The Spectrum of Atherosclerotic Coronary Artery Disease in HIV Patients Abdul Hakeem & Sabha Bhatti & Mehmet Cilingiroglu Published online: 23 February 2010 # Springer Science+Business Media, LLC 2010 Abstract The incidence of HIV is on the rise. With the advent of antiretroviral therapy, the average life expectancy of HIV patients has increased by several decades, but the increasing life expectancy has shifted the spectrum of HIV- associated morbidity and mortality away from opportunistic infections and toward chronic medical conditions. In fact, coronary artery disease has become the leading cause of mortality in patients with HIV. The pathophysiology of atherosclerosis in patients with HIV is very complex, including direct endothelial damage from viremia, a height- ened overall state of inflammation from immune activation, higher prevalence and contribution from traditional athero- sclerotic risk factors, and direct effects from antiretroviral therapy itself. This review focuses on the patterns, predictors, and pathophysiology of atherosclerotic disease in patients with HIV. In addition, the risks and benefits of evidence-based highly active antiretroviral therapy are critically evaluated. Keywords HIV . Atherosclerosis . Coronary artery disease . Highly Active Anti Retroviral Theraphy (HAART) Introduction More than 1 million Americans are infected with HIV, which is the culprit organism for AIDS [1]. In 2007, there were 2.7 million new cases of HIV reported globally, and this number is expected to increase [1–3]. Before the advent of antiretroviral therapy (ART), the major cause of death was primarily infectious burden due to the profound immunodeficiency that accompanies this illness. Since the introduction of ART, life expectancy of HIV patients has increased by an average of more than 13 years [4]. It has long been recognized that HIV infection along with ART therapy contributes to altered lipoprotein metabolism. Over the past several years, premature atherosclerotic disease has increasingly been found in patients with HIV disease. The atherosclerotic burden in HIV patients cannot be explained purely on the basis of traditional risk factors. Numerous studies evaluating this association have been reported that have enhanced our understanding of the diverse pathobiol- ogy of atherosclerosis in HIV patients [1–5]. Additionally, randomized trials evaluating the long-term benefit of ART have demonstrated an increased risk of myocardial infarc- tion (MI) [2, 5]. The spectrum of cardiovascular disease in HIV is not only restricted to enhanced atherosclerosis but also includes HIV-related pulmonary hypertension, myocarditis leading to left ventricular dysfunction, complex cerebrovascu- lar disease, pericardial pathology, endocarditis, and cardiac tumors [2, 3]. This article reviews the patterns, predictors, and pathophysiology of atherosclerotic disease in patients with HIV. In addition, the risks and benefits of evidence-based highly active ART (HAART) are critically evaluated. An approach to the diagnosis and management of atherosclerosis in the context of clinical guidelines is also presented. Prevalence The mortality rate among patients with HIV infection has decreased markedly in the United States since the introduction of ART [2–4]. Data from the HIV Outpatient Study showed a dramatic reduction in morbidity and mortality among patients with CD4+ cell counts under 100 mm 3 [4]. Reductions in death were clearly linked to the increasing use of combination A. Hakeem (*) : S. Bhatti : M. Cilingiroglu Division of Cardiovascular Diseases, Department of Medicine, College of Medicine, University of Cincinnati, 1550 Madison Road # 7, Cincinnati, OH 45206, USA e-mail: ahakeem@gmail.com Curr Atheroscler Rep (2010) 12:119–124 DOI 10.1007/s11883-010-0089-4