HIV and coronary disease – When secondary prevention is insufficient

Abstract

Highly active antiretroviral therapy (HAART) has created a new paradigm for human immunodeficiency virus (HIV)-infected patients, but their increased risk for coronary disease is well documented.We present the case of a 57-year-old man, co-infected with HIV-2 and hepatitis B virus, adequately controlled and with insulin-treated type 2 diabetes and dyslipidemia, who was admitted with non-ST elevation acute myocardial infarction. Coronary angiography performed on day four of hospital stay documented two-vessel disease (mid segment of the right coronary artery [RCA, 90% stenosis] and the first marginal). Tw o drug-eluting stents were successfully implanted. The patient was discharged under dual antiplatelet therapy (aspirin 100 mg/day and clopidogrel 75 mg/day) and standard coronary artery disease medication. He was admitted to the emergency room four hours after discharge with chest pain radiating to the left arm and inferior ST-segment elevation myocardial infarction was diagnosed. Coronary angiography was performed within one hour and documented thrombosis of both stents. Optical coherence tomography revealed good apposition of the stent in the RCA, with intrastent thrombus. Angioplasty was performed, with a good outcome.The acute stent thrombosis might be explained by the thrombotic potential of HIV infection and diabetes. There are no specific guidelines regarding HAART in secondary prevention of acute coronary syndromes. A multidisciplinary approach is essential for optimal management of these patients. © 2017 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. All rights reserved. Document downloaded from http://www.elsevier.es, day 24/08/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. Document downloaded from http://www.elsevier.es, day 24/08/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. 569.e2A.S. Carvalho et al. PALAVRAS-CHAVEVírus da imunodeficiência humana; Trombose de stent; Doença coronária VIH e doença coronária ---quando a prevenção secundária é insuficienteResumo A terapêutica antiretroviral (TARV) alterou o paradigma da infeção pelo vírus da imunodeficiência humana (VIH), conhecendo-se o risco aumentado de doença coronária nestes doentes.Apresenta-se o caso de um homem de 57 anos, melanodérmico, com coinfecção VIH-2/vírus hepatite B, com controlo adequado; diabetes mellitus tipo 2, insulino-tratado e dislipidemia. Internado por enfarte agudo do miocárdio, sem supradesnivelamento ST. Realizou cateterismo ao 4.• dia de internamento, documentando-se doença de dois vasos (segmento médio da coronária direita [CD] [90% estenose] e 1. a obtusa marginal [OM1] com estenose de 95%). Colocaram-se dois stents revestidos, sem intercorrências. Teve alta sob dupla antiagregação (ácido acetilsalicílico 100 mg/dia e clopidogrel 75 mg/dia) e restante terapêutica dirigida à doença coronária. Recorreu ao serviço de urgência quatro horas após a alt...

Coronary revascularization for acute myocardial infarction in the HIV population

“…Conversely, PCI with placement of a stent was associated with reduced mortality, particularly with the use of a DES. Higher incidences of stent thrombosis haven been described in patients with HIV, particularly when CD4 cell count is low (<200 cells/mm 3 ) . In‐stent restenosis and target vessel revascularization appear to be more frequent following PCI with a BMS in HIV‐infected individuals, suggesting potential benefits with the use of DES .…”

Recurrent coronary disease in HIV‐infected patients: role of drug–drug interactions

“…Similarly, Carvalho et al . recently described an early stent thrombosis in a patient treated with both clopidogrel and ritonavir . In our opinion, this drug–drug interaction could also have played a role in these cases and it may also explain the association between exposure to protease inhibitors and increased platelet reactivity which was described by Hauguel‐Moreau et al .…”