Cardiovascular Complications of HIV Infection

Abstract

HIV-infected individuals are at increased risk for cardiovascular events. Widely used cardiovascular disease (CVD) risk calculators to determine indications for statin treatment are not well validated for use in the HIV-infecte population. Some experts advocate including HIV infection as an independent risk factor for CVD. The effects of antiretroviral therapy on lipid profiles and the potentially increased risk for cardiovascular events must be taken into account when selecting treatment for HIV-infected individuals. There is increasing evidence that chronic immune activation and inflammation play a role in the pathogenesis of CVD in the context of HIV infection. This article summarizes a presentation by Marshall J. Glesby, MD, PhD, at the Ryan White HIV/AIDS Program Clinical Care Conference held in New Orleans, Louisiana, in December 2015.

Figure 1.

Risk of myocardial infarction with abacavir use in North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) analyses. Full study population included all users of antiretroviral therapy that did not include abacavir at study entry. Restricted study population included antiretroviral therapy–naive individuals initiating treatment (not necessarily including abacavir). For the D:A:D (Data Collection on Adverse Events of Anti-HIV Drugs) study replication, hazard ratio was adjusted for cumulative exposure to abacavir, age, sex, race, presence of risk factors for HIV infection, calendar year, body mass index, smoking status, years since initiation of antiretroviral therapy, and cohort. For the restricted study population, hazard ratio was adjusted for age; sex; race; presence of risk factors for HIV infection; calendar year; smoking status; coinfection with hepatitis C virus; concomitant hypertension, diabetes mellitus, or renal impairment; high levels of total cholesterol or triglycerides; statin use; CD4+ cell count; HIV RNA level; history of clinical AIDS; previous use of protease inhibitors; and cohort. Adapted with permission from Palella et al.

Figure 2.

Results from a US Food and Drug Administration meta-analysis of academic center, National Institutes of Health (NIH) AIDS Clinical Trials Group (ACTG), and manufacturer trials indicating that there is no increased risk of myocardial infarction (MI) associated with abacavir use. Adapted from Ding et al.

Figure 3.

Proportion of HIV-infected Individuals studied for whom statin treatment was recommended based on 2013 American College of Cardiology (ACC)/American Heart Association (AHA) and 2004 Adult Treatment Panel (ATP) III guidelines, according to coronary plaque status. HRM indicates high-risk morphologic. Adapted from Zanni et al.

Figure 4.

The potential roles of chronic immune activation and inflammation in the pathogenesis of cardiovascular disease in HIV-infected individuals. CMV indicates cytomegalovirus; HBV, hepatitis B virus; HCV, hepatitis C virus; KSHV, Kaposi sarcoma–associated herpesvirus. Adapted from Martin et al.

Figure 5.

Design of the REPRIEVE (Randomized Trial to Prevent Vascular Events in HIV) trial, which is examining the efficacy of pitavastatin in preventing cardiovascular events in asymptomatic HIV-infected individuals with no history of cardiovascular disease CVD). Adapted with permission from the REPRIEVE protocol team.