Cardiovascular disease in patients with chronic human immunodeficiency virus infection

Evaluation of HIV-Related Cardiomyopathy in HIV-Positive Patients in Bushehr, Iran

Objectives

In 2020, according to the UNAIDS (Joint United Nations Programme on HIV/AIDS), more than 37 million people lived with human immunodeficiency virus (HIV) infection worldwide. The disease is known to affect several organs, and one of the most affected organs is the heart. Cardiac diseases are highly prevalent among HIV-infected individuals, and recent findings suggest that this could be due to the damage caused by the virus. HIV patients are subject to advanced immunosuppression, which may lead to cardiac muscle damage and, in turn, cardiomyopathy. We aimed to study the incidence of HIV-related cardiomyopathy.

Methods

A pilot cross-sectional study was conducted to assess cardiomyopathy among 200 HIV patients who presented to the Heart Center, Bushehr, Iran. Patients’ files were used to determine the demographic data including age, gender, education, marital status, history of illicit drug use, unsafe/unprotected sexual contact, and whether the patient was a prisoner. Several laboratory data were also collected from these files. Physical examination of the cardiovascular system and echocardiography were also included as part of the evaluation.

Results

Although at least four out of five patients presented with some kind of cardiac damage, including valvular damage and pericardial effusion, none was diagnosed with cardiomyopathy. Valvular dysfunction was detected in 88.5% of the patients. Diastolic dysfunction was found in 7.7% of them. The mean ejection fraction was found to be 58%. In addition to cardiomyopathy, none of the patients developed systolic dysfunction, wall motion abnormality, intra-cardiac mass, or vegetation.

Conclusions

Cardiovascular complications are common among HIV-infected patients. Cardiomyopathy was not detected in our patients. In addition, the most common manifestations that were detected among our patients were valvular heart diseases and pericardial effusion.

Cardiovascular risk factors and comorbidities in people living with HIV: A cross-sectional multicenter study from Colombia comorbidities in a Colombian PLWHIV population

INTRODUCTION

HIV is an independent risk factor for cardiovascular diseases (CVD). There is insufficient information regarding comorbidities and cardiovascular risk factors in the Colombian HIV population. The aim of this study is to describe the prevalence of cardiovascular risk factors and comorbidities in patients from the HIV Colombian Group VIHCOL.

METHODS

This is a multicenter, cross-sectional study conducted in the VIHCOL network in Colombia. Patients 18 years or older who had at least 6 months of follow-up were included. A stratified random sampling was performed to estimate the adjusted prevalence of cardiovascular risk factors and comorbidities.

RESULTS

A total of 1616 patients were included. 83.2% were men, and the median age was 34 years. The adjusted prevalence for dyslipidemia, active tobacco use, hypothyroidism, and arterial hypertension was 51.2% (99% CI: 48.0%-54.4%), 7.6% (99% CI: 5.9%-9.3%), 7.4% (99% CI: 5.7%-9.1%), and 6.3% (99% CI: 4.8%-7.9%), respectively.

CONCLUSIONS

In this Colombian HIV cohort, there is a high prevalence of modifiable CVD risk factors such as dyslipidemia and active smoking. Non-pharmacological and pharmacological measures for the prevention and management of these risk factors should be reinforced.

Potential role of intermittent fasting on decreasing cardiovascular disease in human immunodeficiency virus patients receiving antiretroviral therapy

Cardiovascular disease (CVD) has become one of the commonest causes of comorbidity and mortality among People living with human immunodeficiency virus (HIV) (PLWH) on antiretroviral therapy (ART). Nearly 50% of PLWH are likely to have an increased risk of developing CVD, including coronary heart disease, cerebrovascular disease, peripheral artery disease and aortic atherosclerosis. Aside from the common risk factors, HIV infection itself and side effects of antiretroviral therapy contribute to the pathophysiology of this entity. Potential non-pharmacological therapies are currently being tested worldwide for this purpose, including eating patterns such as Intermittent fasting (IF). IF is a widespread practice gaining high level of interest in the scientific community due to its potential benefits such as improvement in serum lipids and lipoproteins, blood pressure (BP), platelet-derived growth factor AB, systemic inflammation, and carotid artery intima-media thickness among others cardiovascular benefits. This review will focus on exploring the potential role of intermittent fasting as a non-pharmacological and cost-effective strategy in decreasing the burden of cardiovascular diseases among HIV patients on ART due to its intrinsic properties improving the main cardiovascular risk factors and modulating inflammatory pathways related to endothelial dysfunction, lipid peroxidation and aging. Intermittent fasting regimens need to be tested in clinical trials as an important, cost-effective, and revolutionary coadjutant of ART in the fight against the increased prevalence of cardiovascular disease in PLWH.

