Abstract
Understanding why persons with human immunodeficiency virus (HIV) have accelerated
atherosclerosis and its sequelae, including coronary artery disease (CAD) and myocardial
infarction, is necessary to provide appropriate care to a large and aging population
with HIV. In this review, we delineate the diverse pathophysiologies underlying HIV-associated
CAD and discuss how these are implicated in the clinical manifestations of CAD among
persons with HIV. Several factors contribute to HIV-associated CAD, with chronic inflammation
and immune activation likely representing the primary drivers. Increased monocyte
activation, inflammation, and hyperlipidemia present in chronic HIV infection also
mirror the pathophysiology of plaque rupture. Furthermore, mechanisms central to plaque
erosion, such as activation of toll-like receptor 2 and formation of neutrophil extracellular
traps, are also abundant in HIV. In addition to inflammation and immune activation
in general, persons with HIV have a higher prevalence than uninfected persons of traditional
cardiovascular risk factors, including dyslipidemia, hypertension, insulin resistance,
and tobacco use. Antiretroviral therapies, although clearly necessary for HIV treatment and
survival, have had varied effects on CAD, but newer generation regimens have reduced
cardiovascular toxicities. From a clinical standpoint, this mix of risk factors is
implicated in earlier CAD among persons with HIV than uninfected persons; whether
the distribution and underlying plaque content of CAD for persons with HIV differs
considerably from uninfected persons has not been definitively studied. Furthermore,
the role of cardiovascular risk estimators in HIV remains unclear, as does the role
of traditional and emerging therapies; no trials of CAD therapies powered to detect
clinical events have been completed among persons with HIV.
Résumé
Il est nécessaire de comprendre pourquoi les personnes infectées par le virus de l’immunodéficience
humaine (VIH) souffrent d’athérosclérose accélérée et de ses séquelles, y compris
la coronaropathie et l’infarctus du myocarde, afin d’être en mesure de dispenser des
soins appropriés à une population nombreuse et vieillissante de personnes vivant avec
le VIH. Dans cet article de synthèse, nous distinguons les diverses physiopathologies
sous-jacentes des coronaropathies associées au VIH et nous analysons leur rôle dans
les manifestations cliniques des coronaropathies chez les personnes vivant avec le
VIH. Plusieurs facteurs contribuent à la coronaropathie associée au VIH dont, probablement
au premier chef, l’inflammation chronique et l’activation du système immunitaire.
L’activation accrue des monocytes, l’inflammation et l’hyperlipidémie observées dans
l’infection à VIH chronique reflètent également la physiopathologie de la rupture
des plaques. De plus, les mécanismes jouant un rôle central dans l’érosion des plaques,
notamment l’activation du récepteur de type Toll-2 et la formation de pièges extracellulaires
des neutrophiles, sont très présents dans l’infection à VIH. En plus de l’inflammation
et de l’activation du système immunitaire en général, les personnes vivant avec le
VIH présentent une prévalence plus élevée de facteurs de risque cardiovasculaire que
les personnes non infectées, y compris la dyslipidémie, l’hypertension, l’insulinorésistance
et le tabagisme. Les thérapies antirétrovirales, malgré leur nécessité évidente pour
le traitement et la survie des personnes infectées par le VIH, ont eu différents effets
sur la coronaropathie, mais les schémas thérapeutiques plus récents présentent une
toxicité cardiovasculaire moindre. D’un point de vue clinique, ce mélange de facteurs
de risque joue un rôle dans la survenue plus précoce de la coronaropathie chez les
personnes infectées par le VIH que dans la population non infectée; il n’a pas encore
été déterminé si les caractéristiques de distribution et de contenu des plaques sous-jacentes
de la coronaropathie chez les personnes vivant avec le VIH diffèrent considérablement
de celles observées chez les personnes non infectées. De surcroît, le rôle des estimateurs
du risque cardiovasculaire dans l’infection par le VIH demeure imprécis, tout comme
celui des traitements classiques et des traitements émergents; aucun essai clinique
sur le traitement des coronaropathies ayant la puissance nécessaire pour déceler des
événements cliniques n’a été réalisé dans la population infectée par le VIH.
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Article info
Publication history
Published online: December 04, 2018
Accepted:
November 22,
2018
Received:
August 24,
2018
Footnotes
See page 277 for disclosure information.
Identification
Copyright
© 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
