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Heart Disease & HIV
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Relative risks of various cardiovascular (CVD) manifestations are generally 1.5- to 2-fold greater for PLWH (people living with HIV) compared with uninfected individuals. Although the relative risk has decreased with effective ART, there is a large and rising absolute burden of CVD among PLWH.
PLWH have high rates of traditional risk factors, including dyslipidemia, metabolic disease, smoking, hypertension, and substance use. Aside from traditional risk factors, HIV-specific issues are implicated in CVD and include ART, chronic inflammation, and immune activation in the setting of treated and suppressed HIV disease. Imaging techniques have provided valuable insight into CVD onset and progression in HIV.
HIV infection is associated with metabolic complications, including dyslipidemia, insulin resistance, and body composition changes, which can contribute to CVD. Initially, dyslipidemia in HIV was characterized by increased triglyceride levels, thought to be related to immunodeficiency in the pre-ART era.95 Later, specific ART medications, including several protease inhibitors (PIs) and efavirenz, a non-nucleoside reverse transcriptase inhibitor (NRTI), were associated with dyslipidemia (particularly elevated triglyceride levels). However, current first-line ART regimens have minimal lipid effects.
Expanding the HIV treatment cascade for the prevention of non-AIDS comorbidities is a necessary extension of the treatment cascade paradigm.
Pharmaco-Prevention of Coronary Artery Disease in HIV: Primary prevention to reduce the risk of ASCVD is an important goal for PLWH. Statins significantly reduce CVD events in patients without HIV with increased inflammation and low levels of LDL-C. PLWH often present with normal LDL but increased systemic and arterial inflammation and persistent immune activation despite successful ART. Traditional CVD risk factors, particularly smoking, are also more common and should be targeted in HIV. Statin use in HIV is complicated by potential drug interactions, although newer statin and ART therapies appear to have more benign drug-drug interaction profile.
In terms of clinical adverse events, observational cohorts have shown that most statins (simvastatin and lovastatin excluded) can be safely prescribed for PLWH with lipid-lowering effects similar to those for people without HIV. A caveat to this may be people >75 years of age, for whom there are conflicting data on net statin benefits in the general population.
To address this knowledge gap, the National Institutes of Health launched REPRIEVE, a randomized, placebo-controlled, 7,500-person global trial to test a primary prevention strategy in HIV.
In recent years, several studies of lipid-lowering therapies added to a background of statin therapy have demonstrated that aggressive LDL-C lowering in populations at high ASCVD risk reduces cardiovascular events. The benefit of aggressive LDL-C lowering is demonstrated by data from 14 large statin studies in the non-HIV population (Cholesterol Treatment Trialists' Collaborators) in which each 38.6-mg/dL reduction in LDL-C translated to a reduction in cardiovascular events by 22% PCSK9 (proprotein convertase subtilsin-kexin type 9) binds and degrades LDL receptors, leading to an increase in LDL-C.
PCSK9 inhibitors are monoclonal antibodies with minimal significant drug-drug interactions identified thus far that reduce LDL-C by ≈60% even in the setting of high-intensity statin therapy. Two PCSK9 inhibitors are approved by the US Food and Drug Administration for individuals with heterozygous familial cholesterolemia or clinical ASCVD on maximally tolerated statins who require additional LDL-C lowering. Among uninfected people with ASCVD, PCSK9 inhibitor therapy in addition to statin therapy reduced clinical events by 15% (P<0.001). A longer study demonstrated that PCSK9 inhibitor therapy reduced rates of major adverse cardiovascular events significantly overall and reduced mortality among individuals with an LDL-C ≥100 mg/dL.
Women with HIV may be at particularly elevated risk compared with uninfected women.
Targeted attention and investment are needed. The quality of our care for HIV is further limited by shortcomings in the US healthcare reimbursement system. Healthcare providers are often unable to spend the time required to understand the problems facing the aging HIV population. PLWH who also have CVD often need longer visit times, care coordination, and multidisciplinary team engagement. There are many opportunities for implementation research aimed at leveraging the HIV care infrastructure to deliver integrated cardiovascular preventive and therapeutic care for PLWH. Such structures could include improving health insurance access to specialists, strengthening specialist referral pathways, nurse management, clinical pharmacist engagement,325 team-based approaches, electronic medical record-based approaches to targeting high-risk patients, colocated clinics, and other approaches that consider the specific vulnerabilities in this population.
smoking may be the most important modifiable CVD risk factor among PLWH. Smoking is highly prevalent among PLWH (42% were current smokers and 20% were former smokers in a nationally representative US sample.
cumulative PI use was associated with a 10% greater risk of MI, even after adjustment for cholesterol changes caused by PIs. Analyses from the D:A:D cohort of atazanavir and darunavir, 2 current-generation PIs in widespread clinical use, suggest that ritonavir-boosted or unboosted atazanavir is not associated with increased risk. It appears that the association of PIs with ASCVD events is a class effect, with atazanavir being the exception.
