Coronary artery disease and HIV; getting to the HAART of the matter

Abstract

Premature coronary disease is an important emerging paradigm affecting contemporary HIV patients. Through immune reconstruction HIV causes multisystem pathology. Recent advances in the treatment of AIDS, mainly highly active retroviral therapy (HAART), have transformed this previously terminal illness to a chronic disease. However, an interplay between traditional risk factors in a high risk predominantly male population together with the effect of the long term use of HAART in inducing a metabolic syndrome is leading to a premature and aggressive coronary artery disease phenotype not previously recognised. An association between HAART and increased cardiovascular events appears to exist. However, currently this risk appears to be low, and HAART is vital to maintain adequate viral suppression and disease control. HAART- and viral-associated dyslipidaemia can pose a significant challenge to the clinician as drug interactions may precipitate drug toxicity. In our institution a varied phenotypic pattern of coronary disease is seen angiographically from severe atherosclerotic calcific disease through to aneurysm formation and thrombotic occlusion. This is illustrated by case studies. There is a need for aggressive primary and secondary prevention strategies in this important sub-group of patients with a multi-disciplinary approach required in the management including cardiologists, metabolic physicians and lipidologists.

Keywords: Atherosclerosis; HAART; HIV; Premature coronary artery disease; Protease inhibitors.