Tyler Lonergan, MD, of the UC San Diego Owen Clinic, presents "Stemming the Tide of Cardiovascular Disease: Transitioning from OI to CVD Prophylaxis" for AIDS Clinical Rounds at UC San Diego
Clinical Professor
UC San Diego Owen Clinic
Cardiovascular Disease in HIV-Infected Patients.Predict It and Prevent It.2015Hivlife Info
In this downloadable slideset, Priscilla Y. Hsue, MD, and David A. Wohl, MD, discuss data on using traditional and newer markers and modalities to predict and prevent cardiovascular disease in HIV-infected patients.
Format: Microsoft PowerPoint (.ppt)
File size: 3.21 MB
Date posted: 7/16/2015
HIV and Cardiovascular Disease.How Worried Should We Be ? 2015Hivlife Info
In this downloadable slideset, David A. Wohl, MD, reviews the association between HIV and cardiovascular disease, including potential contributing factors and best practices in prevention.
Format: Microsoft PowerPoint (.ppt)
File size: 5.01 MB
Date posted: 6/26/2015
There are numerous studies that report anemia and hematological
abnormalities in patients with human immunodeficiency virus (HIV) infection
and acquired immunodeficiency syndrome (AIDS). Highly Active Antiretroviral
therapy (HAART) is the best suited regimen that is potent enough to reduce the
viral load in patients with HIV/AIDS. On the other hand, this regimen has the
tendency to cause anemia and bone marrow suppression. We report a case of 26
years female patient confirmed with HIV infection since 6 months and is on
Zidovudine, Lamivudine and Nevirapine therapy for the past 4 months. While the
patient was in this regimen it leads to severe anemia and acute gastritis. The
relationship between the suspected drug and reaction was established by
performing casualty assessment. There is a need of close monitoring at regular
intervals to find the development of bone marrow toxicity and other
complications which help in prevention and better management of disease and
therapy problems
Evolution and Revolution: Current Issues in HIV and HCV Co-infection
Chapter 1 – HIV-Hepatitis C Virus Co-infection: An evolving epidemic
Chapter 2 - Management of HIV infection in HIV/HCV co-infected patients
Chapter 3 - Management of HCV in co-infected patients
Chapter 4 - HCV Therapy: Direct acting antiviral agents in co-infected individuals
Chapter 5 - Drug interactions with directly acting antivirals for HCV: Overview & challenges in HIV/HCV Co-infection
Chapter 6 - Complicated cases
Chapter 7 - Future trials of Hepatitis C therapy in the HIV co-infected
Chapter 8 - HCV infection in marginalized populations
Chapter 9 - HIV/HCV Co-infection: Through the eyes of a co-infected hemophiliac
Cardiovascular Disease in HIV-Infected Patients.Predict It and Prevent It.2015Hivlife Info
In this downloadable slideset, Priscilla Y. Hsue, MD, and David A. Wohl, MD, discuss data on using traditional and newer markers and modalities to predict and prevent cardiovascular disease in HIV-infected patients.
Format: Microsoft PowerPoint (.ppt)
File size: 3.21 MB
Date posted: 7/16/2015
HIV and Cardiovascular Disease.How Worried Should We Be ? 2015Hivlife Info
In this downloadable slideset, David A. Wohl, MD, reviews the association between HIV and cardiovascular disease, including potential contributing factors and best practices in prevention.
Format: Microsoft PowerPoint (.ppt)
File size: 5.01 MB
Date posted: 6/26/2015
There are numerous studies that report anemia and hematological
abnormalities in patients with human immunodeficiency virus (HIV) infection
and acquired immunodeficiency syndrome (AIDS). Highly Active Antiretroviral
therapy (HAART) is the best suited regimen that is potent enough to reduce the
viral load in patients with HIV/AIDS. On the other hand, this regimen has the
tendency to cause anemia and bone marrow suppression. We report a case of 26
years female patient confirmed with HIV infection since 6 months and is on
Zidovudine, Lamivudine and Nevirapine therapy for the past 4 months. While the
patient was in this regimen it leads to severe anemia and acute gastritis. The
relationship between the suspected drug and reaction was established by
performing casualty assessment. There is a need of close monitoring at regular
intervals to find the development of bone marrow toxicity and other
complications which help in prevention and better management of disease and
therapy problems
Evolution and Revolution: Current Issues in HIV and HCV Co-infection
Chapter 1 – HIV-Hepatitis C Virus Co-infection: An evolving epidemic
Chapter 2 - Management of HIV infection in HIV/HCV co-infected patients
Chapter 3 - Management of HCV in co-infected patients
Chapter 4 - HCV Therapy: Direct acting antiviral agents in co-infected individuals
Chapter 5 - Drug interactions with directly acting antivirals for HCV: Overview & challenges in HIV/HCV Co-infection
Chapter 6 - Complicated cases
Chapter 7 - Future trials of Hepatitis C therapy in the HIV co-infected
Chapter 8 - HCV infection in marginalized populations
Chapter 9 - HIV/HCV Co-infection: Through the eyes of a co-infected hemophiliac
Theodoros Katsivas, MD (UC San Diego Owen Clinic), Shira Abeles, MD (UC San Diego Owen Clinic) and Robyn Cunard, MD (UC San Diego) present "Renal Disease in HIV/AIDS"
Dr. Swamy Venuturupalli talks about the latest developments in lupus at the 2015 Latest on Lupus Patient Conference held by Lupus LA on Saturday October 17th at UCLA Medical Center.
