Increased coronary vessel wall thickness in HIV-infected young adults

Cardiometabolic complications in children and adolescents with HIV on antiretroviral therapy

INTRODUCTION

The course of HIV infection has changed radically with the introduction of antiretroviral therapy (ART), which has significantly reduced mortality and improved quality of life. However, antiretroviral drugs can cause adverse effects, including cardiometabolic complications and diseases, which are among the most common. Compared to the adult population, there are fewer studies in the pediatric population on treatment-related complications. The purpose of this review is to provide an update on the literature regarding cardiometabolic complications and diseases in children and adolescents with HIV.

AREAS COVERED

A comprehensive literature review was conducted using PubMed and related bibliographies to provide an overview of the current knowledge of metabolic complications (dyslipidemia, insulin resistance, lipodystrophy, weight gain and liver complications) and diseases (prediabetes/diabetes and cardiovascular diseases) associated with ART in children and adolescents with HIV.

EXPERT OPINION

Metabolic complications are conditions that need to be closely monitored in children and adolescents with HIV, as they increase the risk of early development of non-communicable diseases, such as cardiovascular disease. Key areas for improvement include ensuring access to treatment, reducing side effects and improving diagnostic capabilities. Overcoming existing challenges will require collaborative efforts across disciplines, advances in technology, and targeted interventions to address socioeconomic disparities.

Endothelial Dysfunction in Youth-Onset Type 2 Diabetes: A Clinical Translational Study

BACKGROUND

Youth-onset type 2 diabetes (Y-T2D) is associated with increased risk for coronary atherosclerotic disease, but the timing of the earliest pathological features and evidence of cardiac endothelial dysfunction have not been evaluated in this population. Endothelial function magnetic resonance imaging may detect early and direct endothelial dysfunction in the absence of classical risk factors (severe hyperglycemia, hypertension, and hyperlipidemia). Using endothelial function magnetic resonance imaging, we evaluated peripheral and coronary artery structure and endothelial function in young adults with Y-T2D diagnosed ≤5 years compared with age-matched healthy peers. We isolated and characterized plasma-derived small extracellular vesicles and evaluated their effects on inflammatory and signaling biomarkers in healthy human coronary artery endothelial cells to validate the imaging findings.

METHODS

Right coronary wall thickness, coronary artery flow-mediated dilation, and brachial artery flow-mediated dilation were measured at baseline and during isometric handgrip exercise using a 3.0T magnetic resonance imaging. Human coronary artery endothelial cells were treated with Y-T2D plasma-derived small extracellular vesicles. Protein expression was measured by Western blot analysis, oxidative stress was measured using the redox-sensitive probe dihydroethidium, and nitric oxide levels were measured by 4-amino-5-methylamino-2',7'-difluororescein diacetate.

RESULTS

Y-T2D (n=20) had higher hemoglobin A1c and high-sensitivity C-reactive protein, but similar total and LDL (low-density lipoprotein)-cholesterol compared with healthy peers (n=16). Y-T2D had greater coronary wall thickness (1.33±0.13 versus 1.22±0.13 mm; P=0.04) and impaired endothelial function: lower coronary artery flow-mediated dilation (-3.1±15.5 versus 15.9±17.3%; P<0.01) and brachial artery flow-mediated dilation (6.7±14.7 versus 26.4±15.2%; P=0.001). Y-T2D plasma-derived small extracellular vesicles reduced phosphorylated endothelial nitric oxide synthase expression and nitric oxide levels, increased reactive oxygen species production, and elevated ICAM (intercellular adhesion molecule)-mediated inflammatory pathways in human coronary artery endothelial cells.

CONCLUSIONS

Coronary and brachial endothelial dysfunction was evident in Y-T2D who were within 5 years of diagnosis and did not have severe hyperglycemia or dyslipidemia. Plasma-derived small extracellular vesicles induced markers of endothelial dysfunction, which corroborated accelerated subclinical coronary atherosclerosis as an early feature in Y-T2D.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02830308 and NCT01399385.

Cardiovascular health in people with perinatally acquired HIV - where do we stand?

PURPOSE OF REVIEW

HIV-associated cardiac disease was well recognized in the preantiretroviral (ART) era among children with perinatally-acquired HIV infection (PHIV). While ART has dramatically improved survival, it has become increasingly apparent that individuals with PHIV continue to experience multisystem co-morbidities. We review the cardiac and vascular manifestations in people growing up with PHIV in the ART era.

RECENT FINDINGS

ART has resulted in a drop in incidence of serious cardiac morbidity. However, there is a substantial body of evidence that demonstrates that cardiac and vascular structural and functional abnormalities, mostly subclinical, are common in people with PHIV taking ART. Studies have considerable heterogeneity with respect to types of cardiovascular assessments used. HIV-mediated chronic inflammation and potentially effects of ART contribute to these abnormalities. The long-term clinical significance of these abnormalities remains unknown as studies have mainly been cross-sectional, but it is likely that the burden of cardiovascular disease will grow as individuals with PHIV age and the prevalence of traditional risk factors increases.

SUMMARY

Understanding the pathogenesis of cardiovascular disease in PHIV, is critical to inform screening and interventional strategies. Longitudinal studies are also needed to understand the natural history of cardiovascular abnormalities and incidence of clinical outcomes.

Adults with Perinatally Acquired HIV; Emerging Clinical Outcomes and Data Gaps

In resourced settings, adults living with perinatally acquired HIV are approaching the 5th decade of life. Their clinical and psychological outcomes highlight potential future issues for the much larger number of adolescents growing up with HIV in sub-Saharan Africa, and will inform the development of appropriate healthcare services. Lifelong exposure to HIV, and increasingly to antiretroviral therapy throughout growth and development, contrasts with adults acquiring HIV in later life. This review describes the clinical outcomes for adults living with perinatally acquired HIV including post transition mortality, morbidity and retention in care. Rates of viral suppression, drug resistance and immunological function are explored. Co-morbidities focus on metabolic, cardiovascular, respiratory and bone health with quality-of-life data including neurocognitive functioning and mental health. Sexual and reproductive health including vaccine-preventable disease and the prevention of onward transmission to partners and infants are considered. The data gaps and future research questions to optimise outcomes for this emerging adult cohort are highlighted.

