Scientific statement calls for more research, clinical trials in this population
People living with HIV are at an increased risk of cardiovascular (CV) disease, and treatment and prevention in this population should target both HIV-specific and general CV risk factors, a scientific statement from the American Heart Association (AHA) said.
This population faces higher risks of CV sequelae, including myocardial infarction (MI) and heart failure, versus those who are uninfected, wrote Matthew J. Feinstein, MD, of Northwestern University in Evanston, Illinois, and colleagues, on behalf of the AHA.
Clinicians should assess the CV risk of people living with HIV using the tools available, keeping in mind that CV risk among this population may be higher than the risk calculators indicate, the authors wrote in Circulation.
"Considerable gaps exist in our knowledge about HIV-associated diseases of the heart and blood vessels, in part because HIV's transition from a fatal disease to a chronic condition is relatively recent, so long-term data on heart disease risks are limited," Feinstein said in a statement.
The authors cited research that found a 1.5-to 2-fold increased risk for manifestations of CV disease among people living with HIV versus uninfected individuals. A meta-analysis found that HIV-associated CV disease tripled over the past 2 decades, the authors said, accounting for 2.6 million disability-adjusted life-years per year.
The team speculated about a variety of mechanisms, including interplay between traditional and HIV-specific risk factors, as well as antiretroviral therapy-related dyslipidemia, behavioral factors, and disparities in access to care.
People living with HIV have an increased risk of MI and heart failure, the authors noted. They added that several studies have found that a lower CD4 count is linked with a higher risk of MI and that the risk for MI is higher even with sustained viral suppression or few CV risk factors for those living with HIV than among uninfected people.
Even after adjusting for previous MI, people living with HIV were linked to a more than 1.5-fold higher hazard for heart failure with both preserved ejection fraction and reduced ejection fraction, Feinstein and co-authors said. Unsuppressed viral load and lower CD4 count were both linked with higher risks of heart failure for people living with HIV, the team added.
To assess CV risk factors in this population, the authors recommended tools such as the AHA/American College of Cardiology (ACC) Atherosclerotic Disease Risk Calculator, although they warned that people living with HIV may have a higher risk than these tools indicate -- "a clear best risk estimation model for HIV has not been identified," Feinstein and co-authors stated.
Due to the absence of such data, the authors recommended examining selected Atherosclerotic Cardiovascular Disease risk enhancers previously identified for people living with HIV via the 2018 ACC/AHA cholesterol clinical practice guidelines, including:
- Early history of MI or stroke in men younger than age 55 and women younger than 65
- Persistently elevated low-density lipoprotein-cholesterol (LDL-C) of at least 160 mg/dL
- Preeclampsia or premature menopause
- Subclinical atherosclerosis on imaging (including coronary artery calcium scores)
Treatment and prevention guidelines are similar to those for the general population, the authors said, with emphasis on a healthy lifestyle, including cessation of smoking, heavy drinking, and adherence to ACC/AHA dietary guidelines.
Pharmacotherapy is another potential option -- the authors wrote that statins were linked with a significant reduction in CV events among people living with HIV with increased inflammation and low levels of LDL cholesterol. A clinical trial from the NIH called REPRIEVE was recently launched to explore statin therapy for primary CV prevention in people living with HIV.
The authors of the scientific statement also addressed disparities in care, which remains an important factor for people living with HIV, who can represent a "vulnerable and often stigmatized population." Feinstein, et al. cited statistics showing that people living with HIV with CV disease have fewer clinic visits meeting guidelines for aspirin therapy and use of statins.
The authors called for "targeted attention and investment" for this population, stating that people living with HIV who also have CV disease often need "longer visit times, care coordination, and multidisciplinary team engagement."
"There is a dearth of large-scale clinical trial data on how to prevent and treat cardiovascular diseases in people living with HIV," Feinstein concluded in his statement. "This is an area of research that is needed for informed decision-making and effective CVD prevention and treatment in the aging population of people living with HIV."
Feinstein disclosed support from the AHA and the NIH.
Other co-authors disclosed support from the NIH, Regeneron/Sanofi, Novartis, Gilead, Merck, Theratechnologies, KOWA, and Navidea.
Source Reference: Feinstein MJ, et al "Characteristics, prevention, and management of cardiovascular disease in people living with HIV: A scientific statement from the American Heart Association" Circulation 2019; DOI: 10.1161/CIR.0000000000000695.
Read the original article on Medpage Today: AHA: Heart Disease a Growing Problem in HIV