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Management of Peripheral Neuropathy and Cardiovascular Effects in Vitamin B1...PARUL UNIVERSITY
Peripheral nerves are susceptible to damage by a wide array of toxins, medications, and vitamin
deficiencies. Vitamin B12 (VB12) deficiency neuropathy is a rare debilitating disease that affects
mostly the elderly. It is important to consider these etiologies when approaching patients with a variety
of neuropathic presentations in this review were have included most relevant and latest information on
mechanisms causing Peripheral neuropathy in VB12 deficiency. We also have included cardiovascular
disorders and their management. Hyperhomocysteinemia has been implicated in endothelial
dysfunction and cardiovascular disease. The association of homocysteine (Hcy) and VB12 with
cardiovascular risk factors in patients with coronary artery disease (CAD) has also been studied
Discussion of the current medications of chronic hepatitis treatment in the Egyptian market as well as our protocol of management in the Viral Hepatitis Treatment Centers in Egypt. Discussion of the latest recommendations of AASLD/IDSA and EASL are presented
Сердечно-сосудистые заболевания у ВИЧ-инфицированных пациентов : предсказать ...hivlifeinfo
Cardiovascular Disease in HIV-Infected Patients.Predict It and Prevent It. 2015
In this downloadable slideset, Priscilla Y. Hsue, MD, and David A. Wohl, MD, discuss data on using traditional and newer markers and modalities to predict and prevent cardiovascular disease in HIV-infected patients.
Format: Microsoft PowerPoint (.ppt)
File size: 3.21 MB
Date posted: 7/16/2015
Современное лечение ВИЧ : лечение возрастных пациентов.2017/Contemporary Management of HIV. Management of Aging Patients.2017
In this downloadable slideset, Edgar Turner Overton, MD, and Program Director Joseph J. Eron, Jr., MD, review key data on managing aging patients with HIV.
Source: Contemporary Management of HIV
Date Posted: 4/24/2017
Theodoros Katsivas, MD (UC San Diego Owen Clinic), Shira Abeles, MD (UC San Diego Owen Clinic) and Robyn Cunard, MD (UC San Diego) present "Renal Disease in HIV/AIDS"
Dr. Swamy Venuturupalli talks about the latest developments in lupus at the 2015 Latest on Lupus Patient Conference held by Lupus LA on Saturday October 17th at UCLA Medical Center.
ICN VIctoria: John Botha on Critical Care Renal FailureGerard Fennessy
Professor John Botha from Frankston Hospital in Melbourne talks at the April 2014 Victorian Intensive Care Network meeting on Renal Failure in Critical Care
Management of Peripheral Neuropathy and Cardiovascular Effects in Vitamin B1...PARUL UNIVERSITY
Peripheral nerves are susceptible to damage by a wide array of toxins, medications, and vitamin
deficiencies. Vitamin B12 (VB12) deficiency neuropathy is a rare debilitating disease that affects
mostly the elderly. It is important to consider these etiologies when approaching patients with a variety
of neuropathic presentations in this review were have included most relevant and latest information on
mechanisms causing Peripheral neuropathy in VB12 deficiency. We also have included cardiovascular
disorders and their management. Hyperhomocysteinemia has been implicated in endothelial
dysfunction and cardiovascular disease. The association of homocysteine (Hcy) and VB12 with
cardiovascular risk factors in patients with coronary artery disease (CAD) has also been studied
Discussion of the current medications of chronic hepatitis treatment in the Egyptian market as well as our protocol of management in the Viral Hepatitis Treatment Centers in Egypt. Discussion of the latest recommendations of AASLD/IDSA and EASL are presented
Сердечно-сосудистые заболевания у ВИЧ-инфицированных пациентов : предсказать ...hivlifeinfo
Cardiovascular Disease in HIV-Infected Patients.Predict It and Prevent It. 2015
In this downloadable slideset, Priscilla Y. Hsue, MD, and David A. Wohl, MD, discuss data on using traditional and newer markers and modalities to predict and prevent cardiovascular disease in HIV-infected patients.