Association of Coronary Wall Thickening and Diminished Diastolic Function in Asymptomatic, Low Cardiovascular Disease-Risk Persons Living with HIV

Purpose To assess early subclinical coronary artery disease (CAD) burden and its relation to myocardial function in asymptomatic persons living with HIV (PLWH) who are at low risk for cardiovascular disease (CVD). Materials and Methods In this prospective, HIPAA-compliant study (ClinicalTrials.gov NCT01656564 and NCT01399385) conducted from April 2010 to May 2013, 74 adult PLWH without known CVD and 25 matched healthy controls underwent coronary MRI to measure coronary vessel wall thickness (VWT) and echocardiography to assess left ventricular function. Univariable and multivariable linear regression analyses were used to evaluate statistical associations. Results For PLWH, the mean age was 49 years ± 11 (SD), and the median Framingham risk score was 3.2 (IQR, 0.5-6.6); for matched healthy controls, the mean age was 46 years ± 8 and Framingham risk score was 2.3 (IQR, 0.6-6.1). PLWH demonstrated significantly greater coronary artery VWT than did controls (1.47 mm ± 0.22 vs 1.34 mm ± 0.18; P = .006) and a higher left ventricular mass index (LVMI) (77 ± 16 vs 70 ± 13; P = .04). Compared with controls, PLWH showed altered association between coronary artery VWT and both E/A (ratio of left ventricular-filling peak blood flow velocity in early diastole [E wave] to that in late diastole [A wave]) (P = .03) and LVMI (P = .04). In the PLWH subgroup analysis, coronary artery VWT increase was associated with lower E/A (P < .001) and higher LVMI (P = .03), indicating restricted diastolic function. In addition, didanosine exposure was associated with increased coronary artery VWT and decreased E/A ratio. Conclusion Asymptomatic low-CVD-risk PLWH demonstrated increased coronary artery VWT in association with impaired diastolic function, which may be amenable to follow-up studies of coronary pathogenesis to identify potential effects on the myocardium and risk modification strategies. Keywords: Coronary Vessel Wall Thickness, Diastolic Function, HIV, MRI, Echocardiography, Atherosclerosis Clinical trial registration nos. NCT01656564 and NCT01399385 Supplemental material is available for this article. © RSNA, 2024.

Preventing and diagnosing HIV-related comorbidities in adolescents

Adolescents with HIV are growing into adulthood and are at risk for comorbidities. Comorbidities in adolescents often go unrecognized, increasing morbidity and mortality, and contributing to poorer outcomes for youth with HIV. Youth with perinatally and nonperinatally acquired HIV are at risk of developing HIV-associated and non-HIV comorbidities, including cardiovascular diseases, diabetes, mental health disorders, renal diseases, and bone disorders. Youth with HIV are also at risk for altered fat distribution and weight gain associated with certain classes of antiretroviral therapy. Sexually transmitted infections from inconsistent condom use pose a sexual health challenge for youth with HIV. Prompt interventions through comprehensive history taking, physical exams, regular screening, and prevention and treatment of clinically evident comorbid conditions are needed to prevent progression and complications.

Association of HIV Infection With Cardiovascular Pathology Based on Advanced Cardiovascular Imaging: A Systematic Review

IMPORTANCE

HIV-associated cardiovascular disease is increasing in prevalence, but its mechanisms remain poorly understood.

OBJECTIVE

To systematically review data from advanced cardiovascular imaging studies evaluating computed tomographic coronary angiography, positron emission tomography (PET), and cardiac magnetic resonance (MR), in people living with HIV compared with uninfected individuals.

DATA SOURCES

Three databases and Google Scholar were searched for studies assessing cardiovascular pathology using computed tomographic coronary angiography, cardiac MR, PET, and HIV from inception to February 11, 2022.

STUDY SELECTION

Two reviewers selected original studies without any restrictions on design, date, or language, investigating HIV and cardiovascular pathology.

DATA EXTRACTION AND SYNTHESIS

One investigator extracted data checked by a second investigator. Prevalence ratios (PRs) and differences in inflammation among people living with HIV and uninfected individuals were qualitatively synthesized in terms of cardiovascular pathology. Study quality was assessed using the National Heart, Lung, and Blood Institute quality assessment tool for observational studies.

MAIN OUTCOMES AND MEASURES

Primary outcomes were computed tomographic coronary angiography-defined moderate to severe (≥50%) coronary stenosis, cardiac MR-defined myocardial fibrosis identified by late gadolinium enhancement, and PET-defined vascular and myocardial target to background ratio. Prevalence of moderate to severe coronary disease, as well as myocardial fibrosis, and PRs compared with uninfected individuals were reported alongside difference in vascular target to background ratio.

RESULTS

Forty-five studies including 5218 people living with HIV (mean age, 48.5 years) and 2414 uninfected individuals (mean age, 49.1 years) were identified. Sixteen studies (n = 5107 participants) evaluated computed tomographic coronary angiography; 16 (n = 1698), cardiac MRs; 10 (n = 681), vascular PET scans; and 3 (n = 146), both computed tomographic coronary angiography and vascular PET scans. No studies originated from low-income countries. Regarding risk of bias, 22% were classified as low; 47% moderate; and 31% high. Prevalence of moderate to severe coronary disease among those with vs without HIV ranged from 0% to 52% and 0% to 27%, respectively, with PRs ranging from 0.33 (95% CI, 0.01-15.90) to 5.19 (95% CI, 1.26-21.42). Prevalence of myocardial fibrosis among those with vs without HIV ranged from 5% to 84% and 0% to 68%, respectively, with PRs ranging from 1.01 (95% CI, 0.85-1.21) to 17.35 (95% CI, 1.10-274.28). Differences in vascular target to background ratio among those with vs without HIV ranged from 0.06 (95% CI, 0.01-0.11) to 0.37 (95% CI, 0.02-0.72).

