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Following ACC/AHA Guidelines Will Undertreat Atherosclerosis in HIV Patients
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Conference on Retroviruses and Opportunistic Infections (CROI), February 22-25, 2016, Boston
Mark Mascolini
Clinicians who follow 2013 ACC/AHA guidelines will deny statins to many HIV patients who probably need them, according to HIV heart experts at the University of California, San Francisco (UCSF) [1]. Their 352-person analysis indicates that the guidelines yield "a significant probability statins would not be recommended in [HIV-positive] adults with abnormal carotid [intima media thickness] IMT levels."
The researchers noted that statin recommendations in the 2013 American College of Cardiology/American Heart Association guidelines rest on traditional atherosclerotic cardiovascular disease risk factors. But traditional risk factors do not accurately predict atherosclerotic cardiovascular disease in people with HIV. Carotid ultrasound may indicate atherosclerosis that will respond to statins not recommended by the ACC/AHA guidelines for people with HIV.
To address this possibility, the UCSF team focused on 352 HIV-positive adults without a history of atherosclerotic cardiovascular disease. The researchers determined their eligibility for statin therapy with both the 2013 ACC/AHA guidelines and the 2004 Adult Treatment Panel III (ATP3) guidelines. They used carotid B-mode ultrasound to measure carotid intima media thickness (cIMT) in 12 segments, and they defined carotid plaque as cIMT greater than 1.5 mm at any site.
Of the 352 study participants, 93 (26%) met ACC/AHA criteria for statin therapy and 259 (74%) did not. The statin-eligible group was significantly older (median 53 versus 43, P < 0.0001) and included a higher proportion of blacks (35% versus 25%) and a lower proportion of whites (53% versus 61%) (P = 0.01). The statin group had a higher proportion of men than the nonstatin group (92% versus 85%) and a lower proportion of women (5% versus 14%) (P = 0.08). HIV duration was significantly longer in the statin-eligible group (15 versus 11 years, P < 0.0001). Other factors significantly more prevalent in the statin-eligible group were lipodystrophy, hypertension, diabetes, any smoking, and aspirin use. The statin group took protease inhibitors for a median of 2.8 years, compared with 0.5 years in the nonstatin group (P = 0.05).
ACC/AHA guidelines proved more likely to recommend statins for this HIV population (26%) than do ATP3 guidelines (14%). Both sets of guidelines fail to recommend statins for most people in the HIV group with baseline evidence of carotid plaque. ACC/AHA gave the statin green light to only 32.2% with baseline plaque, while ATP3 endorsed statins for only 17.4% with baseline plaque (ACC/AHA versus ATP3, P = 0.0002).
Multivariate analysis adjusted for gender, race, and disease status identified four factors independently associated with baseline carotid plaque: each decade of age (prevalence ratio [PR] 1.41, P = 0.002), opportunistic infection (PR 1.53, P = 0.001), each 10 pack-years of smoking (PR 1.05, P = 0.05), and each doubling of low-density lipoprotein (LDL) cholesterol (PR 1.5, P = 0.005).
The researchers concluded that the ACC/AHA guidelines and the ATP3 guidelines fail to recommend statins for a sizeable proportion of HIV-positive people with ultrasound evidence of carotid plaque. Although the probability of a statin go-ahead with ACC/AHA rose with increasing cIMT, they added, "there remains a significant probability statins would not be recommended in adults with abnormal carotid IMT levels." The UCSF team suggested that HIV-specific cholesterol guidelines that include detection of subclinical atherosclerosis may identify HIV-positive people with a heightened risk of cardiovascular disease who may benefit from statins.
Reference
1. Weigel B, Phan BAP, Ma Y, et al. 2013 ACC/AHA guideline undertreats HIV-infected adults with atherosclerosis. Conference on Retroviruses and Opportunistic Infections (CROI), February 22-25, 2016, Boston. Abstract 643.
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