diabetes in the HAART era, but not in the pre-HAART era. HCV-HIV coinfected patients should be aggressively screened for diabetes.

Atazanavir: New Option for Treatment of HIV Infection

Atazanavir is a recently approved human immunodeficiency virus (HIV) protease inhibitor that has an important role in the treatment of both antiretroviral-naive and antiretroviral-experienced individuals. Atazanavir (400 mg) can be administered once per day and requires only 2 capsules. Drug exposure can be safely increased with coadministration of a once-daily regimen of atazanavir (300 mg) and ritonavir (100 mg). Atazanavir is not associated with elevations in serum levels of total cholesterol, low-density lipoprotein cholesterol, or triglycerides, potentially reducing the need for lipid-lowering agents. Atazanavir is associated with elevations in unconjugated bilirubin levels, which are usually not dose limiting. For treatment-naive patients receiving atazanavir who experience virologic rebound, the I50L mutation in HIV protease arises, which does not confer cross-resistance to other protease inhibitors. In treatment-experienced patients with high-level resistance to other protease inhibitors, susceptibility to atazanavir is usually reduced, and optimal effects of atazanavir are seen when it is administered with ritonavir. Similar to other protease inhibitors, careful attention must be paid to drug interactions when administering atazanavir with concomitant medications.

Effect of highly active antiretroviral therapy on cardiovascular involvement in children with human immunodeficiency virus infection

The impact of highly active antiretroviral therapy (HAART) on cardiovascular involvement was evaluated in 38 vertically human immunodeficiency virus-infected children followed up for 5 years. This study demonstrates for the first time in a cohort of children the resolution of previous dilated cardiomyopathy after the start of HAART and the absence of cardiovascular events related to metabolic abnormalities during the period of its administration.

HIV-associated lipodystrophy: pathogenesis, prognosis, treatment, and controversies

Potent antiretroviral agents markedly suppress HIV and have dramatically improved the clinical course, prognosis, and survival of HIV-infected patients. Unfortunately, highly active antiretroviral therapy is often compromised by metabolic complications, including insulin resistance, dyslipidemia, and fat redistribution. Together these changes have been termed the HIV-lipodystrophy syndrome, which is estimated to affect a majority of patients treated with potent combination antiretroviral therapy. Routine testing of fasting glucose is recommended for all HIV-infected patients, particularly those who are obese, have a family history of diabetes mellitus, or are receiving protease inhibitor therapy. Preliminary investigations have demonstrated the potential utility of insulin-sensitizing agents and lipid-lowering therapies to ameliorate these metabolic disturbances. Patients with HIV infection who demonstrate fat redistribution and develop hyperinsulinemia and dyslipidemia may be at increased risk of cardiovascular disease. However, the long-term effects on cardiovascular disease have not yet been determined.

Lipid screening in HIV-infected veterans

BACKGROUND

Lipid screening is recommended for patients taking protease inhibitors (PIs).

METHODS

We examined data from the Veterans Administration Immunology Case Registry to assess lipid screening among HIV-infected veterans who received PIs for at least 6 consecutive months during 1999 and 2001. We estimated crude and adjusted associations between lipid screening and patient characteristics (age, gender, HIV exposure, and race/ethnicity), comorbidities (AIDS, cardiovascular disease, diabetes, hypertension, smoking, and hyperlipidemia), and facility characteristics (urban location, case management, guidelines, and quality improvement programs).

RESULTS

Among 4065 patients on PIs, clinicians screened 2395 (59%) for lipids within 6 months of initiating treatment. Adjusting for patient characteristics, comorbidities, facility traits, and clustering, lipid screening was more common among patients who were cared for in urban areas (relative risk [RR] = 1.3, confidence limits: 1.0-1.5), diabetic (RR = 1.2, confidence limits: 1.1-1.3), or previously hyperlipidemic (RR = 1.4, confidence limits: 1.3-1.5) and less common among patients with a history of intravenous drug use (IVDU) (RR = 0.90, confidence limits: 0.79-1.0) or unknown HIV risk (RR = 0.85, confidence limits: 0.75-0.95).

CONCLUSIONS

Six in 10 patients taking PIs receive lipid screening within 6 months of PI use. Systemic interventions to improve overall HIV quality of care should also address lipid screening, particularly among patients with unknown or IVDU HIV risk and those cared for in nonurban areas.

Arterial stiffness and endothelial dysfunction in HIV-infected children

BACKGROUND

The role of antiretroviral therapy in acceleration of atherosclerosis in HIV-infected adults is controversial, partly because of the confounding effects of the involvement of classic cardiovascular risk factors.

OBJECTIVE

To study vascular function in HIV-infected children.

DESIGN

Cross-sectional study of 49 HIV-infected children (34 receiving antiretroviral therapy and 15 never treated) and if 24 age- and sex-matched controls.

METHODS

Automatic, computerized, ultrasonic procedure evaluation of geometric and mechanical properties of the common carotid artery, and of the endothelium-dependent dilation and endothelium-independent dilation.

