Utility of 2013 American College of Cardiology/American Heart Association Cholesterol Guidelines in HIV-Infected Adults With Carotid Atherosclerosis

Abstract

Background—Although HIV is associated with increased atherosclerotic cardiovascular disease (CVD) risk, it is unknown whether guidelines can identify HIV-infected adults who may benefit from statins. We compared the 2013 American College of Cardiology/American Heart Association and 2004 Adult Treatment Panel III recommendations in HIV-infected adults and evaluated associations with carotid artery intima-media thickness and plaque.Methods and Results—Carotid artery intima-media thickness was measured at baseline and 3 years later in 352 HIV-infected adults without clinical atherosclerotic CVD and not on statins. Plaque was defined as IMT >1.5 mm in any segment. At baseline, the median age was 43 (interquartile range, 39–49), 85% were men, 74% were on antiretroviral medication, and 50% had plaque. The American College of Cardiology/American Heart Association guidelines were more likely to recommend statins compared with the Adult Treatment Panel III guidelines, both overall (26% versus 14%; P<0.001), in those with plaque (32% versus 17%; P=0.0002), and in those without plaque (16% versus 7%; P=0.025). In multivariable analysis, older age, higher low-density lipoprotein cholesterol, pack per year of smoking, and history of opportunistic infection were associated with baseline plaque. Baseline IMT (hazard ratio, 1.18 per 10% increment; 95% confidence interval, 1.05–1.33; P=0.005) and plaque (hazard ratio, 2.06; 95% confidence interval, 1.02–4.08; P=0.037) were each associated with all-cause mortality, independent of traditional CVD risk factors.Conclusions—Although the American College of Cardiology/American Heart Association guidelines recommended statins to a greater number of HIV-infected adults compared with the Adult Treatment Panel III guidelines, both failed to recommend therapy in the majority of HIV-affected adults with carotid plaque. Baseline carotid atherosclerosis but not atherosclerotic CVD risk scores was an independent predictor of mortality. HIV-specific guidelines that include detection of subclinical atherosclerosis may help to identify HIV-infected adults who are at increased atherosclerotic CVD risk and may be considered for statins.

Cardiovascular Disease Imaging in HIV

“…10 ] These data expand a growing body of literature describing the unique nature of CVD and using advanced cardiovascular imaging to help us to extend our understanding of the disease. Similar to the study of Phan et al, 9 other studies using coronary computed tomography angiography have demonstrated an increased presence and extent of coronary artery disease, including noncalcified coronary plaque 11,12 and high-risk coronary plaque features, such as low attenuation and positive remodeling, accompanied by increased indices of immune activation. 13 Overall, these data suggest that an increase in systemic inflammation and immune activation manifests itself in a premature CVD phenotype, including disease in large and small vascular beds in patients with HIV.…”

“…Data from the current study concur with prior data in HIV-infected and noninfected populations that the new 2013 ACC/AHA guidelines identify more HIV patients with subclinical CVD CVD Imaging in HIV for statins than the Adult Treatment Panel III guidelines. 15 Of note, Phan et al 9 demonstrate that the presence of plaque, not the risk prediction scores, predicted overall mortality. In contrast, the new guidelines fare far better in non-HIV populations.…”

“…In contrast, the new guidelines fare far better in non-HIV populations. 9 For example, the proportion of subjects with significant coronary artery calcium who would have been recommended for statin therapy increased from 34% (using the Adult Treatment Panel III) to 85% under the new guidelines, thus identifying a much higher proportion of high-risk phenotype than in HIV-infected populations. 15 However, differences in the presentation of subclinical plaque between HIV and non-HIV patients, for example, the presence of more noncalcified plaque in HIV, demand that optimal imaging strategies be developed for the HIV group.…”

Comparing rates of statin therapy in eligible patients living with HIV versus uninfected patients

“…Despite broader statin eligibility with the ACC/AHA guidelines, patients without a history of clinical ASCVD with subclinical plaques failed to be included in previous studies [15][16][17]. A retrospective cohort study (n = 352) of PLWH without clinical ASCVD with a subclinical carotid plaque found that the 2013 ACC/AHA guidelines were more likely to recommend a statin agent than older lipid guidelines (for 32% versus 17% of patients, respectively; P = 0.0002) [16]. Similar results were observed in another retrospective cohort study (n = 108) of PLWH without clinical ASCVD and confirmed coronary atherosclerotic plaque on imaging, where the 2013 ACC/AHA guidelines were more likely to recommend a statin agent than older guidelines (for 26% versus 10% of patients, respectively; P = 0.04) [17].…”

Editorial Commentary: Clinical management of cardiovascular disease in HIV-infected patients

“…Specific management approaches for HIV-associated CVD is much needed considering the unique feature of non-calcified inflammatory plaques in HIV+ patients. Including the assessment of subclinical atherosclerosis by measuring carotid artery intima-media thickness via ultrasound 11 or assessment of plaque features by coronary computed tomography angiography 12 will greatly improve risk stratification models. Further, in HIV+ patients with MI, it is important to diagnose specific types of MI as type 1 (caused by atherosclerosis) and type 2 (caused by bacteremia and recent use of recreational drugs) because they may require different treatment approaches 13 .…”