As in the general population, adherence to a healthy lifestyle is an essential first step for primary and secondary prevention of CVD among PLWH.
Although it is clear that heavy alcohol consumption has adverse effects on CVD and other disease end points, there is debate about whether a "healthy" level of alcohol consumption exists; some large analyses suggested a cardioprotective effect of light to moderate alcohol consumption (<100 g/wk [<7 drinks/wk]), whereas others found no benefit and perhaps elevated HF and stroke risks for light to moderate alcohol consumption.
Regular physical activity is also an essential aspect of lifestyle optimization in HIV given the associations of physical inactivity with poor health and adherence in HIV and, conversely, the improvement in inflammation and cardiometabolic health with increasing physical activity in HIV.
About Heart Disease
The term heart disease refers to several types of heart conditions, including coronary artery disease and heart attack.
Heart disease is the leading cause of death for men in the United States.1
• Heart disease is the leading cause of death for men in the United States, killing 357,761 men in 2019-that's about 1 in every 4 male deaths.1
• Heart disease is the leading cause of death for men of most racial and ethnic groups in the United States, including African Americans, American Indians or Alaska Natives, Hispanics, and whites. For Asian American or Pacific Islander men, heart disease is second only to cancer.2
• About 1 in 13 (7.7%) white men and 1 in 14 (7.1%) black men have coronary heart disease. About 1 in 17 (5.9%) Hispanic men have coronary heart disease.3
• Half of the men who die suddenly of coronary heart disease had no previous symptoms.4 Even if you have no symptoms, you may still be at risk for heart disease.
Although heart disease is sometimes thought of as a man's disease, almost as many women as men die each year of heart disease in the United States.
• Heart disease is the leading cause of death for women in the United States, killing 299,578 women in 2017-or about 1 in every 5 female deaths.2
• Heart disease is the leading cause of death for African American and white women in the United States. Among American Indian and Alaska Native women, heart disease and cancer cause roughly the same number of deaths each year. For Hispanic and Asian or Pacific Islander women, heart disease is second only to cancer as a cause of death.3
• About 1 in 16 women age 20 and older (6.2%) have coronary heart disease, the most common type of heart disease:4
• About 1 in 16 white women (6.1%), black women (6.5%), and Hispanic women (6%)
• About 1 in 30 Asian women (3.2%)
What is heart disease?
The term "heart disease" refers to several types of heart conditions. The most common type of heart disease in the United States is coronary artery disease (CAD), which affects the blood flow to the heart. Decreased blood flow can cause a heart attack.
What are the symptoms of heart disease?
Sometimes heart disease may be "silent" and not diagnosed until a person experiences signs or symptoms of a heart attack, heart failure, or an arrhythmia. When these events happen, symptoms may include1
• Heart attack: Chest pain or discomfort, upper back or neck pain, indigestion, heartburn, nausea or vomiting, extreme fatigue, upper body discomfort, dizziness, and shortness of breath.
• Arrhythmia: Fluttering feelings in the chest (palpitations).
• Heart failure: Shortness of breath, fatigue, or swelling of the feet, ankles, legs, abdomen, or neck veins.
What are the risk factors for heart disease?
High blood pressure, high blood cholesterol, and smoking are key risk factors for heart disease. About half of people in the United States (47%) have at least one of these three risk factors.2 Several other medical conditions and lifestyle choices can also put people at a higher risk for heart disease, including
• Diabetes
• Overweight and obesity
• Unhealthy diet
• Physical inactivity
• Excessive alcohol use
How can I reduce my risk of heart disease?
To reduce your chances of getting heart disease, it's important to do the following:8
• Know your blood pressure. Having uncontrolled blood pressure can result in heart disease. High blood pressure has no symptoms so it's important to have your blood pressure checked regularly. Learn more about high blood pressure.
• Talk to your health care provider about whether you should be tested for diabetes.
Having diabetes raises your risk of heart disease.9 Learn more about diabetes.
• Quit smoking. If you don't smoke, don't start. If you do smoke, learn ways to quit.
• Discuss checking your cholesterol and triglyceride levels with your health care provider. Learn more about cholesterol.
• Make healthy food. Having overweight or obesity raises your risk of heart disease. Learn more about overweight and obesity.
• Limit alcohol intake to one drink a day. Learn more about alcohol.
• Lower your stress level and find healthy ways to cope with stress. Learn more about coping with stress.
Heart Disease Deaths Vary by Sex, Race, and Ethnicity
Heart disease is the leading cause of death for people of most racial and ethnic groups in the United States, including African American, American Indian, Alaska Native, Hispanic, and white men. For women from the Pacific Islands and Asian American, American Indian, Alaska Native, and Hispanic women, heart disease is second only to cancer.5
Below are the percentages of all deaths caused by heart disease in 2015, listed by ethnicity, race, and sex.5
https://www.cdc.gov/heartdisease/about.htm
https://www.cdc.gov/heartdisease/facts.htm
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