RESULTS

Relative systolodiastolic variations in diameter of the carotid artery in HIV-infected children were significantly lower than those in controls, but there was no significant difference in intima-media thickness. Cross-sectional compliance and distensibility were also significantly lower. Wall stiffness, assessed as the incremental elastic modulus, was larger in HIV-infected children. Endothelium-dependent dilation was lower in HIV-infected children but non-endothelium-dependent dilation was similar to that in controls. We did not find differences for any of the vascular variables between HIV-infected children receiving antiretroviral therapy and those never treated. All arterial variables were similar in children with and without dyslipidemia.

CONCLUSIONS

HIV-infected children had a vascular dysfunction in the absence of cardiovascular risk factors. In this short series, no additional detrimental effects were observed after a mean of 5 years of antiretroviral therapy.

HIV infection, HAART, and endothelial adhesion molecules: current perspectives

In this review we summarise the data on the effects of HIV infection and its therapy with antiretroviral drugs on adhesion molecules, considered to be potential biomarkers of endothelial cell function. This is a recent area of interest, given the unexpected associations between antiretroviral therapy, metabolic alterations of lipid profile, and the risk of cardiovascular disease in the absence of clear pathogenetic links. Although convincing prospective data are still scarce, it seems timely to elucidate the potential value of non-invasive, inexpensive tests for predicting cardiovascular risk in HIV-infected patients undergoing highly active antiretroviral therapy (HAART). Endothelial function, the most plausible link between infection, inflammation, and atherosclerosis, has been investigated since the beginning of the HIV epidemic. Increased concentrations of soluble adhesion molecules, such as those from the selectin and immunoglobulin families, have consistently been reported in HIV-positive patients. The introduction of HAART has renewed interest in the study of endothelial function in HIV-positive patients, in view of some HAART-related metabolic abnormalities (hyperlipidaemia, hyperglycaemia, fat redistribution) and several large reports of premature coronary artery disease. Whether HAART reduces endothelial injury associated with HIV infection or contributes to further endothelial cell activation is still a matter of controversy. Also unclear is whether HAART acts directly or indirectly, and if protease inhibitors and other classes of antiretroviral drugs differ in their proatherosclerotic effects. This article attempts to define the state of these emerging issues, identifies areas of controversy and of potential clinical relevance, and suggests some directions for future research.

Progression of atherosclerosis as assessed by carotid intima-media thickness in patients with HIV infection

BACKGROUND

HIV-infected patients may be at increased risk for coronary events. The purpose of this study was to identify predictors of carotid intima-media thickness (IMT) in HIV patients at baseline and to measure IMT progression over 1 year.

METHODS AND RESULTS

We measured blood lipids, inflammatory markers, and IMT in 148 HIV-infected adults (mean age, 45+/-8 years) and in 63 age- and sex-matched HIV-uninfected control subjects. The mean duration of HIV infection was 11 years, and the median duration of protease inhibitor treatment was 3.3 years. Mean baseline IMT was 0.91+/-0.33 mm in HIV patients and 0.74+/-0.17 mm in control subjects (P=0.0001). Multivariable predictors of baseline IMT in HIV patients were age (P<0.001), LDL cholesterol (P<0.001), cigarette pack-years (P=0.005), Latino race (P=0.062), and hypertension (P=0.074). When the control group was added to the analysis, HIV infection was an independent predictor of IMT (P=0.001). The rate of progression among the 121 HIV patients with a repeated IMT measurement at 1 year was 0.074+/-0.13 mm, compared with -0.006+/-0.05 mm in 27 control subjects (P=0.002). Age (P<0.001), Latino race (P=0.02), and nadir CD4 count < or =200 (P=0.082) were multivariable predictors of IMT progression.

CONCLUSIONS

Carotid IMT is higher in HIV patients than in age-matched control subjects and progresses much more rapidly than previously reported rates in non-HIV cohorts. In HIV patients, carotid IMT is associated with classic coronary risk factors and with nadir CD4 count < or =200, suggesting that immunodeficiency and traditional coronary risk factors may contribute to atherosclerosis.

Ritonavir exhibits anti-atherogenic properties on vascular smooth muscle cells

OBJECTIVES

HIV protease inhibitors (PI) such as ritonavir have dramatically decreased HIV-related morbidity and mortality. However they exhibit significant side-effects such as hyperlipidemia, hyperglycemia with or without lipodystrophy, which may increase patients' risk for atherosclerosis. Direct effects of PI on the vascular wall have not been investigated. Platelet-derived growth factor (PDGF) is a major contributor to atherogenesis.

DESIGN

In the present study the effects of ritonavir on PDGF-BB-induced responses of vascular smooth muscle cells (VSMCs) were evaluated.