CONCLUSIONS AND RELEVANCE

In this systematic review of studies of advanced cardiovascular imaging, the estimates of the associations between HIV and cardiovascular pathologies demonstrated large amounts of heterogeneity. The findings provide a summary of the available data but may not be representative of all individuals living with HIV, including those from low-income countries with higher HIV endemicity.

Associations Between Central Obesity and Lifelong Antiviral Therapy in Adults Living With HIV Acquired From Early Childhood

BACKGROUND

Little is known regarding the long-term effects of antiretroviral (ARV) exposure on body composition for people living with HIV (PLWH) since early childhood. This study explores changes in body fat distribution in relation to ARV exposure.

METHODS

We conducted a prospective study of adults with perinatal HIV (n = 70) using dual-energy X-ray absorptiometry and standard anthropometrics. Trunk to limb fat ratio and waist to hip ratio were compared cross-sectionally to 47 matched controls. Furthermore, changes in body composition and ARV exposure were evaluated longitudinally in a subset of 40 PLWH with a median follow-up of 7 years.

RESULTS

Cross-sectional comparisons of PLWH with controls revealed significantly higher waist to hip ratio, trunk to limb fat ratio, HOMA-IR, and triglycerides, whereas BMI did not differ. Among PLWH with longitudinal follow-up, the prevalence of overweight increased from 27.5% to 52.5% and obesity from 12.5% to 25%; waist to hip and trunk to limb fat ratios also increased (P < 0.0001). Changes in waist to hip ratio were positively correlated with longer exposure during follow-up to darunavir (r = 0.36; P = 0.02), whereas increases in trunk to limb fat ratio were positively correlated with longer exposure to stavudine (r = 0.39; P = 0.01) and didanosine (r = 0.39; P = 0.01) but inversely associated with emtricitabine (r = -0.33; P = 0.04). Increases in waist to hip ratio were correlated with increases in triglyceride levels (r = 0.35; P = 0.03).

CONCLUSION

This study presents strong evidence for persistent and worsening central adiposity in young adults with lifelong HIV and extensive ARV exposure. As this cohort ages, continued evaluation of the body composition and metabolic impact of lifelong ARV therapy is warranted to optimize long-term health.

Cardiometabolic Complications in Youth With Perinatally Acquired HIV in the Era of Antiretroviral Therapy

PURPOSE OF REVIEW

Antiretroviral therapy (ART) scale-up has dramatically reduced rates of pediatric HIV mortality and morbidity. Children living with perinatally acquired HIV (PHIV) are now expected to live through adolescence and well into adulthood, such that adolescents now represent the largest growing population living with HIV. This review aims to discuss the prevalence and mechanisms for cardiometabolic comorbidities in the setting of newer ART regimens and the research gaps that remain.

RECENT FINDINGS

Data highlight the continued risks of subclinical cardiometabolic complications in PHIV in the setting of newer ART. Novel techniques in imaging and omics may help identify early cardiometabolic abnormalities in this young population and potentially identify early changes in the mechanistic pathways related to these changes. Further studies to determine risk and management strategies of the cardiometabolic effects in PHIV adolescents, beyond ART, are warranted. Focus should be on prevention of these complications in youth to avoid new epidemic of diabetes and cardiovascular disease when these youths become aging adults.

Coronary Artery Calcification and Plaque Characteristics in People Living With HIV: A Systematic Review and Meta-Analysis

Background

Studies have reported that people living with HIV have higher burden of subclinical cardiovascular disease, but the data are not adequately synthesized. We performed meta‐analyses of studies of coronary artery calcium and coronary plaque in people living with HIV.

Methods and Results

We performed systematic search in electronic databases, and data were abstracted in standardized forms. Study‐specific estimates were pooled using meta‐analysis. 43 reports representing 27 unique studies and involving 10 867 participants (6699 HIV positive, 4168 HIV negative, mean age 52 years, 86% men, 32% Black) were included. The HIV‐positive participants were younger (mean age 49 versus 57 years) and had lower Framingham Risk Score (mean score 6 versus 18) compared with the HIV‐negative participants. The pooled estimate of percentage with coronary artery calcium >0 was 45% (95% CI, 43%–47%) for HIV‐positive participants, and 52% (50%–53%) for HIV‐negative participants. This difference was no longer significant after adjusting for difference in Framingham Risk Score between the 2 groups. The odds ratio of coronary artery calcium progression for HIV‐positive versus ‐negative participants was 1.64 (95% CI, 0.91–2.37). The pooled estimate for prevalence of noncalcified plaque was 49% (95% CI, 47%–52%) versus 20% (95% CI, 17%–23%) for HIV‐positive versus HIV‐negative participants, respectively. Odds ratio for noncalcified plaque for HIV‐positive versus ‐negative participants was 1.23 (95% CI, 1.08–1.38). There was significant heterogeneity that was only partially explained by available study‐level characteristics.

Conclusions

People living with HIV have higher prevalence of noncalcified coronary plaques and similar prevalence of coronary artery calcium, compared with HIV‐negative individuals. Future studies on coronary artery calcium and plaque progression can further elucidate subclinical atherosclerosis in people living with HIV.

Association of epicardial fat with noncalcified coronary plaque volume and with low attenuation plaque in people with HIV

OBJECTIVES

People with HIV are exposed to a higher risk of coronary artery disease (CAD) compared with the general population. Epicardial fat may play a unique role in promoting coronary atherosclerosis. We measured epicardial fat in participants living with HIV and controls and investigated its association with coronary plaque volume and low attenuation plaque, a marker of plaque vulnerability.

DESIGN

This is a cross-sectional study, nested in the Canadian HIV and Aging Cohort Study, a large prospective cohort actively following participants with HIV and controls. Participants with low/intermediate cardiovascular risk without symptoms/history of CAD were invited to undergo cardiac computed tomography (CT).

