Protease inhibitors and cardiovascular disease: analysis of the Los Angeles County adult spectrum of disease cohort

Anti-Protease Activity Deficient Secretory Leukocyte Protease Inhibitor (SLPI) Exerts Cardioprotective Effect against Myocardial Ischaemia/Reperfusion

Inhibition of proteases shows therapeutic potential. Our previous studies demonstrated the cardioprotection by the Secretory Leukocyte Protease Inhibitor (SLPI) against myocardial ischaemia/reperfusion (I/R) injury. However, it is unclear whether the cardioprotective effect of SLPI seen in our previous works is due to the inhibition of protease enzymes. Several studies demonstrate that the anti-protease independent activity of SLPI could provide therapeutic benefits. Here, we show for the first time that recombinant protein of anti-protease deficient mutant SLPI (L72K, M73G, L74G) (mt-SLPI) could significantly reduce cell death and intracellular reactive oxygen species (ROS) production against an in vitro simulated I/R injury. Furthermore, post-ischaemic treatment of mt-SLPI is found to significantly reduce infarct size and cardiac biomarkers lactate dehydrogenase (LDH) and creatine kinase-MB (CK-MB) activity, improve cardiac functions, attenuate I/R induced-p38 MAPK phosphorylation, and reduce apoptotic regulatory protein levels, including Bax, cleaved-Caspase-3 and total Capase-8, in rats subjected to an in vivo I/R injury. Additionally, the beneficial effect of mt-SLPI was not significantly different from the wildtype (wt-SLPI). In summary, SLPI could provide cardioprotection without anti-protease activity, which could be more clinically beneficial in terms of providing cardioprotection without interfering with basal serine protease activity.

Stroke and HIV in Botswana: A prospective study of risk factors and outcomes

OBJECTIVE

HIV is associated with an increased risk of stroke, but there are sparse data on risk factors for stroke in people living with HIV in Sub-Saharan African. The goal of this study was to identify HIV-specific stroke characteristics and risk factors among adults in Botswana.

METHODS

We conducted a prospective cohort study in Gaborone, Botswana from June 2015 to June 2017 comparing risk factors and outcomes among adults with and without HIV admitted for acute stroke. In addition, we conducted a case-control study comparing patients with HIV and stroke to outpatients with HIV and no history of stroke.

RESULTS

A total of 52 patients with imaging-confirmed acute stroke were enrolled. Stroke patients with HIV were younger than those without HIV (median age 40 vs 54, p = .005). Hypertension was the most common risk factor identified in both HIV+ and HIV- groups, but was more common in patients without HIV (81% vs. 55%, p = .04). Patients with HIV were significantly more likely to have a small-vessel lacunar syndrome compared to patients without HIV (67% vs. 29%, p = .02). In the case-control analysis, patients with HIV and stroke were more likely to have hypertension than stroke-free controls (53% vs. 16%; OR 7.2, 95% CI 1.5-33.8, p = .01), and were more likely to drink alcohol (53% vs. 21%, OR 3.7, 95% CI 1.1-12.1, p = .03).

CONCLUSIONS

Individuals with HIV present with strokes at younger ages than individuals without HIV. Among those with HIV, hypertension and alcohol use are significant risk factors for stroke.

Risk of cardiovascular events among patients with HIV treated with atazanavir-containing regimens: a retrospective cohort study

Background

A previous cohort study indicated that atazanavir (ATV), a protease inhibitor used for HIV treatment, is not associated with an increased risk of cardiovascular (CV) events. The objective of this study was to compare the risk of CV events among antiretroviral-naïve patients initiating ATV-containing versus ATV-free ARV regimens.

Methods

Patients with HIV who newly initiated antiretroviral therapy were selected from MarketScan Commercial and Multi-State Medicaid databases. The first claim for an antiretroviral medication between 1/1/2007 and 12/31/2013 was known as the index date. Patients were categorized as initiating an ATV-containing or an ATV-free regimen. Patients who did not have 6 months of continuous enrollment prior to the index date or who had evidence of a CV event during this time period were excluded. Myocardial infarction, stroke, percutaneous coronary intervention, and coronary artery bypass graft were identified through diagnosis and procedure codes. Patients were followed from index date until a CV event, continuous gap of >30 days without initiated ARV, a claim for ATV in the ATV-free cohort, disenrollment, or study end, whichever occurred first. Unadjusted incidence rates (IR) were calculated and propensity-score-weighted Cox proportional hazards models were fit to compare hazards of CV events between the two cohorts.

