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Pan M, Manza-A. Agovi A, Anikpo IO, Fasanmi EO, Thompson EL, Reeves JM, Thompson CT, Johnson ME, Golub V, Ojha RP. Effect of 2018 American College of Cardiology/American Heart Association Guideline Change on Statin Prescription for People Living with HIV. Prev Med Rep 2023; 33:102175. [PMID: 36968517 PMCID: PMC10034116 DOI: 10.1016/j.pmedr.2023.102175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/23/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines were updated in 2018 to explicitly recommend statin use for primary cardiovascular disease prevention among people living with HIV (PLWH), but little is known about the effect of this guideline change. We aimed to assess the effect of the 2018 ACC/AHA guideline change on statin prescription among PLWH. We used data from an institutional HIV registry to identify PLWH aged 40-75 years, engaged in HIV care between June 2016 and May 2021, had a LDL cholesterol between 70 and 189 mg/dl, 10-year atherosclerotic cardiovascular disease (ASCVD) risk score ≥7.5%, no prior statin prescription, and no history of diabetes or ASCVD. Our outcome of interest was a new statin prescription within 12 months of eligibility. We estimated standardized risk difference (RD) with 95% confidence limits (CL) by comparing prescription probabilities before and after guideline change. Our study population comprised 251 PLWH (171 before, 80 after the guideline change), of whom 57% were aged <55 years, 82% were male, and 45% were non-Hispanic black. The standardized 12-month statin prescription risk was 43% (95% CL: 31%, 60%) after the guideline change and 19% (95% CL: 13%, 26%) before the guideline change (RD = 25%, 95% CL: 9.1%, 40%). Our results suggest that the 2018 ACC/AHA guideline change increased statin prescription among PLWH, but a sizable proportion of eligible PLWH were not prescribed statin. Future studies are needed to identify strategies to enhance implementation of statin prescription guidelines among PLWH.
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Marcantoni E, Garshick MS, Schwartz T, Ratnapala N, Cambria M, Dann R, O’Brien M, Heguy A, Berger JS. Antiplatelet Effects of Clopidogrel Vs Aspirin in Virologically Controlled HIV: A Randomized Controlled Trial. JACC Basic Transl Sci 2022; 7:1086-1097. [PMID: 36687270 PMCID: PMC9849466 DOI: 10.1016/j.jacbts.2022.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 11/16/2022]
Abstract
Patients with HIV exhibit platelet activation and increased risk of cardiovascular disease, the prevention of which is not fully known. Fifty-five HIV-positive patients were randomized to clopidogrel, aspirin, or no-treatment for 14 days, and the platelet phenotype and ability to induce endothelial inflammation assessed. Clopidogrel as opposed to aspirin and no-treatment reduced platelet activation (P-selectin and PAC-1 expression). Compared with baseline, platelet-induced proinflammatory transcript expression of cultured endothelial cells were reduced in those assigned to clopidogrel, with no change in the aspirin and no-treatment arms. In HIV, clinical trials of clopidogrel to prevent cardiovascular disease are warranted. (Antiplatelet Therapy in HIV; NCT02559414).
