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HIV-infected patients may be at increased risk for coronary events. The purpose of this study was to identify predictors of carotid intima-media thickness (IMT) in HIV patients at baseline and to measure IMT progression over 1 year.We measured blood lipids, inflammatory markers, and IMT in 148 HIV-infected adults (mean age, 45±8 years) and in 63 age- and sex-matched HIV-uninfected control subjects. The mean duration of HIV infection was 11 years, and the median duration of protease inhibitor treatment was 3.3 years. Mean baseline IMT was 0.91±0.33 mm in HIV patients and 0.74±0.17 mm in control subjects (P =0.0001). Multivariable predictors of baseline IMT in HIV patients were age (P <0.001), LDL cholesterol (P <0.001), cigarette pack-years (P =0.005), Latino race (P =0.062), and hypertension (P =0.074). When the control group was added to the analysis, HIV infection was an independent predictor of IMT (P =0.001). The rate of progression among the 121 HIV patients with a repeated IMT measurement at 1 year was 0.074±0.13 mm, compared with −0.006±0.05 mm in 27 control subjects (P =0.002). Age (P <0.001), Latino race (P =0.02), and nadir CD4 count ≤200 (P =0.082) were multivariable predictors of IMT progression.Carotid IMT is higher in HIV patients than in age-matched control subjects and progresses much more rapidly than previously reported rates in non-HIV cohorts. In HIV patients, carotid IMT is associated with classic coronary risk factors and with nadir CD4 count ≤200, suggesting that immunodeficiency and traditional coronary risk factors may contribute to atherosclerosis.