METHODS

PDGF-induced proliferation of VSMCs was measured by BrdU-incorporation, and chemotaxis was assessed by utilizing modified Boyden chambers. Cytotoxicity and apoptosis were quantified using LDH-release- and apoptosis-kits. Immunoprecipitation and Western blot analyses were performed to evaluate betaPDGF receptor (betaPDGFR) expression and phosphorylation, and to monitor intracellular signaling.

RESULTS

Pretreatment of VSMCs with ritonavir resulted in a significant concentration-dependent inhibition of PDGF-BB-induced cellular responses. At a therapeutic concentration (10 microg/ml), ritonavir significantly reduced PDGF-induced DNA synthesis and chemotaxis by 46.8 +/- 5.5% and 37.2 +/- 3.3%, respectively (P < 0.05 each). In addition it significantly inhibited PDGF-dependent downstream signaling, such as Erk activation. These inhibitory effects were not due to cytotoxicity or apoptosis. Instead, ritonavir inhibited the ligand-induced tyrosine phosphorylation of the betaPDGFR, whereas it did not alter betaPDGFR expression.

CONCLUSIONS

Ritonavir has direct effects on VSMCs at clinically relevant concentrations in vitro, as it inhibits betaPDGFR activation and PDGF-dependent proliferation and migration of VSMCs. Although ritonavir may increase the risk of vascular disease by its metabolic side effects, it may exhibit anti-atherogenic properties on the cellular level.

Effects of exercise training and metformin on body composition and cardiovascular indices in HIV-infected patients

OBJECTIVE

To determine whether exercise training in combination with metformin improves cardiovascular risk indices and insulin in comparison to metformin alone among HIV-infected patients.

METHODS AND DESIGN

We conducted a prospective, randomized, 3-month study of HIV patients on stable antiretroviral therapy with hyperinsulinemia and fat redistribution. Subjects received metformin alone or metformin and exercise training consisting of 1 h of aerobic and resistance training three times a week. Cardiovascular parameters, including blood pressure and endurance during sub-maximal stress testing, body composition, strength, insulin and other biochemical parameters were determined.

RESULTS

Thirty-seven patients were randomized and 25 subjects completed the study. Subjects receiving exercise training and metformin demonstrated significant decreases in median waist-to-hip ratio [-0.02 (-0.06, -0.01) (median (interquartile range) versus -0.01 (0.03, 0.02), P = 0.026], resting systolic [-12 (-20, -4) versus 0 (-11, 11), P = 0.012] and diastolic blood pressures [-10 (-14, -8) versus 0 (-7, 8), P = 0.001], increased thigh muscle cross-sectional area [3 (-3, 12) versus -7 (-11, 0), P = 0.015], and improved exercise time [3 (0, 4) versus 0 (-1, 1), P = 0.045] compared with subjects receiving metformin alone. Fasting insulin and insulin area under the curve decreased significantly more in the exercise and metformin group (P < 0.05). Lipids and resting lactate did not change significantly between treatment groups.

CONCLUSIONS

These data demonstrate that exercise training in combination with metformin significantly improves cardiovascular and biochemical parameters more than metformin alone in HIV-infected patients with fat redistribution and hyperinsulinemia. Combined treatment was safe, well tolerated and may be a useful strategy to decrease cardiovascular risk in this population.

Clinical features of acute coronary syndromes in patients with human immunodeficiency virus infection

BACKGROUND

Patients with HIV infection exhibit increased rates of coronary events; however, the clinical features of acute coronary syndromes (ACS) in HIV-infected patients have not been well defined.

METHODS AND RESULTS

Between 1993 and 2003, 68 HIV-infected patients were hospitalized with ACS. We compared the clinical features and outcome of these patients with those of 68 randomly selected control patients with ACS without HIV. HIV patients were on average more than a decade younger than controls and more likely to be male and current smokers and to have low HDL cholesterol. They were less likely than controls to have diabetes or hyperlipidemia, and their TIMI (Thrombolysis In Myocardial Infarction) risk scores on admission were significantly lower. At coronary angiography, the number of vessels with >50% stenosis was 1.3+/-1.0 in HIV patients and 1.9+/-1.2 in controls (P=0.007). Restenosis developed in 15 of 29 HIV patients who underwent percutaneous coronary intervention compared with 3 of 21 controls (52% versus 14%, P=0.006).

CONCLUSIONS

HIV patients with ACS are younger and more likely to be males and current smokers and to have low HDL cholesterol levels compared with other ACS patients. Their TIMI risk scores are lower, and they are more likely to have single-vessel disease; however, their restenosis rates after percutaneous coronary intervention are unexpectedly high.

Enfermedad cardiovascular sintomática en pacientes infectados por el virus de la inmunodeficiencia humana que reciben tratamiento antirretroviral de gran actividad

BACKGROUND AND OBJECTIVE

Our goal was to assess the main characteristics of cardiovascular disease in HIV-infected patients on highly active antiretroviral therapy (HAART).

PATIENTS AND METHOD

Retrospective analysis of the clinico-epidemiological characteristics of 16 HIV-infected patients treated with HAART who had suffered a cardiovascular event from a 1,459 patients' cohort.