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Affiliation(s)
- Emanuela Marcantoni
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Michael S. Garshick
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA,Center for the Prevention of Cardiovascular Disease, Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Tamar Schwartz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Nicole Ratnapala
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Matthew Cambria
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University School of Medicine, New York, New York, USA
| | - Rebecca Dann
- New York Medical College, Valhalla, New York, USA
| | - Meagan O’Brien
- Regeneron Pharmaceuticals, Inc, Tarrytown, New York, USA
| | - Adriana Heguy
- Genome Technology Center, New York University School of Medicine, New York, New York, USA
| | - Jeffrey S. Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York, USA,Center for the Prevention of Cardiovascular Disease, Department of Medicine, New York University School of Medicine, New York, New York, USA,Division of Hematology, Department of Medicine, New York University School of Medicine, New York, New York, USA,Division of Vascular Surgery, Department of Surgery, New York University School of Medicine, New York, New York, USA,Address for correspondence: Dr Jeffrey S. Berger, Center for the Prevention of Cardiovascular Disease, New York University School of Medicine, 435 East 30th Street, 7th Floor, New York, New York 10016, USA. @plateletdoc
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Fitch KV, Fulda ES, Grinspoon SK. Statins for primary cardiovascular disease prevention among people with HIV: emergent directions. Curr Opin HIV AIDS 2022; 17:293-300. [PMID: 35938463 PMCID: PMC9415230 DOI: 10.1097/coh.0000000000000752] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW While people with HIV (PWH) are living longer due to advances in antiretroviral therapy, recent data have demonstrated an increased risk of cardiovascular disease (CVD) among this population. This increased risk is thought to be due to both traditional (for example, smoking, diabetes) and HIV-specific (for example, inflammation, persistent immune activation) risk factors. This review focuses on the potential for statin therapy to mitigate this increased risk. RECENT FINDINGS Several randomized clinical trials have demonstrated that statins, a class of lipid-lowering medications, are effective as a primary CVD prevention strategy among people without HIV. Among PWH, statins have been shown to lower cholesterol, exert immunomodulatory effects, stabilize coronary atherosclerotic plaque, and even induce plaque regression. SUMMARY Prevention of CVD among the aging population of people with controlled, but chronic, HIV is vital. Data exploring primary prevention in this context are thus far limited. The Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE) is ongoing; this trial will inform the field by investigating the effects of pitavastatin calcium as a primary prevention strategy for major adverse cardiovascular events among PWH on antiretroviral therapy (ART) at low-to-moderate traditional CVD risk.
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Affiliation(s)
- Kathleen V Fitch
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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York LD, Fisher JM, Malladi L, August JA, Ellis KE, Marquez JL, Kaveti A, Khachatryan M, Paz MK, Adams MD, Bedrick EJ, Fantry LE. Antiretroviral Laboratory Monitoring and Implications for HIV Clinical Care in the Era of COVID-19 and Beyond. AIDS Res Hum Retroviruses 2021; 37:297-303. [PMID: 33567992 DOI: 10.1089/aid.2020.0263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In the era of COVID-19, providers are delaying laboratory testing in people with HIV (PWH). The purpose of this study was to examine the clinical significance of renal, liver, and lipid testing. We reviewed the charts of 261 PWH who initiated care at an academic HIV clinic between January 1, 2016 and December 21, 2018. Analysis included one-sided binomial exact tests and multiple linear, Poisson, and Beta regression models. The most common abnormality was a glomerular filtration rate (GFR) <60 mL/min (10%). Age <40 years [estimated relative rate (rr) 0.017, 95% confidence interval (CI) 0.207 to 0.494], cobicistat (rr 0.284, 95% CI 0.128 to 0.63), and tenofovir alafenamide (rr 0.295 95% CI 0.151 to 0.573) were associated with a decreased risk of GFR <60 mL/min. An increased AST and ALT ≥2 × upper limit of normal (ULN) was found in 5% and 3%, respectively. Hepatitis C and use of darunavir and lopinavir were associated with increased AST or ALT. When a GFR was <60 mL/min or an AST or ALT was ≥2 × ULN, no action was taken in 53% of cases. In 18% of cases the only intervention was repeat testing. The most common interventions after lipid results were calculation of a 10-year cardiovascular risk score (31%) and addition of a statin (18%). Taking action after lipid results was strongly associated with age ≥40 (rr 7.37, 95% CI 3.0 to 18.3). Young PWH without hepatitis C rarely have renal, liver, or lipid test results that alter clinical care. Decreased testing should be considered.