Results

A total of 22,211 patients (2437 ATV-containing and 19,774 ATV-free) were identified in the Commercial Database and 7136 patients were identified (1505 ATV-containing and 5631 ATV-free) in the Medicaid Database. CV events were uncommon (Commercial IR per 1000 person-years for a CV event: ATV-containing = 3.01, ATV-free = 3.26; Medicaid IR: ATV-containing = 10.9, ATV-free = 9.9). In propensity-score-weighted models combining the two populations, there was no significant difference in the hazards of a CV event for patients initiating an ATV-containing regimen compared with those initiating an ATV-free regimen (hazard ratio = 1.16, 95 % confidence interval 0.67–1.99).

Conclusions

In this real-world analysis, there was no significant increase in the risk of CV events associated with exposure to ATV-containing regimens.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1827-1) contains supplementary material, which is available to authorized users.

Traditional and HIV-specific risk factors for cardiovascular morbidity and mortality among HIV-infected adults in Brazil: a retrospective cohort study

BACKGROUND

Antiretroviral therapy (ART) agents potentially associated with adverse metabolic profiles are commonly used in low- and middle-income countries. We assessed risk factors for cardiovascular disease (CVD)-related morbidity and mortality in a cohort of HIV-infected, ART-treated adults in Rio de Janeiro, Brazil.

METHODS

Hospital records and mortality data between 2000-2010 were examined for incident CVD-related ICD-10 and Coding of Death in HIV diagnoses among adults ≥18 years old on ART, enrolled in an observational cohort. Poisson regression models assessed associations between demographic and clinical characteristics and ART agent or class on CVD event risk.

RESULTS

Of 2960 eligible persons, 109 had a CVD event (89 hospitalizations, 20 deaths). Participants were 65 % male, 54 % white, and had median age of 37 and 4.6 years on ART. The median nadir CD4(+) T lymphocyte count was 149 cells/mm(3). The virologic suppression rate at the end of study follow-up was 60 %. In multivariable models, detectable HIV-1 RNA prior to the event, prior CVD, less time on ART, age ≥40 at study baseline, nadir CD4(+) T lymphocyte count ≤50 cells/mm(3), non-white race, male gender, and a history of hypertension were significantly associated with CVD event incidence (p < 0.05), in order of decreasing strength. In multivariate models, cumulative use of tenofovir, zidovudine, efavirenz and ritonavir-boosted atazanavir, darunavir and/or lopinavir were associated with decreased CVD event risk. Recent tenofovir and boosted atazanavir use were associated with decreased risk, while recent stavudine, nevirapine and unboosted nelfinavir and/or indinavir use were associated with increased CVD event risk.

CONCLUSIONS

Virologic suppression and preservation of CD4(+) T-lymphocyte counts were as important as traditional CVD risk factor burden in determining incident CVD event risk, emphasizing the overall benefit of ART on CVD risk and the need for metabolically-neutral first- and second-line ART in resource-limited settings.

A meta-analysis investigating incidence and features of stroke in HIV-infected patients in the highly active antiretroviral therapy era

OBJECTIVE

Recent studies have suggested a close biological and clinical association between HIV infection and risk of myocardial infarction, whereas contrasting data have been reported about incidence of stroke and its clinical predictors.

DESIGN AND SETTING

Studies including HIV-infected patients developing a cerebral ischemic event were systematically searched for in MEDLINE/PubMed.

PATIENTS AND MAIN OUTCOME MEASURES

Baseline, treatment and outcome data were appraised and pooled with random-effects methods computing summary estimates (95% confidence intervals).

RESULTS

Five studies comprising 89,713 participants were included: they were young [46 (46-50) years, mainly male (70% (68-79)] with a moderate prevalence of diabetes [19% (14-21)]. Atrial fibrillation and history of previous coronary artery disease were observed in 3% (2-5) and 18% (15-22), respectively. All patients were on highly active antiretroviral therapy (HAART) and had been treated for a mean of 5 (2-6) years. After a median of 4 (3-5) years of follow-up, 1245 ischemic strokes occurred [1.78% (0.75-2.81)]. Traditional risk factors such as age (five studies), hypertension (three studies), smoking (two studies), hyperlipidemia (one study), atrial fibrillation (one study) and diabetes (one study) were identified as independent predictors of stroke. In one study, RNA viral load [log of odds ratio = 1.10 (1.04-1.17)] and CD4+ cell count less than 200/μl were clinically related to stroke, whereas HAART therapy showed a neutral effect.

