The plenary session this morning on this last day of CROI on “Cardiovascular Disease in HIV Patients: An emerging Paradigm and Call to Action” was presented by Steven Grinspoon – an endocrinologist.
He reminded us of the 35000000 people living with HIV and the increased cardiovascular risk (myocardial infarction, stroke and sudden death ) in HIV positive patients.
Several important points were brought up, some of which we may already aware of
· CVD risk in HIV infected patients is beyond that predicted by traditional risk factors
· Excess mortality from smoking has been seen in HIV positive patients
· Although there have been studies in the past demonstrating cART being associated with diabetes, hypertension, lipid problems, increased platelet activity etc. and various studies associating cART with myocardial infarction, Steven emphasized the importance of looking at the the newer studies showing the positive effect of cART with respect to cardiovascular risk.
· The SMART study and the potential mechanisms for beneficial effects of viral suppression on cardiovascular diseases including decreased I 6 and increased HDL.
· Description of persistent viral replication and microbial translocation resulting in T cell activation and monocyte activation contributing to increased inflammation and increase cardiovascular risk.
· Steven discussed studies showing increased capacity of cholesterol efflux with cART in patients with acute HIV infection and that the duration of immune suppression and nadir CD4 related to AMI
· HIV is a state of immune activation and suppression with implications of atherogenesis pathogenesis
· Immune activation relates to novel atherosclerotic phenotype in HIV. In HIV patients atherosclerotic plaques are inflamed and associated with immune activation markers.
· Markers of monocyte activation are seen in HIV postive patients with CVD. Monocytes play an important part
· There is immune activation at surface of high risk plaque
· Increased rates of atherosclerosis in HIV have been seen by coronary CT angiography with the presence of these plague higher in HIV patients
· HIV positive patients have increased higher risk morphological plaques with the associated clinical implications for these high risk morphological plagues
Importance of identification of patients with disease, optimizing time and use of ART and safe effective strategies for primary prevention
He continues to discuss the importance of interventions addressing both traditional risk modification strategies and immune response risk factors. Immune interventions mentioned included CCR5 antagonists, IL antagonists, methotrexate, statins, renin-angiotensin blockers
He concluded the need of large RCT to inform clinical pactice. It is unknown if statins prevent CVD and should be recommended for the HIV population.
Discussion of REPRIEVE study a prospective RCT
In summary, traditional and non-traditional risk factors contribute to increase CVD risk in HIV manifesting itself with inflammed non-calcified high risk plaque in association with immune activation
I would encourage colleagues to look at the webcast when available.
Our HIV population in Australia is aging and we need to be continue being informed of the comorbidities associated with HIV especially cardiovascular disease.