The pavia consensus statement

Cardiovascular risk factors among Ghanaian patients with HIV: A cross-sectional study

BACKGROUND

Cardiovascular disease (CVD) poses a significant cause of morbidity and mortality among people living with human immunodeficiency virus (HIV). However, data are limited on CVD risk burden among HIV patients in Ghana. We describe the age- and sex-adjusted prevalence of CVD risk factors among HIV patients in Ghana.

METHODS

From January 2013 to May 2014, we identified eligible HIV patients 18 years and older, as well as uninfected adult blood donors presenting to the Komfo Anokye Teaching Hospital as controls. Using a standardized protocol, we collected demographic, clinical, laboratory, and electrocardiographic data. We created multivariable logistic regression models to compare the prevalence of abnormal risk factors between the two groups.

RESULTS

We recruited 345 patients with HIV (n = 173 on HAART, n = 172 not on HAART) and 161 uninfected adult blood donors. Patients with HIV were older (mean [SD] age: 41 [11] vs 32 [11] years) and were more likely to be female (72% vs 28%) than blood donors. Among patients on HAART, median (interquartile range) treatment duration was 17 (4-52) months. The prevalence of hypertension, hypercholesterolemia, and diabetes mellitus among HIV patients was 9%, 29%, and 5%, respectively, compared with 5%, 15%, and 0.6% among uninfected blood donors. Smoking was the least prevalent CVD risk factor (1%-2%). After adjustment for age, sex, and body mass index, HIV patients had a 10-fold higher odds of prevalent diabetes compared with controls, (adjusted OR = 10.3 [95% CI: 1.2, 86.7]).

CONCLUSION

CVD risk factors are common among HIV patients in Ghana, demonstrating the urgent need for creation and implementation of strategic CVD interventions.

Heart failure in patients with human immunodeficiency virus: a review of the literature

Coronary artery disease represents the leading cause of death for HIV patients treated with highly active antiretroviral treatment. Besides this, an extensive amount of data related to the risk of overt heart failure and consequently of atrial fibrillation and sudden cardiac death (SCD) in this population has been reported. It seems that persistent deregulation of immunity in HIV-infected patients is a common pathway related to both of these adverse clinical outcomes. Despite the fact that atrial fibrillation and heart failure are relatively common in HIV, few data are reported about screening, diagnosis, and potential treatment of these conditions.

Impact of clinical and therapeutic factors on incident cardiovascular and cerebrovascular events in a population-based cohort of HIV-infected and non-HIV-infected adults

BACKGROUND

Cardiovascular and cerebrovascular (CVD) events/diseases are a common cause of non-acquired immunodeficiency syndrome (AIDS)-related mortality in the aging human immunodeficiency virus (HIV)-infected population. The incidence rate and clinical correlates of CVD in people living with HIV/AIDS compared to the general population warrants further investigation.

HYPOTHESIS

HIV/AIDS is associated with increased risk CVD compared to general population.

METHODS

CVD events in a matched cohort of HIV-infected and non-HIV-infected adults, ≥18 years old, served through the South Carolina Medicaid program during 1994 to 2011 were examined using time-dependent proportional hazards regression and marginal structural modeling.

RESULTS

A retrospective cohort of 13,632 adults was followed longitudinally for an average of 51 months. The adjusted hazard ratio (aHR) of incident CVD events was higher among HIV-infected individuals exposed to combination antiretroviral therapy (cART) (aHR = 1.15) compared to the non-HIV-infected group, but did not differ from the subgroup of cART-naïve HIV-infected adults. A higher aHR of incident CVD was associated with comorbid hypertension (aHR = 2.18), diabetes (aHR = 1.38), obesity (aHR = 1.30), tobacco use (aHR = 1.47), and hepatitis C coinfection (aHR = 1.32), and older age (aHR = 1.26), but with a lower risk among females (aHR = 0.86). A higher risk of incident CVD events was also apparent in HIV-infected individuals with exposure to both protease inhibitors (adjusted risk ratio [aRR] = 1.99) and non-nucleoside reverse transcriptase inhibitors (aRR = 2.19) compared to those with no exposure. Sustained viral load suppression was associated with a lower risk of incident CVD events (aRR = 0.74).

