AHA Scientific Statement on CVD and HIV

Megan Brooks

June 03, 2019

A new scientific statement from the American Heart Association (AHA) provides "pragmatic" recommendations on how to approach cardiovascular disease (CVD) prevention and management in the growing number of people living with HIV infection.

The statement was published online June 3 in Circulation.

With the advent of highly effective antiretroviral therapy (ART), HIV has transitioned from a progressive, fatal disease to a chronic manageable disease marked by increased risk for chronic comorbid diseases, including CVD, the statement notes.

Compared with uninfected peers, people living with HIV have up to a twofold higher risk for various CVD manifestations, such as myocardial infarction (MI), ischemic stroke, heart failure, pulmonary hypertension, and venous thrombosis.

The underlying mechanisms for the increase likely include an interplay among traditional risk factors, HIV-specific factors (chronic immune activation/inflammation), ART-related dyslipidemia and other metabolic comorbidities, behavioral factors (smoking alcohol use, low levels of physical activity), and disparities in access to or receipt of care.

"CVD risk assessment in HIV is challenging given the relatively recent evolution of HIV as a chronic disease and the resulting dearth of long-term data on CVD incidence in the modern ART era," notes the writing group, led by Matthew J. Feinstein, MD, assistant professor of medicine and preventive medicine, Feinberg School of Medicine, Northwestern University, Chicago.

For now, the statement advises a nuanced approach to assess CVD risk in a person living with HIV. This includes quantifying traditional CVD risk-factor burden using tools such as the atherosclerotic disease risk calculator from the AHA and the American College of Cardiology (ACC), which estimates a person's 10-year risk for MI, stroke, or other CV condition, as a starting point.

The statement cautions, however, that people living with HIV may have a higher risk than indicated by the calculator, and additional considerations should be factored into the CVD risk assessment. These include low current or nadir CD4 count or a history of prolonged viremia, and family history of premature atherosclerotic CVD, chronic kidney disease, or atherosclerosis on imaging.

As in the general population, maintaining a healthy lifestyle that includes smoking cessation, adequate physical activity, eliminating or reducing alcohol intake, and a healthy diet are also important in people living with HIV.

The statement calls for future studies to address gaps in implementation to ensure that people living with HIV who are at risk for or have CVD are identified and provided appropriate CVD care. "If these steps are taken, perhaps we can reverse the trend of the growing burden of CVD in HIV," the authors conclude.

Another area of concern is the aging population; 75% of people living with HIV are older than 45 years, Jules Levin notes in a patient perspective published with the statement.

"Aging with HIV differs greatly from the aging issues facing the general population," says Levin, who has been living with HIV for 35 years and is the founder and executive director of the National AIDS Treatment Advocacy Project.

On average, people living with HIV who are older than 60 years old have three to seven comorbid medical conditions, and many take 12 to 15 medications daily, Levin points out.

"As they age, people living with HIV are often alone and disabled, emotionally homebound due to depression, and are socially isolated. In addition, they often suffer from lack of mobility and an impaired ability to perform normal daily functions," he says.

"Ultimately, if we are to curb the oncoming epidemic of HIV and aging, we will need better awareness and more patient-focused research and care efforts. We owe better to the aging population of people living with HIV, without whose years of advocacy and engagement in research and care we would undoubtedly be in a worse position than we are today," Levin concludes.

Feinstein has served as a consultant for Gilead and Merck & Co. Disclosures for the writing committee are listed in the paper. Levin has disclosed no conflicts of interest.

Circulation. Published online June 3, 2019. Full text, Patient perspective

 

 

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