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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 10
| Issue : 1 | Page : 1-5 |
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Myocardial infarction in people living with HIV/AIDS
Shailesh Singh1, Katyayni Singh2
1 Department of Cardiology, Fortis Escorts Heart Institute, New Delhi, India
2 Department of Paediatrics, Lal Bahadur Shastri Hospital, New Delhi, India
| Date of Submission | 20-Jan-2020 |
| Date of Acceptance | 03-Feb-2020 |
| Date of Web Publication | 20-Apr-2020 |
Correspondence Address:
Dr. Shailesh Singh
M.429, Ashiana Colony, Lucknow - 226 012, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JICC.JICC_4_20
The advancements in the field of antiretroviral therapy and prevention, diagnosis and treatment of deadly opportunistic infections in HIV has led to prolongation of life of these patients. As these patients now have a higher life expectancy and since they are dying less of infectious diseases, a rise in cardiovascular and metabolic diseases has been seen in these patients. More and more patients have been found to be suffering from acute coronary syndrome, peripheral vascular disease, and stroke.
Keywords: Acute coronary syndrome, HIV/AIDS, myocardial infarction
How to cite this article:
Singh S, Singh K. Myocardial infarction in people living with HIV/AIDS. J Indian coll cardiol 2020;10:1-5 |
| Introduction | |  |
The advancements in the field of antiretroviral therapy (ART) and prevention, diagnosis, and treatment of deadly opportunistic infections in HIV have led to prolongation of life of these patients. As these patients now have a higher life expectancy and since they are dying less of infectious diseases, a rise in cardiovascular and metabolic diseases has been seen in these patients. More and more patients have been found to be suffering from acute coronary syndrome (ACS), peripheral vascular disease, and stroke.
| Incidence of Acute Cardiovascular Complications in Hiv | | |
Studies have found that HIV-infected patients are more likely to suffer from acute myocardial infarction (MI) than the general population.[1],[2] This becomes even more pronounced in patients who are receiving highly active ART (HAART).[2],[3],[4]
There is some in concrete evidence pointing toward increased incidence of coronary artery disease (CAD) in patients who are being prescribed protease inhibitors.[5] However, the definitive association between the two is not proven.[6]
| Spectrum of Disease | | |
Multiple cases of CAD in HIV-infected patients have been reported worldwide.[7],[8],[9],[10],[11],[12],[13],[14]
Like their noninfected counterparts, HIV-infected patients can either present as chronic stable angina or unstable ACS or ST-elevation MI.
Boccara et al.[14] found among 20 HIV+ patients admitted with an ACS, of which majority suffered from MI and 19 patients were male. Majority of the patients had a history of tobacco consumption (80%). Dyslipidemia was present in 65%. Fourteen patients had received protease inhibitors.
Duong et al.[13] prospectively evaluated the presence of silent MI in HIV+ patients. The authors found that silent myocardial ischemia, as detected by the treadmill test, increased in HIV-infected patients more than the general population (11% vs. 5%). The authors also found that the patients who developed silent myocardial ischemia were older, had fat redistribution with more central fat, and have hypercholesterolemia.
Bergersen et al.[15] demonstrated that the risk of CAD was higher in HIV-infected patients compared to the general population. The study reported that compared to controls, twice as many HIV-infected patients on HAART had an estimated 10-year coronary heart disease (CHD) Framingham risk above 20% (11.9% vs. 5.3%). The main contributors to increased risk of CHD were increased prevalence of daily smoking, elevated total cholesterol and low high-density lipoprotein (HDL) in the patient on HAART.
Neumann et al.[16] demonstrated that the risk of cardiovascular event is related to the age of HIV-infected patients. The authors also found that total cholesterol, low-density lipoprotein cholesterol (LDL-C), and triglycerides increased with increasing age.
Hadigan et al.[17] compared the 10-year CHD risk among HIV-infected patients with noninfected counterparts and concluded that the CHD risk is increased in male HIV patients with fat redistribution.
A study[18] compared three cardiovascular risk-predicting equations, i.e. Framingham, PROCAM, and SCORE, for risk assessment in HIV+ patients. Majority of HIV+ patients were found to be at low cardiovascular risk by all of the methods. However, when the three systems were compared, the Framingham equation classified a higher number of HIV positive male patients with moderate cardiovascular risk.
A French study[19] studied the risk factors for CHD in HIV+ patients treated and compared with the general population. HIV-infected patients were more likely to be a smoker, hypertensive, have lower HDL cholesterol with high triglycerides, and have a higher waist-to-hip ratio.
The Swiss HIV cohort study[20] studied the prevalence of risk factors for cardiovascular disease in HIV-infected patients. Smoking, low HDL cholesterol, high triglycerides, and hypertension were found to be the most common cardiovascular risk factors.