Format: Microsoft PowerPoint (.ppt)
File size: 3.21 MB
Date posted: 7/16/2015
Современное лечение ВИЧ : лечение возрастных пациентов.2017/Contemporary Management of HIV. Management of Aging Patients.2017
In this downloadable slideset, Edgar Turner Overton, MD, and Program Director Joseph J. Eron, Jr., MD, review key data on managing aging patients with HIV.
Source: Contemporary Management of HIV
Date Posted: 4/24/2017
Wesley Campbell, M.D., of U.S. Navy Medicine, presents "Neurocognitive Changes in Newly Diagnosed Patient with Low CD4: Implications for Prognosis and Employment"
Contemporary Management of HIV.How Aging Affects ART Management.2018hivlifeinfo
In this downloadable slideset, Expert Faculty review key data on managing aging patients with HIV.
Format: Microsoft PowerPoint (.ppt)
File size: 720 KB
Date posted: 3/7/2018
Tyler Lonergan, MD
Clinical Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Cathy Logan, MD, of the UC San Diego AntiViral Research Center, presents "Solid Organ Transplantation and HIV" at AIDS Clinical Rounds on August 29, 2014
Scott Letendre, MD, of the UC San Diego HIV Neurobehavioral Research Program, presents "Overview of HIV & Aging" for AIDS Clinical Rounds at UC San Diego
Contemporary Management of HIV.How Common Comorbidities Affect ART Management...hivlifeinfo
In this downloadable slideset, expert faculty review key data and offer important guidance on managing HIV treatment in patients with frequently encountered comorbidities, including cardiovascular disease, osteopenia, and HCV coinfection.
Format: Microsoft PowerPoint (.ppt)
File size: 2.27 MB
Date posted: 2/12/2018
HIV Transplant Case Report, Transplant Outcomes in Clinical Trials, and Organ Availability in High Risk Donors
Katya Prakash
03/15/2019
UCSD HIV & Global Health Rounds
Katherine Promer Flores, MD (she/her)
Staff Physician
Division of Infectious Diseases and Global Public Health
Department of Medicine
University of California San Diego
Daniel Lee, MD
Clinical Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Leandro Mena, MD, MPH
Chair and Professor of Population Health Science
Department of Population Health Science
University of Mississippi Medical Center
Maile Young Karris, MD
Associate Professor
Co-Director San Diego Center for AIDS Research Clinical Investigations Core
Divisions of Infectious Diseases & Global Public Health and Geriatrics & Gerontology
Department of Medicine
University of California San Diego
Edward Cachay, MD, MAS
Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Gabriel Wagner, MD
Associate Clinical Professor
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Jocelyn Keehner, MD
Infectious Disease Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Richard Garfein, PhD, MPH
Professor
Herbert Wertheim School of Public Health and Human Longevity Science
Adjunct Professor
Division of Infectious Disease and Global Public Health
Department of Medicine
University of California, San Diego
Laura Bamford, MD, MSCE
Associate Professor of Medicine
Medical Director, Owen Clinic
Division of Infectious Diseases and Global Public Health
Department of Medicine
University of California, San Diego
Davey Smith, MD, MAS
Professor of Medicine
Chief, Division of Infectious Diseases and Global Public Health
Co-Director, San Diego Center for AIDS Research (CFAR)
Department of Medicine
University of California, San Diego
Elliot Welford, MD
Infectious Diseases Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Darcy Wooten, MD
Assistant Professor of Medicine
Associate Program Director, Infectious Diseases Fellowship
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Amutha Rajagopal, MD
Associate Physician Diplomate
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
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Stemming the Tide of Cardiovascular Disease: Transitioning from OI to CVD Prophylaxis
1. AIDS CLINICAL ROUNDS
The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease clinicians, physicians and
researchers. The goal of these presentations is to provide the most
current research, clinical practices and trends in HIV, HBV, HCV, TB
and other infectious diseases of global significance.
The slides from the AIDS Clinical Rounds presentation that you are
about to view are intended for the educational purposes of our
audience. They may not be used for other purposes without the
presenter’s express permission.