RESULTS

Clinical presentation of cardiovascular disease was an acute coronary syndrome in 12 cases, ischemic stroke in 2 and peripheral vascular disease in 2. Patients included in the study had a mean of 3.2 cardiovascular risk factors, smoking and low HDL levels being the more prevalent risk factors. Eight (50%, 95% CI, 25-75%) patients fulfilled the criteria of metabolic syndrome. The mean CD4 count was 548 x 10(6)/l.

CONCLUSIONS

HIV-infected patients on HAART ha-ve a high cardiovascular risk. A strict management of modifiable risk factors must be warranted in these patients.

Acute myocardial infarction in patients infected with human immunodeficiency virus

BACKGROUND

Recent clinical and post-mortem reports suggests that human immunodeficiency virus (HIV) infection may participate in the process of atherosclerosis independent of other coronary risk factors. In this prospective and observational study, we investigated whether an associative link exists between HIV infection and coronary artery disease.

METHODS

Of 690 patients admitted to our hospital in a 3-year period, 29 patients (28 men and 1 woman) with a mean age of 46 +/- 10 years had an acute myocardial infarction (AMI) on the basis of acute prolonged chest pain, ischemic electrocardiogram abnormalities, and elevated serum markers of myocardial necrosis at presentation.

RESULTS

ST-segment elevation MI was present in 15 patients, and non-ST-segment elevation MI was present in 14 patients. Twenty-two patients (76%) were <55 years; 17 of these patients had no or 1 coronary risk factor, and 5 patients had 2 or 3 risk factors. Five patients >55 years had 1 coronary risk factor, and 2 patients had 2 risk factors. Thirteen patients underwent a myocardial revascularization procedure, and 1 patient died during hospitalization.

CONCLUSIONS

HIV infection, as a cause of endothelial injury, may initiate the inflammatory process of early atherosclerosis and participate in the evolution of the atherothrombotic lesion responsible for AMI. This study suggests that the association of HIV infection and acute coronary syndrome may be more common than previously reported and underscores the need for further clinical studies.

Distribución anormal de la grasa corporal y tipo de tratamiento antirretroviral como predictores de riesgo de enfermedad cardiovascular en pacientes infectados por el virus de la inmunodeficiencia humana

BACKGROUND AND OBJECTIVE

Dyslipidemia, insulin resistance and body fat redistribution are respectively short and long-term complications of protease inhibitor-containing antiretroviral regimens. To establish whether differences in the type of antiretroviral therapy (protease-containing or protease-sparing) or the presence and severity of body fat redistribution, explained differences in cardiovascular risk, we undertook a cross-sectional study.

PATIENTS AND METHOD

The study was carried out in 219 consecutive HIV-infected patients attending an outpatient HIV clinic between February and April, 2002. Age, sex, smoking status, weight, height, waist circumference, blood pressure, antihypertensive treatment, total cholesterol, HDL cholesterol, triglycerides, and glucose concentrations, in addition to changes in body fat distribution were measured in 31 HIV-infected patients with no antiretroviral therapy, 35 HIV-infected patients treated with protease inhibitor-sparing regimens, and 153 HIV-infected patients treated with protease inhibitor-containing regimens. A ten-year cardiovascular disease risk was estimated according to the Framingham score.

RESULTS

Patients treated with protease inhibitor-containing regimens as well as patients treated with protease inhibitor-sparing agents showed higher concentrations of cholesterol (p < 0.001), triglycerides (p = 0.004), glucose (p = 0.028), and greater changes in body fat distribution (p = 0.001) than patients with no antiretroviral therapy. An abnormal body fat distribution score was more strongly associated (p < 0.001) with the estimated 10-year cardiovascular disease risk than the type of HAART (p = 0.036). Ten-year cardiovascular disease risk increased linearly from 7.48% to 11.16% and to 19.50% in patients with no or mild, moderate and severe lipodystrophy scores, respectively.

CONCLUSIONS

The results of this study encourage the use of cardiovascular preventive strategies in HIV-infected patients with severe lipodystrophy.

Riesgo vascular en pacientes con infección crónica por el VIH-1: controversias con implicaciones terapéuticas, clínicas y pronósticas

Atherosclerosis increases cardiovascular risk and the possibility of developing acute myocardial infarction (AMI) or stroke. Patients infected with human immunodeficiency virus (HIV) often present morphological and metabolic alterations (hypercholesterolemia, hypertriglyceridemia, insulin resistance, diabetes) that can increase vascular risk. The frequent coexistence of classic risk factors (atherogenic diet, smoking, physical inactivity, cocaine abuse), the progressive increase in mean age of HIV-1 infected patients, and the polymedication they receive make it difficult to estimate the direct effect that new therapies may have on cardiovascular risk. Retrospective clinical studies with diverse designs in large cohorts offer contradictory results for cardiovascular risk in the HIV-infected population. Longer observational periods are needed and the effect of other classic risk factors needs to be controlled, in order to establish the possible detrimental effect the new therapies may have on cardiovascular risk in this population.

