Slide 1: December 1 is World AIDS Day! Many parts of the world are now seeing mortality from HIV transitioning away from opportunistic infections and to chronic illnesses. Specifically, heart disease is under-treated in HIV patients. Despite being one of the major causes of mortality today, patients with HIV are less likely to receive guideline-directed statin and aspirin therapy.

Slide 2: The diagnosis of cardiovascular disease and risk is challenging in HIV. Inflammation and immune activation contribute to mostly non-calcified plaques, which limits the usefulness of common tools such as coronary artery calcium (CAC) scoring. More troubling, the traditional ASCVD risk calculator routinely underestimates risk in HIV, leading to the expert recommendation to multiply scores by 1.5 to 2.0 when using such calculators.

Slide 3: In terms of treatment, drug interactions should not preclude life-saving medications such as statins. Of the common statins, pravastatin is the least likely to interact with antiretrovirals. Finally, it is interesting to note the HIV itself may cause release of renin-like peptides that up regulate the renin-angiotensin-aldosterone system (RAAS). It may make more sense mechanistically, therefore, to prefer aldosterone antagonists for the treatment of hypertension in HIV.

References

  • GBD 2016 Causes of Death Collaborators. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017 Sep 16;390(10100):1151-1210. PMID 28919116.
  • Ladapo JA, Richards AK, DeWitt CM, Harawa NT, Shoptaw S, Cunningham WE, Mafi JN. Disparities in the Quality of Cardiovascular Care Between HIV-Infected Versus HIV-Uninfected Adults in the United States: A Cross-Sectional Study. J Am Heart Assoc. 2017 Nov 14;6(11):e007107. PMID 29138182.
  • Feinstein MJ, Hsue PY, Benjamin LA, Bloomfield GS, Currier JS, Freiberg MS, Grinspoon SK, Levin J, Longenecker CT, Post WS. Characteristics, Prevention, and Management of Cardiovascular Disease in People Living With HIV: A Scientific Statement From the American Heart Association. Circulation. 2019 Jul 9;140(2):e98-e124. PMID 31154814.
  • Arbab-Zadeh A, Nakano M, Virmani R, Fuster V. Acute coronary events. Circulation. 2012 Mar 6;125(9):1147-56. PMID 22392862.
  • Sharma SK, Evans DB, Hui JO, Heinrikson RL. Could angiotensin I be produced from a renin substrate by the HIV-1 protease? Anal Biochem. 1991 Nov 1;198(2):363-7. PMID 1799223.

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