Letters to the Editor
To the Editor:
There is an increasing awareness that cardiovascular disease (CVD) is augmented in HIV-infected patients.1 Lower-extremity peripheral arterial disease (PAD) is a powerful indicator of systemic atherosclerosis and a strong predictor of death from cardiovascular causes,2 equivalent to that of patients with coronary or cerebrovascular disease. However, to date, no studies have evaluated PAD in HIV-infected patients. To estimate the prevalence of PAD, we measured the ankle-brachial index (ABI) in a population of HIV-infected patients with 2 or more cardiovascular risk factors.
A prospective cross-sectional study was performed at the HIV clinic of the University Hospital of Elche, Spain. HIV-infected patients with 2 or more traditional cardiovascular risk factors3 cared for in the clinic from January 2006 to January 2007 were invited to enroll in the study. The investigation was approved by the Ethics Committee for Clinical Research. Ninety-one (81.2%) of 112 patients with 2 or more traditional cardiovascular risk factors gave their informed consent to participate. Clinical and laboratory data were obtained at the visit. To calculate the ABI, systolic arterial pressure (SAP) in both arms and legs (posterior tibial and dorsalis pedis arteries) was taken with the blood pressure cuff and a Doppler probe (Smartdop 30; Hayashi Denki, Kawasaki, Japan) in supine. The highest readings were used to calculate the ABI of each leg, and the lowest ABI values were used to assess PAD. To define PAD, a cutpoint of <0.9 in either leg was used.4
Demographic and clinical characteristics of the patients are shown in Table 1. Thirty-three (36.3%) patients had 3 cardiovascular risk factors, and 26 (28.6%) had 4 or more. Low (<0.9) ABI was present in 4 (4.39%; 95% confidence interval [CI]: 1.41 to 11.49) patients. Patients with low ABI were males older than 45 years (median: 55.1; range: 48 to 73). Three patients were on antiretroviral therapy, 2 with protease inhibitor (PI)-based regimens and 1 with nonnucleoside reverse transcriptase inhibitors (NNRTIs), and all had previous exposure to PIs. Lipodystrophy was present in 3 patients and lipoatrophy in 2. Three patients had 3 or more cardiovascular risk factors, mainly dyslipidemia, smoking, hypertension, and family history of early coronary heart disease. Framingham score was moderate (10% to 20%) in 2 patients and high (>20%) in 1 patient. Two of the patients developed a heart attack a few months after this cross-sectional study was carried out.
This is the first study evaluating asymptomatic PAD in HIV-infected patients. We used the ABI, a validated, simple, and inexpensive diagnostic test, which is currently considered the method of choice to identify lower-extremity PAD.2 Our results show a low prevalence of peripheral artery damage in a cohort of HIV-infected patients with several cardiovascular risk factors. In the general population, the prevalence of PAD ranges from 5% to 30%, mainly depending on the age of the patients and the presence of cardiovascular risk factors,5,6 but most of the studies evaluated patients older than those included in the current investigation. A higher prevalence of PAD in HIV-infected patients is expected as patients get older.
Despite the low prevalence found in the study, assessing PAD might be useful as an adjunct to estimate overall cardiovascular risk in HIV-infected patients with several risk factors. In addition to being a marker of systemic atherosclerosis, PAD is associated with a high frequency of fatal and nonfatal cardiovascular disease events.2 Awareness of PAD elevates asymptomatic patients to a higher risk category and justifies intense therapeutic intervention in primary prevention, equivalent to that of secondary prevention.
Enrique Bernal, MD*
Mar Masiá, MD*
Sergio Padilla, MD*
Ildefonso Hernández, MD†
Félix Gutiérrez, MD*
*Infectious Diseases Unit Hospital General Universitario de Elche Universidad Miguel Hernández Elche, Spain
†Public Health Department Universidad Miguel Hernández Elche, Spain
1. Friis-Moller N, Sabin CA, Weber R, et al. Combination antiretroviral therapy and the risk of myocardial infarction. N Engl J Med
2. Doobay AV, Anand SS. Sensitivity and specificity of the ankle-brachial index to predict future cardiovascular outcomes: a systematic review. Arterioscler Thromb Vasc Biol
3. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The 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). JAMA
4. Hiatt WR. Medical treatment of peripheral arterial disease and claudication. N Engl J Med
5. Meijer WT, Hoes AW, Rutgers D, et al. Peripheral arterial disease in the elderly: The Rotterdam Study. Arterioscler Thromb Vasc Biol
6. Belch JJ, Topol EJ, Agnelli G, et al. Critical issues in peripheral arterial disease detection and management: a call to action. Arch Intern Med