Cardiovascular disease, and particularly
coronary heart disease, is an emerging area of concern in the HIV population. Since the advent of efficient antiretroviral
therapies and the consequent longer patient life span, an increased risk for
myocardial infarction has been observed in HIV-infected patients compared with the general population in Western countries. The pathophysiology of this accelerated atherosclerotic process is complex and multifactorial. Traditional cardiovascular risk factors-overrepresented in the HIV population-associated with uncontrolled viral replication and exposure to antiretroviral drugs (per se or through
lipid and
glucose disturbances) could promote acute ischemic events. Thus, despite successful
antiviral therapy, numerous studies suggest a role of chronic
inflammation, together with immune activation, that could lead to vascular dysfunction and
atherothrombosis. It is time for physicians to prevent
coronary heart disease in this high-risk population through the use of tools employed in the general population. Moreover, the lower median age at which
acute coronary syndromes occur in HIV-infected patients should shift prevention to include patients <45 years of age. Available cardiovascular risk scores in the general population usually fail to screen young patients at risk for
myocardial infarction. Moreover, the novel vascular risk factors identified in HIV-related
atherosclerosis, such as chronic
inflammation, immune activation, and some
antiretroviral agents, are not taken into account in the available risk scores, leading to underestimation of cardiovascular risk in the HIV population. Cardiovascular prevention in HIV-infected patients is a challenge for both cardiologists and physicians involved in HIV care. We require new tools to assess this higher risk and studies to determine whether intensive primary prevention is warranted.