Current HIV/AIDS Reports

, Volume 8, Issue 2, pp 114–121

Noninvasive Assessment of HIV-related Coronary Artery Disease



Highly active antiretroviral therapy has led to significant declines in infection-related mortality in HIV-infected patients. Cardiovascular disease has emerged as a leading cause of morbidity and mortality in this population, and is likely related to both an increased prevalence of traditional cardiovascular risk factors and HIV-specific factors associated with antiretroviral therapy, chronic inflammation, and direct viral effects. Accurate clinical assessment of cardiovascular risk in HIV-infected patients is a critical challenge now facing practitioners. Multiple modes of noninvasive vascular imaging are available to enhance the ability to identify patients at high cardiovascular risk, and may ultimately assist in targeting use of intensive medical therapy to reduce cardiac events in this population. This review will examine several of these noninvasive tests and is intended to aid practitioners making cardiovascular risk assessments in HIV patients.


Human immunodeficiency virus (HIV) Atherosclerosis Coronary artery disease Cardiovascular risk stratification 


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Sackoff JE, Hanna DB, Pfeiffer MR, Torian LV. Causes of death among persons with AIDS in the era of highly active antiretroviral therapy: New York City. Ann Intern Med. 2006;145:397–406.PubMedGoogle Scholar
  2. 2.
    The Data Collection on Adverse Events of Anti-HIV Drugs Study Group. Combination antiretroviral therapy and the risk of myocardial infarction. N Engl J Med. 2003;349:1993–2003.CrossRefGoogle Scholar
  3. 3.
    Currier JS, Lundgren JD, Carr A. Epidemiological evidence for cardiovascular disease in HIV-infected patients and relationship to HAART. Circulation. 2008;118:e29–e35.PubMedCrossRefGoogle Scholar
  4. 4.
    Saves M, Chene G, Ducimetiere P. French WHO MONICA Project and the APROCO (ANRS EP11) Study Group. Risk factors for coronary hear disease in patients treated for HIV infection compared with the general population. Clin Infect Dis. 2003;37:292–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Kaplan RC, Kingsley LA, Sharrett AR. Ten-year predicted coronary heart disease risk in HIV-infected men and women. Clin Infect Dis. 2007;45:1074–81.PubMedCrossRefGoogle Scholar
  6. 6.
    Riddler SA, Samit E, Cole SR. Impact of HIV infection and HAART on serum lipids in med. JAMA. 2003;289:2978–82.PubMedCrossRefGoogle Scholar
  7. 7.
    Brown TT, Cole SR, Li X. Antiretroviral therapy and the prevalence and incidence of diabetes mellitus in the Multicenter AIDS Cohort Study. Arch Intern Med. 2005;165:1179.PubMedCrossRefGoogle Scholar
  8. 8.
    Hsue PY, Squires K, Bolger AF, Capili B, Mensah GA, Temesgen Z. Screening and assessment of coronary heart disease in HIV-infected patients. Circulation. 2008;118:e41–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Wilson PWF, D’Agostino RB, Levy D, Albert AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97:1837–43.PubMedGoogle Scholar
  10. 10.
    National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel, III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002, 106:3143.Google Scholar
  11. 11.
    • Rossi R, Nuzzo A, Guaraldi G, Orlando G, Squillace N, Ligabue G, et al. The role of the Framingham risk score to predict the presence of subclinical coronary atherosclerosis in patients with HIV infection. J Acquir Immune Defic Syndr. 2009;52:303–304. Demonstrates cardiovascular risk in young asymptomatic HIV patients with that of a high-risk population. PubMedCrossRefGoogle Scholar
  12. 12.
    Guimaraes MM, Greco DB, Garces AH, de Oliveria AR, Foscolo RB, Machado LJ. Coronary heart disease risk assessment in HIV-infected patients: a comparison of Framingham, PROCAM and SCORE risk assessment functions. Int J Clin Pract. 2010;64:664–6.CrossRefGoogle Scholar
  13. 13.
    Knobel H, Jerico C, Montero M, Sorli M, Velat M, Guelar A, et al. Global cardiovascular risk in patients with HIV infection: concordance and differences in estimates according to three risk equations (Framingham, SCORE and PROCAM). AIDS Patients Care STDs. 2007;21:452–7.CrossRefGoogle Scholar
  14. 14.