CONCLUSION

Stroke represents a relatively common complication in young, HAART-treated HIV patients. Apart from traditional cardiovascular risk factors, HIV-RNA viral load may help to target and manage patients at risk.

Correlates of hypertension in patients with AIDS in the era of highly active antiretroviral therapy

BACKGROUND

It is unclear whether HIV-related factors modify risk of hypertension (HTN). In a cohort of patients with AIDS, the authors determined HTN incidence and prevalence and assessed associated traditional, HIV-specific, and retinal vasculature factors.

METHODS

Prospective observational cohort included 2390 patients with AIDS (1998-2011). Univariate analysis was used to assess the impact of traditional- and AIDS-related risk factors for HTN prevalence and incidence. Multivariate regression analyses were used to evaluate the adjusted impact of these factors.

RESULTS

Hypertension prevalence was 22%(95% confidence interval [CI] 21%-24%) and was associated with traditional HTN risk factors (age, black race, and higher weight) as well as diabetes, hyperlipidemia, time since AIDS diagnosis, and higher CD4 counts. Hypertension incidence was 64.1 per 1000 person-years (95% CI 58.7/1000-69.9/1000). Age, race, weight, and diabetes were associated with incident HTN but HIV-specific factors were not.

CONCLUSIONS

Hypertension, a prevalent cardiovascular risk factor in patients with AIDS, is associated with traditional and metabolic risk factors.

Risk of cardiovascular disease from antiretroviral therapy for HIV: a systematic review

Background

Recent studies suggest certain antiretroviral therapy (ART) drugs are associated with increases in cardiovascular disease.

Purpose

We performed a systematic review and meta-analysis to summarize the available evidence, with the goal of elucidating whether specific ART drugs are associated with an increased risk of myocardial infarction (MI).

Data Sources

We searched Medline, Web of Science, the Cochrane Library, and abstract archives from the Conference on Retroviruses and Opportunistic Infections and International AIDS Society up to June 2011 to identify published articles and abstracts.

Study Selection

Eligible studies were comparative and included MI, strokes, or other cardiovascular events as outcomes.

Data Extraction

Eligibility screening, data extraction, and quality assessment were performed independently by two investigators.

Data Synthesis

Random effects methods and Fisher’s combined probability test were used to summarize evidence.

Findings

Twenty-seven studies met inclusion criteria, with 8 contributing to a formal meta-analysis. Findings based on two observational studies indicated an increase in risk of MI for patients recently exposed (usually defined as within last 6 months) to abacavir (RR 1.92, 95% CI 1.51–2.42) and protease inhibitors (PI) (RR 2.13, 95% CI 1.06–4.28). Our analysis also suggested an increased risk associated with each additional year of exposure to indinavir (RR 1.11, 95% CI 1.05–1.17) and lopinavir (RR 1.22, 95% CI 1.01–1.47). Our findings of increased cardiovascular risk from abacavir and PIs were in contrast to four published meta-analyses based on secondary analyses of randomized controlled trials, which found no increased risk from cardiovascular disease.

Conclusion

Although observational studies implicated specific drugs, the evidence is mixed. Further, meta-analyses of randomized trials did not find increased risk from abacavir and PIs. Our findings that implicate specific ARTs in the observational setting provide sufficient evidence to warrant further investigation of this relationship in studies designed for that purpose.

Relative risk of cardiovascular disease among people living with HIV: a systematic review and meta-analysis

OBJECTIVES

The aim of this study was to estimate the relative risk of cardiovascular disease (CVD) among people living with HIV (PLHIV) compared with the HIV-uninfected population.

METHODS

We conducted a systematic review and meta-analysis of studies from the peer-reviewed literature. We searched the Medline database for relevant journal articles published before August 2010. Eligible studies were observational and randomized controlled trials, reporting CVD, defined as myocardial infarction (MI), ischaemic heart disease, cardiovascular and cerebrovascular events or coronary heart disease among HIV-positive adults. Pooled relative risks were calculated for various groupings, including different classes of antiretroviral therapy (ART).

