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
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
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
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
🔸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
↪️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
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)
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
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
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
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
🔹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
⁉️ 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
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
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
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
🔴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
↪️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
🔹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
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