METHODS

Volume of epicardial fat, coronary plaque and low attenuation component of the plaque were measured. Association between epicardial fat, coronary plaque volume and low attenuation component was tested using adjusted regression analysis.

RESULTS

A total of 169 participants with HIV and 81 controls underwent cardiac CT. Participants with HIV had a greater epicardial fat volume compared with controls (P = 0.019). In participants with HIV, epicardial fat volume was positively associated with duration of nonnucleoside reverse transcriptase inhibitors (NNRTI) (β=2.19, P = 0.004). After adjustment for cardiovascular risk factors, epicardial fat volume was positively associated to noncalcified plaque volume [odds ratio (OR) = 1.09, P = 0.028] and to the low-attenuation plaque component portion (β=0.38, P = 0.026).

CONCLUSION

The association of epicardial fat volume to noncalcified plaque volume and to low attenuation component plaque may suggest a potential mechanism by which epicardial fat could be a silent driver of CAD in the HIV population.

A Meta-Analysis of Different Types of Cardiac Adipose Tissue in HIV Patients

Background

Antiretroviral therapy transformed HIV infection into a chronic disease but accelerated cardiovascular disease (CVD). Both of epicardial adipose tissue (EAT) and pericardial fat (PCF) have close relationships with CVD. The associations between these two cardiac adipose tissue and HIV are unclear.

Methods

Eligible studies were searched in PubMed, Embase, Web of Science, and Scopus from database inception to March 24, 2020. The summarized standard mean difference (SMD) or weighted mean difference (WMD) with 95% confidence intervals (CIs) was used to assess the association between EAT/PCF and HIV. Subgroup analysis was performed based on EAT types. Trial sequential analysis was conducted to estimate whether the evidence of the results is sufficient.

Results

In total, 2561 HIV patients and 1767 non-HIV participants were included. Compared to the control group, EAT was significantly higher in the HIV overall group and subgroup with EAT thickness (SMD = 0.59, 95% CI: 0.24-0.95, P = 0.001; SMD = 1.10, 95% CI: 0.41-1.79, P = 0.002); however, the EAT volume and PCF volume were unchanged in the HIV group (SMD = 0.16, 95% CI: -0.07-0.39, P = 0.169; WMD = 10.78, 95% CI: -14.11-35.67, P = 0.396). Trial sequential analysis indicated that the available samples were sufficient in the HIV overall group and subgroup with EAT thickness, and more studies are needed for EAT volume and PCF volume.

Conclusions

EAT thickness was significantly higher in patients with HIV. The association between EAT/PCF volume and HIV needs more studies to confirm.

Left Ventricular Function, Epicardial Adipose Tissue, and Carotid Intima-Media Thickness in Children and Adolescents With Vertical HIV Infection

BACKGROUND

Life expectancy of HIV patients has increased considerably as a result of antiretroviral therapy (ART), and cardiovascular (CV) disease has emerged as an important late concern. People with HIV infection could have an impaired systolic function; however data on diastolic function and markers of CV risk, such as epicardial adipose tissue (EAT) and intima-media thickness (IMT), are lacking. Aim of this study is to evaluate left ventricular function, EAT, and IMT in children and adolescents with vertically acquired HIV infection.

METHODS

We enrolled 29 subjects on ART (13, 45% men; median age of 13.0, and interquartile range 9-18), and 29 age-matched controls. All patients and controls underwent echocardiographic evaluation, with study of the systolic and diastolic function and measurement of the EAT, and a carotid ultrasound study for IMT measurement.

RESULTS

Comparing HIV-infected patients to healthy controls, we found a statistically significant increase of EAT and IMT (mean ± SD) (EAT: 3.16 ± 1.05 vs 1.24 ± 0.61 mm; P < 0.0001. IMT: 0.77 ± 0.15 vs 0.51 ± 0.11 mm; P < 0.0001), and a significant reduction of ejection fraction, evaluated with the biplane Simpson method (mean ± SD) (58.5% ± 6.66% vs 66% ± 4.24%; P = 0.029). These results are not related with age, gender, degree of lipodystrophy, dyslipidemia, hyperinsulinism, and ART duration or the use of single antiretroviral classes.

CONCLUSIONS

Vertically infected HIV children and adolescents show an increased thickness of EAT and IMT, expression of potentially increased CV risk. They also show an impaired systolic function.

To fast or not to fast: Lipid measurement and cardiovascular disease risk estimation in rural sub-Saharan Africa

Background

Cardiovascular disease (CVD) morbidity and mortality are increasing in sub-Saharan Africa (sSA), highlighting the need for tools to enable CVD risk stratification in the region. Although non-HDL-cholesterol (nHDL-C) has been promoted as a method to measure lipids without a requirement for fasting in the USA, its diagnostic validity has not been assessed in sSA. We sought to estimate: 1) the association between LDL-cholesterol (LDL-C) and nHDL-C, 2) the impact of fasting on their measurement, and 3) their correlation with carotid atherosclerosis, within a rural Ugandan population with high HIV prevalence.

Methods

We collected traditional CVD risk factors, blood for serum lipid levels, self-reported fasting status, and performed carotid ultrasonography in 301 participants in rural Uganda. We fit regression models, stratified by fasting status, to estimate associations between carotid intima media thickness (cIMT), LDL-C, and nHDL-C.

Results

Median age was 50 years (interquartile range = 46-54), 49% were female, 51% were HIV-positive, and at the time of blood collection, 70% had fasted overnight. Mean LDL-C, nHDL-C, and triglycerides in the non-fasting and fasting groups were 85 vs 88 mg/dL (P = 0.39), 114 vs 114 mg/dL (P = 0.98), and 130 vs 114 mg/dL (P = 0.05) mg/dL, respectively. In unadjusted models, mean cIMT (mm) was associated with both increased LDL-C (β = 0.0078 per 10mg/dL, P < 0.01) and nHDL-C (β = 0.0075, P < 0.01), and these relationships were similar irrespective of fasting status. After adjustment for traditional CVD risk factors, we observed similar associations, albeit with muted effect sizes within the fasting group.