RESULTS

The relative risk of CVD was 1.61 [95% confidence interval (CI) 1.43-1.81] among PLHIV without ART compared with HIV-uninfected people. The relative risk of CVD was 2.00 (95% CI 1.70-2.37) among PLHIV on ART compared with HIV-uninfected people and 1.52 (95% CI 1.35-1.70) compared with treatment-naïve PLHIV. We estimate the relative risk of CVD associated with protease inhibitor (PI)-, nucleoside reverse transcriptase inhibitor- and nonnucleoside reverse transcriptase inhibitor-based ART to be 1.11 (95% CI 1.05-1.17), 1.05 (95% CI 1.01-1.10) and 1.04 (95% CI 0.99-1.09) per year of exposure, respectively. Not all ART was associated with increased risk; specifically, lopinavir/ritonavir and abacavir were associated with the greater risk and the relative risk of MI for PI-based versus non-PI-based ART was 1.41 (95% CI 1.20-1.65).

CONCLUSION

PLHIV are at increased risk of cardiovascular disease. Although effective in prolonging survival, ART (in particular PI-based regimens) is related to further increased risk of CVD events among people at highest initial absolute risk of cardiovascular disease.

HIV Infection, Antiretroviral Therapy and Cardiovascular Risk

In the last 15 years, highly active antiretroviral therapy (HAART) has determined a dramatic reduction of both morbidity and mortality in human immunodeficiency virus (HIV)-infected subjects, transforming this infection in a chronic and manageable disease. Patients surviving with HIV in the developed world, in larger number men, are becoming aged. As it would be expected for a population of comparable age, many HIV-infected individuals report a family history of cardiovascular disease, a small proportion have already experienced a cardiovascular event and an increasing proportion has diabetes mellitus. Smoking rate is very high while an increasing proportion of HIV-infected individuals have dyslipidaemia. Studies suggest that these traditional risk factors could play an important role in the development of cardiovascular disease in these patients as they do in the general population. Thus, whilst the predicted 10-year cardiovascular disease risk remains relatively low at present, it will likely increase in relation to the progressive aging of this patient population. Thus, the long-term follow-up of HIV infected patients has to include co-morbidity management such as cardiovascular disease prevention and treatment. Two intriguing aspects related to the cardiovascular risk in patients with HIV infection are the matter of current investigation: 1) while these subjects share many cardiovascular risk factors with the general population, HIV infection itself increases cardiovascular risk; 2) some HAART regimens too influence atherosclerotic profile, partly due to lipid changes. Although the mechanisms involved in the development of cardiovascular complications in HIV-infected patients remain to be fully elucidated, treatment guidelines recommending interventions to prevent cardiovascular disease in these individuals are already available; however, their application is still limited.

HIV protease inhibitors elicit volume-sensitive Cl- current in cardiac myocytes via mitochondrial ROS

HIV protease inhibitors (HIV PI) reduce morbidity and mortality of HIV infection but cause multiple untoward effects. Because certain HIV PI evoke production of reactive oxygen species (ROS) and volume-sensitive Cl(-) current (I(Cl,swell)) is activated by ROS, we tested whether HIV PI stimulate I(Cl,swell) in ventricular myocytes. Ritonavir and lopinavir elicited outwardly rectifying Cl(-) currents under isosmotic conditions that were abolished by the selective I(Cl,swell)-blocker DCPIB. In contrast, amprenavir, nelfinavir, and raltegravir, an integrase inhibitor, did not modulate I(Cl,swell) acutely. Ritonavir also reduced action potential duration, but amprenavir did not. I(Cl,swell) activation was attributed to ROS because ebselen, an H(2)O(2) scavenger, suppressed ritonavir- and lopinavir-induced I(Cl,swell). Major ROS sources in cardiomyocytes are sarcolemmal NADPH oxidase and mitochondria. The specific NADPH oxidase inhibitor apocynin failed to block ritonavir- or lopinavir-induced currents, although it blocks I(Cl,swell) elicited by osmotic swelling or stretch. In contrast, rotenone, a mitochondrial e(-) transport inhibitor, suppressed both ritonavir- and lopinavir-induced I(Cl,swell). ROS production was measured in HL-1 cardiomyocytes with C-H(2)DCFDA-AM and mitochondrial membrane potential (ΔΨ(m)) with JC-1. Flow cytometry confirmed that ritonavir and lopinavir but not amprenavir, nelfinavir, or raltegravir augmented ROS production, and HIV PI-induced ROS production was suppressed by rotenone but not NADPH oxidase blockade. Moreover, ritonavir, but not amprenavir, depolarized ΔΨ(m). These data suggest ritonavir and lopinavir activated I(Cl,swell) via mitochondrial ROS production that was independent of NADPH oxidase. ROS-dependent modulation of I(Cl,swell) and other ion channels by HIV PI may contribute to some of their actions in heart and perhaps other tissues.

