Comparison of four international cardiovascular disease prediction models and the prevalence of eligibility for lipid lowering therapy in HIV infected patients on antiretroviral therapy

AimTo compare four cardiovascular disease (CVD) risk models and to assess the prevalence of eligibility for lipid lowering therapy according to the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, European AIDS Clinical Society Guidelines (EACS), and European Society of Cardiology and the European Atherosclerosis Society (ESC/EAS) guidelines for CVD prevention in HIV infected patients on antiretroviral therapy.MethodsWe performed a cross-sectional analysis of 254 consecutive HIV infected patients aged 40 to 79 years who received antiretroviral therapy for at least 12 months. The patients were examined at the HIV-treatment centers in Belgrade and Zagreb in the period February-April 2011. We compared the following four CVD risk models: the Framingham risk score (FRS), European Systematic Coronary Risk Evaluation Score (SCORE), the Data Collection on Adverse Effects of Anti-HIV Drugs study (DAD), and the Pooled Cohort Atherosclerotic CVD risk (ASCVD) equations.ResultsThe prevalence of current smoking was 42.9%, hypertension 31.5%, and hypercholesterolemia (>6.2 mmol/L) 35.4%; 33.1% persons were overweight, 11.8% were obese, and 30.3% had metabolic syndrome. A high 5-year DAD CVD risk score (>5%) had substantial agreement with the elevated (≥7.5%) 10-year ASCVD risk equation score (kappa = 0.63). 21.3% persons were eligible for statin therapy according to EACS (95% confidence intervals [CI], 16.3% to 27.4%), 25.6% according to ESC/EAS (95% CI, 20.2% to 31.9%), and 37.9% according to ACC/AHA guidelines (95% CI, 31.6 to 44.6%).ConclusionIn our sample, agreement between the high DAD CVD risk score and other CVD high risk scores was not very good. The ACC/AHA guidelines would recommend statins more often than ESC/EAS and EACS guidelines. Current recommendations on treatment of dyslipidemia should be applied with caution in the HIV infected population.Observational studies found higher rates of myocardial infarction and cerebrovascular events in HIV infected than in uninfected persons (1-6). Hence, prevention of cardiovascular disease (CVD) in HIV infected patients should be an integral part of current clinical practice. In routine HIV clinical care in developed countries it is recommended to calculate the CVD risk using prediction models (7-9). Preventable and modifiable predisposing factors for CVD should be identified, and lifestyle and pharmacological interventions should be undertaken.CVD prevention in HIV-infected persons is mainly based on recommendations for the HIV uninfected population. The American College of Cardiology/American Heart Association (ACC/AHA) published the 2013 Guideline on the Assessment of Cardiovascular Risk (10) and the European Society of Cardiology and European Atherosclerosis Society (ESC/EAS) published one of the major European guidelines (11). The European AIDS Clinical Society (EACS) addresses many complications of HIV disease, including recommendations for lipid lowering therapy (7). All guidelines use different models for assessing cardiovascular risk. EACS recommends the Framingham Risk Scoring (FRS), while ESC/EAS recommends the European Systematic Coronary Risk Evaluation score (SCORE). The FRS has been widely used for estimation of coronary heart disease (angina, myocardial infarction, and coronary death), hard coronary events (myocardial infarction and coronary deaths), stroke, and global CVD (including CVD deaths, coronary disease, transient ischemic attack, and stroke) (12). SCORE estimates the 10-year risk of a first fatal atherosclerotic event (eg, myocardial infarction, stroke, aortic aneurysm), and calibrated versions exist to adjust for different death rates in European countries (13). These estimates have an important role in identifying high risk patients and in recommending lipid lowering therapy (7,11,14). ACC/AHA recommends the Pooled Cohort Equations for atherosclerotic cardiovascular disease (ASCVD) risk to evaluate the need for treatment of blood cholesterol levels in the non-HIV infected population (10).CVD risk estimation formulas are primarily intended to assist physicians in identifying high risk healthy persons older than 40 years with no signs of clinical atherosclerotic disease (7,10,11,14). Patients with diabetes are generally recommended more intensive interventions and considered at a higher risk for CVD (11,14). Cardiovascular risk models designed for the HIV infected population have also been developed, the most widely known is the Data Collection on Adverse Effects of Anti-HIV Drugs Study (DAD) risk equation, which also includes HIV-specific variables such as duration of indinavir or lopinavir use and current use of indinavir, lopinavir, or abacavir (15). However, the follow-up in the DAD Study is still relatively short and the DAD risk equation has yet not been formally recommended for CVD risk assessment in routine clinical care for HIV-infected persons.Southeastern European countries such as Bulgaria, Croatia, Hungary, Romania, and Serbia have high rates of age-standardized mortality from cardiovascular disease, (ie, ischemic heart disease and cerebrovascular disease) (16,17). The aim of our study was to analyze the agreement of the high DAD CVD score with other CVD scores (CVD-FRS, SCORE, ASCVD) developed for the non-HIV infected population in HIV infected patients receiving antiretroviral therapy (ART) in Croatia and Serbia. We also examined the prevalence of eligibility for lipid lowering therapy according to the 2013 ACC/AHA guidelines, EACS, and European ESC/EAS guidelines for cardiovascular disease prevention.