Thread by @Gurleen_Kaur96

1/ Day 3 & last session of #ASPC2021 on special populations

Talk on MI & HF among people with HIV by Dr. Markella Zanni

Follow this🧵on:
🔹MI risk in people w/ HIV
🔹HF in PWH
🔹CVD preventive approaches tailored to people w/ HIV

@ASPCardio @CardioNerds

2/ Patients with HIV are now living longer ➡️increased risk of CVD

Global burden of atherosclerotic CVD in people living with HIV has tripled over past 2 decades

Relative risk of MI is 1.5-2 in high-income countries

pubmed.ncbi.nlm.nih.gov/23459863/

#ASPC2021

3/ From US Partners database study – adjusted relative risk for MI was around 3 for women & 1.5 for men – regionally specific

Type 1 vs. type 2 MI: both ~50%
Women – more type 2 MI

pubmed.ncbi.nlm.nih.gov/17456578/

#ASPC2021

4/ 🔥Mechanisms🔥
🔸Social & environmental
-ART cohort collaboration study – 6 fold 📈 in events w/ cigarette smoking
🔸Immune dysfunction
🔸Metabolic
🔸Specific effects from ART regimen
-Traditional risk factors (HTN, HLD, BMI, renal dysfunction) also affected by ART

#ASPC2021

5/ US veterans aging cohort study – 50%⬆️MI risk even after adjusting for sex & risk factors

↪️immune dysfunction and activation

HIV promotes inflammation – augmented by social & metabolic risk factors

ART📉inflammatory markers, but still⬆️than pts w/o HIV

#ASPC2021

6/ 📈arterial inflammation in ART treated people w/ HIV (PWH) vs. no HIV #ASPC2021
jamanetwork.com/journals/jama/…

In MACS cohort, increased prevalence of subclinical coronary atherosclerosis on CCTA
ncbi.nlm.nih.gov/pmc/articles/P…

High risk plaque morphology & systemic arterial inflammation

7/ #ASPC2021

In women w/ HIV, studies have shown:
🟤⬆️burden of traditional metabolic risk factors but are less likely to be given prescriptions
🟤Stronger interferon alpha response
🟤⬆️systemic biomarkers
🟤Advanced reproductive aging – low anti-mullerian hormone (AMH)

8/ pubmed.ncbi.nlm.nih.gov/25339186/

ART-treated women w/ HIV ➡️select markers of immune activation 📈across reproductive aging spectrum

‼️ But don't have ⬆️ prevalence of coronary plaque ‼️

Possibly due to systemic inflammation, more microvascular dysfunction & type 2 MI

#ASPC2021

9/ Now onto heart failure...#ASPC2021

RR for HF in women w/ HIV is 3.7 & for men is 2

US Veterans Aging cohort study➡️increased risk of HF in men w/ HIV vs no HIV
pubmed.ncbi.nlm.nih.gov/28384660/

US Partners healthcare database – women➡️more HFpEF

10/ Diastolic dysfunction rate is 30% in people living w/ HIV vs. 12% in general population

Metabolic dysregulation and inflammation lead to diastolic dysfunction

#ASPC2021

11/ HIV treated w/ ART:⬆️intramyocardial triglyceride content #ASPC2021

🔹Inverse relationship w/ steatosis & diastolic dysfunction
🔹IMTG 📈across reproductive aging continuum
🔹Circulating monocytes ⬆️CCR2 receptor in HIV women – expression related to myocardial fibrosis

12/ Preventive Approaches Tailored to PWH

⁉️ ART ⁉️

🔑D:A:D study: association between ART & CVD
🔑SMART study: continuous ART better than intermittent ART
🔑START study: intermediate ART decreases events & mortality

#ASPC2021

13/ But, even ART started early may not sufficiently reduce arterial inflammation

Newly diagnosed PWH - ART suppressed viremia but no reduction in arterial inflammation (via FDG-Pet/CT)
jamanetwork.com/journals/jamac…

#ASPC2021

14/ Address social, behavioral, & environmental factors
Ex: D:A:D study showed significant📉in CHD w/ smoking cessation

Also, medication-based modification of traditional risk factors

But...traditional CVD risk assessment algorithms not validated in people w/ HIV

#ASPC2021

15/ Possible Immune modulatory strategies

But need to be careful & ideally for ART treated HIV would want to decrease atherogenic immune activation without decreasing body’s immune defenses

#ASPC2021

16/ Statins in HIV
🔴Effectively⬇️LDL
🔴⬇️ immune activation markers
🔴⬇️coronary atherosclerotic plaque

BUT low prescribing patterns in this population

Had the opportunity to work on this review on cholesterol-lowering therapy in pts w/ HIV:
pubmed.ncbi.nlm.nih.gov/32979175/

#ASPC2021

17/ REPRIEVE trial hypothesis #ASPC2021
↪️Statin therapy will prevent ASCVD MACE in pts w/ HIV on ART

🔸7,000 pts w/ HIV & no CVD
🔸Pitavastatin,🚫interact w/ ART
🔸Explore sex specific mechanisms

Historically women have been underrepresented in HIV research & CVD prevention

18/ Summary #ASPC2021

🔹People w/ HIV living longer:⬆️risk of MI & HF
🔹Social/behavioral & environmental factors, traditional metabolic + persistent systemic immune activation
🔹Need to tailor preventive approaches
🔹Awaiting results of REPREIVE trial
reprievetrial.org