Cardiovascular disease is the leading cause of death in women, responsible for more deaths each year than all other causes combined.^1-3 As we know, the incidence of myocardial infarction in women increases dramatically after menopause, and overall mortality as a result of coronary heart disease (CHD) is higher in women than in men, an effect largely due to comorbidities that include increased age, smoking, dyslipidemia and obesity.^4,5

Multiple studies have reported an increase in cardiovascular disease associated with HIV therapy, particularly with use of protease inhibitors.^6,7 Fat redistribution syndromes are also associated with HIV therapy, and visceral or abdominal obesity in particular is associated with a metabolic syndrome that may significantly increase the risk of cardiovascular events. Women (and men) living with HIV may be more at risk for cardiovascular events than HIV-uninfected women due to increased risks for lipodystrophy and dyslipidemia, which may be associated with accelerated atherosclerosis as well as insulin resistance.⁷ Little is known, though, about the actual increased risk these women are facing.

Inflammation has a role in the pathogenesis of cardiovascular events; therefore, measuring markers of inflammation has been proposed as a method to improve the prediction of these risks.⁸

Sara Dolan and colleagues investigated the use of newer inflammatory markers in evaluating the cardiovascular risk of HIV-infected women compared with that of a comparable control group of healthy females. C-reactive protein (CRP), interleukin-6, adiponectin, lipid and glucose levels were measured. Although age and weight were similar in both groups, the HIV-infected women had more abdominal visceral fat and less extremity fat by both computed tomography and dual-energy X-ray absorptiometry scans, as well as a higher waist-to-hip ratio. They also had higher CRP (the Women's Health Study found that CRP is a strong independent risk factor for cardiovascular disease in women^8-10), higher triglycerides and serum glucose after a glucose challenge test, higher fasting insulin, and lower high-density lipoprotein cholesterol and adiponectin (low serum concentrations are associated with type II diabetes) when compared with the control group while controlling for smoking and use of hormone replacement therapy.

These findings clearly show increased risk factors for cardiovascular disease in HIV-infected women, and indicate that abnormal fat redistribution is quite significantly associated with increased cardiovascular risk indices. These results should encourage medical providers to monitor female patients more closely for cardiovascular risk factors, and to develop strategies to reduce their risks. This is essential when women are potentially living longer with HIV, and more women are living beyond menopause, when they typically face an even greater risk for cardiovascular events.

Footnotes

1. Eaker ED, Chesebro JH, Sacks FM, Wenger NK, Whisnant JP, Winston M. Cardiovascular disease in women. Circulation. October 1, 1993;88(4):1999-2009.

2. Higgins M, Thom T. Cardiovascular disease in women as a public health problem. In: Wenger NK, Speroff L, Packard B, eds. Cardiovascular Health and Disease in Women. Conn: Le Jacq Communications; 1993:15.

3. Mosca L, Manson JE, Sutherland SE, Langer RD, Manolio T, Barrett-Connor E. Cardiovascular disease in women: a statement for healthcare professionals from the American Heart Association. Circulation. October 7, 1997;96(7):2468-2482.

4. Roger VL, Jacobsen SJ, Pellikka PA, Miller TD, Bailey KR, Gersh BJ. Gender differences in the use of stress testing and coronary heart disease mortality: a population-based study in Olmsted County, Minnesota. J Am Coll Cardiology. August 1998;32(2):345-352.

5. Wang XL, Tam C, McCredie RM, Wilcken DE. Determinants of severity of coronary artery disease in Australian men and women. Circulation. May 1, 1994;89(5):1974-1981.

6. Krishnaswamy G, Chi DS, Kelley JL, et al. The cardiovascular and metabolic complications of HIV infection. Cardiology Review. September-October 2000;8(5):260-268.

7. Carr A, Samaras K, Burton S, et al. A syndrome of peripheral lipodystrophy, hyperlipidemia and insulin resistance in patients receiving HIV protease inhibitors. AIDS. May 7, 1998;12(7):F51-F58.

8. Ridker PM, Hennekens CH, Buring JE, Rifai N. C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med. March 23, 2000;342(12):836-843.

9. Rifai N, Buring JE, Lee I-M, Manson JE, Ridker PM. Is C-reactive protein specific for vascular disease in women? Ann Intern Med. April 2, 2002;136(7):529-533.

10. Ridker PM, Rifai N, Rose L, Buring JE, Cook NR. Comparison of C-reactive protein and low-density lipoprotein cholesterol levels in the prediction of first cardiovascular events. N Engl J Med. November 14, 2002;347(20):1557-1565.