Maggi Paolo, Di Biagio Antonio, Rusconi Stefano, Cicalini Stefania, D'Abbraccio Maurizio, d'Ettorre Gabriella, Martinelli Canio, Nunnari Giuseppe, Sighinolfi Laura, Spagnuolo Vincenzo, Squillace Nicola
Clinica Malattie Infettive Policlinico, Bari, Italy.
Clinica Malattie Infettive, Policlinico Ospedale S. Martino, Genoa, Italy.
BMC Infect Dis. 2017 Aug 9;17(1):551. doi: 10.1186/s12879-017-2626-z.
Aim of this review is to focus the attention on people living with HIV infection at risk of developing a cardiovascular event. What is or what would be the most suitable antiretroviral therapy? Which statin or fibrate to reduce the risk? How to influence behavior and lifestyles?
Prevention of cardiovascular disease (CVD) risk remains the first and essential step in a medical intervention on these patients. The lifestyle modification, including smoking cessation, increased physical activity, weight reduction, and the education on healthy dietary practices are the main instruments. Statins are the cornerstone for the treatment of hypercholesterolemia. They have been shown to slow the progression or promote regression of coronary plaque, and could also exert an anti-inflammatory and immunomodulatory effect. However the current guidelines for the use of these drugs in general population are dissimilar, with important differences between American and European ones. The debate between American and European guidelines is still open and, also considering the independent risk factor represented by HIV, specific guidelines are warranted. Ezetimibe reduces the intestinal absorption of cholesterol. It is effective alone or in combination with rosuvastatin. It does not modify plasmatic concentrations of antiretrovirals. A number of experimental new classes of drugs for the treatment of hypercholesterolemia are being studied. Fibrates represent the first choice for treatment of hypertriglyceridemia, however, the renal toxicity of fibrates and statins should be considered. Omega 3 fatty acids have a good safety profile, but their efficacy is limited. Another concern is the high dose needed. Other drugs are acipimox and tesamorelin. Current antiretroviral therapies are less toxic and more effective than regimens used in the early years. Lipodistrophy and dyslipidemia are the main causes of long-term toxicities. Not all antiretrovirals have similar toxicities. Protease Inhibitors may cause dyslipidemia and lipodystrophy, while integrase inhibitors have a minimal impact on lipids profile, and no evidence of lipodystrophy. There is still much to be written with the introduction of new drugs in clinical practice.
Cardiovascular risk among HIV infected patients, interventions on behavior and lifestyles, use of drugs to reduce the risk, and switch in antiretroviral therapy, remain nowadays major issues in the management of HIV-infected patients.
本综述的目的是关注有发生心血管事件风险的HIV感染者。什么是或什么会是最合适的抗逆转录病毒疗法？使用哪种他汀类药物或贝特类药物来降低风险？如何影响行为和生活方式？
预防心血管疾病（CVD）风险仍然是对这些患者进行医学干预的首要且关键步骤。生活方式的改变，包括戒烟、增加体育活动、减轻体重以及开展健康饮食习惯教育，是主要手段。他汀类药物是治疗高胆固醇血症的基石。它们已被证明可减缓冠状动脉斑块的进展或促使其消退，还可能发挥抗炎和免疫调节作用。然而，目前这些药物在普通人群中的使用指南并不相同，美国和欧洲的指南之间存在重要差异。美国和欧洲指南之间的争论仍未解决，而且考虑到HIV所代表的独立风险因素，制定具体指南很有必要。依折麦布可减少肠道对胆固醇的吸收。它单独使用或与瑞舒伐他汀联合使用均有效。它不会改变抗逆转录病毒药物的血浆浓度。正在研究一些用于治疗高胆固醇血症的新型实验性药物类别。贝特类药物是治疗高甘油三酯血症的首选药物，然而，应考虑贝特类药物和他汀类药物的肾毒性。ω-3脂肪酸具有良好的安全性，但它们的疗效有限。另一个问题是所需剂量较高。其他药物有阿西莫司和替莫瑞林。目前的抗逆转录病毒疗法比早年使用的方案毒性更低、效果更好。脂肪代谢障碍和血脂异常是长期毒性的主要原因。并非所有抗逆转录病毒药物都有相似的毒性。蛋白酶抑制剂可能导致血脂异常和脂肪代谢障碍，而整合酶抑制剂对血脂谱的影响最小，且没有脂肪代谢障碍的证据。随着新药引入临床实践，仍有许多内容有待书写。
HIV感染患者的心血管风险、对行为和生活方式的干预、使用药物降低风险以及抗逆转录病毒疗法的转换，如今仍是HIV感染患者管理中的主要问题。