    Law MG. The use of the Framingham equation to predict myocardial infarctions in HIV-infected patients: comparison with observed events in the D:A:D Study. HIV Med. 2006;7:218.PubMedCrossRefGoogle Scholar
  15. 15.
    Hsue PY, Lo JC, Franklin A, Bolger AF, Martin JN, Deeks SG, et al. Progression of atherosclerosis as assessed by carotid intima-media thickness in patients with HIV infection. Circulation. 2004;109:1603–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Guaraldi G, Zona S, Alexopoulos N, Orlando G, Carli F, Ligabue G, et al. Coronary aging in HIV-infected patients. Clin Infect Dis. 2009;49:1756–62.PubMedCrossRefGoogle Scholar
  17. 17.
    The DAD Study Group. Class of antiretroviral drugs and the risk of myocardial infarction. N Engl J Med. 2007;356:1723–35.CrossRefGoogle Scholar
  18. 18.
    Kaplan RC, Kingsley LA, Gange SJ, Benning L, Jacobson LP, Lazar J, et al. Low CD4+ T-cell count as a major atherosclerosis risk factor in HIV-infected woman and men. AIDS. 2008;22:1615–24.PubMedCrossRefGoogle Scholar
  19. 19.
    Lichtenstein KA, Armon C, Buchacz JS, Buckner K, Tedaldi EM, Wood K, et al. Low CD4+ T cell count is a risk factor for cardiovascular disease events in the HIV outpatient study. Clin Infect Dis. 2010;51:435–47.PubMedCrossRefGoogle Scholar
  20. 20.
    Hansson GK. Atherosclerosis—an immune disease. Atherosclerosis. 2009;202:2–10.PubMedCrossRefGoogle Scholar
  21. 21.
    Kuller LH, Tracy R, Belloso W, De Wit S, Drummond F, Lane HC, et al. Inflammatory and coagulation biomarkers and mortality in patients with HIV infection. PLoS Med. 2008;5:1496–508.CrossRefGoogle Scholar
  22. 22.
    Chan W, Sviridov D, Dart AM. HIV, atherosclerosis and inflammation: implications for treatment. J HIV Ther. 2009;14:61–8.PubMedGoogle Scholar
  23. 23.
    May M, Sterne JC, Shipley M, Brunner E, D’Agostino R, Whincup P, et al. A coronary heart disease risk model for predicting the effect of potent antiretroviral therapy in HIV-1 infected men. Int J Epidemiol. 2007;36:1309–18.PubMedCrossRefGoogle Scholar
  24. 24.
    •• Friis-Moller N, Thiebaut R, Reiss P, Weber R, Monforte AS, De Wit S, et al. Predicting the risk of cardiovascular disease in HIV-infected patients: the data collection on the adverse effects of anti-HIV drugs study. Eur J Cardiovasc Prev Rehabil. 2010;5:491–501. Study using DAD study data to develop a more accurate clinical prediction score specifically for HIV-positive patients on ART. Google Scholar
  25. 25.
    Micheletti RG, Fishbein GA, Fishbein MC, Singer EJ, Weiss RE, Jeffries RA, et al. Coronary atherosclerotic lesions in human immunodeficiency virus-infected patients: a histopathology study. Cardiovasc Pathol. 2009;18:28–36.PubMedCrossRefGoogle Scholar
  26. 26.
    Rumberger JA, Simons DB, Fitzpatrick LA. Coronary artery calcium area by electron beam computed tomography and coronary atherosclerotic plaque area: a histopathologic correlative study. Circulation. 1995;95:2157–62.Google Scholar
  27. 27.
    Arad Y, Goodman KJ, Roth M, Newstein D, Guerci AD. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events. J Am Coll Cardiol. 2005;46:158–65.PubMedCrossRefGoogle Scholar
  28. 28.
    Greenland P, Bonow RO, Brundage BH. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography). J Am Coll Cardiol. 2007;49:378–402.PubMedCrossRefGoogle Scholar
  29. 29.
