1. HDL Particles but not LDL Particles Predict Cardiovascular Disease Events in HIV Patients: Results from Strategies for Management of ART Study (SMART) Daniel A Duprez, MD, PhD On behalf of the SMART/INSIGHT Group University of Minnesota

2. Background In the SMART Study, intermittent ART compared to continuous ART was found to cause an excess risk of all-cause mortality and cardiovascular disease. ART interruption is associated with a decline in HDL-and LDL-cholesterol. Lower levels of HDL-cholesterol are associated with an increased risk of CVD.

3. Subjects with same HDL-cholesterol can have different HDL-particle concentrations 52-yr man Total Chol205 mg/dL Triglycerides180 mg/dL HDL-chol 36 mg/dL LDL-chol115 mg/dL Small LDL-p 1100nmol/L Large LDL-p 500nmol/L Large HDL-p 8µmol/L Small HDL-p 23µmol/L 52-yr man 195 mg/dL 185 mg/dL 36 mg/dL 122 mg/dL 1100nmol/dL 500nmol/dL 3µmol/L 28µmol/L

4. Chylomicron Remnants Density, g/mL Chylomicron 1.20 1.10 1.06 1.02 1.006 0.95 510204060801000 VLDL IDL LDL HDL l HDL s Diameter, nm VLDL Remnants Lp(a) VLDL Lipoprotein Particles Chylomicron Segrest JP et al. Adv Protein Chem. 1994;45:303–369

5. Background Nuclear magnetic resonance (NMR) enables quantification of concentrations of lipid particles of varying size. Data suggest that smaller LDL particle size, specifically a predominance of small dense LDL or a greater number of small LDL particles, is a predictor of coronary artery disease. Studies of non-HIV-infected cohorts have also reported that HDL particle sizes are related to ischemic heart disease.

6. SMART and CVD Outcome: Nested Case-Control Study Aim: To describe the relationship of baseline levels of lipoprotein particle size and concentration with CVD Baseline and follow-up plasma samples identified for patients who developed CVD (248 patients) prior to study closure on July 11, 2007 and for two matched controls for each CVD case (480 patients). Matching on: – Country – Age (+/- 5 years) – Gender; and – Date of randomization (+/- 3 months) Conditional logistic used to estimate odds ratios (OR) for CVD with participants in lowest quartile as reference. Adjustment for baseline covariates – Age, race ART, HIV RNA, CD4+ count, BMI, at smoking, diabetes, hep B/C co-infection, use of lipid BP lowering medication, prior CVD, and major baseline ECG abnormalities – Also LDL and triglycerides – Also hsCRP, IL-6 and D-dimer

7. Baseline Characteristics of CVD Cases and Matched Controls CVD Cases (N=248) Controls (N=480)P-value* Demographics Age (median) Gender (% female) Black (%) 49 19.4 39.1 49 19.4 37.1 NA NA 0.50 CD4+ (cells/mm 3 ) (median)5766200.47 HIV RNA ≤ 400 copies/mL67.6 0.91 Prior AIDS (%)37.124.80.0005 Current smoker (%)52.439.80.001 Diabetes (%)16.98.30.0007 Blood pressure lowering drugs (%)45.230.6<0.0001 Lipid lowering drugs (%)27.822.70.15 Prior CVD (%)13.35.20.0004 * P-value obtained from univariate conditional logistic model.

8. Baseline Lipids of CVD Cases and Matched Controls CVD Cases (N=248) Controls (N=480)P-value* Total cholesterol (mg/dL) (median)1961930.29 HDL cholesterol (mg/dL) (median)38420.03 LDL cholesterol (mg/dL) (median)111 0.76 Triglycerides (mg/dL) (median)1931780.39 Total/HDL cholesterol (median)5.24.70.05 * P-value obtained from univariate conditional logistic model.

9. Baseline Lipoprotein Particles of CVD Cases and Matched Controls MedianCVD Cases (N=248) Controls (N=480)P-value* Total LDL-p (nmol/L)136413220.30 Total VLDL-p (nmol/L) 85.781.30.38 Total HDL-p (µmol/L) 28.430.20.0001 * P-value obtained from univariate conditional logistic model.

10. CVD Event Type and SMART CVD Outcome Type Number -Non-fatal CHD 124 Clinical MI, Silent MI, CABG, PCI, CAD requiring medical therapy -Non-fatal Atherosclerotic non-CHD 62 Stroke, Peripheral Arterial Disease -Non-fatal CHF 26 -Fatal CVD 36 CVD or unwitnessed death

11. CVD Event Type and Baseline Lipid Particles CVD Event TypeN CasesUnadj. OR (4 th /1 st Q)P-value Non-Fatal CHD124 Total VLDL-p2.8 (1.3 – 6.0)0.007 Total LDL-p2.0 (1.0 – 3.9)0.05 Small LDL-p2.2 (1.1 – 4.2)0.02 Total HDL-p0.4 (0.2 – 0.8)0.006 Non-Fatal Atherosclerotic CHD62 Total HDL-p0.2 (0.1 – 0.6)0.005 Non-Fatal CHF26 Total HDL-p1.1 (0.3 – 4.1)0.90 Fatal CVD36 Total HDL-p0.3 (0.1 – 1.1)0.08

12. HDL Particle Concentrations and Cardiovascular Disease Un-adjustedAdjusted HDL Particle (μmol/L)OR (4 th /1 st )P-valueOR (4 th /1 st )P-value Total0.41<0.00010.410.001 Large0.690.090.680.16 Medium0.910.671.070.80 Small0.530.0070.550.03

13. Difference in HDL Particle Concentration (µmol/L) One Month After Randomization Baseline Average DC-VS Difference at 1 MonthP-value Total HDL p29.2-2.2<0.0001 Large HDL p5.8-0.30.10 Medium HDL p4.9-1.10.002 Small HDL p18.5-0.90.03 DC = Treatment Interruption VS = Continuous ART

14. Impact of Covariate Adjustment on the Odds Ratio for 4 th vs. 1 st Quartile of Total HDL-p Total HDLpOR (4 th /1 st )P-value Unadjusted0.41<0.0001 Adjusted for major risk factors, excluding lipids 0.410.01 Also adjusted for LDL, TG0.410.001 Also adjusted for IL-6 hsCRP D-dimer 0.50 0.50 0.49 0.02 0.02 0.02

15. Odds Ratios for CVD by Total HDL-p and IL-6 Levels ≥ 2.4 < 2.4 ≥ 29 < 29 Total HDLp (µmol/L) OR for CVD OR=2.58 P <0.001 OR=3.36 P <0.001 OR=1.49 P=0.14 OR=1.00 IL-6 pg/mL

16. Conclusions In the SMART Trial lower total HDL-p and especially small HDL-p are predictive for cardiovascular events in HIV patients. Intermittent ART therapy (DC) is associated with a decrease in HDL-p concentration in comparison with continuous therapy (VS) after one month. The long-term effects of ART on HDL-chol and particles and therapy to increase it need to be further studied in randomized trials in HIV patients.