Cardiovascular disease risk among transgender women living with HIV in the United States

BACKGROUND

Transgender women (TW) are disproportionately affected by both HIV and cardiovascular disease (CVD).

OBJECTIVES

We aim to quantify prevalence of elevated predicted CVD risk for TW compared to cisgender women (CW) and cisgender men (CM) in HIV care and describe the impact of multiple operationalizations of CVD risk score calculations for TW.

DESIGN

We conducted a cross-sectional analysis of patients engaged in HIV care between October 2014 and February 2018.

SETTING

The Centers for AIDS Research Network of Integrated Clinical Systems, a collaboration of 8 HIV clinical sites in the United States contributed data for this analysis.

PATIENTS

221 TW, 2983 CW, and 13467 CM.

MEASUREMENTS

The measure of interest is prevalence of elevated 10-year cardiovascular disease risk based on ACC/AHA Pooled Cohort Risk Assessment equations (PCE) and the Framingham Risk Score (FRS), calculated for TW by: birth-assigned sex (male); history of exogenous sex hormone use (female/male); and current gender (female).

RESULTS

Using birth-assigned sex, the adjusted prevalence ratio (aPR) was 2.52 (95% CI: 1.08,5.86) and 2.58 (95% CI: 1.71,3.89) comparing TW to CW, by PCE and FRS, respectively. It was 1.25 (95% CI: 0.54,2.87) and 1.25 (95% CI: 0.84,1.86) comparing TW to CM, by PCE and FRS, respectively. If TW were classified according to current gender versus birth-assigned sex, their predicted CVD risk scores were lower.

LIMITATIONS

PCE and FRS have not been validated in TW with HIV. Few adjudicated CVD events in the data set precluded analyses based on clinical outcomes.

CONCLUSIONS

After adjustment for demographics and history of HIV care, prevalence of elevated CVD risk in TW was similar to CM and equal to or higher than in CW, depending operationalization of the sex variable. Future studies with CVD outcomes are needed to help clinicians accurately estimate CVD risk among TW with HIV.

Rate of dyslipidemia higher among women living with HIV: A comparison of metabolic and cardiovascular health in a cohort to study aging in HIV

OBJECTIVES

Combination antiretroviral therapy has largely restored the lifespan of persons living with HIV. Data suggest early comorbidities of aging in this population. Past studies focused on men; limited data exist regarding the prevalence of dyslipidaemia in women living with HIV (WLWH). We investigated the prevalence of cardiometabolic abnormalities among WLWH and HIV-negative women in the Children and Women: Antiretrovirals and Markers of Aging (CARMA) cohort, and their relationships to cellular aging markers.

METHODS

We conducted a cross-sectional analysis of nonpregnant female patients (156 WLWH and 133 HIV-negative controls, aged 12-69 years) enrolled in CARMA between 2013 and 2017. The Framingham risk score (FRS) and the prevalences of hypertension, diabetes, metabolic syndrome and dyslipideamia were determined using self-report, anthropometrics, chart review and laboratory data. Cellular aging was determined by assessing leukocyte telomere length and blood mitochondrial DNA content. Diagnoses were based on current Canadian guidelines and definitions.

RESULTS

HIV-infected status was associated with dyslipidaemia [odds ratio (OR) 2.89; 95% confidence interval (CI) 1.69-5.01], but not diabetes, higher FRS, hypertension or metabolic syndrome. The median age was 43.5 [interquartile range (IQR) 36.8-50.9] years in WLWH and 46.2 (IQR 30.3-54.9) years in HIV-negative controls. WLWH were less likely to be menopausal or use alcohol, and more often had hepatitis C virus infection or a current or past smoking history. Lower mitochondrial DNA content was associated with metabolic syndrome; no other associations were noted between cardiometabolic abnormalities and markers of cellular aging.

