Cardiovascular disease risk prediction by the American College of Cardiology (ACC)/American Heart Association (AHA) Atherosclerotic Cardiovascular Disease (ASCVD) risk score among HIV-infected patients in sub-Saharan Africa

Abstract

ObjectivesHIV-infected patients are at increased risk for cardiovascular disease (CVD). However, general population CVD risk prediction equations that identify HIV-infected patients at elevated risk have not been widely assessed in sub-Saharan African (SSA).MethodsHIV-infected adults from 30–50 years of age with documented viral suppression were enrolled into a cross-sectional study in Gaborone, Botswana. Participants were screened for CVD risk factors. Bilateral carotid intima-media thickness (cIMT) was measured and 10-year predicted risk of cardiovascular disease was calculated using the Pooled Cohorts Equation for atherosclerotic CVD (ASCVD) and the 2008 Framingham Risk Score (FRS) (National Cholesterol Education Program III–NCEP III). ASCVD ≥7.5%, FRS ≥10%, and cIMT≥75th percentile were considered elevated risk for CVD. Agreement in classification of participants as high-risk for CVD by cIMT and FRS or ASCVD risk score was assessed using McNemar`s Test. The optimal cIMT cut off-point that matched ASCVD predicted risk of ≥7.5% was assessed using Youden’s J index.ResultsAmong 208 HIV-infected patients (female: 55%, mean age 38 years), 78 (38%) met criteria for ASCVD calculation versus 130 (62%) who did not meet the criteria. ASCVD classified more participants as having elevated CVD risk than FRS (14.1% versus 2.6%, McNemar’s exact test p = 0.01), while also classifying similar proportion of participants as having elevated CVD like cIMT (14.1% versus 19.2%, McNemar’s exact test p = 0.34). Youden’s J calculated the optimal cut point at the 81st percentile for cIMT to correspond to an ASCVD score ≥7.5% (sensitivity = 72.7% and specificity = 88.1% with area under the curve for the receiver operating characteristic [AUC] of 0.82, 95% Mann-Whitney CI: 0.66–0.99).ConclusionWhile the ASCVD risk score classified more patients at elevated CVD risk than FRS, ASCVD score classified similar proportion of patients as high risk when compared with established subclinical atherosclerosis. However, potential CVD risk category misclassification by established equations such as ASCVD may still exist among HIV-infected patients; hence there is still a need for development of a CVD risk prediction equation tailored to HIV-infected patients in SSA.

The association between HIV and atherosclerotic cardiovascular disease in sub-Saharan Africa: a systematic review

“…Among patients on ART for more than 34 months in Cameroon, 61% had one CVD risk factor, and 18% had two or more CVD risk factors [ 90 ]. Among virologically suppressed PLWH ages 40-50 in Botswana, the American Heart Association (AHA)/American College of Cardiology (ACC) risk equation demonstrated elevated risk of CVD outcomes, which correlated with cIMT measurements [ 91 ]. However, only 3.6% of patients who were actively screened for CVD risk factors in a South African study were found to have more than a 10% risk of a CVD event in the next 10 years, using a risk stratification tool from the World Health Organization and International Society of Hypertension [ 63 ].…”

Prevention of cardiovascular disease among people living with HIV in sub-Saharan Africa

“…85 For example, studies in the United States have under-predicted CVD risk for both CAD and stroke events for PLWH, 162 more pronounced in African Americans. 163 Studies in both Botswana and Uganda have shown only modest correlations between the Framingham Risk Score, the Atherosclerotic Cardiovascular Disease (ASCVD) Risk Score, and the Reynolds Risk Score and presence of pre-clinical atherosclerosis measured with cIMT 165 Consequently, as efforts are made to improve CVD event data collection, an important parallel effort is needed to develop CVD risk prediction models that are better suited to populations of PLWH in SSA.…”

Quantifying the burden of cardiovascular diseases among people living with HIV in sub-Saharan Africa: findings from a modeling study for Uganda

“…Note: 77% of HIV-infected women and 54% of HIV-infected men were on ART risk profile, 18 to prevent over-or under-estimation of CVD risk when models developed for high-income countries are used in sub-Saharan African populations. 28 We also revised the model to include the direct effect of HIV.…”