Conclusions

We found a high correlation between LDL-C and nHDL-C, and both were correlated with cIMT, irrespective of fasting or HIV serostatus in rural Uganda. Our findings support use of either fasting or non-fasting serum lipids for CVD risk estimation in rural sSA.

Age-specific associations between HIV infection and carotid artery intima-media thickness in China: a cross-sectional evaluation of baseline data from the CHART cohort

BACKGROUND

Inconclusive results have been reported in studies evaluating the association between HIV infection and subclinical atherosclerosis. Unsolved issues include whether the increased atherosclerosis burden observed in some studies is attributed to greater prevalence of traditional risk factors or HIV infection. Therefore, we evaluated the association of HIV infection with subclinical atherosclerosis as assessed by carotid artery intima-media thickness, while controlling for the effects of traditional risk factors as operationalised by the Framingham risk score (FRS).

METHODS

We did a cross-sectional evaluation of data derived from the baseline assessment of the Comparative HIV and Aging Research in Taizhou (CHART) cohort, an ongoing longitudinal study being done in Zhejiang province, China. HIV-positive and HIV-negative individuals aged 18 years and older were recruited between Feb 1, and Dec 10, 2017, and were frequency-matched for age and sex in a 1:2 ratio. Subclinical atherosclerosis was defined as carotid artery intima-media thickness of 780 μm or higher. Logistic regression was used to assess the associations of HIV-positive serostatus and FRS with subclinical atherosclerosis.

FINDINGS

480 of 1425 (36·1%, 95% CI 33·6-38·6) HIV-positive and 784 of 2850 (27·5%, 95% CI 25·9-29·2) HIV-negative individuals had subclinical atherosclerosis (p<0·0001), and these patterns remained significant (adjusted odds ratio [adjOR] 1·72, 95% CI 1·47-2·01) in the adjusted model. After stratifying by age, higher prevalence of subclinical atherosclerosis was observed in HIV-positive than in HIV-negative individuals across the age groups 18-29 years (41 [16·0%] of 256 vs 13 [2·5%] of 512, p<0·0001), 30-44 years (128 [24·0%] of 533 vs 153 [14·4%] of 1066, p<0·0001), and 45-59 years (182 [46·6%] of 391 vs 294 [37·6%] of 782, p=0·0032), but not 60-75 years (163 [66·5%] of 245 vs 324 [66·1%] of 490, p=0·912). Significant negative interaction between HIV-positive serostatus and age on subclinical atherosclerosis was observed (p<0·0001). ORs adjusted for age, sex, and FRS were 8·84 (95% CI 4·50-17·34) for the age group 18-29 years, 2·09 (1·59-2·74) for 30-44 years, 1·54 (1·19-1·98) for 45-59 years, and 1·04 (0·75-1·44) for 60-75 years. Among HIV-positive individuals, none of the HIV-specific variables were significantly associated with carotid artery intima-media thickness estimates except for being antiretroviral therapy naive.

INTERPRETATION

HIV infection is associated with subclinical atherosclerosis, independent of classic risk factors. The association is stronger at younger ages, suggesting early onset of subclinical atherosclerosis among young adults. These findings highlight the need to modify HIV/AIDS treatment guidelines to incorporate cardiovascular evaluation in China.

FUNDING

China National Science and Technology Major Projects on Infectious Diseases, National Natural Science Foundation of China, and Shanghai Municipal Health and Family Planning Commission.

Imaging inflammation and its resolution in health and disease: current status, clinical needs, challenges, and opportunities

Inflammation is a normal process in our body; acute inflammation acts to suppress infections and support wound healing. Chronic inflammation likely leads to a wide range of diseases, including cancer. Tools to locate and monitor inflammation are critical for developing effective interventions to arrest inflammation and promote its resolution. To identify current clinical needs, challenges, and opportunities in advancing imaging-based evaluations of inflammatory status in patients, the U.S. National Institutes of Health convened a workshop on imaging inflammation and its resolution in health and disease. Clinical speakers described their needs for image-based capabilities that could help determine the extent of inflammatory conditions in patients to guide treatment planning and undertake necessary interventions. The imaging speakers showcased the state-of-the-art in vivo imaging techniques for detecting inflammation in different disease areas. Many imaging capabilities developed for 1 organ or disease can be adapted for other diseases and organs, whereas some have promise for clinical utility within the next 5-10 yr. Several speakers demonstrated that multimodal imaging measurements integrated with serum-based measures could improve in robustness for clinical utility. All speakers agreed that multiple inflammatory measures should be acquired longitudinally to comprehend the dynamics of unresolved inflammation that leads to disease development. They also agreed that the best strategies for accelerating clinical translation of imaging inflammation capabilities are through integration between new imaging techniques and biofluid-based biomarkers of inflammation as well as already established imaging measurements.-Liu, C. H., Abrams, N. D., Carrick, D. M., Chander, P., Dwyer, J., Hamlet, M. R. J., Kindzelski, A. L., PrabhuDas, M., Tsai, S.-Y. A., Vedamony, M. M., Wang, C., Tandon, P. Imaging inflammation and its resolution in health and disease: current status, clinical needs, challenges, and opportunities.

