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The increasing longevity of individuals living with HIV presents new challenges for clinicians, extending beyond managing the virus itself to addressing the long-term health consequences. Among these is a growing awareness of cardiovascular disease (CVD) as a significant cause of morbidity and mortality in this population. Recent research highlights the complexities of managing asymptomatic carotid webs – a subtle narrowing of the internal carotid artery – particularly in high-risk patients, like those with HIV.

A comprehensive review published in International Journal of Molecular Sciences in February 2025, authored by Sorina Șoldea and colleagues at the University of Medicine and Pharmacy Craiova in Romania, delves into the current understanding and clinical implications of CVD in HIV patients. The study underscores that as HIV treatment advances and life expectancy increases, the spectrum of cardiovascular manifestations expands, demanding a nuanced approach to diagnosis and management.

The Evolving Landscape of HIV and Cardiovascular Health

For years, the focus in HIV care was primarily on controlling viral load and bolstering the immune system. However, the success of antiretroviral therapy (ART) has dramatically altered the clinical picture. Individuals with HIV are now living longer, often into their 60s and 70s, and are increasingly susceptible to age-related conditions, including CVD. The prevalence of cardiac involvement in AIDS patients has been reported to range between 28% and 73% as noted in JAMA Internal Medicine, a figure that continues to be refined as diagnostic techniques improve and patient lifespans extend.

Carotid webs, in particular, present a diagnostic and management dilemma. These are benign, fibrous ridges within the carotid artery that can potentially disrupt blood flow and increase the risk of stroke. Often asymptomatic, they are frequently discovered incidentally during imaging studies performed for other reasons. The challenge lies in determining which patients with asymptomatic carotid webs are at genuine risk and require intervention, and which can be safely monitored.

Why HIV Increases Cardiovascular Risk

The link between HIV and CVD is multifaceted. Traditional cardiovascular risk factors – such as hypertension, hyperlipidemia (high cholesterol), diabetes, and smoking – are often more prevalent in people living with HIV. However, the virus itself also contributes to cardiovascular dysfunction through several mechanisms. Chronic inflammation, immune activation, and endothelial dysfunction (damage to the lining of blood vessels) are all hallmarks of HIV infection and can accelerate the development of atherosclerosis – the buildup of plaque in the arteries. Research published in Circulation Research highlights the deepening understanding of these pathogenic processes.

some antiretroviral medications have been associated with adverse lipid profiles, potentially exacerbating cardiovascular risk. This necessitates careful consideration of ART regimens and proactive management of lipid levels. The interplay between the virus, the immune system, ART, and traditional risk factors creates a complex scenario that demands individualized assessment and management strategies.

The Asymptomatic Carotid Web: A Management Challenge

The case of an asymptomatic carotid web in a high-risk patient – such as someone with HIV and multiple other cardiovascular risk factors – is particularly challenging. Current guidelines generally recommend medical management (lifestyle modifications and risk factor control) for asymptomatic carotid webs, with surgical intervention reserved for symptomatic cases (those causing stroke-like symptoms) or those with significant stenosis (narrowing) of the artery. However, the threshold for intervention may be lower in high-risk populations.

The review by Șoldea et al. Emphasizes the need for a comprehensive risk assessment that goes beyond the degree of stenosis. Factors such as the patient’s overall cardiovascular risk profile, the presence of other arterial disease, and the characteristics of the web itself (size, location, and flow dynamics) should all be considered. Advanced imaging techniques, such as carotid duplex ultrasound, computed tomography angiography (CTA), and magnetic resonance angiography (MRA), can provide valuable information to guide decision-making.

What Does This Signify for Patients?

For individuals living with HIV, this means a heightened awareness of cardiovascular risk and the importance of regular screening. Routine blood pressure and cholesterol checks, along with assessments for diabetes and other risk factors, are crucial. If a carotid web is detected, a thorough discussion with a cardiologist or vascular surgeon is essential to determine the most appropriate management strategy.

It’s crucial to remember that an asymptomatic carotid web does not automatically necessitate surgery. In many cases, diligent control of risk factors – including blood pressure, cholesterol, and blood sugar – along with lifestyle modifications such as a healthy diet, regular exercise, and smoking cessation, can effectively mitigate the risk of stroke.

The Role of Cardiac Imaging and Immunology

Advances in cardiac imaging modalities and immunology are continually refining our understanding of HIV-associated CVD. Techniques like echocardiography, cardiac MRI, and positron emission tomography (PET) can detect subtle cardiac abnormalities that may not be apparent on traditional tests. Research into the immunological mechanisms underlying cardiovascular dysfunction in HIV is paving the way for novel therapeutic strategies. As detailed in a review published in the International Journal of Molecular Sciences, this evolving knowledge base is crucial for optimizing the care of individuals with HIV and preventing cardiovascular events.

Looking Ahead: Surveillance, Research, and Guidance Updates

Ongoing surveillance of cardiovascular disease trends in the HIV population is essential to monitor the effectiveness of current prevention and treatment strategies. Clinical trials are needed to evaluate the optimal management of asymptomatic carotid webs in high-risk patients, including the potential role of more aggressive medical therapy or even prophylactic intervention. Continued research into the underlying mechanisms of HIV-associated CVD will undoubtedly lead to the development of new and more targeted therapies. Expect to spot guidance from organizations like the American Heart Association and the Infectious Diseases Society of America updated as new evidence emerges, refining recommendations for cardiovascular risk assessment and management in people living with HIV.