Top Things to Know: Characteristics Prevention and Management of Cardiovascular Disease in People Living With HIV
Published: June 03, 2019
- Persons living with HIV (PLWH) are at higher risk than uninfected persons for cardiovascular diseases (CVDs), including myocardial infarction (MI), heart failure (HF), and stroke. These elevated risks remain significant after accounting for demographic considerations and common CVD risk factors.
- The global burden of HIV-associated CVD - which currently accounts for 2.6 million disability-adjusted life years lost per year - is substantial. This burden is increasing as PLWH are living longer, resulting in an aging population living with HIV at risk for multi-morbidity from non-communicable diseases.
- Primary drivers of the elevated risks of CVD among PLWH are thought to be chronic inflammation and immune activation, as well as high levels of traditional CVD risk factors such as smoking among PLWH.
- Pathways of inflammation and immune activation are distinct in HIV compared with the general population; more research is needed regarding therapies targeting these pathways to prevent and treat CVD in HIV.
- HIV-specific factors associated with heightened CVD risk are the presence of a detectable HIV viral load and advanced immunosuppression (CD4 count <200 cells/mm^3 and <350 cells/mm^3 in some studies) during the past or at present, as well as unique social and demographic factors in vulnerable PLWH.
- Whereas antiretroviral therapy (ART) was initially thought to be a primary driver of CVD risk, many ART medications are not associated with CVD. Furthermore, the effect of specific ART regimens that may be associated with CVD appears to be small compared with the other risk-enhancing factors discussed above. In any case, the overall benefit of treating PLWH with ART clearly outweighs the adverse effects.
- Calculators of CVD risk (such as the ACC/AHA ASCVD Risk Estimator and Framingham Risk Score) may underestimate CVD risk in HIV and the accuracy of the ACC/AHA ASCVD Risk Estimator has not been well validated for PLWH. HIV-specific calculators have not performed much better. Therefore, there is no clear consensus at present on the best CVD risk estimation tool for PLWH.
- Statin therapy (with the exception of simvastatin and lovastatin) appears to be safe in PLWH and effective for lipid-lowering, although no trials investigating statins and hard CVD endpoints have been completed. The first randomized trial of statin therapy to prevent CVD in HIV patients on ART, REPRIEVE, is underway and randomizes PLWH to pitavastatin vs. placebo; the study is powered for CVD events and results are expected in 2023.
- Risks and benefits of antithrombotic therapy in HIV remain largely unknown. Studies evaluating the impact of aspirin on subclinical vascular endpoints in HIV have had mixed results.
- Key gaps in research remain regarding: (1) Optimal therapies for atherosclerotic CVD prevention in HIV; (2) Mechanisms and interventions related to thrombosis in HIV; (3) Epidemiology and mechanisms of heart failure in HIV; and (4) Interventions to optimize CVD screening and prevention among persons with HIV; among other gaps.
Citation
Feinstein MJ, Hsue PY, Benjamin LA, Bloomfield GS, Currier JS, Freiberg MS, Grinspoon SK, Levin J, Longenecker CT, Post WS; on behalf of the American Heart Association Prevention Science Committee of the Council on Epidemiology and Prevention and Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Stroke Council. Characteristics, prevention, and management of cardiovascular disease in people living with HIV: a scientific statement from the American Heart Association [published online ahead of print June 3, 2019]. Circulation. doi: 10.1161/CIR.0000000000000695