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Atazanavir Switch Improved Lipids But Limited Impact on Cardiovascular Risk Score; Should Intervene with Other Risk Factors
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8th International Congress on Drug Therapy in HIV Infection
November 12-16, 2006
Glasgow, Scotland
Mark Mascolini
Although switching to atazanavir improved lipid values in a single-center Italian study, the change had only a modest impact on cardiovascular risk score, perhaps because of other heart risk factors in this 204-person cohort or perhaps because follow-up extended only a little over 1 year [1]. Manuela Colafigli and colleagues at Rome's Catholic University believe their results do support switching to atazanavir in people with high lipids but recommend that "intervention on other risk factors should accompany this strategy in order to obtain more significant reductions of the cardiovascular risk."
The analysis involved 204 antiretroviral-treated patients without a history of heart disease, 63% of them men, 76% smokers, 13% with a history of diabetes, and 16% with a history of antihypertensive therapy. Their age averaged 45 years (standard deviation 6.6), and they had well controlled HIV infection, with a median viral load of 50 copies (interquartile range [IQR] 50 to 830 copies) and a median CD4 count of 444 (IQR 305 to 595). Lipid values when they switched to atazanavir averaged 209 mg/dL for total cholesterol, 42 mg/dL for "good" high-density lipoprotein (HDL) cholesterol, 169 mg/dL for non-HDL cholesterol, and 271 mg/dL for triglycerides.
After an average 13 months of treatment with atazanavir, triglycerides fell significantly to 198.5 mg/dL (P < 0.001). Total cholesterol also dropped significantly to 191 mg/dL (P < 0.001), reflecting declines in both HDL cholesterol to 40 mg/dL (P = 0.02) and non-HDL cholesterol to 152 mg/dL (P < 0.001). Proportions of people with total cholesterol above 240 mg/dL, triglycerides above 200 mg/dL, and triglycerides above 400 mg/dL also dropped during follow-up (from 23.8% to 16%, 42.8% to 35%, and 13.9% to 8%), though the proportion with non-HDL above 190 mg/dL rose from 42.8% to 49.7%.
The researchers figured cardiovascular risk by a validated scoring system based on 10-year cumulative risk of a major cardiovascular event in an Italian population. The score does not take smoking into account, but it does factor in age, diabetes mellitus, systolic blood pressure, prescription of antihypertensives, total cholesterol, and HDL cholesterol. Thus the high smoking rate in this cohort would not drive up the risk of heart disease in this equation.
In an analysis not adjusted for other risk factors, the cardiovascular risk score barely budged after 13 months of atazanavir, inching down from 3.43 to 3.38. An analysis adjusted for age did chart a drop in the heart risk score from 3.43 to 3.14. Although this 8% decline reached statistical significance (P = 0.001), the Catholic University team judged it a "modest decrease." Higher total cholesterol and triglycerides before the change to atazanavir predicted greater drops in cardiovascular risk at the end of follow-up.
Reference
1. Colafigli M, Di Giambenedetto S, Bracciale L, et al. Improvement of lipid metabolism does not change the cardiovascular risk score in 13 months of observation of patients switched to atazanavir-based regimen. 8th International Congress on Drug Therapy in HIV Infection, November 12-16, 2006, Glasgow. Abstract P128.
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