Antiretrovirals induce endothelial dysfunction via an oxidant-dependent pathway and promote neointimal hyperplasia

Human immunodeficiency virus-1 antiretroviral treatment is associated with an increased incidence of atherosclerosis. We hypothesized that antiretrovirals directly impair endothelial function after short-term exposure and that with chronic exposure, this dysfunction promotes a proliferative response, inducing neointimal hyperplasia, thus contributing to vascular lesion formation. To test this hypothesis, we treated mice with the nucleoside reverse transcriptase inhibitor azidothymidine (AZT), the protease inhibitor indinavir, or AZT + indinavir. Treatment with AZT or AZT + indinavir for 5 days impaired endothelium-dependent vessel relaxation. Though indinavir treatment alone did not alter vessel relaxation, it potentiated the impairment of endothelium-dependent relaxation induced by AZT. Coadministration of the antioxidant Mn (III) tetrakis (1-methyl-4-pyridyl) porphyrin attenuated antiretroviral-induced endothelial dysfunction, suggesting that oxidant production may have a causal role in the observed endothelial dysfunction. To test whether the antiretrovirals promote a proliferative response following endothelial dysfunction, we treated mice with antiretrovirals for 14 days and then induced a carotid endothelial injury. Two weeks later, we observed a dramatic increase in neointimal formation in all antiretroviral-treated animals, and the newly formed neointima was comprised mainly of proliferated smooth muscle cells. Although a functional endothelium surrounding the lesioned area and re-endothelialization across the area of injury is important in reducing proliferation in this model, we tested whether the neointimal hyperplasia was associated with endothelial dysfunction. Plasma levels of asymmetric dimethylarginine, a biomarker of endothelial dysfunction, increased after treatment with indinavir or AZT + indinavir. On the other hand, treatment with AZT or AZT + indinavir increased endothelial vascular cell adhesion molecule staining. We conclude that short-term treatment with antiretrovirals elicited a direct impairment in endothelial function, in part via an oxidant-dependent pathway. These antiretrovirals also exacerbated injury-induced vascular smooth muscle cell proliferation and neointimal hyperplasia, likely because of their inhibition of endothelial function.

Kidney function and the risk of cardiovascular events in HIV-1-infected patients

OBJECTIVE

Cardiovascular events (CVEs) are a significant cause of mortality in HIV/AIDS patients. The objective is to determine the correlation between kidney function and the risk of CVEs in the HIV-infected population.

DESIGN

Nested, matched, case-control study design was employed.

METHODS

: We performed a single-center study of 315 HIV-infected patients (63 patients who had CVEs and 252 controls). Estimated glomerular filtration rate (eGFR), calculated by the Chronic Kidney Disease Epidemiology Collaboration formula and the Modification of Diet in Renal Disease equation, and proteinuria were the primary exposures of interest.

RESULTS

Mean eGFR was significantly lower in the patients compared with controls (68.4 vs. 103.2 ml/min per 1.73 m, P < 0.001 by Chronic Kidney Disease Epidemiology Collaboration formula and 69.0 vs. 103.1 ml/min per 1.73 m, P < 0.001 by Modification of Diet in Renal Disease equation). In univariate analysis, an eGFR of less than 60 ml/min per 1.73 m was associated with a 15.9-fold increased odds of a CVE compared with an eGFR of at least 60 ml/min per 1.73 m (P < 0.001). In multivariate analysis, a 10 ml/min per 1.73 m decrease in eGFR was associated with a 20% increased odds of a CVE (odds ratio 1.2, 95% confidence interval 1.1-1.4). The prevalence of proteinuria in the patients was approximately twice that of controls (51 vs. 25%, P < 0.001). Proteinuria was associated with CVEs both in univariate and multivariate analyses (odds ratio 3.6, 95% confidence interval 1.9-7.0 and odds ratio 2.2, 95% confidence interval 1.1-4.8, respectively). Traditional cardiovascular risk factors, such as history of previous CVEs, diabetes mellitus, and dyslipidemia, along with low CD4 cell counts were also found as significant predictors of risk of CVEs.

CONCLUSION

Our study shows a significant independent association between decreased kidney function and increased risk of CVE in HIV-1-infected patients.

