AHA Offers CVD Guidance for Patients with HIV

By Kelly Young

Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH

The American Heart Association offers new guidance in preventing and managing cardiovascular disease in patients with HIV.

Here are some of the group's recommendations, published in Circulation:

• Patients with HIV should have their risk for atherosclerotic cardiovascular disease (ASCVD) assessed with the ACC/AHA ASCVD Risk Estimator or an alternative calculator.

• If any of the following risk factors are present, a person's CVD risk may be higher than the calculated ASCVD risk: hepatitis C coinfection; metabolic syndrome, lipodystrophy/lipoatrophy, or fatty liver disease; HIV treatment failure/nonadherence; low CD4 count (less than 350 cells/mm³); or a history of prolonged HIV viremia or delayed initiation of antiretroviral therapy (ART).

• Simvastatin and lovastatin should be avoided. Pravastatin and pitavastatin are the least likely statins to interfere with antiretroviral therapy. Atorvastatin and rosuvastatin may also be considered.

Dr. Carlos del Rio, an editor with NEJM Journal Watch Infectious Diseases, comments: "With effective antiretroviral therapy, people living with HIV (PLWH) can live near normal lives but they are at increased risk of comorbid conditions including cardiovascular diseases. Rates of myocardial infarction, heart failure and stroke, for example, are significantly higher in people living with HIV compared to uninfected controls."

He continues: "In this newly published scientific statement from the American Heart Association, and in the absence of large-scale randomized controlled trial data, experts in the field of HIV and cardiovascular disease review the existing evidence and provide pragmatic recommendations for prevention and management. Traditional ASCVD risk factors such as age, diabetes, smoking, hypertension, and dyslipidemia are associated with elevated ASCVD risk among PLWH. Advanced HIV (CD4 < 200 cells/ml) and sustained untreated viremia are risk factors for ASCVD. The population-level impact of ART toxicities on ASCVD risk is low and the use of ART with virologic suppression far outweighs any increased risk.

"Smoking is the most important modifiable CVD risk among PLWH, and efforts should be made to get patients to stop smoking. The use of statins should follow the current recommendations. Their use in all PLWH without traditional indications is being evaluated in the REPRIEVE Trial. Adherence to a healthy lifestyle -- including smoking cessation, low-to-moderate alcohol consumption, regular physical activity and adherence to ACC/AHA dietary guidelines — is recommended."