LAUSR

We read with great interest the paper by van Zoest and coworkers focusing on cardiovascular prevention in HIV-positive individuals. As physicians, we have gone through the phase of thinking that cardiovascular prevention in HIVpositive individuals was barely imaginable. That was the period of uncontrolled HIV infection, when patients were presenting with HIV/AIDS and severe heart failure in the context of myocarditis, opportunistic infections, nutritional deficiencies and severe immunosuppression. At that time, approximately half of HIV-infected patients showing heart failure in the presence of a dilated and hypokinetic ventricle would not survive longer than a few months despite the very best care. Fortunately enough, the revolution caused by the introduction of antiretroviral therapy (ART) has produced a dramatic increase in life expectancy, even though not equally distributed in developing countries. There is no doubt that ART has indeed changed the whole scenario of cardiovascular disease in HIV-positive individuals, at the same time raising new challenges. The paper by van Zoest and coworkers reflects the change of this paradigm, contributing to expand the attention of cardiologists and HIV specialists (but more in general of the medical community), which should now be directed equally to the treatment of refractory symptomatic ventricular dysfunction as well as towards early prevention of cardiovascular events. It is known that HIV-positive individuals have a higher prevalence of traditional risk factors for atherosclerosis compared to the general population. However, the prevalence of traditional risk factors reported in previous studies varies significantly, being influenced by the varying geographical locations of the study participants as well as by differences in behavioural characteristics. Besides traditional risk factors, chronic inflammation and immune activation associated with HIV infection play a central role in accelerated atherosclerotic disease among HIV-infected persons. Several serum inflammation markers and ultrasonographic or computed tomography findings have thus been evaluated to define better the cardiovascular risk in this population, even though clinical and experimental data are not yet fully concordant. Moreover, although the combination ART usually reduces cardiovascular risk depending on the uncontrolled viral replication, a small but significant increase in cardiovascular disease risk has been associated with some specific antiretroviral drugs, including abacavir and some protease inhibitors (such as lopinavir/ritonavir and darunavir/ritonavir). In the study by van Zoest and coworkers, the authors analysed the prevalence of traditional cardiovascular risk factors in 528 HIV-positive individuals on combined ART and in 521 HIV-negative subjects recruited from the Amsterdam Cohort Studies on HIV/AIDS or attending the sexual health clinic of the Amsterdam Public Health Service. We believe the decision to enrol this specific group of HIV-negative individuals, although presenting the drawback of being non-representative of the general population, allowed the authors to enrol HIV-positive and HIV-negative study participants of a similar age, male gender prevalence and sexual behaviours. The study findings clearly showed that the prevalence of traditional risk factors was nevertheless higher in HIV-positive individuals. In line with these results, HIV-positive individuals were also characterised by a higher predicted cardiovascular risk at 10 years. These findings are not altogether surprising, because protease inhibitors themselves may