Subclinical Atherosclerosis Imaging in People Living with HIV

In many, but not all studies, people living with HIV (PLWH) have an increased risk of coronary artery disease (CAD) events compared to the general population. This has generated considerable interest in the early, non-invasive detection of asymptomatic (subclinical) atherosclerosis in PLWH. Ultrasound studies assessing carotid artery intima-media thickness (CIMT) have tended to show a somewhat greater thickness in HIV+ compared to HIV-, likely due to an increased prevalence of cardiovascular (CV) risk factors in PLWH. Coronary artery calcification (CAC) determination by non-contrast computed tomography (CT) seems promising to predict CV events but is limited to the detection of calcified plaque. Coronary CT angiography (CCTA) detects calcified and non-calcified plaque and predicts CAD better than either CAC or CIMT. A normal CCTA predicts survival free of CV events over a very long time-span. Research imaging techniques, including black-blood magnetic resonance imaging of the vessel wall and 18F-fluorodeoxyglucose positron emission tomography for the assessment of arterial inflammation have provided insights into the prevalence of HIV-vasculopathy and associated risk factors, but their clinical applicability remains limited. Therefore, CCTA currently appears as the most promising cardiac imaging modality in PLWH for the evaluation of suspected CAD, particularly in patients <50 years, in whom most atherosclerotic coronary lesions are non-calcified.

Sexual Dimorphism of Coronary Artery Disease in a Low- and Intermediate-Risk Asymptomatic Population: Association with Coronary Vessel Wall Thickness at MRI in Women

Purpose

To demonstrate the association between coronary vessel wall thickness (VWT) measured at MRI and coronary artery disease (CAD) risk in asymptomatic groups at low and intermediate risk on the basis of Framingham score.

Materials and Methods

A total of 131 asymptomatic adults were prospectively enrolled. All participants underwent CT angiography for scoring CAD, and coronary VWT was measured at 3.0-T MRI. Nonlinear single and multivariable regression analyses with consideration for interaction with sex were performed to investigate the association of traditional atherosclerotic risk factors and VWT with CT angiography-based CAD scores.

Results

The analysis included 62 women and 62 men with low or intermediate Framingham score of less than 20%. Age (mean age, 45.0 years ± 14.5 [standard deviation]) and body mass index were not different between the groups. Age, sex, and VWT were individually significantly associated with all CT angiography-based CAD scores (P < .05). Additionally, sex was a significant effect modifier of the associations with all CAD scores. In men, age was the only statistically significant independent risk factor of CAD; in women, VWT was the only statistically significant independent surrogate associated with increased CAD scores (P < .05).

Conclusion

In asymptomatic women, VWT MRI was the primary independent surrogate of CAD, whereas age was the strongest risk factor in men. This study suggests that VWT may be used as a CAD surrogate in women at low or intermediate risk of CAD. Further longitudinal studies are required to determine the potential implication and use of this MRI technique for the preventative management of CAD in women.© RSNA, 2019.

Metabolic risk factors in young adults infected with HIV since childhood compared with the general population

AIM

Metabolic risk factors are poorly documented for the first generation of young adults who have lived with HIV since childhood. We compared their metabolic profile with that of adults of same age from the general population.

METHODS

We conducted a cross-sectional analysis of data from two populations: (1) COVERTE (ANRS-CO19), a French national cohort of 18 to 30-year-old patients HIV-infected since childhood, and (2) ENNS, a national cross-sectional population-based household survey on nutrition. Body mass index (BMI), blood pressure, waist circumference, fasting glucose, triglycerides, and HDL-, LDL- and total cholesterol were measured in both studies. Direct standardization on overweight and education level and logistic regression were used to compare the prevalence of metabolic abnormalities between the two populations.

RESULTS

Data from 268 patients from COVERTE and 245 subjects from ENNS were analyzed. Tobacco use was similar in both groups. HIV-infected patients had increased mean waist-to-hip ratio and triglycerides to HDL-cholesterol ratio and decreased mean HDL-cholesterol as compared to their counterparts from the general population in both genders. In HIV-infected patients, metabolic syndrome was identified in 13.2% of men (95% confidence interval [CI]: 7.1-19.2) and 10.4% (95% CI: 5.4-15.3) of women versus 10.6% (95%CI: 1.5-19.7) and 1.7% (95%CI: 0-4.1) in subjects from the general population, respectively.

CONCLUSION

Young adults infected with HIV since childhood had a higher prevalence of dyslipidemia and metabolically detrimental fat distribution than adults of same age of the general population, supporting close monitoring for cardiometabolic diseases.

Effect of antiretroviral therapy on allele-associated Lp(a) level in women with HIV in the Women's Interagency HIV Study

We previously demonstrated an association between lipoprotein (a) [Lp(a)] levels and atherosclerosis in human immunodeficiency virus (HIV)-seropositive women. The effects of antiretroviral therapy (ART) on Lp(a) levels in relation to apo(a) size polymorphism remain unclear. ART effects on allele-specific apo(a) level (ASL), an Lp(a) level associated with individual apo(a) alleles within each allele-pair, were determined in 126 HIV-seropositive women. ART effects were tested by a mixed-effects model across pre-ART and post-ART first and third visits. Data from 120 HIV-seronegative women were used. The mean age was 38 years; most were African-American (∼70%). Pre-ART ASLs associated with the larger (4.6 mg/dl vs. 8.0 mg/dl, P = 0.024) or smaller (13 mg/dl vs. 19 mg/dl, P = 0.041) apo(a) sizes were lower in the HIV-seropositive versus HIV-seronegative group, as was the prevalence of a high Lp(a) level (P = 0.013). Post-ART ASL and prevalence of high Lp(a) or apo(a) sizes and frequency of small size apo(a) (22 kringles) did not differ between the two groups. ART increased Lp(a) level (from 18 to 24 mg/dl, P < 0.0001) and both ASLs (P < 0.001). In conclusion, regardless of genetic control, Lp(a) can be modulated by HIV and its treatment. ART initiation abrogates HIV-induced suppression of Lp(a) levels and ASLs, contributing to promote CVD risk in HIV-seropositive individuals.

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.