    Acevedo M, Sprecher DL, Calabrese L, Pearce GL, Coyner DL, Halliburton SS, et al. Pilot study of coronary atherosclerotic risk and plaque burden in HIV patients: a call for cardiovascular prevention. Atherosclerosis. 2002;162:349–54.CrossRefGoogle Scholar
  30. 30.
    Mangili A, Gerrior J, Tang AM, O’Leary DH, Polak JF, Schaefer EJ, et al. Risk of cardiovascular disease in a cohort of HIV-infected adults: a study using carotid intima-media thickness and coronary artery calcium score. Clin Infect Dis. 2006;43:1482–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Mangili A, Jacobson DL, Gerrior J, Polak JF, Gorbach SL, Wanke CA. Metabolic syndrome and subclinical atherosclerosis in patients infected with HIV. Clin Infect Dis. 2007;44:1368–74.PubMedCrossRefGoogle Scholar
  32. 32.
    Meng Q, Lima JAC, Lai H, Vlahov D, Celentano DD, Strathdee SA, et al. Coronary artery calcification, atherogenic lipid changes, and increased erythrocyte colume in black injection drug users infected with human immunodeficiency virus-1 treated with protease inhibitors. Am Heart J. 2002;144:642–8.PubMedGoogle Scholar
  33. 33.
    Fitch KV, Lo J, Abbara S, Ghoshhajra B, Shturman L, Soni A, et al. Increased coronary artery calcium score and noncalcified plaque among HIV-infected men: relationship to metabolic syndrome and cardiac risk parameters. J Acquir Immune Defic Syndr. 2010;55:495–9.PubMedCrossRefGoogle Scholar
  34. 34.
    •• Lo J, Abbara S, Shturman L, Soni A, Wei J, Rocha-Filho JA, et al. Increased prevalence of subclinical coronary atherosclerosis detected by coronary computed tomography angiography in HIV-infected men. AIDS. 2010;24:243–53. Important study using coronary CTA to demonstrate the prevalence of noncalcified coronary plaques in asymptomatic HIV patients. PubMedCrossRefGoogle Scholar
  35. 35.
    Chambless LE. Association of coronary heart disease incidence with carotid arterial wall thickness and major risk factors: the atherosclerosis risk in communities (ARIC) Study, 1987–1993. Am J Epidemiol. 1997;146:483–94.PubMedGoogle Scholar
  36. 36.
    Bots M. Common carotid intima-media thickness and risk of stroke and myocardial infarction: the Rotterdam Study. Circulation. 1997;96:1432–7.PubMedGoogle Scholar
  37. 37.
    O’Leary DH. For the Cardiovascular Health Study Collaborative Research Group. Carotid-artery intima media thickness as a risk factor for myocardial infarction and stoke in older adults. N Engl J Med. 1999;340:14–22.PubMedCrossRefGoogle Scholar
  38. 38.
    Stein JH, Korcarz CE, Hurst RT, Lonn E, Kendall CB, Mohler ER, et al. Use of carotid ultrasouns to identify subclinical vascular disease and evaluate cardiovascular disease risk: a consensus statement from the American Society of Echocardiography Carotid Intima-Media Thickness Task Force. J Am Soc Echocardiogr. 2008;21:93–111.PubMedCrossRefGoogle Scholar
  39. 39.
    Maggi P. Premature leasions of the carotid vessels in HIV-1-infected patients treated with protease inhibitors. AIDS. 2000;14:123–8.CrossRefGoogle Scholar
  40. 40.
    Depairon M. Premature atheroscelosis in HIV_infected individuals—focus on protease inhibitor therapy. AIDS. 2001;15:329–34.PubMedCrossRefGoogle Scholar
  41. 41.
    Mercie P. Evaluation of cardiovascular risk factors in HIV-1 infected patients using carotid intima-media thickness measurement. Ann Med. 2002;34:55–63.PubMedCrossRefGoogle Scholar
  42. 42.
    Seminari E. Assessment of atherosclerosis using carotid ultrasonography in a cohort of HIV-positive patients treated with protease inhibitors. Atherosclerosis. 2002;162:433–8.PubMedCrossRefGoogle Scholar
  43. 43.
    Maggi P. Colour-Doppler ultrasonography of carotid vessels in patients treated with antiretroviral therapy: a comparative study. AIDS. 2004;18:1023–8.PubMedCrossRefGoogle Scholar
  44. 44.
