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Statin Use in HIV–infected Patients: Is CVD Risk Underestimated?
Based on 2013 clinical guidelines, nearly three-quarters of HIV-infected patients with dangerous subclinical atherosclerotic plaque would not be considered for statin therapy, a new study finds.
Patients with HIV infection have a high risk for coronary artery disease.1 The 2013 American College of Cardiology/American Heart Association (ACC/AHA) cholesterol guidelines (which replace the previous guidelines from the Adult Treatment Panel [ATP] III) have been generally applied to HIV-infected patients to determine the need for lipid-lowering medication. However, the guidelines have never been validated in this population-a group also known for its high prevalence of subclinical high-risk morphology (HRM) coronary atherosclerotic plaque.
A new study published in the journal AIDS compared the recommendations for statin therapy based on the 2013 ACC/AHA guidelines with those in the 2004 Adult Treatment Panel III guidelines, among HIV-infected subjects. The investigators examined data from 108 HIV-infected subjects without known cardiovascular disease (CVD) and not taking lipid-lowering treatment whot underwent contrast-enhanced CT angiography. The researchers then compared the recommendations for statin therapy according to 2013 versus 2004 guidelines in these patients.2
Interestingly, while the 10-year atherosclerotic cardiovascular disease (ASCVD) risk score was 3.3% (1.6, 6.6) among all patients, 36% of subjects had HRM coronary plaque. Among patients found to have HRM coronary plaque, 26% were found eligible for statin therapy according to the 2013 guidelines, and 10% by the 2004 guidelines (Pâ=.04). In patients without HRM coronary plaque, statins would be recommended for 19% following 2013 guidelines versus 7% by following recommendations in the 2004 guidelines (Pâ=.005).2
The results of this study illustrate that the 2013 ACC/AHA cholesterol guidelines recommend statin therapy for a higher percentage of HIV-infected subjects with and without HRM coronary plaque relative to the 2004 guidelines. However, even when following the most recent version of the guidelines, most HIV-infected subjects (74%) with subclinical HRM coronary plaque will not meet guideline-recommended thresholds for statin therapy.2
For primary care physicians who see patients with HIV infection, it is important to be aware that current clinical guidelines on the management of cholesterol significantly underestimate disease prevalence in this group. More studies are needed to understand the effects of atherosclerotic plaques in HIV-infected patients and to optimize treatment recommendations for this high-risk population.2
References:
- Grinspoon SK, Grunfeld C, Kotler DP, et al. State of the science conference: initiative to decrease cardiovascular risk and increase quality of care for patients living with HIV/AIDS: executive summary. Circulation. 2008;118:198–210.
- Zanni, MV, Fitch, KV, Feldpausch, M, et al. 2013 American College of Cardiology/American Heart Association and 2004 Adult Treatment Panel III cholesterol guidelines applied to HIV-infected patients with/without subclinical high-risk coronary plaque. AIDS. 2014;28:2061-2070.