Effect of antiretroviral therapy use and adherence on the risk of hyperlipidemia among HIV-infected patients, in the highly active antiretroviral therapy era

HIV-infected patients exposed to antiretroviral therapy (ART) have an increased risk for hyperlipidemia and cardiovascular disease. We performed a longitudinal, comprehensive, and population-based study to investigate the cumulative effect of different types of ART regimens on hyperlipidemia risk in the Taiwanese HIV/ART cohort. A total of 13,370 HIV-infected patients (2,674 hyperlipidemia and 10,696 non-hyperlipidemia patients) were recruited after matching for age, gender, and the first diagnosis date of HIV infection by using the National Health Insurance Research Database in Taiwan. Hyperlipidemia risk associated with cumulative ART use, ART adherence, and their combination was assessed. The matched hyperlipidemia group had a larger number of patients using ART and a higher incidence of comorbidities, specifically, respiratory disease and diabetes. Patients with high ART dosage and dose-dependent manner adherence, respectively, demonstrated an increased risk of hyperlipidemia. For single ART regimens, patients receiving nucleoside reverse-transcriptase inhibitors (NRTI/NRTI)- containing regimen had the highest hyperlipidemia risk, followed by protease inhibitor (PI)- containing and non-NRTI- containing regimens. For combination ART regimens, patients receiving a NRTI/NRTI + PI regimen had the highest hyperlipidemia risk. An increased cumulative drug dose was observed in patients who received the PI, NRTI/NRTI, NRTI, and NNRTI regimens in the hyperlipidemia group, when compared to the non-hyperlipidemia group. In conclusion, ART cumulative use, adherence, and regimen may affect hyperlipidemia risk among HIV-infected patients in a dose-dependent manner.

Review of cardiovascular magnetic resonance in human immunodeficiency virus-associated cardiovascular disease

Despite ongoing advances in the treatment of patients with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), they remain a major global public health concern conferring an increased risk of morbidity and mortality in affected individuals. This is, in part, because of the widespread dysfunction imposed by HIV and its treatment on the cardiovascular system, including the myocardium, valvular apparatus, pericardium and coronary, pulmonary and peripheral vasculature. In recent times, cardiovascular magnetic resonance (CMR) imaging has emerged as the gold standard tool for assessment of a variety of indications, allowing comprehensive characterisation of functional, morphological, metabolic and haemodynamic sequelae of several cardiovascular pathologies. Furthermore, continued advancement in imaging techniques has yielded novel insights into the underlying pathophysiology and guides future therapeutic strategies. In this article, we review the various clinical phenotypes of HIV-associated cardiovascular disease and highlight the utility of CMR in their assessment.

Weak HIV Antibody Responses in Perinatally Infected Young Adults: Weak HIV Antibody Responses in Perinatally Infected Adults

We compared the antibody response to HIV using 2 serologic cross-sectional incidence assays in adults with perinatally acquired HIV, to elite controllers and individuals exposed to antiretroviral therapy who were all infected as adults. Low antibody responses were seen more frequently in adults with perinatally acquired HIV, both overall and when stratified by viral suppression status.

Lipoprotein(a) and HIV: Allele-Specific Apolipoprotein(a) Levels Predict Carotid Intima-Media Thickness in HIV-Infected Young Women in the Women's Interagency HIV Study

OBJECTIVE

In the general population, lipoprotein(a) [Lp(a)] has been established as an independent causal risk factor for cardiovascular disease. Lp(a) levels are to a major extent regulated by a size polymorphism in the apolipoprotein(a) [apo(a)] gene. The roles of Lp(a)/apo(a) in human immunodeficiency virus (HIV)-related elevated cardiovascular disease risk remain unclear.

APPROACH AND RESULTS

The associations between total plasma Lp(a) level, allele-specific apo(a) level, an Lp(a) level carried by individual apo(a) alleles, and common carotid artery intima-media thickness were assessed in 150 HIV-infected and 100 HIV-uninfected women in the WIHS (Women's Interagency HIV Study). Linear regression analyses with and without adjustments were used. The cohort was young (mean age, ≈31 years), with the majority being Blacks (≈70%). The prevalence of a small size apo(a) (≤22 Kringle repeats) or a high Lp(a) level (≥30 mg/dL) was similar by HIV status. Total plasma Lp(a) level (P=0.029) and allele-specific apo(a) level carried by the smaller apo(a) sizes (P=0.022) were significantly associated with carotid artery intima-media thickness in the HIV-infected women only. After accounting for confounders (age, race, smoking, body mass index, blood pressure, hepatitis C virus coinfection, menopause, plasma lipids, treatment status, CD4⁺ T cell count, and HIV/RNA viral load), the association remained significant for both Lp(a) (P=0.035) and allele-specific apo(a) level carried by the smaller apo(a) sizes (P=0.010) in the HIV-infected women. Notably, none of the other lipids/lipoproteins was associated with carotid artery intima-media thickness.

CONCLUSIONS

Lp(a) and allele-specific apo(a) levels predict carotid artery intima-media thickness in HIV-infected young women. Further research is needed to identify underlying mechanisms of an increased Lp(a) atherogenicity in HIV infection.

Premature Coronary Artery Disease and ST-Elevation Myocardial Infarction in a 24-Year-Old Man With Perinatally Acquired Human Immunodeficiency Virus: A Case Report

Patients with human immunodeficiency virus (HIV) have increased risk of cardiovascular disease. Although evidence of subclinical atherosclerosis in perinatally acquired HIV (PHIV) is available, myocardial infarction has not been described in this population. We report a case of myocardial infarction in a patient with PHIV with a brief literature review.

Coronary atherosclerosis and dilation in hyper IgE syndrome patients: Depiction by magnetic resonance vessel wall imaging and pathological correlation

BACKGROUND AND AIMS

Autosomal dominant hyper-IgE (AD-HIES) is a primary immunodeficiency caused by mutations in STAT3. Elevated levels of IgE, an ineffective immune response, connective tissue abnormalities, and coronary arterial dilation and tortuosity characterize AD-HIES. To date, coronary artery evaluation in AD-HIES patients has been limited to lumenography measurements. Direct in vivo coronary vessel wall (VW) imaging may allow for better interrogation of coronary vessel abnormalities. The goal of this prospective study was to evaluate the coronary VW of AD-HIES patients using Magnetic Resonance Imaging (MRI) and histology. VW image findings were compared in healthy subjects and subjects with coronary atherosclerotic disease (CAD).

