UNUSUAL CASES - <br />
Stent Implantation for Acute Left Main Coronary Artery Occlusion in an HIV-Infected Patient on Protease Inhibi

Severe metabolic disorders and related cardiovascular complications, including myocardial infarction, peripheral vascular disease and stroke, have been reported in human immunodeficiency virus (HIV) patients on high-activity antiretroviral therapy (HAART) including protease inhibitors. We discuss the different mechanisms by which HIV infection or its treatment may promote atherosclerosis and acute arterial thrombosis. Case Report. A 47-year-old American man with HIV infection first diagnosed in 1991 was admitted to a coronary care unit for a first episode of acute anterior wall myocardial infarction in July 1998. On admission, Killip class was II. There was no history of angina pectoris or heart disease. The only vascular risk factor was mild dyslipidemia first detected on admission. He had a negative history for smoking and cocaine use. He had been on HAART with nucleoside analogue zidovudine, protease inhibitors ritonavir and saquinavir for one year, and lamivudine (3TC) for four months. He had no history of opportunistic infections. One month before admission, his viral load was 1.05 mmol/L) and moderate increase in triglycerides (3.0 mmol/l; normal,

1. De Feyter PJ, Serruys PW. Thrombolysis of acute total occlusion of the left main coronary artery in evolving myocardial infarction. Am J Cardiol 1984;53:1727–1728. 2. Cohen MC, Ferguson DW. Survival after myocardial infarction caused by acute left main coronary artery occlusion: Case report and review of the literature. Cathet Cardiovasc Diagn 1989;16:230–238. 3. Gillard M, Bouquin V, Boschat J, et al. Acute myocardial infarction by occlusion of the left main coronary artery: Four case reports and a review of the literature. Arch Mal Coeur et Vx 1997;9:1277–1283. 4. Mejia S, Gomez M, Ordonez A, et al. PTCA and stenting in a young patient with acute myocardial infarction and left main coronary artery occlusion. J Invas Cardiol 1999;11:245–247. 5. Zimmern SH, Rogers WJ, Bream PR, et al. Total occlusion of the left main coronary artery: The coronary artery survey study (CASS) experience. Am J Cardiol 1982;49:2003–2010. 6. Flexner C. Drug therapy: HIV-protease inhibitors. N Engl J Med 1998;338:1281–1291. 7. Hammer SM, Squires KE, Hugues MD, et al. A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per millimeter or less. N Engl J Med 1997;337:725–733. 8. Vigouroux C, Gharakhanian S, Salhi Y, et al. Adverse metabolic disorders during highly active antiretroviral treatments (HAART) of HIV disease. Diabetes Metab 1999;25:383–392. 9. Henry K, Melroe H, Huebsch J, et al. Severe premature coronary artery disease with protease inhibitors. Lancet 1998;351:1328. 10. Berhens G, Schmidt H, Meyer D, et al. Vascular complications associated with use of HIV protease inhibitors. Lancet 1998;351:1958. 11. Gallet B, Pulik M, Gene P, et al. Vascular complications associated with use of HIV protease inhibitors. Lancet 1998;351:1958–1959. 12. Vittecoq D, Escaut L, Monsuez JJ. Vascular complications associated with use of HIV protease inhibitors. Lancet 1998;351:1959. 13. Flynn TE, Bricker LA. Myocardial infarction in HIV-infected men receiving protease inhibitors. Ann Intern Med 1999;131:548. 14. Danesh J, Collins R, Peto R. Chronic infections and coronary diseases: Is there a link? Lancet 1997;350:430–436. 15. Barbaro G, Barbarini G, Pellicelli AM. HIV-associated coronary arteritis in a patient with fatal myocardial infarction. N Engl J Med 2001;344;1799–1800. 16. Carr A, Samaras K, Thorisdottir A, et al. Diagnosis, prediction, and natural course of HIV-1 protease-inhibitor-associated lipodystrophy, hyperlipidaemia, and diabetes mellitus: A cohort study. Lancet 1999;353:2093–2099. 17. Monsuez JJ, Dufaux J, Vittecoq D, Vicaut E. Reduced reactive hyperemia in HIV-infected patients. J Acquir Immune Defic Syndr 2000;25:434–442. 18. Stein JH, Klein MA, Bellehumeur JL, et al. Use of human immunodeficiency virus-1 protease inhibitors is associated with atherogenic lipoprotein changes and endothelial dysfunction. Circulation 2001;104 :257–262. 19. Tabib A, Greenland T, Mercier I, et al. Coronary lesions in young HIV-positive subjects at necropsy. Lancet 1992;340:730. 20. Tabib A, Leroux C, Mornex JF, Loire R. Accelerated coronary atherosclerosis and arteriosclerosis in young human immunodeficiency virus positive patients. Coron Artery Dis 2000;11:41–46. 21. Laurence J, Mitra D, Steiner M, et al. Plasma from patients with idiopathic and human immunodeficiency virus associated thrombotic thrombocytopenic purpura induces apoptosis in microvascular endothelial cells. Blood 1996;87:3245–3254.