CONCLUSIONS

After adjusting for traditional risk factors and sociodemographic differences, there is higher risk of incident cardiovascular events among HIV-infected individuals exposed to combined antiretroviral medications compared to the general population.

Atherosclerotic Cardiovascular Disease Risk in the HAART-Treated HIV-1 Population

Atherosclerotic cardiovascular disease (CVD), a leading cause of morbidity and mortality in the general population, is also an increasing cause for concern for HIV-infected patients. A number of risk factors for CVD are also associated with HIV disease and HIV therapy, particularly insulin resistance, metabolic dyslipidemia, and inflammation. For example, atherogenic dyslipidemia, a side effect of HIV therapy, is an established risk for CVD in the non-HIV-infected population. As our understanding of atherosclerotic disease evolves, new markers of CVD risk have been identified, including metabolic syndrome definitions and C-reactive protein, a marker of inflammation. Use of these markers, in association with established risk factor guidelines, may serve as important tools in helping HIV physicians implement drug regimens that allow optimum management of metabolic complications associated with HIV and HAART, and thereby reduce CVD risk. The objective of this article is to review the mechanisms of atherosclerotic CVD and to discuss risk factors and markers that can be applied in the evaluation and treatment of CVD in the HIV-positive population.

Human immunodeficiency virus & cardiovascular risk

Highly active antiretroviral therapy (HAART) significantly changed the prevalence of the cardiovascular manifestations of human immunodeficiency virus (HIV)/AIDS. In developed countries, a 30 per cent reduction in the prevalence of cardiomyopathy and pericardial effusion was observed, possibly related to a reduction of opportunistic infections and myocarditis. In developing countries, however, where the availablity of HAART is limited, and the pathogenic impact of nutritional factors is significant, a 32 per cent increase was seen in the prevalence of cardiomyopathy and related high mortality rate from congestive heart failure. Also, some HAART regimens in developed countries, especially those including protease inhibitors, may cause, in a high proportion of HIV-infected patients, a lipodystrophy syndrome that is associated with an increased risk of cardiovascular events related to a process of accelerated atherosclerosis. Careful cardiac screening is warranted for patients who are being evaluated for, or who are receiving HAART regimens, particularly for those with known underlying cardiovascular risk factors, according to the most recent clinical guidelines.

Cerebrovascular disease in HIV-infected individuals in the era of highly active antiretroviral therapy

The widespread use of highly active antiretroviral therapy (HAART) in HIV-infected individuals mostly in developed countries has dramatically improved their prognosis. In such advantaged regions of the world, therefore, many patients are now transitioning from middle into older age, with altered patterns of disease. While previously a rare complication of HIV infection, cerebrovascular disease (particularly that associated with atherosclerosis) is becoming relatively more important in this treated group of individuals. This review summarises the evidence regarding the shifting epidemiology of cerebrovascular diseases affecting HIV-infected individuals. While outlining the association between HIV infection and AIDS and cerebrovascular disease, as well as opportunistic diseases and HIV-associated vasculopathies, the current evidence supporting an increase in atherosclerotic disease in treated HIV-infected individuals is emphasised and a management approach to ischaemic stroke in HIV-infected individuals is presented. Evidence supporting the important role of HAART and HIV infection itself in the pathogenesis of atherosclerotic disease is discussed, together with preventative approaches to this increasingly important disease process as the population ages. Finally, a discussion regarding the significant association between cerebrovascular disease and HIV-associated neurocognitive disorder is presented, together with possible mechanisms behind this relationship.

