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Cardiovascular Disease: Predicting Risk and Monitoring Outcomes Monica R. Shah, MD, FACC NHLBI AIDS Coordinator Conference on Retroviruses and Opportunistic Infections March 5, 2013. Overview. HIV-Related Cardiovascular Disease (CVD) - PowerPoint PPT Presentation
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Cardiovascular Disease: Predicting Risk and Monitoring Outcomes
Monica R. Shah, MD, FACCNHLBI AIDS Coordinator
Conference on Retroviruses and Opportunistic InfectionsMarch 5, 2013
HIV-Related Cardiovascular Disease (CVD)
NHLBI AIDS Working Group (WG) – Scientific Priorities
NHLBI AIDS Program – Future Initiatives
Overview
2
AIDS – An Evolving Population
AIDS Patients Face Downside of Living Longer January 2008
In the US ~1.2 million people living with HIV; 50,000 new infections each year
By 2015, HIV patients aged 50 and older will account for >50% of HIV/AIDS cases1
Chronic, non-infectious diseases such as CVD increasing public health problem
1 www.cdc.gov; Slide courtesy P. Hsue
HIV-related CVD – Significant Mortality
1,876 deaths among 39,727 patients Non-AIDS related deaths accounted for 50.5% ~16% were due to CVD
13 HIV Cohorts1996-2006
CVD15.7%
Non-AIDSinfection
16.3%
Non-AIDSMalignancy
23.5%
Violence, Substance
abuse 15.4%
Liver-related14.1%
Other
9.0%Respiratory
3.1%
Renal3%
Antiretroviral Therapy Cohort Collaboration. Clin Infect Dis. 2010;50:1387-1396Slide courtesy JS Currier
Risk of CVD in HIV vs. Non-HIV Patients
HIV – no ARTRR 1.61 (1.43-1.81)
p<0.001
HIV – on ARTRR 2.0 (1.7-2.37)
P<0.001
Islam, FM, et al. HIV Medicine; 2012; 13:453-68.
Complex interplay between Conventional risk factors
- Higher rates of smoking, dyslipidemia, hypertension, diabetes
- Obesity Renal disease Cardio-metabolic adverse effects of ART HIV infection Inflammation and Immune Activation
HIV-Related CV Disease
Inflammation and Immune Activation
Gut microbiome
Hypercoagulability Aging
HIV Infection
Hsue, P et al. The Journal of Infectious Disease. 2012; 13: S375-82.
Coronary artery disease
Arrhythmias and sudden cardiac death
Heart failure
Pulmonary hypertension
Hypertension/vascular disease
HIV-Related CV Disease
The NHLBI AIDS Program provides global leadership for research, training, and education
programs to promote the prevention and treatment of HIV-related cardiovascular, pulmonary, and hematologic disease.
The NHLBI AIDS Program believes that critical research in this area will result in discovery that enhances the survival and quality of life of patients with HIV, and may also lead
to knowledge that benefits all patients with heart, lung, and blood disease.
NHLBI AIDS Program – Mission
NHLBI AIDS WG: CV Scientific Priorities
EpidemiologyScientific Gaps Approaches to Gaps
Incidence/prevalence of HIV-related CVD
• Utilize existing HIV and CV cohorts to examine questions about HIV-related CVD
Interplay of HIV, inflammation, ART, co-infections, and traditional risk factors on development of HIV-related CVD
• Enrich HIV cohort studies with data on CV events/imaging and thrombotic events
• Enrich ongoing CVD studies with HIV patients
HIV/AIDS WG: CV Scientific Priorities
PathophysiologyScientific Gaps Approaches to Gaps
Mechanisms of the interplay of HIV, inflammation, ART, co-infections, and traditional risk factors
• Studies of these factors in the progression of atherosclerosis
• Studies of molecular pathways responsible for chronic inflammation
• Studies of microbial translocation, viral replication, and inflammation in altering lipid metabolism, endothelial function, immune senescence, and thrombosis
Synergy of pathophysiological mechanisms with smoking
• Mechanistic and imaging studies that elucidate pathogenesis of HIV-related CVD
NHLBI AIDS WG: CV Scientific Priorities
Prevention & Treatment
Scientific Gaps Approaches to GapsPotential differences in the prevention and treatment of CAD
• Add CV outcomes to HIV trials, increase enrollment of HIV patients in CV trials
Actual efficacy and effectiveness of evidence-based therapies in HIV patients
• Leverage existing CV databases, claims data, and EHR to evaluate CV patterns of care, variation in prevention, diagnosis, and treatment, post-event outcomes, and implementation of evidence-based care
Appropriate targets for therapy in HIV patients
• Collaborate with HIV trial networks early during protocol development
Novel therapies to address unique pathophysiology of CAD in HIV patients
• Conduct pilot trials of novel agents in HIV-related CVD
Multi-disciplinary collaboration Critical need for HIV and CV researchers to work
together to advance field Leverage existing research resources
Cross-institute collaboration Training
Training programs that allow clinical and basic investigators to learn fundamentals of HIV & CVD research
NHLBI AIDS WG: Research Strategies
Focus on scientific gaps identified by WG Broadly stimulate science Promote multi-disciplinary collaboration Encourage peer-review, investigator-initiated
research Educate scientific community that NHLBI is a
primary Institute for AIDS research
NHLBI Future Initiatives – Goal 2014
Conclusion
Increasing focus on HIV-related CVD
Progress in science
NHLBI uniquely poised to support research in this area