Combining estimates of interest in prognostic modelling studies after multiple imputation: current practice and guidelines

Background

Multiple imputation (MI) provides an effective approach to handle missing covariate data within prognostic modelling studies, as it can properly account for the missing data uncertainty. The multiply imputed datasets are each analysed using standard prognostic modelling techniques to obtain the estimates of interest. The estimates from each imputed dataset are then combined into one overall estimate and variance, incorporating both the within and between imputation variability. Rubin's rules for combining these multiply imputed estimates are based on asymptotic theory. The resulting combined estimates may be more accurate if the posterior distribution of the population parameter of interest is better approximated by the normal distribution. However, the normality assumption may not be appropriate for all the parameters of interest when analysing prognostic modelling studies, such as predicted survival probabilities and model performance measures.

Methods

Guidelines for combining the estimates of interest when analysing prognostic modelling studies are provided. A literature review is performed to identify current practice for combining such estimates in prognostic modelling studies.

Results

Methods for combining all reported estimates after MI were not well reported in the current literature. Rubin's rules without applying any transformations were the standard approach used, when any method was stated.

Conclusion

The proposed simple guidelines for combining estimates after MI may lead to a wider and more appropriate use of MI in future prognostic modelling studies.

Cardiovascular complications in HIV management: past, present, and future

Highly active antiretroviral therapy (HAART) has significantly improved the prognosis for many individuals with HIV infection. Consequently, HIV infection has become a chronic and manageable disease. The focus on long-term management of patients with HIV infection has broadened to include comorbid conditions, most notably cardiovascular disease. Patients with HIV infection share many cardiovascular risk factors with the general population, and HIV infection itself may increase cardiovascular risk. Changes in lipid profiles associated with increased cardiovascular risk that have been observed with some HAART regimens have been a cause for concern among clinicians who treat HIV-infected patients. However, the lipid effects of HAART seem to depend on the type and duration of regimens employed. They can be managed effectively according to current guidelines that recommend lifestyle changes (eg, improved diet, increased exercise, smoking cessation) and pharmacologic therapy described in established treatment paradigms for patients on antiretroviral therapy and similar to measures currently used by the general population. A review of the clinical data indicates that the virologic and immunologic benefits of HAART clearly outweigh any metabolic effects observed in some patients over time and that preexisting, established cardiovascular risk factors contribute significantly to the potential development of cardiovascular events. These benefits of antiretroviral therapy have been demonstrated in studies comparing the superior efficacy of continuous vs. intermittent HAART.

Psychiatric and neurophysiological predictors of obesity in HIV/AIDS

The objective of the study was to identify predictors of obesity. One hundred eleven nonobese and 48 obese HIV-1 seropositive patients provided information on medical history and other characteristics. They were then asked to detect the passage of 2-s time intervals while the contingent negative variation (CNV) was recorded. Obese patients were healthier, more likely to be receiving Highly Active Antiretroviral Therapy, and less likely to be substance dependent. Obese patients also exhibited a greater CNV slope and responded prematurely. A path model suggested that CD4+count and protease inhibitor use directly predicted obesity. Depression had no direct effect. However, when incorporated into a hypothetical construct, "mood dysregulation," that also included childhood conduct problems and stimulant dependence, the shared variance among the indicators did predict obesity. This relationship was mediated through premature response preparation (anterior scalp CNV amplitude) and its hypothesized association with impatience/impulsivity.

Cardiovascular complications and atherosclerotic manifestations in the HIV-infected population: type, incidence and associated risk factors

Before the introduction of successful antiretroviral therapy (ART), cardiovascular complications in HIV-infected patients were largely those resulting from immunosuppression (e.g. myocarditis, pericarditis, tamponade). With the advent of ART, there has been a spectacular decrease in morbidity and mortality in HIV-infected individuals. However, alongside metabolic complications caused by ART such as insulin resistance, dyslipidemia and lipodystrophy syndrome have been observed, which potentially increase the risk of cardiovascular complications, in particular coronary artery disease. Whether HIV infection and ART are independent and individual coronary risk factors is still controversial. More and more data are available demonstrating that increasing the duration of exposure to ART, and in particular protease inhibitors, increases the risk of myocardial infarction. At the same time, chronic infection, inflammation and the disruption of immune balance as a result of HIV infection itself may have the potential to alter vascular structure and function. In this article, we will review cardiovascular complications in HIV-infected patients before and after the advent of ART, focusing on coronary artery disease, its diagnosis, prognosis and therapy.