Right ventricular mass in an asymptomatic HIV positive patient

Human immunodeficiency virus (HIV)- positive patients are known to have a higher risk of cardiovascular complications that are related to the underlying infection itself and also to the complications of their medical treatment. As longevity of these patients has increased owing to the advances in antiretroviral therapies, cardiovascular diseases including coagulative disorders may be more commonly encountered. A case of a right ventricular mass in an asymptomatic HIV positive patient detected by echocardiography is presented and the surgical management is described.

Assessment and modification of cardiovascular disease risk in the HIV-infected individual

HIV-infected patients are living decades longer than before owing to combination antiretroviral therapy. However, complications are emerging in this population at rates higher than the general population, including cardiovascular disease (CVD). HIV-infected patients have many traditional risk factors that account for a significant part of their increased risk of CVD. However, HIV factors, including complications from antiretroviral therapy and increased inflammation associated with chronic HIV infection, also play a role. Clinicians need to be ever-vigilant to calculate and help attenuate any modifiable CVD risk factors for each HIV-infected individual.

Comparison between the Framingham and prospective cardiovascular of Münster scores for risk assessment of coronary heart disease in human immunodeficiency virus-positive patients in Pernambuco, Brazil

BACKGROUND

The Framingham score is used in most studies on human immunodeficiency virus (HIV)-positive patients to estimate the risk for coronary heart disease; however, it may have some limitations for detecting risk among these individuals.

OBJECTIVE

The aim of this study was to evaluate the agreement between the Framingham and Prospective Cardiovascular of Münster (PROCAM) scores among HIV-positive individuals and to investigate the factors associated with disagreement between the two scores.

METHOD

A cross-sectional study was conducted in a population of HIV/acquired immunodeficiency syndrome (AIDS) patients attending the outpatient's clinics of two reference centers for HIV/AIDS in Pernambuco, Brazil. Agreement between the Framingham and PROCAM scores was evaluated using the kappa index. From this analysis, a variable called "disagreement between scores" was created, and univariate and multivariate analysis were performed to investigate the factors associated with this variable.

RESULTS

The prevalence of low, moderate, and high risk were, respectively, 78.7%, 13.5%, and 7.8% by Framingham score and 88.5%, 4.3%, and 7.2% by PROCAM (kappa = 0.64, P ≤ 0.0001). Agreement in the subgroup with metabolic syndrome by the International Diabetes Federation (IDF) (kappa = 0.51, P ≤ 0.0001) and the National Cholesterol Education Program (NCEP) (kappa = 0.59, P ≤ 0.0001) criteria was moderate. The Framingham score identified greater proportion of women with moderate risk. Factors independently associated with disagreement were: smoking, sex, age, low-density lipoprotein cholesterol, diastolic blood pressure, and metabolic syndrome.

CONCLUSION

There was a good agreement between the Framingham and PROCAM scores in HIV-positive patients, but a higher proportion of moderate-high risk was identified by the Framingham score. This disagreement should be evaluated in cohort studies to observe clinical outcomes over the course of time.

Heart and HAART: Two sides of the coin for HIV-associated cardiology issues

The introduction of highly active antiretroviral therapy (HAART) has generated a contrast in the cardiac manifestations of acquired immunodeficiency syndrome. In developed countries, we have observed an approximately 30% reduction in the prevalence of human immunodeficiency virus (HIV)-associated cardiomyopathy, possibly related to a reduction of opportunistic infections and myocarditis. In developing countries, however, where the availablity of HAART is limited and the pathogenic impact of nutritional factors is significant, we have observed an approximately 32% increase in the prevalence of HIV-associated cardiomyopathy and a related high mortality rate from congestive heart failure. Also, some HAART regimens in developed countries, especially those including protease inhibitors, have been shown to cause, in a high proportion of HIV-infected patients, an iatrogenic metabolic syndrome (HIV-lipodystrophy syndrome) that is associated with an increased risk of cardiovascular events related to a process of accelerated atherosclerosis, even in young HIV-infected people. Careful cardiac screening is warranted for patients who are being evaluated for, or who are receiving, HAART regimens, particularly for those with known underlying cardiovascular risk factors. A close collaboration between cardiologists and infectious disease specialists is needed for decisions regarding the use of antiretrovirals, for a careful stratification of cardiovascular risk factors, and for cardiovascular monitoring of HIV-infected patients receiving HAART, according the most recent clinical guidelines.