CONCLUSIONS

Despite their relatively young age, almost two-thirds of WLWH had dyslipidaemia, a significantly greater proportion than in controls. Strategies to address dyslipidaemia and decrease smoking rates may improve long-term outcomes among WLWH.

Treatment Bias in Management of HIV Patients Admitted for Acute Myocardial Infarction: Does It Still Exist?

INTRODUCTION

Previous studies have reported lower rates of coronary angiography and revascularization, and significantly higher mortality among patients infected with human immunodeficiency virus (HIV) presenting with acute myocardial infarction (AMI). This observational study was designed to evaluate characteristics and inpatient outcomes of patients with seropositive HIV infection presenting with AMI.

METHODS

Using the National Inpatient Sample (NIS) database, we identified patients (admissions) with a primary diagnosis of myocardial infarction and a co-occurring HIV. We described baseline characteristics and outcomes. Our primary outcomes of interest were prevalence of coronary angiography, revascularization (percutaneous coronary intervention (PCI) or CABG), and mortality.

RESULTS

From 2010 to 2014, of about 2,977,387 patients with a primary diagnosis of AMI, 10,907 (0.4%) were HIV seropositive. Patients with HIV were younger and more likely to be African American or Hispanic. Coronary angiography and revascularization were performed more frequently in the HIV population. The higher prevalence of revascularization was driven by a higher incidence of PCI. In a multivariable model, patients with HIV were no more likely to undergo revascularization than the general population. This was also the case for PCI. Unadjusted all-cause mortality was lower among patients with HIV. After controlling for confounders, this finding was not significant (OR 0.97, 95% CI 0.75-1.25, p = 0.79). The length of stay between both groups was comparable.

CONCLUSION

In this current analysis, we did not note any treatment bias or difference in the rate of in-hospital total mortality for HIV-seropositive patients presenting with AMI compared with the general population.

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

INTRODUCTION

Cardiovascular (CV) risk is known to be increased in HIV-infected individuals. Our aim was to assess CV risk in HIV-infected adults.

METHODS

CV risk was estimated for each patient using three different risk algorithms: SCORE, the Framingham risk score (FRS), and DAD. Patients were classified as at low, moderate or high CV risk. Clinical and anthropometric data were collected.

RESULTS

We included 571 HIV-infected individuals, mostly male (67.1%; n=383). Patients were divided into two groups according to antiretroviral therapy (ART): naïve (7.5%; n=43) or under ART (92.5%; n=528). The mean time since HIV diagnosis was 6.7±6.5 years in the naive group and 13.3±6.1 years in the ART group. Metabolic syndrome (MS) was identified in 33.9% (n=179) and 16.3% (n=7) of participants in the ART and naïve groups, respectively. MS was associated with ART (OR=2.7; p=0.018). Triglycerides ≥150 mg/dl (OR=13.643, p<0.001) was one of the major factors contributing to MS. Overall, high CV risk was found in 4.4% (n=23) of patients when the SCORE tool was used, in 20.5% (n=117) using the FRS, and in 10.3% (n=59) using the DAD score. The observed agreement between the FRS and SCORE was 55.4% (k=0.183, p<0.001), between the FRS and DAD 70.5% (k=0.465, p<0.001), and between SCORE and DAD 72.3% (k=0.347, p<0.001).

CONCLUSION

On the basis of the three algorithms, we detected a high rate of high CV risk, particularly in patients under ART. The FRS was the algorithm that classified most patients in the high CV risk category (20.5%). In addition, a high prevalence of MS was identified in this patient group.

Promoting Cardiovascular Health in Patients Living with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

Patients living with human immunodeficiency virus/acquired immunodeficiency syndrome (PLWHA) are at increased risk of cardiovascular disease because of advances in human immunodeficiency virus/acquired immunodeficiency syndrome treatment and increased life expectancy. Cardiovascular health promotion in PLWHA includes strategies for risk factor reduction, disease prevention, early detection, and treatment of cardiovascular disease.

