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June 2016
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Trends: Devices Used to Access the Guidelines Website

Update: What We're Reading
Cardiovascular Risk Scores and CVD Risk Reduction among People Living with HIV
Christopher J. Hoffmann, MD, MPH, Johns Hopkins University

Primary methods of preventing cardiovascular disease (CVD) with smoking cessation, control of hypertension, and use of aspirin and HMG-CoA reductase inhibitors can substantially reduce the risk of myocardial infarction. Guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) recommend risk-based prescription of HMG-CoA reductase inhibitors. The ACC/AHA guidelines use a specific population-based risk calculator; however, other scores are also available, including the Framingham Risk Score and the D:A:D cardiac risk score for people living with HIV (PLH). Among PLH, it remains unclear how well these scores predict risk of myocardial infarction caused by plaque rupture.

Monroe and colleagues [AIDS 2016, PMID 27203714] used data from the Multicenter AIDS Cohort Study (MACS), a multisite longitudinal cohort of HIV-infected and -uninfected men who have sex with men, to assess the performance of risk calculators for predicting coronary atherosclerosis, coronary calcium, or coronary stenosis of greater than 50%, as measured using cardiac computed tomography (CT). The authors reported a poor association between cardiac risk score and the presence of any plaque (area under the curve is 0.65 for PLH; an area under the curve of 0.5 indicates no correlation). Among PLH who were at low risk according to the ACC/AHA formula, 36% had a coronary artery calcium score greater than 0, 63% had any plaque (calcified and non-calcified), and 11% had greater than 50% stenosis. Performance was marginally better for those without HIV infection; however, 53% with any plaque and 5.4% with greater than 50% stenosis were in the low-risk category.

There are several potential interpretations of these findings:
  • The MACS population is different from everyone else, and risk calculators do not apply.
  • Compared with the general population, PLH have different needs and risk profiles for some aspects of primary care, such as CVD risk management, and calculators may not be the best approach to CVD risk management in PLH.

Limitations of this study include its use of a cohort that is not representative of the general PLH population and its use of coronary calcium score and atherosclerosis on CT as opposed to hard endpoints, such as CVD events.

 
Studies such as this raise questions regarding use of HMG-CoA reductase inhibitors among PLH. In other words, are we treating the right people? The ongoing REPRIEVE clinical trial is aimed at helping to answer this question.

 

Don't Miss: Quick References Guides
The HIV Clinical Guidelines Program has published a series of quick reference guides for primary care providers: HIV in Older Adults, Mental Health Screening, and Insomnia Screening and Treatment. These pocket references are available online, as PDF downloads, or in print, through the NYSDOH Distribution Center.
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