METHODS

A total of 28 subjects (10 with AD-HIES, 8 healthy, 10 with CAD) were studied by coronary VW MRI imaging. Additionally, a post-mortem coronary artery from one VW imaged AD-HIES patient was examined.

RESULTS

Coronary VW in AD-HIES was thicker than in healthy controls but not significantly different from VW thickness in CAD subjects. AD-HIES coronaries showed increased VW area compared to healthy controls and CAD subjects. On histology, the AD-HIES coronary artery had findings consistent with atherosclerotic plaque, but had minimal luminal narrowing, deficient adventitia thickening and absence of both internal and external elastic laminae.

CONCLUSIONS

This is the first study to demonstrate subclinical coronary atherosclerosis in AD-HIES patients on VW imaging by MRI. Histologic evaluation confirmed the presence of atherosclerosis with lack of supportive adventitial thickening and elastic components. These findings suggest mechanisms for coronary dilation in AD-HIES and thereby help direct clinical management.

T-cell Activation and E-selectin Are Associated With Coronary Plaque in HIV-infected Young Adults

We evaluated immune activation and coronary artery plaque in young adults with human immunodeficiency virus acquired in early life (n = 31). Coronary plaque was positively associated with lipids, immune activation marker %CD8+CD38+DR+ and E-selectin, a marker of endothelial inflammation. Immune activation and endothelial inflammation may drive coronary plaque formation during the early stages of atherosclerosis in the context of chronic human immunodeficiency virus.

Rationale and design of the Progression of AtheRosclerotic PlAque DetermIned by Computed TomoGraphic Angiography IMaging (PARADIGM) registry: A comprehensive exploration of plaque progression and its impact on clinical outcomes from a multicenter serial coronary computed tomographic angiography study

BACKGROUND

The natural history of coronary artery disease (CAD) in patients with low-to-intermediate risk is not well characterized. Although earlier invasive serial studies have documented the progression of atherosclerotic burden, most were focused on high-risk patients only. The PARADIGM registry is a large, prospective, multinational dynamic observational registry of patients undergoing serial coronary computed tomographic angiography (CCTA). The primary aim of PARADIGM is to characterize the natural history of CAD in relation to clinical and laboratory data.

DESIGN

The PARADIGM registry (ClinicalTrials.govNCT02803411) comprises ≥2,000 consecutive patients across 9 cluster sites in 7 countries. PARADIGM sites were chosen on the basis of adequate CCTA volume, site CCTA proficiency, local demographic characteristics, and medical facilities to ensure a broad-based sample of patients. Patients referred for clinically indicated CCTA will be followed up and enrolled if they had a second CCTA scan. Patients will also be followed up beyond serial CCTA performance to identify adverse CAD events that include cardiac and noncardiac death, myocardial infarction, unstable angina, target vessel revascularization, and CAD-related hospitalization.

SUMMARY

The results derived from the PARADIGM registry are anticipated to add incremental insight into the changes in CCTA findings in accordance with the progression or regression of CAD that confer prognostic value beyond demographic and clinical characteristics.

Risk of Cardiovascular Disease in an Aging HIV Population: Where Are We Now?

With more effective and widespread antiretroviral treatment, the overall incidence of AIDS- or HIV-related death has decreased dramatically. Consequently, as patients are aging, cardiovascular disease (CVD) has emerged as an important cause of morbidity and mortality in the HIV population. The incidence of CVD overall in HIV is relatively low, but it is approximately 1.5-2-fold higher than that seen in age-matched HIV-uninfected individuals. Multiple factors are believed to explain this excess in risk such as overrepresentation of traditional cardiovascular risk factors (particularly smoking), toxicities associated with cumulative exposure to some antiretroviral agents, together with persistent chronic inflammation, and immune activation associated with HIV infection. Tools are available to calculate an individual's predicted risk of CVD and should be incorporated in the regular follow-up of HIV-infected patients. Targeted interventions to reduce this risk must be recommended, including life-style changes and medical interventions that might include changes in antiretroviral therapy.

START or SMART? Timing of Antiretroviral Therapy Initiation and Cardiovascular Risk for People With Human Immunodeficiency Virus Infection

The Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection (START) study has reinforced the benefits of early initiation of antiretroviral therapy (ART). However, a notable secondary finding from that study was that immediate initiation of ART did not prevent cardiovascular disease (CVD) events (0.17 vs 0.20 events/1000 person-years, P = .65). This result appears to contradict a body of evidence, most notably from the Strategies for Management of Antiretroviral Therapy (SMART) study, which reported a 70% increased hazard of cardiovascular events for those deferring or interrupting treatment. Thus, an important unresolved question is whether the timing of ART impacts CVD risk. In this review, published data on relationships between timing of ART and CVD risk are reviewed. The data support a role for ART in mitigating CVD risk at lower CD4 counts, but data also suggests that, among those initiating therapy early, ART alone appears to suboptimally mitigate CVD risk. Additional interventions to address CVD risk among human immunodeficiency virus-infected populations are likely to be needed.

Noninvasive Imaging of Atherosclerotic Plaque Progression: Status of Coronary Computed Tomography Angiography

The process of coronary artery disease progression is infrequently visualized. Intravascular ultrasound has been used to gain important insights but is invasive and therefore limited to high-risk patients. For low-to-moderate risk patients, noninvasive methods may be useful to quantitatively monitor plaque progression or regression and to understand and personalize atherosclerosis therapy. This review discusses the potential for coronary computed tomography angiography to evaluate the extent and subtypes of coronary plaque. Computed tomographic technology is evolving and image quality of the method approaches the level required for plaque progression monitoring. Methods to quantify plaque on computed tomography angiography are reviewed as well as a discussion of their use in clinical trials. Limitations of coronary computed tomography angiography compared with competing modalities include limited evaluation of plaque subcomponents and incomplete knowledge of the value of the method especially in patients with low-to-moderate cardiovascular risk.