Cardiovascular complications in patients with HIV infection

As advances in early diagnosis and aggressive therapy, as well as better supportive care, become available to a larger number of patients with HIV infection, survival is being prolonged, and more patients are experiencing cardiac abnormalities. The most common cardiac manifestations of HIV disease are dilated cardiomyopathy, myocarditis, pericardial effusion, endocarditis, pulmonary hypertension, HIV-associated malignant neoplasms, and drug-related cardiotoxicity. The introduction of highly active antiretroviral therapy (HAART) regimens has substantially modified the course of HIV disease by lengthening survival and improving quality of life of HIV-infected patients. However, early data have raised concerns about HAART being associated with an increase in peripheral and coronary arterial disease. This review discusses the principal HIV-associated cardiovascular manifestations and emphasizes new knowledge about their prevalence, pathogenesis, and treatment.

Increased risk of myocardial infarction with duration of protease inhibitor therapy in HIV-infected men

BACKGROUND

In the current context of dyslipidaema, hyperglycaema and lipodystrophia observed among HIV-seropositive subjects, it is important to study the risk of myocardial infarction (MI) in this population. The French Hospital Database on HIV, which includes a large number of seropositive subjects followed for substantial periods, offers the opportunity to analyse the impact of protease inhibitors (PI) on the risk of MI among men.

METHODS

Cox model was used to study the risk factors of MI occurrence. Standardized morbidity ratios (SMR) in men exposed to PI were calculated with data from the French general male population (FGMP) of the same age as reference.

RESULTS

Between 1996 and 1999, MI was diagnosed in 60 men among 88 029 person-years (PY), including 49 cases among men exposed to PI. In the Cox model, exposure to PI was associated with a higher risk of MI [relative hazard (RH), 2.56; 95% confidence interval (CI), 1.03-6.34]. The expected incidence in the FGMP was 10.8/10,000 PY. The SMR relative to the FGMP was 0.8 (95% CI, 0.5-1.3) for men exposed to PI for < 18 months (G1), 1.5 (95% CI, 0.8-2.5) for men exposed for 18-29 months (G2) and 2.9 (95% CI, 1.5-5.0) for men exposed for >or= 30 months (G3). With G1 as reference, the SMR was 1.9 (95% CI, 1.0-3.1) for G2 and 3.6 (95% CI, 1.8-6.2) for G3.

CONCLUSION

Our results point to a duration-related effect relationship between PI and MI, with a higher MI incidence rate among men exposed to PI for 18 months or more.

Combination antiretroviral therapy and the risk of myocardial infarction

BACKGROUND

It remains controversial whether exposure to combination antiretroviral treatment increases the risk of myocardial infarction.

METHODS

In this prospective observational study, we enrolled 23,468 patients from 11 previously established cohorts from December 1999 to April 2001 and collected follow-up data until February 2002. Data were collected on infection with the human immunodeficiency virus and on risk factors for and the incidence of myocardial infarction. Relative rates were calculated with Poisson regression models. Combination antiretroviral therapy was defined as any combination regimen of antiretroviral drugs that included a protease inhibitor or a nonnucleoside reverse transcriptase inhibitor.

RESULTS

Over a period of 36,199 person-years, 126 patients had a myocardial infarction. The incidence of myocardial infarction increased with longer exposure to combination antiretroviral therapy (adjusted relative rate per year of exposure, 1.26 [95 percent confidence interval, 1.12 to 1.41]; P<0.001). Other factors significantly associated with myocardial infarction were older age, current or former smoking, previous cardiovascular disease, and male sex, but not a family history of coronary heart disease. A higher total serum cholesterol level, a higher triglyceride level, and the presence of diabetes were also associated with an increased incidence of myocardial infarction.

CONCLUSIONS

Combination antiretroviral therapy was independently associated with a 26 percent relative increase in the rate of myocardial infarction per year of exposure during the first four to six years of use. However, the absolute risk of myocardial infarction was low and must be balanced against the marked benefits from antiretroviral treatment.

Highly Active Antiretroviral Therapy and the Cardiovascular System: The Heart of the Matter

Highly active antiretroviral therapy (HAART) has prolonged many patients' lives, but many cardiac sequelae of HIV are not affected by HAART and continue to develop even with treatment. In addition, HAART itself causes in a high proportion of patients a metabolic syndrome, characterized by lipodystrophy/lipoatrophy, dyslipidemia and insulin resistance that may be associated with an increase in coronary artery disease and stroke. Careful cardiovascular evaluation in the course of HIV disease can identify cardiac complications early enough to treat. All HIV-infected patients are candidates for antiretroviral therapy and patients already under treatment should undergo an assessment that includes the evaluation of the cardiovascular risk according to the available guidelines.

