Noninvasive coronary artery calcification assessment in people living with HIV: A call for integrated risk screening

Coronary artery calcification (CAC) is a well-established marker of subclinical coronary atherosclerosis and a strong predictor of cardiovascular events. In people living with HIV (PLWH), CAC progression is accelerated by the complex interplay between traditional cardiovascular risk factors and HIV-specific contributors, including chronic inflammation, immune activation, and long-term antiretroviral therapy.

A new review authored by a research team led by consultant cardiologist Haijian Luo at Shanghai Public Health Clinical Center, Fudan University, synthesizes current evidence on the epidemiology, pathophysiology, and clinical implications of CAC in PLWH, while critically evaluating existing risk stratification approaches. The authors note that CAC scoring provides independent prognostic value beyond traditional risk calculators, which frequently underestimate cardiovascular disease (CVD) risk in this population. Underlying mechanisms involve HIV-associated arterial inflammation, altered macrophage activity, and increased vascular-calcification pathways.

Cardiac computed tomography offers a reliable and reproducible noninvasive method for CAC assessment, yet its clinical adoption in HIV care remains limited. The review also highlights the association between CAC and long-term mortality, and identifies major knowledge gaps, including the lack of prospective trials validating CAC-guided preventive strategies in PLWH.

To improve risk prediction, the authors propose integrating CAC detection with novel biomarkers, such as inflammatory cytokines (e.g., IL-6, hs-CRP), immune activation markers (e.g., CD8+ T-cell subsets, sCD163), and polygenic risk scores for coronary artery disease. While polygenic risk scores have shown associations with CAC in PLWH, their performance varies by racial or ethnic group and HIV serostatus.

Accordingly, the authors propose a multimodal risk model combining CAC scores with inflammatory, immune, and genetic biomarkers to identify individuals at highest risk for rapid CAC progression and future cardiovascular events. Prospective validation of such integrated screening pathways is essential to enable targeted, timely, and personalized preventive interventions in PLWH.