Only half of HIV-positive patients at a Chicago clinic eligible for statin therapy according to the latest US guidelines are receiving this treatment, investigators report in the online edition of the Journal of Acquired Immune Deficiency Syndromes. The researchers say their findings raise concerns about suboptimal cardiovascular disease (CVD) prevention among people living with HIV.
The study also found that only a third of patients potentially eligible for statins as preventative treatment, as distinct from treatment of diagnosed CVD, were receiving statin therapy. More reassuringly, the majority of patients with clinical CVD and/or diabetes were taking statins.
“Less than half of those for whom statins are recommended by 2013…guidelines were prescribed statins,” comment the authors. “Though we acknowledge that current cardiovascular guidelines have not been validated for the HIV+ population, this study highlights potentially suboptimal CVD prevention and management among HIV+ patients.”
People living with HIV have an increased risk of CVD, even when their viral load is undetectable. Despite this, HIV is not mentioned as a consideration in the 2013 edition of the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for assessing CVD risk and use of lipid-lowering medications to prevent atherosclerotic cardiovascular disease (ASCVD) risk.
The US guidelines identified four groups of people who would benefit from statins: people with clinical CVD, people with LDL cholesterol of 190 mg/dL or above (> 4.9mmol/L), people with type 1 or 2 diabetes, or people aged 40-75 with an estimated CVD disease risk of 7.5% or above. (European AIDS Clinical Society 2016 guidelines recommend preventative statin treatment if the lifetime risk of CVD reaches 10% or above.)
There are limited data on statin use by people with HIV at risk of CVD. Investigators from the Infectious Diseases Center at Northwestern University therefore designed a retrospective study analysing the prescription of statins at their clinic to HIV-positive patients who would qualify for this therapy according to ACC/AHA 2013 guidelines.
The study population consisted of 460 patients. Most (81%) were male and the median age was 52 years.
Risk factors for statin use were the presence of existing CVD (coronary heart disease, peripheral arterial disease or prior stroke) or, age, race, gender, cholesterol, blood pressure, hypertension, diabetes mellitus and smoking.
On the basis of the 2013 ACC/AHA guidelines, 194 patients were eligible for statins. However, only 95 of these individuals (49%) were prescribed this treatment.
Patients were more likely to be prescribed statins if they had clinical ASCVD (OR = 46.5; 95% CI, 14-154, p < 0.0001) or diabetes mellitus (OR = 6.2; 95% CI, 3.4-11.4, p < 0.0001). Statins were prescribed to 93% of patients with ASCVD, 56% of patients with diabetes mellitus and 93% of individuals with both conditions.
However, patients with a ten-year risk score for CVD above 7.5% but no clinical disease were not significantly more likely to be prescribed statins, and only 29% of patients eligible for statins for CVD prevention were on this treatment.
White patients were more likely than black patients to be on statins (p = 0.015) but there was no significant gender difference (p = 0.059). Nor did viral load have a significant effect on the likelihood of being on statins.
“Available evidence strongly supports statin use in HIV+ patients,” write the investigators. “HIV+ persons are exceptionally vulnerable to ASCVD compared to the general population due to an increased burden of high-risk, non-calcified plaque and higher prevalence of ASCVD risk factors.”
They recommend that the 2013 ACC/AHA guidelines combined with an assessment of ten-year CVD risk should be used to determine which HIV-positive patients should be offered statins.
“The growing evidence of increased CVD risk in HIV+ patients, likely even higher than predicted by the ACC/AHA guidelines, underscores the need for corrective measures,” conclude the researchers. “Further studies are needed to evaluate 2013 ACC/AHA guidelines uptake in broader HIV+ patient populations, and strategies are needed to optimize compliance and best practice for cardiovascular health in HIV+ patients.”
Kelly SD et al. Statins prescribing practices in the comprehensive care for HIV-infected patients. J Acquir Immune Defic Syndr, online edition. DOI: 10.1097/QAI. 0000000000001454, 2017.