Cardiovascular risk factors in HIV-infected patients

Highly active antiretroviral therapy (HAART) commonly leads to persistent dyslipidemia and insulin resistance that appear likely to confer an increased incidence of cardiovascular disease (CVD). Both protease inhibitors (PIs) and, to a lesser extent, nucleoside analog reverse transcriptase inhibitors (NRTIs) appear to be involved, through direct metabolic effects of PIs and an indirect effect of PI and NRTI-related lipodystrophy. Several studies have found a variable relationship between CVD incidence and HAART, but these studies were not prospective and may not have been adequately powered. A variety of treatment strategies have been evaluated for dyslipidemia and insulin resistance, including lifestyle changes, drugs, and antiretroviral switching, but their relative safety, efficacy and roles are unclear. Although treatment of dyslipidemia and insulin resistance is commonly recommended, it should be remembered that such therapy is likely to be of greater benefit in those with a greater perceived CVD risk (i.e., multiple risk factors) and the lowest risk of HIV disease progression.

A comparison of the effects of nevirapine and nelfinavir on metabolism and body habitus in antiretroviral-naive human immunodeficiency virus-infected patients: a randomized controlled study

New HIV therapies have significantly increased survival, but are associated with multiple metabolic changes, most of them related to the protease inhibitors (PIs). The objective of this study was to elucidate and compare morphological and metabolic alterations in HIV-infected antiretroviral-naive patients receiving two nucleosides plus the PI nelfinavir (NFV) or the nonnucleoside reverse transcriptase inhibitor nevirapine (NVP). Forty-three patients (NFV, n = 20; NVP, n = 23) receiving 6-12 months of treatment were analyzed. Morphological changes were evaluated by bioelectrical impedance analysis, standard anthropometrics, and clinical examination. Serum total cholesterol (TC), low-density and high- density (HDL-c) lipoprotein cholesterol, triglycerides, glucose, and insulin were determined, among other metabolic parameters. No baseline differences were observed between groups. TC increased in both arms (NVP, 11%; NFV, 17%). HDL-c also increased in both groups, although more markedly in those receiving NVP (44% vs. 20%); on-treatment levels were also elevated (1.57 vs. 1.28 mmol/liter). As a consequence of these changes, the TC/HDL-c ratio dropped by 22% in the NVP arm and remained stable in the NFV group. With the use of NFV, the TC/HDL-c ratio and attendant cardiovascular risk did not change. In contrast, NVP offered benefits regarding lipid status, as manifested by enhanced HDL-c concentrations and decreased TC/HDL-c ratios. Inclusion of NVP should be considered when deciding upon antiretroviral regimens for patients at high coronary risk.

Rates and Risk Factors for Condition-Specific Hospitalizations in HIV-Infected and Uninfected Women

BACKGROUND

The rates and risk factors for overall and medical condition-specific hospitalizations in HIV-positive women have not been examined in detail or compared with rates in risk factor-matched HIV-negative women.

OBJECTIVE

To determine the rates and risk factors for overall and condition-specific hospitalizations.

METHODS

Prospective cohort study of 885 HIV-positive women and 425 HIV-negative women followed for semiannual research visits between 1993 and 2000 in 4 urban locations in the United States. Outcome measures were hospitalization diagnoses with diabetes mellitus, nonacute renal conditions, cardiovascular conditions, liver conditions, AIDS defining conditions, and overall hospitalizations. Clinical and laboratory risk factors were assessed at research visits every 6 months, and effects of risk factors on hospitalization rates were calculated using generalized estimating equations and Poisson regression.

RESULTS

Renal laboratory abnormalities, hypertension, and clinical AIDS were each associated with 3 of the 5 condition-specific hospitalization rates. Over time, diabetes-, nonacute renal-, and cardiovascular-related rates were flat or slightly increased and liver-related rates were significantly increased in HIV-positive women. Hospitalization rates with an AIDS-defining condition declined sharply in the latter half of the study period.

CONCLUSIONS

In this population of largely African-American, inner-city, HIV-infected women, renal abnormalities, hypertension, and hepatitis C virus infection were common. Rate ratios indicated that "non-AIDS" risk factors were important predictors of hospitalization. In the highly active antiretroviral therapy era, clinicians must pay attention to these risk factors for morbidity and should closely monitor renal abnormalities, hypertension, and hepatitis status.

Endothelial function in HIV-infected patients receiving protease inhibitor therapy: does immune competence affect cardiovascular risk?

BACKGROUND

The use of HIV protease inhibitors (PIs) as a component of combination antiretroviral therapy in HIV-infected patients has been associated with dyslipidaemia, but its significance as a risk factor for cardiovascular disease is unclear. Endothelial dysfunction is an early phase of atherogenesis that may be assessed non-invasively with ultrasonography in vivo.

AIM

To evaluate vascular function and investigate potential determinants of endothelial dysfunction of the peripheral circulation in PI-treated, HIV-infected men with dyslipidaemia.