Is estimated cardiovascular risk higher in HIV-infected patients than in the general population?

Cardiovascular disease (CVD) is an increasing concern for human immunodeficiency virus (HIV)-infected patients, and risk assessment is recommended in routine HIV care. The absolute cardiovascular risk in an individual is determined by several factors, and various algorithms may be applied. To date, few comparisons of HIV patients with persons of the same age from the general population have been conducted. We hypothesized that the calculated risk of CVD may be increased in HIV patients. The probability for acute coronary events within 10 y (Framingham Risk Score) and the probability for fatal cardiovascular disease (SCORE algorithm) were assessed in 403 consecutive HIV-positive subjects free from overt cardiovascular disease, as well as in 96 age- and gender-matched control subjects drawn from the general population living in the same geographical area. The average 10-y risk for acute coronary events (Framingham Risk Score) was 7.0%+/-5% in HIV subjects and 6.3%+/-5% in the control group (p =0.32). The 10-y estimated risk for cardiovascular mortality (SCORE algorithm) was 1.23%+/-2.3% and 0.83%+/-0.9%, respectively (p =0.01). The main contributor to the increased CVD risk was the high proportion of smokers, but not an increase in cholesterol level. In conclusion, a limited increase in estimated risk of CVD was found in HIV-infected patients compared to the general population. In HIV-infected individuals other factors of less value in the general population and not included in any cardiovascular algorithm might be important. In our patients intervention to modify traditional risk factors should be addressed primarily towards modifying smoking habits.

Metabolic syndrome associated with HIV and highly active antiretroviral therapy

The introduction of highly active antiretroviral therapy (HAART) has significantly improved the clinical outcome of HIV disease with increased survival rates. However, some HAART regimens, especially those including protease inhibitors, have been shown to cause in a high proportion of HIV-infected patients metabolic (dyslipidemia, insulin resistance) and somatic (lipodystrophy/lipoatrophy) changes that are associated with an increased risk of cardiovascular disease (coronary artery disease and stroke). The pathogenesis of HAART-associated metabolic syndrome and of its atherogenic profile is complex, and several factors are involved, including direct effects of HAART on lipid metabolism, endothelial and adipocyte cell function, activation of proinflammatory cytokines, and mitochondrial dysfunction. A better understanding of the molecular mechanisms responsible for this syndrome will lead to the discovery of new drugs that will reduce the incidence of lipodystrophy and related metabolic complications in HIV-infected patients facing long-term HAART.

Immune reconstitution inflammatory syndrome and human immunodeficiency virus-associated myocarditis

Myocarditis is a well-recognized cardiac manifestation of human immunodeficiency virus (HIV) infection, and alterations in the immune system likely play an important role in the pathogenesis of heart muscle disease in HIV-infected patients. Highly active antiretroviral therapy (HAART) has greatly improved survival in HIV patients but not without uncovering new and unique manifestations of disease. Immune reconstitution inflammatory syndrome is a collection of inflammatory disorders in which a pathologic inflammatory response and clinical deterioration occur during recovery of the immune system after HAART. To our knowledge, a correlation between immune reconstitution inflammatory syndrome and HIV-associated myocarditis has not been described previously. We report a case of acute myocarditis presenting with refractory ventricular arrhythmias in a patient with AIDS who experienced rapid immune recovery with the initiation of HAART. The case underscores the importance of recognizing this potential complication of AIDS treatment and calls for renewed vigilance concerning cardiac manifestations of HIV, especially during the immune reconstitution phase.