Cardiovascular Disease in the Setting of Human Immunodeficiency Virus Infection

Background:

Since the introduction of Antiretroviral Therapy (ART), the life expectancy and health quality for patients infected with Human Immunodeficiency Virus (HIV) have significant-ly improved. Nevertheless, as a result of not only the deleterious effects of the virus itself and pro-longed ART, but also the effects of aging, cardiovascular diseases have emerged as one of the most common causes of death among these patients.

Objective:

The purpose of this review is to explore the new insights on the spectrum of Cardiovascu-lar Disease (CVD) in HIV infection, with emphasis on the factors that contribute to the atherosclerot-ic process and its role in the development of acute coronary syndrome in the setting of infection.

Methods:

A literature search using PubMed, ScienceDirect and Web of Science was performed. Ar-ticles up to Mar, 2017, were selected for inclusion. The search was conducted using MeSH terms, with the following key terms: [human immunodeficiency virus AND (cardiovascular disease OR coronary heart disease) AND (antiretroviral therapy AND (cardiovascular disease OR coronary heart disease))].

Results:

Clinical cardiovascular disease tends to appear approximately 10 years before in infected in-dividuals, when compared to the general population. The pathogenesis behind the cardiovascular, HIV-associated complications is complex and multifactorial, involving traditional CVD risk factors, as well as factors associated with the virus itself - immune activation and chronic inflammation – and the metabolic disorders related to ART regimens.

Conclusion:

Determining the cardiovascular risk among HIV-infected patients, as well as targeting and treating conditions that predispose to CVD, are now emerging concerns among physicians.

Sex differences in the contemporary management of HIV patients admitted for acute myocardial infarction

BACKGROUND

Studies have reported sex differences in the management of patients with acute myocardial infarction (AMI) in the general population. This observational study is designed to evaluate whether sex differences exist in the contemporary management of human immunodeficiency virus (HIV) patients admitted for diagnosis of AMI.

HYPOTHESIS

There is no difference in management of HIV patients with AMI.

METHODS

Using the National Inpatient Sample database, we identified patients with a primary diagnosis of AMI and a secondary diagnosis of HIV. We described baseline characteristics and outcomes using NIS documentation. Our primary areas of interest were revascularization and mortality.

RESULTS

Among 2 977 387 patients presenting from 2010 to 2014 with a primary diagnosis of AMI, 10907 (0.4%) had HIV (mean age, 54.1 ± 9.3 years; n = 2043 [18.9%] female). Females were younger, more likely to be black, and more likely to have hypertension, diabetes, obesity, and anemia. Although neither males nor females were more likely to undergo coronary angiography in multivariate analysis, revascularization was performed less frequently in females than in males (45.4% vs 62.7%; P < 0.01), driven primarily by lower incidence of PCI. In a multivariate model, females were less likely to undergo revascularization (OR: 0.59, 95% CI: 0.45-0.78, P < 0.01), a finding driven solely by PCI (OR: 0.64, 95% CI: 0.49-0.83, P < 0.01). All-cause mortality was similar in both groups.

CONCLUSIONS

AMI was more common in males than females with HIV. Females with HIV were more likely to be younger and black and less likely to be revascularized by PCI.

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

BACKGROUND

Ischemic cardiovascular events are a relevant cause of morbidity and mortality in HIV-infected patients. Use of abacavir (ABC), a nucleoside analog reverse transcriptase inhibitor, has been associated with increased risk of myocardial infarction (MI) and with platelet hyperreactivity. We explored whether low-dose aspirin reduces in vivo platelet activation and platelet hyperreactivity induced by ABC in HIV-infected subjects.

METHODS AND RESULTS

In a randomized, placebo-controlled, cross-over study forty HIV-infected patients with ABC-associated platelet hyperreactivity, defined by a score based on laboratory variables reflecting in vivo platelet activation and ex vivo platelet hyperresponsiveness, were randomized to aspirin 100 mg daily for 15 days with subsequent cross-over to placebo for additional 15 days or placebo for 15 days with subsequent cross-over to aspirin for further 15 days. In vivo and ex vivo platelet activation markers were measured at day 15 and 30. One group of healthy subjects, one of untreated HIV infected-patients and one treated without ABC, were studied concomitantly. Serum TxB₂ and urinary 11-dehydro-TxB₂ were decreased by aspirin in ABC-treated patients, but not as much as in healthy controls. Aspirin therapy reduced significantly platelet hyperreactivity (score: from 9.3, 95% CIs 8.7 to 10.0, to 7.5, 6.9 to 8.0), however without bringing it back to the levels of healthy controls (score: 4.6, 95% CIs 3.6 to 5.6).