DESIGN

Observational, case-control study.

METHODS

We studied 24 HIV-infected, PI-treated men with dyslipidaemia and 24 normolipidaemic, healthy male controls matched for age and body mass index. Brachial artery endothelial function was studied using high-resolution ultrasound and computerized edge-detection software. This non-invasive technique measured post-ischaemic flow-mediated dilatation (FMD), and the endothelium-independent vasodilatory response to glyceryl trinitrate (GTN).

RESULTS

Within the HIV patient group, FMD was significantly associated with percentage of 'naïve' CD4 + 45RA + T cells (p = 0.03), while plasma lipid/lipoprotein and insulin levels, body mass, and smoking status did not correlate with endothelial function. FMD was not significantly different between the study group and the controls.

CONCLUSIONS

The atherogenic potential of PI-associated dyslipidaemia may be attenuated in HIV-infected patients with decreased immune competence, reflecting a possible contribution of cell-mediated immune responses to the pathogenesis of atherosclerosis.

[Adverse effects of antiretroviral therapy. Aspects of pathogenesis]

Highly active antiretroviral therapy has resulted in remarkable reduction of morbidity and mortality of HIV infection. With increasing duration of therapy metabolic alterations such as hyperlipidemia, diabetes mellitus type 2 and lipodystrophy are encountered which considerably reduced quality of life for the patients. These adverse events are most likely due to protease inhibitors and nucleoside analogues with synergistic effects. The pathogenesis is related to metabolic alterations of the adipocytes with cellular insulin resistance and enhanced apoptosis of these cells caused by adipocytic cytokines such as adiponectin, leptin, TNF-alpha and interleukin 2. Switch of therapy regimens with elimination of the most suspicious substances and certain protease inhibitors can lead to improvement of deranged metabolism. Also symptomatic therapy is possible to cope with hyperlipidemia and diabetes, although no effective treatment is available to reverse already existing lipodystrophy. Our knowledge about the pathogenesis of these alterations might lead to new concepts and causal therapy in the future.

An open-label, prospective, observational study of the incidence of coronary artery disease in patients with hiv infection receiving highly active antiretroviral therapy

BACKGROUND

The association of highly active antiretroviral therapy (HAART) regimens that include protease inhibitors (PIs) with metabolic and somatic disorders has raised concerns about the possibility of an increased risk of coronary artery disease (CAD) in patients with HIV infection.

OBJECTIVE

The aim of this study was to assess the incidence of CAD in previously untreated HIV infected outpatients who received reverse transcriptase inhibitors with or without PIs.

METHODS

In this open-label, multicenter, prospective, observational trial, previously untreated and asymptomatic HIV-infected Italian patients were followed to assess the incidence of CAD (primary end point) according to the HAART regimen they received: 2 nucleoside analogue reverse transcriptase inhibitors (NRTIs) in combination with PIs (group PI+) or 1 non-nucleoside reverse transcriptase inhibitor in combination with 2 NRTIs (group PI-). Patients underwent clinical examination and laboratory testing every 4 months.

RESULTS

A total of 1551 HIV-infected patients (994 [64%] men; median age, 35 years; range, 22-50 years) were followed for a median 36 months (range, 34-42 months). The cumulative annual incidence of CAD-related events was 9.8/1000 in group PI+ and 0.8/1000 in group PI- (P < 0.001). The annual incidence of myocardial infarction was 5.1/1000 in group PI+ and 0.4/1000 in group PI- (P < 0.001). Independent of patient age, the incidence of CAD was greater among men (P < 0.001) and patients who smoked >20 cigarettes per day (P < 0.001). Lipodystrophy and metabolic alterations were observed in 62% of patients in group PI+ and in 4% of patients in group PI- (P < 0.001). Of 23 patients receiving PIs who developed CAD, 17 (73.9%) had lipodystrophy and all 23 had hypertriglyceridemia and hypercholesterolemia.

CONCLUSIONS

According to our findings, HAART that includes PIs may accelerate the onset of CAD-related events in young, male, heavy smokers who develop metabolic disorders and lipodystrophy during therapy. Patients with increased coronary risk should receive careful cardiac monitoring if treated with PIs.

Frequency of and outcome of acute coronary syndromes in patients with human immunodeficiency virus infection

Fifty-one patients with human immunodeficiency virus infection and acute coronary syndromes were identified. Nearly all patients (98%) had traditional coronary risk factors. Revascularization procedures were performed safely with low in-hospital mortality.