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Affiliation(s)
- Lawrence D York
- Department of Medicine, University of Arizona, College of Medicine, Tucson, Arizona, USA
| | - Julia M Fisher
- Statistics Consulting Laboratory, BIO5 Institute, University of Arizona, Tucson, Arizona, USA
| | - Lakshmeeramya Malladi
- College of Medicine, University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | | | - Kristen E Ellis
- Department of Medicine, University of Arizona, College of Medicine, Tucson, Arizona, USA
| | - Jose L Marquez
- Department of Medicine, University of Arizona, College of Medicine, Tucson, Arizona, USA
| | - Ashwini Kaveti
- College of Medicine, University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | - Marine Khachatryan
- College of Medicine, University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | - Marissa K Paz
- College of Medicine, University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | - Matthew D Adams
- Department of Medicine, University of Arizona, College of Medicine, Tucson, Arizona, USA
| | - Edward J Bedrick
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona Health Sciences Center, Tuscon, Arizona, USA
| | - Lori E Fantry
- Department of Medicine, University of Arizona, College of Medicine, Tucson, Arizona, USA
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Nguyen I, Kim AS, Chow FC. Prevention of stroke in people living with HIV. Prog Cardiovasc Dis 2020; 63:160-169. [PMID: 32014514 PMCID: PMC7237326 DOI: 10.1016/j.pcad.2020.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 01/29/2020] [Indexed: 12/13/2022]
Abstract
In the era of effective antiretroviral therapy (ART), HIV has become a manageable disease marked by an elevated risk of non-AIDS-related comorbidities, including stroke. Rates of stroke are higher in people living with HIV (PLWH) compared with the general population. Elevated stroke risk may be attributable to traditional risk factors, HIV-associated chronic inflammation and immune dysregulation, and possible adverse effects of long-standing ART use. Tailoring stroke prevention strategies for PLWH requires knowledge of how stroke pathogenesis may differ from non-HIV-associated stroke, knowledge of long-term stroke outcomes in HIV, and accurate stroke risk assessment tools. As a result, the approach to primary and secondary stroke prevention in PLWH relies heavily on guidelines developed for the general population, with an emphasis on optimization of traditional vascular risk factors and early initiation of ART. This review summarizes existing evidence on HIV-associated stroke mechanisms and considerations for stroke prevention for PLWH.
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Affiliation(s)
- Ivy Nguyen
- Department of Neurology, University of California, San Francisco, CA, United States of America
| | - Anthony S Kim
- Department of Neurology, University of California, San Francisco, CA, United States of America
| | - Felicia C Chow
- Department of Neurology, University of California, San Francisco, CA, United States of America; Department of Medicine, Division of Infectious Diseases, University of California San Francisco, CA, United States of America.
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Abstract
PURPOSE OF REVIEW The aim of this study was to discuss the most recent research in the management of cardiovascular disease (CVD) in people living with HIV (PLWHIV) with a focus on screening, primary and secondary prevention. RECENT FINDINGS The cause of CVD in PLWHIV is complex and multifactorial and creates a demand for a multifaceted approach to screening and prevention. Current screening and management of CVD risk factors in PLWHIV is suboptimal, reasons for this are not clear and the data are still scarce both in the primary and secondary preventive setting. There are no optimal routine risk screening tools available to accurately detect early and subclinical disease; PLWHIV are undertreated with preventive drugs such as statins and aspirin and antihypertensives; there are still no programmes that have been shown significantly efficient over time with regards to improved smoking cessation, increased physical activity and optimal diet, and recent reports call for intensified focus on HIV-positive women as a particularly vulnerable subgroup. SUMMARY There is a need for further studies investigating barriers to optimal CVD risk factor management in PLWHIV and an increased focus of CVD prevention in HIV-positive women.
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Todd JV, Cole SR, Wohl DA, Simpson RJ, Jonsson Funk M, Brookhart MA, Cocohoba J, Merenstein D, Sharma A, Lazar J, Milam J, Cohen M, Gange S, Lewis TT, Burkholder G, Adimora AA. Underutilization of Statins When Indicated in HIV-Seropositive and Seronegative Women. AIDS Patient Care STDS 2017; 31:447-454. [PMID: 29087746 DOI: 10.1089/apc.2017.0145] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Increased life expectancy of persons living with HIV infection receiving antiretroviral therapy heightens the importance of preventing and treating chronic comorbidities such as cardiovascular disease. While guidelines have increasingly advocated more aggressive use of statins for low-density lipoprotein (LDL) cholesterol reduction, it is unclear whether people with HIV, especially women, are receiving statins when indicated, and whether their HIV disease is a factor in access. We assessed the cumulative incidence of statin use after an indication in the Women's Interagency HIV Study (WIHS), from 2000 to 2014. Additionally, we used weighted proportional hazards regression to estimate the effect of HIV serostatus on the time to initiation of a statin after an indication. Cumulative incidence of statin use 5 years after an indication was low: 38% in HIV-seropositive women and 30% in HIV-seronegative women. Compared to HIV-seronegative women, the weighted hazard ratio for initiation of a statin for HIV-seropositive women over 5 years was 0.94 [95% confidence interval (CI) 0.62, 1.43]. Applying the American College of Cardiology and the American Heart Association (ACC/AHA) guidelines increased the proportion of HIV-seropositive women with a statin indication from 16% to 45%. Clinicians treating HIV-seropositive women should consider more aggressive management of the dyslipidemia often found in this population.
