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High Rate of Coronary Artery Problems in Young People Tied to TDF/FTC
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17th Conference on Retroviruses and Opportunistic Infections, February 16-19, 2010, San Francisco
Mark Mascolini
Magnetic resonance imaging spotted coronary artery abnormalities in half of adolescents and young adults evaluated by Irene Mikhail and collaborators at the National Institute of Allergy and Infectious Diseases (NIAID) [1]. For the first time in an HIV-heart risk study, cumulative exposure to tenofovir/emtricitabine (TDF/FTC) raised the risk of coronary artery problems.
Research in the general population found that otherwise healthy 18- to 30-year-olds have a 9.3% incidence of coronary artery disease on CT scan [2]. To estimate coronary artery disease risk in a similarly aged group of people taking antiretrovirals, NIAID investigators and colleagues studied 31 youth and young adults infected with HIV in infancy or early childhood and monitored in a natural history cohort from November 2008 to February 2009. Their age averaged 18.9 years (+/- 4.1 standard deviation [SD]), their CD4 count 694 (+/- 398 SD), and their viral load 21,672 copies (+/- 87,511). These young people had already spent an average 15 years on antiretroviral therapy, including an average 1.5 years on TDF.
The NIAID team measured inflammatory markers and lipids, performed echocardiograms and electrocardiograms, and scrutinized coronary arteries by cardiac MRI with angiography. They defined a coronary artery abnormality as greater than mild irregularity of any coronary artery. Twenty-seven people had an MRI and the remaining 4 underwent the other tests. Of the 27 people with an MRI, 14 (52%) had evidence of coronary artery irregularity. Two study participants also had decreased ejection fraction.
People with coronary artery irregularities had taken TDF/FTC significantly longer than people without these aberrations (P = 0 01). Longer use of protease inhibitors or any antiretrovirals did not correlate with a higher risk of coronary artery problems. Youth and young adults with evidence of coronary artery irregularities tended to be smokers more than people without these problems, but this difference fell short of statistical significance (29% versus 8%, P = 0.17). Ominous low-density lipoprotein (LDL) cholesterol tended to be higher in people with coronary artery problems (91 versus 78 mg/dL, P = 0.24).
The NIAID team believes the high coronary artery abnormality rate in this population "suggests possible early atherosclerosis" in young people with HIV. They stress that modifiable risk factors--smoking and high LDL cholesterol--also tended to heighten the risk of coronary artery aberrations. The investigators caution, though, that all the associations they found rest on results in a small group analyzed in the absence of a control population. They hope to address these limitations by expanding the study group, enrolling a control group, and adding other tests to assess cardiovascular disease.
Reference
1. Mikhail I, Purdy J, Dimock D, et al. High rate of coronary artery abnormalities in adolescents and young adults infected with HIV early in life. 17th Conference on Retroviruses and Opportunistic Infections. February 16-19, 2010. San Francisco. Abstract 864.
2. Yan LL, Liu K, Daviglus ML, et al. Education, 15-year risk factor progression, and coronary artery calcium in young adulthood and early middle age: the Coronary Artery Risk Development in Young Adults study. JAMA. 2006;295:1793-1800.
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