Sub-clinical atherosclerosis in HIV-infected patients: prevalence and risk factors
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Department of Infectious Diseases, Fattouma Bourguiba Hospital, Monastir, Tunisia
Department of Cardiology, Fattouma Bourguiba Hospital, Monastir, Tunisia
Department of Radiology, Fattouma Bourguiba Hospital, Monastir, Tunisia
Submission date: 2021-11-16
Final revision date: 2022-03-08
Acceptance date: 2022-03-09
Publication date: 2023-11-15
HIV & AIDS Review 2023;22(4):290-294
Antiretroviral therapy has significantly improved the prognosis of human immunodeficiency viruses (HIV) infection. Therefore, life expectancy of people living with HIV (PLHIV) has increased. However, this therapy may have some side effects. This study aimed to detect the prevalence of sub-clinical carotid and coronary atherosclerosis among asymptomatic patients living with HIV, free from known cardiovascular diseases, and to identify the factors associated with sub-clinical athe­rosclerosis.

Material and methods:
We conducted a cross-sectional prospective study over one year (between July 2018 and June 2019). We included 75 PLHIV, followed-up in the outpatient clinic of the Infectious Diseases Department of the University Hospital Fattouma Bourguiba in Monastir, Tunisia. Cardiovascular assessment, including carotid doppler ultrasonography, electrocardiogram, exercise stress testing, and transthoracic echocardiography was proposed to all study participants.

The cardiovascular assessment revealed sub-clinical atherosclerosis in 9 PLHIV (12%): carotid atherosclerosis in 9 cases and coronary artery atherosclerosis in one case. One patient had presented both carotid and coronary atherosclerosis. After multivariate regression analysis, smoking (OR = 2.6; 95% CI: 1.08-6.62%; p = 0.03) and age ≥ 40 years (OR = 2.3; 95% CI: 1.02-5.22%; p = 0.04) were found to be independent risk factors of sub-clinical atherosclerosis in PLHIV.

Our study revealed that sub-clinical atherosclerosis was present in 1 of 8 PLHIV. Therefore, screening for atherosclerosis using carotid ultrasound imaging, transthoracic echocardiography, and exercise stress test should be suggested for all PLHIV under 40 years and/or smokers.

Llibre JM, Fuster-Ruizdeapodaca MJ, Rivero A, Fernández E. Clinical care of patients with HIV. Enferm Infecc Microbiol Clin 2018; 36: 40-44.
De Lima LR, Petroski EL, Moreno YM, et al. Dyslipidemia, chronic inflammation, and subclinical atherosclerosis in children and adolescents infected with HIV: the PositHIVe Health Study. PLoS One 2018; 13: e0190785. DOI: 10.1371/journal.pone.0190785.
Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020; 41: 111-188.
Wang SC, Kaur G, Schulman-Marcus J, et al. Implementation of cholesterol-lowering therapy to reduce cardiovascular risk in persons living with HIV. Cardiovasc Drugs Ther 2022; 36: 173-186.
Hsue PY, Waters DD. HIV infection and coronary heart disease: mechanisms and management. Nat Rev Cardiol 2019; 16: 745-759. .
Meijboom LJ, Timmermans J, van Tintelen JP, et al. Evaluation of left ventricular dimensions and function in Marfan’s syndrome without significant valvular regurgitation. Am J Cardiol 2005; 95: 795-797.
Marcadet DM. Électrocardiogramme d’effort. EMC Cardiol Angéiol 2004; 1: 281-309.
Howard DPJ, Gaziano L, Rothwell PM; Oxford Vascular Study. Risk of stroke in relation to degree of asymptomatic carotid stenosis: a population-based cohort study, systematic review, and meta-analysis. Lancet Neurol 2021; 20: 193-202.
León R, Reus S, López N, et al. Subclinical atherosclerosis in low Framingham risk HIV patients. Eur J Clin Invest 2017; 47: 591-599.
Phan BAP, Weigel B, Ma Y, et al. Utility of 2013 American College of Cardiology/American Heart Association cholesterol guidelines in HIV-infected adults with carotid atherosclerosis. Circ Cardiovasc Imaging 2017; 10: e005995. DOI: 10.1161/CIRCIMAGING.116.005995.
D’Ascenzo F, Cerrato E, Calcagno A, et al. High prevalence at computed coronary tomography of non-calcified plaques in asymptomatic HIV patients treated with HAART: a meta-analysis. Atherosclerosis 2015; 240: 197-204.
Hsue PY, Hunt PW, Sinclair E, et al. Increased carotid intima-media thickness in HIV patients is associated with increased cytomegalovirus-specific T-cell responses. AIDS 2006; 20: 2275-2283.
Post WS, Budoff M, Kingsley L, et al. Associations between HIV infection and subclinical coronary atherosclerosis. Ann Intern Med 2014; 160: 458-467.
Kelleher P, Xu XN. Hard-to-kill macrophages lead to chronic inflammation in HIV. Nat Immunol 2018; 19: 433-434. .
Beltrán LM, Rubio-Navarro A, Amaro-Villalobos JM, Egido J, García-Puig J, Moreno JA. Influence of immune activation and inflammatory response on cardiovascular risk associated with the human immunodeficiency virus. Vasc Health Risk Manag 2015; 11: 35-48.
Sandler NG, Sereti I. Can early therapy reduce inflammation? Curr Opin HIV AIDS 2014; 9: 72-79.
Thakkar AB, Ma Y, Dela Cruz M, et al. Effect of HIV-1 infection on angiopoietin 1 and 2 levels and measures of microvascular and macrovascular endothelial dysfunction. J Am Heart Assoc 2021; 10: e021397. DOI: 10.1161/JAHA.121.021397.
Gleason RL Jr, Caulk AW, Seifu D, et al. Current efavirenz (EFV) or ritonavir-boosted lopinavir (LPV/r) use correlates with elevate markers of atherosclerosis in HIV-infected subjects in Addis Ababa, Ethiopia. PLoS One 2015; 10: e0117125. doi: 10.1371/journal.pone.0117125.
Salmazo PS, Bazan SGZ, Shiraishi FG, Bazan R, Okoshi K, Hueb JC. Frequency of subclinical atherosclerosis in Brazilian HIV-infected patients. Arq Bras Cardiol 2018; 110: 402-410.
Hsue PY, Hunt PW, Schnell A, et al. Role of viral replication, antiretroviral therapy, and immunodeficiency in HIV-associated atherosclerosis. AIDS 2009; 23: 1059-1067.
Lai H, Moore R, Celentano DD, et al. HIV infection itself may not be associated with subclinical coronary artery disease among African Americans without cardiovascular symptoms. J Am Heart Assoc 2016; 5: 25-29.
Di Yacovo S, Saumoy M, Sánchez-Quesada JL, et al. Lipids, biomarkers, and subclinical atherosclerosis in treatment-naive HIV patients starting or not starting antiretroviral therapy: comparison with a healthy control group in a 2-year prospective study. PLoS One 2020; 15: e0237739. doi: 10.1371/journal.pone.0237739.
Dube MP, Lipshultz SE, Fichtenbaum CJ, Greenberg R, Schecter AD, Fisher SD; Working Group 3. Effects of HIV infection and antiretroviral therapy on the heart and vasculature. Circulation 2008; 118: e36-e40. DOI: 10.1161/CIRCULATIONAHA.107.189625.
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