Global cardiovascular risk in patients with HIV infection: concordance and differences in estimates according to three risk equations (Framingham, SCORE, and PROCAM)

To compare cardiovascular risk stratification according to Framingham, PROCAM (Prospective Cardiovascular Münster), and SCORE (Systematic Coronary Risk Evaluation) equations in patients with HIV infection, a cross-sectional study of a well-characterized cohort of 760 HIV-infected adults managed at the outpatient Infectious Disease Unit in 2003 was conducted. Cardiovascular risk score was examined and patients were classified as having low, moderate, or high risk using Framingham and PROCAM (<10%, 10%-20%, and <20%, respectively) and SCORE (<3%, 3%-4%, and >/=5%, respectively) equations. The prevalence of patients with low, moderate and high cardiovascular risk was 76.6%, 15.1%, and 8.3% by the Framingham, respectively, 90.1%, 4.9%, and 5% by the PROCAM, respectively, and 88.6%, 3%, and 8.4% by SCORE, respectively. Concordance between these three risk functions was significant, but globally moderate (Framingham and PROCAM, kappa 0.36, p < 0.0001; Framingham and SCORE, kappa 0.32, p < 0.0001; PROCAM and SCORE, kappa 0.46, p < 0.0001). The Framingham equation categorized a higher proportion of HIV-infected male patients with moderate cardiovascular risk and a lower proportion of those with low risk (p < 0.0001) compared with PROCAM and SCORE. The present study showed a high prevalence of HIV-infected patients at low cardiovascular risk regardless of the assessed coronary risk system used. However, compared with PROCAM and SCORE, Framingham risk equation in HIV-infected patients identified a higher number of male patients with moderate cardiovascular risk.

Highly Active Antiretroviral Therapy-Associated Metabolic Syndrome and Cardiovascular Risk

The introduction of highly active antiretroviral therapy (HAART) has significantly modified the course of human immunodeficiency virus (HIV) disease, with longer survival and improved quality of life of HIV-infected subjects. However, HAART regimens, especially those including protease inhibitors, have been shown to cause in a high proportion of HIV-infected patients a metabolic syndrome (lipodystrophy/lipoatrophy, dyslipidemia, type 2 diabetes mellitus, insulin resistance) that may be associated with an increased risk of cardiovascular disease (coronary artery disease and stroke). A careful stratification of the cardiovascular risk and cardiovascular monitoring of patients under HAART is needed according to the most recent clinical guidelines.

Highly Active Antiretroviral Therapy–Associated Metabolic Syndrome: Pathogenesis and Cardiovascular Risk*

The introduction of highly active antiretroviral therapy (HAART) has significantly modified the course of HIV disease, with longer survival and improved quality of life of HIV-infected subjects. However, HAART regimens, especially those including protease inhibitors (PIs) have been shown to cause in a high proportion of HIV-infected patients a metabolic syndrome that may be associated with an increased risk of cardiovascular disease (about 1.4 cardiac events per 1,000 years of therapy according to the Framingham score). Metabolic features associated with somatic changes (lipodystrophy/lipoatrophy) include dyslipidemia (about 70% of patients), insulin resistance (elevated C-peptide and insulin), type 2 diabetes mellitus (8%-10% of the patients), hypertension (up to 75% of patients), coagulation abnormalities (25% of patients), lactic acidemia, and elevated hepatic transaminases (nonalcoholic steatohepatitis). HAART-associated metabolic syndrome is an increasingly recognized clinical entity. A better understanding of the molecular mechanisms responsible for this syndrome will lead to the discovery of new drugs that will reduce the cardiovascular risk in patients under HAART. A careful stratification of the cardiovascular risk and cardiovascular monitoring of patients under HAART is needed according to the most recent clinical guidelines.

Clinical characteristics and mid-term prognosis of acute coronary syndrome in HIV-infected patients on antiretroviral therapy

OBJECTIVES

Acute coronary syndromes (ACSs) and coronary artery disease are emerging complications in HIV-infected patients on highly active antiretroviral treatment. The aim of this study was to determine the mid-term prognosis of ACS in HIV-infected patients.