CONCLUSION

Aspirin reduces ABC-induced in vivo platelet activation and platelet hyperreactivity in HIV-infected patients, however without normalizing them. Whether the observed reduction of platelet activation is sufficient to prevent cardiovascular events requires a prospective trial.

Ethnic disparities in estimated cardiovascular disease risk in Amsterdam, the Netherlands : The HELIUS study

Background

Ethnic differences have been reported in cardiovascular disease (CVD) risk factors. It is still unclear which ethnic groups are most at risk for CVD when all traditional CVD risk factors are considered together as overall risk.

Objectives

To examine ethnic differences in overall estimated CVD risk and the risk factors that contribute to these differences.

Design

Using data of the multi-ethnic HELIUS study (HEalthy LIfe in an Urban Setting) from Amsterdam, we examined whether estimated CVD risk and risk factors among those eligible for CVD risk estimation differed between participants of Dutch, South Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan origin. Using the Systematic COronary Risk Evaluation (SCORE) algorithm, we estimated risk of fatal CVD and risk of fatal plus non-fatal CVD. These risks were compared between ethnic groups via age-adjusted linear regression analyses.

Results

The SCORE algorithm was applicable to 9,128 participants. Relative to the fatal CVD risk of participants of Dutch origin, South Asian Surinamese participants showed a higher fatal CVD risk, Ghanaian males a lower fatal CVD risk, and participants of other ethnic origins a similar fatal CVD risk. For fatal plus non-fatal CVD risk, African Surinamese and Turkish men also showed a higher risk. When diabetes was incorporated in the CVD risk algorithm, all but Ghanaian men showed a higher CVD risk relative to the participants of Dutch origin (betas ranging from 0.98–3.10%). The CVD risk factors that contribute the most to these ethnic differences varied between ethnic groups.

Conclusion

Ethnic minority groups are at a greater estimated risk of fatal plus non-fatal CVD relative to the group of native Dutch. Further research is necessary to determine whether this will translate to ethnic differences in CVD incidence and, if so, whether ethnic-specific CVD prevention strategies are warranted.

Electronic supplementary material

The online version of this article (10.1007/s12471-018-1107-3) contains supplementary material, which is available to authorized users.

HIV and coronary disease - When secondary prevention is insufficient

Highly active antiretroviral therapy (HAART) has created a new paradigm for human immunodeficiency virus (HIV)-infected patients, but their increased risk for coronary disease is well documented. We present the case of a 57-year-old man, co-infected with HIV-2 and hepatitis B virus, adequately controlled and with insulin-treated type 2 diabetes and dyslipidemia, who was admitted with non-ST elevation acute myocardial infarction. Coronary angiography performed on day four of hospital stay documented two-vessel disease (mid segment of the right coronary artery [RCA, 90% stenosis] and the first marginal). Two drug-eluting stents were successfully implanted. The patient was discharged under dual antiplatelet therapy (aspirin 100 mg/day and clopidogrel 75 mg/day) and standard coronary artery disease medication. He was admitted to the emergency room four hours after discharge with chest pain radiating to the left arm and inferior ST-segment elevation myocardial infarction was diagnosed. Coronary angiography was performed within one hour and documented thrombosis of both stents. Optical coherence tomography revealed good apposition of the stent in the RCA, with intrastent thrombus. Angioplasty was performed, with a good outcome. The acute stent thrombosis might be explained by the thrombotic potential of HIV infection and diabetes. There are no specific guidelines regarding HAART in secondary prevention of acute coronary syndromes. A multidisciplinary approach is essential for optimal management of these patients.

Cardiac Disease Associated with Human Immunodeficiency Virus Infection

Over the last 2 decades human immunodeficiency virus (HIV) infection has become a chronic disease requiring long-term management. Aging, antiretroviral therapy, chronic inflammation, and several other factors contribute to the increased risk of cardiovascular disease in patients infected with HIV. In low-income and middle-income countries where antiretroviral therapy access is limited, cardiac disease is most commonly related to opportunistic infections and end-stage manifestations of HIV/acquired immunodeficiency syndrome, including HIV-associated cardiomyopathy, pericarditis, and pulmonary arterial hypertension. Cardiovascular screening, prevention, and risk factor management are important factors in the management of patients infected with HIV worldwide.

