IAS: HIV Treatment Requires Cardiac Assessment

SYDNEY, July 24 -- As the long-term prognosis for patients with HIV improves, it becomes more important to assess the patient's risk for cardiovascular disease and other health issues, researchers suggested here.

"In settings where antiretroviral therapy is readily accessible, the long-term prognosis for people living with HIV/AIDS has dramatically improved," Judith Currier, M.D., of the University of California, Los Angeles, told attendees at an industry-sponsored symposium held in conjunction with the International AIDS Society meeting.

"Clinical management of HIV infection now needs to include provision of screening and interventions to reduce morbidity and mortality from other chronic diseases such as cardiovascular disease," she said.

Dr. Currier reviewed a series of clinical studies that attempted to tease out the question of whether HIV itself is responsible for increased risk of cardiovascular disease; whether the problem is rooted in the treatment of HIV disease with highly active antiretroviral therapy (HAART); and which of the components of HAART might be the culprit for increasing the risk of heart disease in patients.

She said that one of the surprising results of the SMART study was that patients with HIV who were assigned to a regimen in which treatment was guided by levels of CD4-positive cells and were able to take less medication actually had worse cardiovascular disease outcomes than did patients who never stopped taking the HAART regimen. (See Interrupting HIV Treatment Raises Cardio Risk)

On the other hand, she noted, data from the DAD study indicated that use of protease inhibitors increased HIV patients' risk of myocardial infarction by about 16% a year. (See Protease Inhibitors Linked to Increased Heart Attack Risk)

Dr. Currier also noted that treatment of cardiovascular disease requires that the physician be aware of interactions between statins and protease inhibitors. For example, fluvastatin and pravastatin appear safe for use in HIV patients, but lovastatin and simvastatin are contraindicated. The other statins have to be used with caution, she said.

While there is reason to consider the cardiovascular risk profile of a patient with HIV, Dr. Currier noted, "The absolute risk of cardiovascular disease in the HIV population remains low (about 2%). Modification of coronary heart disease risk and use of antiretroviral agents less likely to cause metabolic disturbances may be warranted when patients have many options, but the fear of coronary heart disease should not preclude the use of effective HAART," she said.

Peter Reiss, M.D., of the Academic Medical Centre, in Amsterdam, illustrated how the choices of treatment fit into selection of therapy for a patient, noting that the risk of heart disease could be reduced by selecting specific HIV drugs.

However, he said, the best way to get his patient to dramatically reduce his Framingham Heart Score was to get the individual to quit smoking.

"Cardiovascular risk assessment has become an integral component of the care for persons with HIV infection," Dr. Reiss said. "Careful choice of antiretroviral regimens may contribute to optimization of lipid profile. Cardiovascular disease risk reduction, however, involves much more than just paying attention to lipids."

The International AIDS Society does not require presenters to identify possible financial conflicts of interest. Dr. Currier said she has possible conflicts with Abbott, Bristol-Myers Squibb, GlaxoSmithKline, Merck and Tibotec. Dr. Reiss did not list conflicts, nor did symposium chairman Andrew Carr, MD, professor of medicine at the University of New South Wales, Sydney.