    Hulten E, Mitchell J, Scally J, Gibbs B, Villines TC. HIV positivity, protease inhibitor exposure and sublinical atherosclerosis: a systematic review and meta-analysis of observational studies. Heart. 2009;95:1826–35.PubMedCrossRefGoogle Scholar
  45. 45.
    Neunteufl T, Heher S, Katenschlager R. Late prognostic value of flow-mediated dilation in the brachial artery of patients with chest pain. Am J Cardiol. 2000;86:207–10.PubMedCrossRefGoogle Scholar
  46. 46.
    Gokce N, Keaney JF, Hunter LM, Watkings MT, Nedeljkovic ZS, Menzoian JO, et al. Predictive value of noninvasively determined endothelial dysfunction for long-term cardiovascular events in patients with peripheral vascular disease. J Am Coll Cardiol. 2003;41:1769–75.PubMedCrossRefGoogle Scholar
  47. 47.
    Juonala M, Viikari JSA, Laiteinen T, Marniemi J, Helenius H, Ronnemaa T, et al. Interrelations between brachial endothelial function and carotid intima-media thickness in young adults. Circulation. 2004;110:2918–23.PubMedCrossRefGoogle Scholar
  48. 48.
    Solanges A, Vita JA, Thornton DJ, Murray J, Heeren T, Craven DE, et al. Endothelial function in HIV-infected patients. Clin Infect Dis. 2006;42:1325–32.CrossRefGoogle Scholar
  49. 49.
    Mondy KE, de la Fuentes L, Waggoner A, Onen NF, Bopp CS, Lass-Claxton S, et al. Insultin resistance predicts endothelial dysfunction and cardiovascular risk in HIV-infected persons on long-term highly active antiretroviral therapy. AIDS. 2008;22:849–56.PubMedCrossRefGoogle Scholar
  50. 50.
    • Ross AC, Rizk N, O’Riordan MA, Dogra V, El-Bejjani D, Storer N, et al. Relationship between inflammatory markers, endothelial activation markers, and carotid intima-media thickness in HIV-infected patients receiving antiretroviral therapy. Clin Infect Dis. 2009;49:1119–27. Further exploration of the connection between inflammation, vascular health, and atherosclerosis.PubMedCrossRefGoogle Scholar
  51. 51.
    Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation. 2002;106:1883–92.PubMedCrossRefGoogle Scholar
  52. 52.
    Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, et al. ACC/AHA 2002 guideline update for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). 2002. American College of Cardiology Web site. Available at:
  53. 53.
    Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol. 2009;53:2201.PubMedCrossRefGoogle Scholar
  54. 54.
    • Lytwin M, Fallah-Rad N, Walker J, Bohonis S, Hussain F, Barac I, et al. The utility of dobutamine stress echocardiography for the diagnosis of coronary artery disease in the HIV population. Echocardiography. 2010;27: 1228–1232. One of the only studies of stress testing performed in a specifically HIV-positive cohort. CrossRefGoogle Scholar
  55. 55.
    Gibbons LW, Mitchell TL, Wei M, Blair SN, Cooper KH. Maximal exercise test as a predictor of risk for mortality from coronary heart disease in asymptomatic men. Am J Cardiol. 2000;86:53–8.PubMedCrossRefGoogle Scholar
  56. 56.
    Shaw LJ, Iskandrian AE. Prognostic value of gated myocardial perfusion SPECT. J Nucl Cardiol. 2004;11:171–85.PubMedCrossRefGoogle Scholar
  57. 57.
    The Strategies for Management of Antiretroviral Therapy (SMART) Study Group. CD4+ count-guided interruption of antiretroviral treatment. N Engl J Med. 2006;355:2283–96.CrossRefGoogle Scholar
  58. 58.
    US Preventative Services Task Force. Screening for abdominal aortic aneurysm: recommendation statement. Ann Intern Med. 2005;142:198–202.Google Scholar
  59. 59.
    Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2010;56:2182–99.CrossRefGoogle Scholar
  60. 60.
    U.S. Preventive Services Task Force. Screening for coronary heart disease: recommendation statement. Ann Intern Med. 2004;140:569–72.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.NYU Langone Medical CenterNew YorkUSA

Personalised recommendations