Coronary heart disease in HIV-infected individuals

It is currently unknown whether there is an increased risk of coronary heart disease (CHD) in patients with HIV infection. In addition, the contribution of antiretroviral therapy (ART) to CHD risk has not been quantified. We reviewed administrative claims data for HIV-infected and -uninfected individuals from the California Medicaid population and compared the incidence of and relative risk (RR) for CHD using log-linear regression analyses between groups. The association between exposure to ART and CHD incidence was also assessed. Of 3,083,209 individuals analyzed, 28,513 were HIV-infected. The incidence of CHD among young men (up to age 34) and women (up to age 44) with HIV infection was significantly higher than that among non-HIV-infected individuals. The covariate-adjusted RR for the development of CHD in individuals receiving ART compared with those not receiving ART was 2.06 (P < 0.001) in HIV-infected individuals aged 18-33 years. There were no statistically significant associations between ART exposure and CHD in other age groups. CHD incidence appears accelerated among young HIV-infected individuals. Strategies to reduce CHD risk should be incorporated into HIV primary care.

Increased use of lipid-lowering therapy in patients receiving human immunodeficiency virus protease inhibitors

Although human immunodeficiency virus (HIV) protease inhibitors (PIs) improve survival in patients with HIV infection, many patients receiving PIs develop hyperlipidemia, which may increase risk of future coronary events. The purpose of this study was to estimate the changing prevalence of lipid-lowering therapy (LLT) in patients with HIV and to evaluate its association with the use of HIV PIs. This was a cross-sectional study of adults with HIV infection who were registered in the Medicaid of California (MEDI-CAL) administrative claims database. Frequencies of HIV-related and dyslipidemia diagnoses were determined from International Classification of Diseases-9th Edition codes. Use of lipid-lowering and antiretroviral medications was determined by National Drug Codes. Multivariate statistical techniques were used to evaluate trends in use of PIs and lipid-lowering medications from January 1996 to June 2002. The number of HIV-infected patients in MEDI-CAL ranged from 15,764 in 1996 to 13,349 in 2000. The prevalence of LLT use among HIV-infected patients on PIs increased by sixfold (1.7% to 10.6%, p <0.05), and in 2000, exceeded use in the overall MEDI-CAL population (p = 0.09). The increasing rate of LLT in patients taking PIs was greater than in HIV-infected patients not on PIs and in MEDI-CAL (p = 0.002). In multivariate models, increasing age (odds ratio 2.30) and use of PIs (odds ratio 2.08) predicted use of LLT (p <0.001). Thus, in patients taking HIV PIs, use of LLT increased more than sixfold, at a faster rate than in the general population. It has not been proved that use of LLT in HIV-infected patients taking PIs improves survival.

A comparison of regimens based on non-nucleoside reverse transcriptase inhibitors or protease inhibitors in preventing Kaposi's sarcoma

OBJECTIVE

To determine the incidence of Kaposi's sarcoma (KS) in a prospective longitudinal cohort of HIV-1-infected individuals before during and after the introduction of highly active antiretroviral therapy (HAART) and to compare the incidence of KS between specific HAART regimens.

DESIGN

Univariate and multivariate analysis of 8640 HIV-1-infected individuals.

METHODS

The protective effect of HAART regimens based on either protease inhibitors (PI) or non-nucleoside reverse transcriptase inhibitors (NNRTI) on the development of KS was examined in prospectively recorded data to determine whether treatments based on the two types of drug were comparable with regard to a reduction in the incidence of KS.

RESULTS

A total of 1204 patients with KS were identified. The incidence of KS decreased from 30/1000 patient-years prior to 1995 to 0.03/1000 patient-years in 2001. Multivariate analysis showed that age, nadir CD4 cell count and antiretroviral class exposure were significant independent predictors of KS. NNRTI-based HAART (adjusted rate ratio, 0.42; 95% confidence interval 0.24-0.37) had a similar protective effect to PI-based HAART (adjusted rate ratio, 0.47; 95% confidence interval 0.38-0.58). Most patients who develop KS on HAART [30/35 (86%)] had evidence of virological treatment failure.

CONCLUSION

PI- and NNRTI-based HAART regimens are equally effective as protection against KS. This is the first study to demonstrate a decreased incidence of an AIDS-defining disease with NNRTI-based therapy.

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

The distribution of risk factors for cardiovascular disease in patients aged 35-44 years who were treated for human immunodeficiency virus type 1 (HIV-1) infection was compared with that for a population-based cohort. HIV-1-infected men treated with a protease inhibitor-containing regimen (n=223), compared with HIV-1-uninfected men (n=527), were characterized by a lower prevalence of hypertension, a lower mean high-density lipoprotein cholesterol level, a higher prevalence of smoking, a higher mean waist-to-hip ratio, and a higher mean triglyceride level. No difference was found for total plasma or low-density cholesterol levels, nor for the prevalence of diabetes. Similar trends were observed among female subjects. The predicted risk of coronary heart disease was greater among HIV-1-infected men (relative risk [RR], 1.20) and women (RR, 1.59; P<10(-6) for both), compared with the HIV-1-uninfected cohort. The estimated attributable risks due to smoking were 65% and 29% for HIV-1-infected men and women, respectively. Because most HIV-1-infected people will ultimately need antiretroviral therapy, risk factors for cardiovascular disease should be determined at the initiation of treatment, and interventions should be considered for all patients who have them.