Regular ArticlePrognostic Indicators for Recurrent Thrombotic Events in HIV-infected Patients with Acute Coronary Syndromes: Use of Registry Data From 12 sites in Europe, South Africa and the United States
Introduction
Antiretroviral therapy (ART) dramatically increases life expectancy for patients with human immunodeficiency virus (HIV) [1], such that their long term outlook appears to be similar to that of general population in the highly active antiretroviral therapy (HAART) era [2]. The shift from an acute to a chronic condition leads subjects with HIV to exposition to the long-term detrimental effects of both disease progression and antiretroviral therapy [3], [4].
Heart disease represents one of the most important causes of morbidity and mortality for these patients [4], [5]. Before the introduction of HAART, clinically significant cardiomyopathy mainly related to myocarditis was already reported in up to 10% of patients [6], [7], [8], [9]. In the HAART era, increased and persistent arterial inflammation leading to aggressive atherosclerosis [10] was demonstrated, most likely related to a complex (and not yet thoroughly clarified) relationship between coronary HIV infection, immune-mediated response and adverse risk factor profile [11].
The high risk of cerebro- and cardiovascular events (CV) [12], [13] and especially acute coronary syndromes (ACS) represents the clinical consequence of these pathological processes. Most of the evidence on HIV and ACS, however, derives from small studies [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], not performed in the contemporary era, and with a subspecialty focus, thus limiting a comprehensive clinical evaluation of these patients.
We thus designed the Percutaneous coronary intervention and surgical revascularization in HIV Database (PHD) study whose aim was to investigate the outcome of HIV-positive patients treated as in contemporary practice.
Section snippets
Design, Patients and Treatments
The PHD study was a retrospective registry conducted at 12 sites in Europe and USA. All consecutive HIV-positive patients presenting with ACS between January 2001 and September 2012 were enrolled, irrespectively of their management by percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or medical therapy. International guidelines on ACS were used to diagnose and classify ACS [23], [24], distinguishing ST-elevation myocardial infarction (STEMI), non-ST-elevation
Results
10,050 patients with ACS were screened, and among them a total of 201 (2.0%) fulfilled the inclusion criteria (see Fig. 1). 179 (89%) were men, with median age of 53 (47-62) years (Table 1). Traditional CV risk factors were highly prevalent, with 98 patients (48%) reporting hypertension, and 36 patients (18%) diabetes mellitus. HAART was started 1.4 ± 1.0 years before the ACS current T CD4 + cell count was 651 ± 510 cells/mm3, with 17% of patients not being fully suppressed that is with a high viral
Discussion
To the best of our knowledge, this is the largest study with HIV-positive patients presenting with ACS in the contemporary era.
The main findings are: a) this population presents with a high prevalence of high-.risk clinical features and of subsequent thrombotic events; b) CD4 cell count < 200 cells/mm3 and not being treated with NRTI represents a powerful predictor of cardiac prognosis.
HIV patients are exposed to higher rates of recurrence of ischemic events, particularly if presenting with a
Disclosures
None.
Conflict of Interests
None.
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2022, Trends in Cardiovascular MedicineCitation Excerpt :These rates are higher than in HIV-uninfected individuals where numerous studies have demonstrated stent thrombosis to be <1% after one year (and 0.2–0.4% per year thereafter) with clinical in-stent restenosis of 5% [50]. The recurrent events are likely related to a combination of stent thrombosis, and accelerated in-stent and de novo atherosclerosis [23,30,42]. To emphasize recurrent events in individual HIV-positive patients it may be necessary that future studies compare MACE per patient-years versus HIV-negative patients, rather than adverse events per group.
Cardiovascular Events Recurrence and Coronary Artery Disease in HIV Patients: The Price We Have to Pay for the Chronicization of the Disease
2020, Canadian Journal of CardiologyCoronary Artery Disease Manifestations in HIV: What, How, and Why
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2018, International Journal of CardiologyCitation Excerpt :A significantly larger mean scar area and mean scar-per-vessel area, as well as a worse all-cause survival at 1-year follow-up was found in HIV-infected patients who experienced MI, after adjusting for traditional CV risk factors [59]. Furthermore, increased risk for cardiac death was observed in patients not taking nucleoside reverse transcriptase inhibitors (HR: 9.9; CI: 2.1–46), and of recurrent MI (if patients had CD4+ cell count <200/mm3) [60]. After invasive management of ACS, HIV-infected patients had longer in-hospital stay and high rates of in-stent restenosis at routine angiographic follow-up, compared to HIV-negative individuals.
A New Face of Cardiac Emergencies: Human Immunodeficiency Virus–Related Cardiac Disease
2018, Cardiology Clinics
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Both the authors gave the same contribute.