Management of cardiovascular conditions in a cohort of patients with HIV: experience from a joint HIV/cardiology clinic

The aim of this study was to assess cardiovascular diagnoses and management in a cohort of patients diagnosed with HIV, and the performance of a joint HIV/Cardiology Clinic in a tertiary hospital setting. A retrospective analysis was performed on all patients referred to a joint HIV/Cardiology Clinic at our hospital. Data on 120 patients were collected. In this predominantly male population (male 101 and female 19) coronary artery disease (CAD) was the most common diagnosis (34%, n = 41). Other diseases included hypertension (12.5%, n = 15), cardiomyopathy (12.5%, n = 15) and arrhythmia (6%, n = 8). The majority of remaining cases included non-cardiac chest pain and palpitations. In addition to usual primary and secondary preventive measures for CAD, complex procedures, such as percutaneous coronary intervention, cardiac resynchronisation therapy for left ventricular systolic dysfunction and radiofrequency ablation for arrhythmias, were carried out. Overall cardiovascular mortality among the group was 2.5% (n = 3) over 4 years. The results indicate the efficacy of a specialist joint HIV/Cardiology Clinic in diagnosing and managing various cardiac conditions in a complex cohort of patients with HIV.

Comparison of Rates of Death Having any Death-Certificate Mention of Heart, Kidney, or Liver Disease Among Persons Diagnosed with HIV Infection with those in the General US Population, 2009-2011

OBJECTIVE

Compare age-adjusted rates of death due to liver, kidney, and heart diseases during 2009-2011 among US residents diagnosed with HIV infection with those in the general population.

METHODS

Numerators were numbers of records of multiple-cause mortality data from the national vital statistics system with an ICD-10 code for the disease of interest (any mention, not necessarily the underlying cause), divided into those 1) with and 2) without an additional code for HIV infection. Denominators were 1) estimates of persons living with diagnosed HIV infection from national HIV surveillance system data and 2) general population estimates from the US Census Bureau. We compared age-adjusted rates overall (unstratified by sex, race/ethnicity, or region of residence) and stratified by demographic group.

RESULTS

Overall, compared with the general population, persons diagnosed with HIV infection had higher age-adjusted rates of death reported with hepatitis B (rate ratio [RR]=42.6; 95% CI: 34.7-50.7), hepatitis C (RR=19.4; 95% CI: 18.1-20.8), liver disease excluding hepatitis B or C (RR=2.1; 95% CI: 1.8-2.3), kidney disease (RR=2.4; 95% CI: 2.2-2.6), and cardiomyopathy (RR=1.9; 95% CI: 1.6-2.3), but lower rates of death reported with ischemic heart disease (RR=0.6; 95% CI: 0.6-0.7) and heart failure (RR=0.8; 95% CI: 0.6-0.9). However, the differences in rates of death reported with the heart diseases were insignificant in some demographic groups.

CONCLUSION

Persons with HIV infection have a higher risk of death with liver and kidney diseases reported as causes than the general population.

HIV and the spectrum of human disease

Infection with the human immunodeficiency virus (HIV) causes systemic T cell destruction and reduced cell-mediated immunity that leads to a wide range of opportunistic infections and cancers. Second, it directly damages many tissues - gut, brain, lung - through mononuclear cell infection and activation. Third, through immune activation and effects on endothelia, it can cause more subtle systemic organ damage, such as chronic cardiovascular, hepatic, pulmonary and central nervous system disease. Antiretroviral treatment has enabled HIV-infected persons to live with chronic infection, although with some side-effects and mortality, including reactions due to the immune reconstitution inflammatory syndrome (IRIS). As cohorts of infected people get older, age-related diseases will combine with chronic HIV infection to produce disabilities whose scale is not yet understood. HIV is detectable in tissues by immunohistochemistry when infection loads are high, such as at first presentation. Pathologists should proactively consider HIV disease in routine diagnostic work, so as to identify more HIV-infected patients and enable their optimal management.