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Affiliation(s)
- Jonathan V Todd
- 1 Institute for Global Health and Infectious Diseases, University of North Carolina , Chapel Hill, North Carolina
- 2 Department of Epidemiology, University of North Carolina , Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Stephen R Cole
- 1 Institute for Global Health and Infectious Diseases, University of North Carolina , Chapel Hill, North Carolina
- 2 Department of Epidemiology, University of North Carolina , Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - David A Wohl
- 1 Institute for Global Health and Infectious Diseases, University of North Carolina , Chapel Hill, North Carolina
| | - Ross J Simpson
- 3 Division of Cardiology, Department of Medicine, University of North Carolina , Chapel Hill, North Carolina
| | - Michele Jonsson Funk
- 2 Department of Epidemiology, University of North Carolina , Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - M Alan Brookhart
- 2 Department of Epidemiology, University of North Carolina , Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Jennifer Cocohoba
- 4 Department of Clinical Pharmacy, University of California San Francisco School of Pharmacy , San Francisco, California
| | - Daniel Merenstein
- 5 Department of Family Medicine, Georgetown University Medical Center , Washington, District of Columbia
| | - Anjali Sharma
- 6 Department of Medicine, Albert Einstein College of Medicine , Bronx, New York
| | - Jason Lazar
- 7 Department of Cardiovascular Disease, SUNY Downstate Medical Center , Brooklyn, New York
| | - Joel Milam
- 8 Department of Preventive Medicine, Keck School of Medicine, University of Southern California , Los Angeles, California
| | - Mardge Cohen
- 9 Department of Medicine, Cook County Health and Hospital System and Rush University , Chicago, Illinois
| | - Stephen Gange
- 10 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Tené T Lewis
- 11 Department of Epidemiology, Rollins School of Public Health, Emory University , Atlanta, Georgia
| | - Greer Burkholder
- 12 Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Adaora A Adimora
- 1 Institute for Global Health and Infectious Diseases, University of North Carolina , Chapel Hill, North Carolina
- 2 Department of Epidemiology, University of North Carolina , Gillings School of Global Public Health, Chapel Hill, North Carolina
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Relationship Between HIV Infection, Antiretroviral Therapy, Inflammatory Markers, and Cerebrovascular Endothelial Function Among Adults in Urban China. J Acquir Immune Defic Syndr 2017; 74:339-346. [PMID: 27875362 DOI: 10.1097/qai.0000000000001254] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cerebrovascular risk is increased in people living with HIV infection compared with age-matched uninfected individuals. Cerebrovascular endothelial dysfunction related to antiretroviral therapy (ART) and inflammation may contribute to higher stroke risk in HIV infection. METHODS We compared cerebral vasoreactivity-a measure of cerebrovascular endothelial function assessed by the breath-holding index (BHI) using transcranial Doppler ultrasound-between virologically suppressed Chinese HIV-infected individuals followed in an HIV clinic in Beijing, China, and uninfected controls. We constructed mixed-effects models to evaluate the association of HIV, ART, and inflammatory markers with cerebral vasoreactivity. RESULTS In an unadjusted model, HIV infection was associated with a trend toward lower cerebral vasoreactivity (BHI 1.08 versus 1.26, P = 0.079). In multivariable analyses, cholesterol modified the association between HIV infection and cerebral vasoreactivity (P = 0.015 for interaction). At a lower total cholesterol of 4.15 mmol/L, HIV was associated with lower cerebral vasoreactivity (BHI -0.28, P = 0.019), whereas at a cholesterol of 5.15 mmol/L, the reduction in cerebral vasoreactivity associated with HIV was no longer statistically significant (BHI -0.05, P = 0.64). Among HIV-infected individuals, use of lopinavir/ritonavir compared with efavirenz was associated with lower cerebral vasoreactivity (BHI -0.24, P = 0.040). We did not find a significant association between inflammatory markers and cerebral vasoreactivity. CONCLUSIONS Cerebrovascular endothelial dysfunction associated with HIV infection may be most relevant for individuals with less traditional vascular risk, such as those with lower cholesterol. Further study of the impact of ART on cerebrovascular endothelial function is warranted to aid with ART selection in individuals at high cerebrovascular risk.
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