METHODS

We evaluated the clinical characteristics and follow-up profile [38+/-15 months; mean+/-standard deviation (SD)] of ACS in 20 HIV-infected patients (mean +/-SD: age 44+/-8 years; range 35-65 years). All had coronary angiograms performed mean time 3+/-48 h after the onset of symptoms.

RESULTS

Eighteen patients were on antiretroviral therapy, of whom 13 patients were on regimens including protease inhibitors (mean duration+/-SD: 19+/-13 months). Fifteen patients had a first episode of ST segment elevation ACS and five had non-ST segment elevation ACS. Tobacco consumption (80%) and hypercholesterolaemia (50%) were the most frequent cardiovascular risk factors. During initial hospitalization, four patients were treated with thrombolysis, two had primary coronary angioplasty and seven had secondary coronary angioplasty. At follow up, 10 patients (50%) had had 18 cardiovascular events: one cardiovascular death, seven episodes of recurrent myocardial ischaemia in four patients, three pulmonary oedemas in two patients, and seven revascularization procedures in five patients.

CONCLUSIONS

This preliminary report highlights the risk of ACS and related complications in HIV-infected patients and raises questions regarding the implications of antiretroviral treatment.

HIV and anesthesia

Human immunodeficiency virus [HIV disease or acquired immunodeficiency syndrome (AIDS)] is the greatest health crisis of the twentieth and early twenty-first century. In sub-Saharan Africa, the epidemic rivals the "Black Death" of fourteenth-century Europe. AIDS is a multiorgan disease that has broad implications for anesthesiologists. New drug therapies are highly effective in most cases and have significant potential for drug interactions. The purpose of this article is to help anesthesiologists better manage persons who have HIV/AIDS in the operating room, labor and delivery suite, and other areas in which this patient population will require an increasing amount of care.

An open-label, prospective, observational study of the incidence of coronary artery disease in patients with hiv infection receiving highly active antiretroviral therapy

BACKGROUND

The association of highly active antiretroviral therapy (HAART) regimens that include protease inhibitors (PIs) with metabolic and somatic disorders has raised concerns about the possibility of an increased risk of coronary artery disease (CAD) in patients with HIV infection.

OBJECTIVE

The aim of this study was to assess the incidence of CAD in previously untreated HIV infected outpatients who received reverse transcriptase inhibitors with or without PIs.

METHODS

In this open-label, multicenter, prospective, observational trial, previously untreated and asymptomatic HIV-infected Italian patients were followed to assess the incidence of CAD (primary end point) according to the HAART regimen they received: 2 nucleoside analogue reverse transcriptase inhibitors (NRTIs) in combination with PIs (group PI+) or 1 non-nucleoside reverse transcriptase inhibitor in combination with 2 NRTIs (group PI-). Patients underwent clinical examination and laboratory testing every 4 months.

RESULTS

A total of 1551 HIV-infected patients (994 [64%] men; median age, 35 years; range, 22-50 years) were followed for a median 36 months (range, 34-42 months). The cumulative annual incidence of CAD-related events was 9.8/1000 in group PI+ and 0.8/1000 in group PI- (P < 0.001). The annual incidence of myocardial infarction was 5.1/1000 in group PI+ and 0.4/1000 in group PI- (P < 0.001). Independent of patient age, the incidence of CAD was greater among men (P < 0.001) and patients who smoked >20 cigarettes per day (P < 0.001). Lipodystrophy and metabolic alterations were observed in 62% of patients in group PI+ and in 4% of patients in group PI- (P < 0.001). Of 23 patients receiving PIs who developed CAD, 17 (73.9%) had lipodystrophy and all 23 had hypertriglyceridemia and hypercholesterolemia.

CONCLUSIONS

According to our findings, HAART that includes PIs may accelerate the onset of CAD-related events in young, male, heavy smokers who develop metabolic disorders and lipodystrophy during therapy. Patients with increased coronary risk should receive careful cardiac monitoring if treated with PIs.