An Interview With David Alain Wohl, M.D.
Monitoring, Curbing and Communicating Cardiovascular Risk: Advice for Clinicians
For providers, how do they continue to monitor this, or make sure that the risk is not as high?
I think we don't do anything different right now. I don't think that the authors would suggest we do anything different right now, clinically. You hear that a lot in studies, and that's because you have to be careful, because you don't want to extrapolate too far.
Right here and now, there are several things I'd do. I'd risk-stratify, as far as cardiovascular disease. I'd change the things that can be changed, and the things that can't be changed, we have to figure out more about. Do we try to use anti-inflammatories? Do we try to use statins? Do we give more aspirin than we should? Those are the types of things that are being studied. But they're not innocuous.
Right now, I'd do the usual stuff. For the majority of my patients, there are levers I can pull that work that have nothing to do with how much CRP they have, or IL-6 -- these are inflammatory markers. It has to do with cutting down on their smoking. It has to do with losing weight. It has to do with eating less french fries, and cookies, and soft drinks.
There are some people who are great [about these things]. These are the people that I feel for, who -- they're doing everything right. Their cholesterol is good. They may be on a statin. They exercise. They look great. And they're like, "Do I carry excess risk because of my HIV infection?" For those people, I hand-wring. I'm not sure. The data suggests: somewhat. You're doing everything you can to reduce your risk.
But, look: We all carry different risks, right? Because of our genetics. If you carry a gene that protects you against heart disease, but I carry a gene that gives me a propensity to heart disease -- like, my dad's had stents placed in his heart. If I carry that gene, we're starting already with an uneven playing field. That happens all the time in life. Maybe HIV is like that gene; it gives you another hit, another risk. It may be one that we can't change -- just like we can't change our genes.
Again: We're trying to figure out what we can change, what we can't change. There's a lot of work being done. The vast majority of risk reduction is happening right now. We should just keep doing that and not go crazy.
Some of my patients get really excited that they carry this excess risk, and [they fear] they're basically going to spontaneously combust. We have to cool our jets. That's not going to happen. That's not what's happening. Very, very few people actually go on and get heart attacks who are HIV positive. The D:A:D cohort presented really nice, updated data. And when you look at the number of people who've been followed in that cohort in Europe, and the time that they've been followed, and the number of actual heart attacks they've been able to document: It is such a small, small number.
So, relative risk may go up, but absolute risk remains low. We're taking a rare event and making it somewhat less rare. But it's still a rare event.
Extrapolating MACS Results Outside of Urban MSM
How do these results impact the people who weren't included: younger people with HIV, or women?
That's a great question. I think younger people have natural protection, so we don't worry as much. I'm sure cardiologists would say, "Well, wait a second; the groundwork for some of these plaques and stuff like that happens early on, so those people are not exempt from practicing healthy lifestyles." You do damage early on, it's hard to reverse it; or it may be irreversible. So we want to keep a healthy lifestyle from an early age.
For women, the story may be different. Women are very hard to compare when you talk about HIV positive and HIV negative, because there's a bunch of factors. Most women with HIV are African American, or women of color. When you start looking at HIV negatives, controls: If they're more white, you've got to adjust for that. With color and race come a bunch of different confounders that we have to adjust for. I could go long into that, whether they be lifestyle, or community, or living with stress. There's a whole body of literature that could be brought into that.
Even so, there are some data that really do suggest women may be more at risk for cardiovascular disease with HIV, compared to HIV-negative women. Again, those studies are really hard to do. We're trying to get a better handle on it. But women have to pay attention to this, too -- maybe even more so than men, is what some of the data seem to be suggesting.
If there's anything you want to add, or any other takeaways that you wanted to include, please feel free.
I think this is a great topic. I think this is a really good study. It gets us incrementally closer to where we want to be to understand this. It was really well done, and it's important. But I think even the investigators would say there are caveats here. We have to understand more about this. I'd just caution my patients not to overinterpret these data just yet.
OK. I hope everyone keeps that in mind. Thank you very much.
This transcript has been lightly edited for clarity.
Warren Tong is the research editor for TheBody.com and TheBodyPRO.com.
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