The European AIDS Clinical Society (EACS) guidelines state that the intensity of efforts to prevent cardiovascular (CV) disease should depend on the underlying risk of its development, which can be estimated.1
Screening for CV disease in people living with HIV (PLWHIV) should be performed in men aged >40 years and women aged >50 years without CV disease.1 Routine assessments for CV disease include:
the ASCVD Risk Estimator; tis equation also provides specific recommendations to reduce CV risk5
i. Use the Framingham equation; a risk equation developed from HIV populations has been developed (see www.cphiv.dk/tools.aspx). This assessment and the associated considerations outlined in this figure should be repeated annually in all patients under care to ensure that the various interventions are initiated in a timely way.
ii. Options for ART modification include: (1) replace PI/r with NNRTI, RAL or by another PI/r known to cause less metabolic disturbances; (2) consider replacing d4T, ZDV or ABC with TDF or use a NRTI sparing regimen.
iii. Of the modifiable risk factors outlined, drug treatment is reserved for certain subgroups where benefits are considered to outweigh potential harm. Of note, there is a combined benefit of various interventions in target groups identified. Per 10 mmHg reduction in systolic blood pressure, per 1 mmol/L (39 mg/dL) reduction in TC and with use of acetylsalicylic acid, each reduces risk of IHD by 20-25 %; the effect is additive. Observational studies suggest that smoking cessation results in greatest reductions in risk of IHD-50 % – and this is additive to other interventions.
iv. See discussion on drug treatment of patients with lower CVD risk at www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm.
v. Target levels are to be used as guidance and are not definitive – expressed as mmol/L with mg/dL in parenthesis. In case LDL cannot be calculated because of high triglyceride levels, the non-HDL-c (TC minus HDL-c) target should be used which is 0.8 mmol/L (30 mg/dL) higher than the corresponding LDL-c target. Target levels for TG are not listed because an independent contribution from TG to CVD risk is uncertain and hence whether this condition should be treated.
vi. Evidence for benefit when used in persons without a history of CVD (including diabetics) is less compelling.
Lifestyle modification for substance use may also be considered.2
If an individual has a CV disease risk ≥20%, change of ARV therapy may be considered:1
Key modifiable risk factors, such as blood pressure, coagulation, glucose and lipids, should be assessed. Drug treatment should be reserved for patients where benefits are considered to outweigh any potential risk.1
|Risk factor||Circumstances for drug treatment1||Recommended targets1|
|BP||SBP ≥140 or DBP ≥90 mmHg (especially if 10-year CV disease risk ≥20%*)||If diabetic/prior CV disease/CKD + proteinuria – SBP <130, DBP <80 Others – SBP <140, DBP <90|
|Coagulation||Established CVD or ≥50 years old and 10-year CV disease risk ≥20%*||Target not available, but consider treating with acetylsalicylic acid 75–150 mg, particularly those with a history of CV disease and those with diabetes mellitus|
|Glucose||Confirm diabetes mellitus and treat with drugs||HbA1c <6.5–7.0%|
|Lipids||Established CV disease or type 2 diabetes mellitus or 10-year CV disease risk ≥20%*†||Total cholesterol Optimal – ≤4 mmol/L (155 mg/dL) Standard – ≤5 mmol/L (190 mg/dL) LDL cholesterol Optimal – ≤2 mmol/L (80 mg/dL) Standard – ≤3 mmol/L (115 mg/dL)|
*CV disease risk assessed using the Framingham equation.
†For patients with a lower CV disease risk, the Third report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III Final Report) can be viewed for a discussion on drug treatment of abnormal lipid levels.10
LDL = low-density lipoprotein; SBP = systolic blood pressure; DBP = diastolic blood pressure; CKD = chronic kidney disease.
|For people living with HIV|
|European AIDS Clinical Society1||EACS guidelines||Section on preventing CV disease in people living with HIV.|
|New York State Department of Health AIDS Institute with John Hopkins University Division of Infectious Diseases2||Prevention of secondary disease: preventive medicine. Lipid screening and cardiovascular risk||Recommendations on lipid screening and CV disease risk.|
|Department of Health and Human Services11||Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents||
|International AIDS Society-USA Panel12||Antiretroviral treatment of adult HIV infection. 2010 recommendations of the International AIDS Society-USA Panel||
|American Heart Association13||Prevention Strategies for Cardiovascular Disease in HIV-Infected Patients||Conference proceedings on management strategies for CV disease prevention in HIV patients|
|For the general population|
|American College of Cardiology/American Heart Association14||American College of Cardiology/American Heart Association joint guidelines||A wealth of guidelines on all aspects of CV disease prevention.|
|European Society of Cardiology6||European guidelines on cardiovascular disease prevention in clinical practice||
|NCEP ATP III15||National Institutes of Health. National Cholesterol Education Program. Expert panel on detection, evaluation, and treatment of high blood cholesterol in adults||Provides detailed information on primary and secondary prevention.|
|World Health Organisation16||Guidelines for assessment and management of cardiovascular risk||A comprehensive guide on reducing disability and premature deaths from CV disease in people at high risk who have not yet experienced a CV event.|
|US Preventive Services Task Force8||Guide to clinical preventive services 2010–2011||Includes recommendations on screening and assessment of heart and vascular diseases.|