Men with HIV may be at greater risk of heart attack

HIV-infected men on antiretroviral drugs tend to develop more and larger plaque in their arteries that may put them at higher risk for heart attacks.

HIV and the aging population

When HIV was first recognized as a disease, most patients didn’t survive for a long time post-diagnosis. With the introduction of a battery of antiretroviral medications, survival has been greatly increased. It’s not rare to find patients who have survived 20+ years and are now entering their 50s and 60s or older. Some of these patients will die from diseases other than HIV, diseases that also affect the rest of us like cardiovascular disease, cancer and a number of others.

Initially, when HIV/AIDS was raging, clinicians and patients didn’t think about long-term treatment of the patient. Often there was no long-term, it was just a matter of trying to prolong survival for a few months or a year. Now, with more survivors, researchers are looking at problems that occur in those who are aging with HIV.

As with the non-HIV population, death from cardiovascular disease is common. A study published in the Annals of Internal Medicine shows that HIV patients undergoing treatment have a higher risk of dying from cardiovascular diseases than controls who don’t have HIV. 

The researchers studied about 600 men with HIV who were on antiretroviral therapy. They also enrolled about 400 men as controls in the study. The controls were HIV negative and not on antiretroviral medications. None of these men had overt signs of cardiovascular disease. That is, they didn’t have any symptoms that would make clinicians suspect that they had cardiovascular disease.

Atherosclerosis (courtesy of Nephron)

Atherosclerosis (courtesy of Nephron)

The scientists wanted to look at plaque build up in these men. Plaque is a deposit of fats and other components that can lodge in arteries, gradually making them more narrow and, consequently, decreasing blood flow through them to the tissues that they’d normally supply. This build up of plaque is called atherosclerosis. The plaque can be of different consistencies. It is often classified as either soft plaque (non-calcified), hard plaque (calcified) or intermediate plaque. Soft plaque seems to be more prone to lead to a heart attack.

More, and larger, soft plaque in HIV positive patients

The researchers found that about 10% more patients who had HIV had significant amounts of coronary atherosclerosis than those men who didn’t have HIV.

Even when they considered other risk factors that can lead to cardiovascular disease (like smoking, diabetes, high blood pressure and others), it turned out that the number of men with soft plaques was higher in the HIV group. And their plaques tended to be larger in size.

The researchers also noted that those HIV-infected men who did have significant amounts of plaque had two things in common:

1. They tended to have lower CD4+ cell counts. As the CD4+ count decreased, the risk of atherosclerosis increased. (Also, the risk of a heart attack increased depending on how long the men were on the antiretroviral medications.); and

2. Those who were on antiretrovirals for a long time had an increased risk of having an occlusion of a coronary artery.

Additional research could show whether or not this soft plaque could turn to hard plaque, whether or not the amount of soft plaque increases or decreases, effect of treatment on the amount of plaque, etc.

What this research demonstrates

What this research demonstrates is that men with HIV tend to have a greater risk to develop soft plaques in their coronary arteries. And these plaques tend to be larger. This could lead to increased risk of a heart attack. The risk may increase the longer a patient has been on HIV medications. And may increase in proportion to the decrease in CD4+ cells.

So HIV positive men should be aware that they have an increased risk of plaque formation versus men who do not have HIV. They need to discuss this with their doctors to get guidance as to appropriate studies that may need to be done (e.g blood tests, imaging studies, etc.) and, possibly start on a risk reduction program that might include weight loss, changes in diet, regular exercise, medications and other strategies to help reduce their risk for a cardiovascular event.

Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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