Mascolini: Should HIV clinicians consider primary prevention with aspirin?
Stein: Again I would default to the regular recommendations for people without HIV infection [see box].15 Aspirin is not a benign drug. It can prevent heart attacks, especially in men. It seems to prevent more strokes in women than heart attacks. If your patient already has cardiovascular disease, aspirin is already indicated. And if your patient has diabetes mellitus, aspirin is probably indicated.
For everyone else you really have to look at the balance of bleeding and cardiovascular disease prevention. I think defaulting to the usual guidelines is the way to go -- use the Framingham risk score and look at the age and sex of your patient to determine if aspirin is needed. GI bleeding is a real problem. The rare but more feared complication is intracranial bleeding. We can't just give patients aspirin and think it's a completely benign drug.
Mascolini: Everyone knows smoking has a huge impact on cardiovascular risk, but physicians often throw up their hands in despair when you suggest they get their patients to quit. How do you recommend HIV clinicians approach this challenge?
Stein: The first way they approach the challenge is by doing an attitude adjustment. If the clinician doesn't think it's going to work, the patient will pick up on that. Then you go through this empty ritual of telling the patient to quit smoking when you don't think it's going to work and they don't think it's going to work. And when they leave the office and fail to quit you have a self-fulfilling but very dysfunctional prophesy.
Cigarette smoking is the single most powerful modifiable risk factor for cardiovascular disease. It's incontrovertible. We're fortunate enough to live in an era in which we have multiple options for help with smoking cessation, ranging from counseling and lifestyle intervention through dual pharmacologic therapy. I'm not going to say it's easy to quit smoking. It's not easy for patients; it's not easy for clinicians working with patients. But for all our worry over nutritional supplements and LDL targets and baseline ECG screening, the single most important thing would be to help people quit smoking.
I recommend that clinicians approach smoking cessation with a positive attitude and realize that it takes the average patient six or seven quit attempts before they're successful. Clinicians have to work with patients to develop a strategy for quitting based on how addicted to cigarettes they are, previous experiences with quit attempts, and concurrent medications, because polypharmacy is an issue for people with HIV.
In our research in people without HIV we have found that dual nicotine replacement therapy with a nicotine patch supplemented with a lozenge is the most effective strategy.16 But of course it has to be personalized. If someone has failed nicotine replacement therapy they could use bupropion (Wellbutrin, Zyban) or they could use varenicline (Chantix). But there's some art in dealing with the drug interactions.
If a physician doesn't have the time or interest in working with patients on smoking cessation, they should refer patients to a preventive cardiology clinic, or to a smoking cessation clinic, or to a clinical trial that will enroll people with HIV infection.
I think that smoking cessation in people with HIV is an untapped research need. I would much rather see some research money invested in helping people with HIV quit smoking than in worrying more about LDL cholesterol targets. That's how important it is.
|Main USPSTF Recommendations on Aspirin for Prevention of Cardiovascular Disease*|
* For the complete report: US Preventive Services Task Force. Aspirin for the Prevention of Cardiovascular Disease. March 2009.
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