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Prevention and Management of HIV-Associated Cardiovascular Disease

November 17, 2014

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"Our understanding of mechanisms of HIV-associated cardiovascular disease (CVD) has not yet translated into tailored clinical interventions," says Virginia Triant, M.D., M.P.H., of Massachusetts General Hospital. Triant provided a state-of-the-art presentation on cardiovascular complications in people living with HIV at IDWeek 2014.

The first article in this series covered the context and causes of HIV-related CVD. This second article focuses on how healthcare providers can integrate the prevention and management of CVD into HIV chronic care -- addressing both the traditional risk factors of CVD, and other risk factors that are HIV-specific.


Estimating Risk

Part of the challenge for clinicians is that it is unclear to what extent general population guidelines can be applied in the management of CVD in people living with HIV.

It isn't clear that any of the available tools to predict CVD risk in the general population underestimate risk in HIV. For instance, the Framingham risk score (FRS) was found to underestimate risk of AMI (acute mydocardial infarction) and stroke in people living with HIV on antiretroviral therapy in the D.A.D study and stroke in the Multicenter AIDS Cohort study.

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However, new cardiovascular risk guidelines from the 2013 American College of Cardiology/American Heart Association (ACC/AHA) have added some complexity to HIV-specific risk prediction. These guidelines employ new CVD risk prediction equations -- the pooled cohorts equations (PCE). There have been reports that they may overestimate risk in the general population but they also appear to underestimate risk in people living with HIV.

Furthermore, the Framingham risk score and ACC/AHA guidelines do not seem to be in complete agreement about which people living with HIV are at low or high risk of CVD -- with discordant results in about 17% of cases.

Triant suggested that clinicians should consider calculating both the Framingham risk score and the ACC/AHA risk score.

Patients who are in a high-risk category by at least one score (greater than 10% for FRS and greater than 7.5% for ACC/AHA) merit:

  • Suppressive antiretroviral therapy, if not already treated
  • Strong consideration of statins
  • Aggressive CVD risk-factor reduction


Management of Dyslipidemia in HIV

Some questions about the ACC/AHA guidelines remain. Rates of dyslipidemia are much higher in people living with HIV than in control patients, with a distinctive pattern of low high-density lipoprotein (HDL) and high triglycerides. Although statins are the main treatment, dyslipidemia may be more difficult to treat in people living with HIV, and the effects as well as drug interactions with antiretroviral drugs need to be considered.

In patients living with HIV, the use of statins has been shown to effectively lower low-density lipoprotein (LDL). Data presented at CROI 2014 also suggested that statin use may also decrease immune activation, and contribute to immune reconstitution independently of antiretroviral therapy. In addition, in at least one observational cohort, statin use was associated with significantly decreased mortality in people living with HIV who were on suppressive antiretroviral therapy.

There are controversies, however, regarding the approach to treating cholesterol recommended by the 2013 ACC/AHA cholesterol treatment guidelines. These recommend statin initiation in four major benefit groups:

  • Those with clinical atherosclerotic cardiovascular disease (ASCVD)
  • LDL ≥ 190 mg/dL
  • Diabetes age 40-75
  • Estimated 10-year ASCVD risk ≥ 7.5%

In contrast to the past, the guidelines set no LDL treatment targets and recommend no non-statin therapies. Using the new risk calculator (the PCEs) to estimate 10-year ASCVD risk, the guidelines recommend substantially increased statin treatment in general population -- with 12.8 million additional adults eligible for statin therapy (mostly among older patients without cardiovascular disease).

They also recommend significantly increased statin use in people living with HIV without traditional risk factors for CVD -- despite the fact that people living with HIV have a different typical cholesterol profile and for whom the mechanism of CVD is different. At present, there is not much evidence of efficacy and safety from randomized clinical trials for treating people living with HIV at risk as determined by the new ACC/AHA risk calculator and the guidelines statin intensity definition is not directly applicable in this population.

Nevertheless, Triant believes it is likely that that statins will be effective in the risk groups outlined by guidelines. The question might rather be, "Do they go far enough?" Even using both Framingham and PCE risk calculation, the risk of CVD appears to be underestimated in HIV, and there is a chance that a larger segment of the population living with HIV may benefit from statins. Future research will address some of these gaps.

In the meantime, on the basis of the available guidelines and published data on the use of statins in people living with HIV to date, Triant recommended the following clinical strategy for the management of dyslipidemia in HIV:

  • Check fasting lipids
    • At HIV diagnosis
    • Prior to and within 1-3 months after starting or changing antiretroviral therapy
    • Every 6-12 months
  • Consider starting statins based on ACC/AHA cholesterol guidelines
  • Consider therapy with:
    • Statins, if LDL is above ATP-III (adult treatment panel) goal, or TG (triglyceride) is between 200-500 with elevated non-HDL
    • Fibrates, if TG > 500
  • 2013 HIV primary care guidelines include detailed statin-antiretroviral interaction chart
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This article was provided by TheBodyPRO.com. It is a part of the publication IDWeek 2014.
 


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Please note: Knowledge about HIV changes rapidly. Note the date of this summary's publication, and before treating patients or employing any therapies described in these materials, verify all information independently. If you are a patient, please consult a doctor or other medical professional before acting on any of the information presented in this summary. For a complete listing of our most recent conference coverage, click here.

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