Antiretroviral therapy with heart

Abstract

Antiretroviral therapy (ART) has resulted in a substantial improvement in the morbidity and mortality associated with human immunodeficiency virus (HIV) infection. As this population ages, cardiovascular disease is becoming an increasingly important health burden. It is clear that many factors are involved in the development of this problem, with traditional risk factors (smoking, dyslipidemia, diabetes, family history, hypertension) the main contributors. ART and HIV infection itself can modify the risk of cardiovascular disease. Not only does this increased risk seem to be mediated through effects on traditional cardiovascular risk factors, namely dyslipidemia and insulin resistance, but there is also some evidence that HIV and ART may be associated with accelerated atherosclerosis and endothelial dysfunction. Current data are conflicting and further investigation into this area is needed. Drugs from both nucleoside reverse transcriptase inhibitor and protease inhibitor classes have been demonstrated to increase cardiovascular risk; however these effects are variable not only between classes but also between drugs in the same class. As newer therapies become available (in existing and new drug classes), the cardiovascular impact of these will need careful evaluation. Currently published guidelines suggest regular monitoring of cardiovascular risks (both before and after commencing ART) and pre-emptive treatment. Existing risk assessment tools have not been fully validated in an HIV setting and need to be used with caution. Lifestyle modification, in the first instance, and pharmacological intervention to reduce traditional risk factors are important management strategies. Initiating, or switching to, ART with a lower potential for metabolic derangement should also be considered.