Effect of highly active antiretroviral therapy on ischemic cardiovascular disease in patients with HIV-1 infection.

a 10 (1.7) a Death due to cardiac involvement 17 (3.1) 6 (1.6) 4 (0.7) b NOTE. Data are no. (%) of patients. a when compared with the first period of observation (1989–1995) of the cohort group (by P ! .0001 Fisher's exact test). b when compared with the first period of observation (1989–1995) of the cohort group (by P p .0031 Fisher's exact test). Sir—In their recently published article, David et al. [1] raised important concerns about the risk factors for ischemic cardio-vascular disease (ICD). In particular, these investigators showed that ICD events are more common among patients with a lower CD4 lymphocyte count and among patients with more-prolonged exposure to nucleoside reverse-transcriptase inhibitors (NRTIs); they also showed that exposure to protease inhibitors (PIs) was not directly associated with a greater risk of development of ICD. However, the investigators did not rule out the possibility that longer duration of exposure to PIs might be related to increased risk for ICD. The role of PIs and, more generally , highly active antiretroviral therapy (HAART) in cardiac involvement is still controversial, even though several studies have indirectly shown that PIs can be implicated in the development of ICD because of several associated metabolic complications, including atherogenic dys-lipidemia [2, 3]. In a previous study of a cohort of 1042 patients with HIV-1 infection , we observed a marked and significant reduction in cardiac involvement (in particular , ischemia, dilated cardiomyopathy, and arrhythmia) while patients were receiving HAART (2 NRTIs and 1 PI; period of evaluation, 1996–1998), compared with cardiac involvement noted in HIV-1–in-fected patients who were receiving treatment with NRTIs only (period of evaluation , 1989–1995) [4]. We successively evaluated an additional cohort of 600 HIV-1–infected patients who had cardiac involvement and who were treated with HAART during 1999– 2001. Table 1 shows, for this cohort of patients, the incidence of ICD and the mortality rate associated with cardiac involvement (primarily with complications of dilated cardiomyopathy and cardiac ischemia). As shown in table 1, there was a progressive and significant decrease in the incidence of ICD among HIV-1–infected patients who were treated with HAART, especially during the last 3 years of our evaluation (1999–2001). In addition, we noted a significant reduction in the mortality rate associated with cardiac involvement in the groups of patients who were treated with HAART (in 1996–1998 and in 1999–2001). However, it should be noted that blood levels …