Many studies have shown that HIV+ patients have a higher incidence of risk factors for cardiovascular disease; thus, they are at a higher risk of CHD.[21],[22],[23]
Protease inhibitors have been implicated in the pathogenesis of MI.[24],[25]
| Pathophysiology | | |
Accelerated atherosclerosis in HIV infection can be attributed to factors such as insulin resistance, lipodystrophy syndrome,[23],[26],[27] dyslipidemia,[27],[28],[29],[30],[31],[32] chronic inflammation and inflammatory pathway,[33],[34],[35],[36],[37],[38],[39],[40],[41],[42] prothrombotic state,[34],[43],[44] metabolic abnormalities in HIV,[45],[46] and direct vascular toxicity of the virus.[47]
| Prognosis | | |
The prognosis of HIV-infected patients during the acute phase of ACS has been evaluated in a few studies.[48],[49],[50],[51],[52] The inhospital mortality rate varied from 0% to 8%, and no differences in terms of heart failure and reinfarction were found when a control group was included.[50],[52] However, when long-term follow-up of HIV-infected patients was compared with controls, HIV-positive patients were more likely to have recurrent ischemia, but there was no significant difference in long-term cardiovascular and total mortality.[50],[52]
| Primary Prevention | | |
Aspirin
In primary prevention, aspirin should be given if the level of CHD risk is high and in the absence of contraindications.[53] Recently, questions have been raised about platelet function and activity in HIV-infected patients.[54],[55]
| Empiric Statin Therapy – Is There a Role? | | |
Considering the high risk of atherosclerotic cardiovascular disease in HIV+ patients, empiric statin therapy can be considered in the absence of contraindications.[56]
Lo et al. randomized 40 HIV patients without vascular disease or an existing indication for statin therapy to receive either atorvastatin or placebo. The study showed that statin therapy slowed coronary plaque progression.[57]
Funderburg et al.[58] found that 48 weeks of rosuvastatin treatment reduced significantly several markers of inflammation. Another study found that the patients with HIV infection who received statin therapy had smaller reductions in low-density lipoprotein cholesterol.[59]
| Management of Dyslipidemia and Cardiovascular Risk Reduction in Hiv+ Patients | | |
If dyslipidemia is present, the patient should be screened for secondary causes such as the general population. Underlying causes such as diabetes mellitus, hypothyroidism, excessive alcohol use, obstructive liver disease, chronic renal failure, hypogonadism, and drug-induced elevated LDL-C (progestins, anabolic steroids, and corticosteroids) should be ruled out. Statins and other lipid-lowering agents should be strongly considered.
A study has shown that statin therapy can cause a 26% reduction in LDL-C in HIV+ patients, which is less than that seen in non-HIV-infected individuals.[59]
A study has shown that statin therapy improves high-risk plaque morphology.[57]
Studies have shown that pitavastatin causes more reduction of arterial inflammation and LDL lowering among HIV patients compared to pravastatin, a more commonly used drug.[60],[61]
The standard dose rosuvastatin or pravastatin or fluvastatin is a safe choice because they do not have an interaction with cytochrome P-450 (CYP).
| Smoking Cessation | | |
Compared to the general population, HIV+ patients were more likely to be the prevalence of smoking cigarettes.[62] Smoking cessation should be a priority for HIV-infected patients and physicians, integrated into a global risk reduction approach (dyslipidemia, diabetes mellitus, overweight, and inactivity) to prevent future coronary events.[63]
| Systemic Hypertension | | |
Few studies have studied the prevalence of hypertension in HIV+ patients.[64],[65]
Sattler et al.[65] showed that hypertension was more common in HIV-infected patients with lipodystrophy compared with HIV-infected patients without it (74 vs. 48%, P = 0.01).
The prevalence of systemic hypertension was studied in a cohort of 214 HIV-1-infected patients, and it was found to be 29%. These hypertensive patients were much older and had a higher waist to hip ratio than normotensive individuals. Hypertensive patients were more likely to suffer from CHD and MI.[66]
Crane et al.[67] found that treatment with lopinavir/ritonavir was significantly associated with hypertension. The likely explanation for the phenomenon was an increase in body mass index. Atazanavir was the least likely cause of hypertension among the protease inhibitors.
Renin angiotensin aldosterone system inhibitors (RAAS inhibitors) are considered the first-line therapy for hypertension in HIV+ patients because of their protective effects on glucose metabolism and kidney function.
| Secondary Prevention | | |
HIV+ patients presenting with ACS should be managed as per standard guidelines for the general population in terms of thrombolytic, antithrombotic therapy, and coronary revascularization modalities.
Patients should receive β-blockers, aspirin, angiotensin-converting enzyme inhibitors, and lipid-lowering therapy as a part of medical management.
| Antiplatelets | | |
Dual antiplatelet therapy, which includes aspirin plus clopidogrel, prasugrel, or ticagrelor, should be given to the patients as per the guidelines for the general population.
A study has reported a potential drug interaction between ritonavir and prasugrel.[68] Concerns have been raised about the potential drug interaction between ticagrelor and protease inhibitors as the former is metabolized by CYP 3A4/5 pathway, and the latter is its inhibitor.[69]
| Percutaneous Interventions for Hiv+ Patients With Myocardial Infarction | | |
A study has found that HIV-infected individuals are less likely to undergo percutaneous coronary intervention and, more likely to receive a Bare metal stent (BMS) instead of a Drug- eluting stent (DES), have higher mortality rates, and hospitalization costs are higher than their noninfected counterparts.[70] HIV+ patients have been found to have higher incidences of stent thrombosis, especially when CD4 cell count is low (>200 cells/mm3).[71],[72] Studies have reported a higher frequency of in stent restenosis and target vessel revascularization in HIV+ patients who received BMS, suggesting potential benefits with the use of DES.[73],[74] Studies have reported a higher frequency of in-stent restenosis and target vessel revascularization in HIV+ patients who received BMS, suggesting potential benefits with the use of DES.[75],[76]
| Coronary Artery Bypass Graft for Hiv+ Patients With Myocardial Infarction/coronary Artery Disease | | |
Evidence suggests that the immediate and postoperative periods after coronary artery bypass graft in HIV-infected patients are uneventful and are not different from those in non-HIV-infected patients. There was no difference in the rate of cardiovascular death in long term follow up.[75],[76],[77],[78]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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