2. Stemming the Tide of Cardiovascular
Disease in HIV-infected Persons:
Transitioning from OI Prophylaxis to
CVD Prevention
Tyler Lonergan, MD
Clinical Professor of Medicine
3. Case Presentation
• 51 year old male w/ HIV (CD4=406/20%, VL<20 on ART) and HTN
who presented to Owen Clinic complaining of epigastric pain
• Pt experienced extreme dizziness on the night before, while getting
out of the jacuzzi at the gym. It was followed by a dull epigastric
pain, which he suspected to be due to indigestion. The pain
progressed overnight, became sharp in quality, radiated to the L
side of his chest, back, and L arm. It was accompanied by nausea,
non-bloody emesis, and loose stools
• In the following morning, he called the Owen Clinic and scheduled
an appointment to be seen in the afternoon despite their advice to
go to the UCSD Hillcrest ED
• At around 14:30 while standing in line to check into the clinic, he
became weak, lightheaded, diaphoretic, and developed L hand
numbness
4. Case Presentation
• PMHx: HIV Dx 2002 (CD4 nadir 29), Herpes Zoster, LTBI,
hypogonadism, depression/ anxiety, osteoporosis, s/p appy,
HTN, dyslipidemia (TC 197, HDL 37, LDL 109, TG 253)
• Meds: efavirenz, abacavir, lamivudine, testosterone gel,
losartan, paroxetine, alendronate, Vit D, Ca
• ScHx: single, lives alone, homosexual (not sexually active),
smokes 1-2 ppw x 12 years, no etoh or illicit drug abuse
• FmHx: mother MI @ 82 yo; uncle, aunt & GF CVA in late 60s
• PEx: thin, anxious, ill appearing, T: 97.8 , BP: 88/58, HR: 87
HEENT: no icterus, no oral lesions, JVP <5 cm, no lad
CV: RRR, nl s1,2, no m,r,g Lungs: CTAB
Abd: nabs, soft, ttp over epigastric area, no HSM Ext: no
edema
• DDx: PUD, pancreatitis, acute MI
• Sent to ED via ambulance
5. ED Course
• Upon arrival in ED at 16:12,
he was hypotensive at
80s/50s, HR 80s, and had
abnormal ECG. A STEMI
code was called, and cath
lab was emergently
activated. Serum cardiac
markers (CPK, CK-MB and
index, Troponin T) were all
elevated. Heparin bolus
and drip, prasugrel, ASA,
atorvastatin and oxygen
given
6. ED and Cath Lab
• Developed 3rd degree AV block, bradycardia in
30-40s. Atropine given and external, transcutaneous pacing initiated. Pt then went into
VT/VF and was shocked once at 150J and
converted back into sinus bradycardia. Also
received a dose of Amiodarone
• In the cath lab, his RCA was found to be 100%
occluded and 2 DES were placed. He continued
dopamine drip to sustain SBP in the 70s-80s
7. Hospital Course
• Echocardiogram: inferior and posterior wall hypokinesis, EF
48%
• Peak CPK: 6306
• Pressure on the chest, sob, dizziness slowly improved over
the week
• New onset of dry cough morning HD#2. Found to have
pulmonary edema on CXR. Edema resolved w/ diuresis
• Pt was in persistent sinus bradycardia but it slowly
converted to a normal rate over the week
• His hemodynamic status was initially grossly unstable w/
low BP, requiring dopamine infusion for 5 days. Unable to
start BB or ACEI due to borderline BP and bradycardia
8. Question #1
• For this patient which of the following is not a
risk factor for CVD?
–
–
–
–
–
–
–
–
HIV
CD4
Abacavir
Lipids
Age
Smoking
HTN
None of the above (all RFs)
9. Question #2
• Prior to his MI which lipid lowering medication
would you have prescribed?
– Statin
– Niacin
– Fibrate
– Omega 3 Fatty Acids
– None of the above
10. Question #3
• Prior to his MI would you have prescribed
aspirin?
– Yes
– No
– Uncertain
12. Prevalence of CHD by Age and Gender
National Health and Nutrition Examination Survey: 2007-2010
Source: National Heart, Lung and Blood Institute
13. AMI rates in HIV vs non-HIV VA patients
• More than 80,000
veterans with nearly 6
years of follow-up had
871 acute myocardial
infarctions (AMIs)
• Across 3 decades of age,
mean AMIs per 1000
person-years was
consistently higher for
PLHIV than HIV negative
people
• Hazard ratio was 1.5
after adjusting for
Framingham risk factors,
comorbidities, and
substance use
15. Increased Rates of other CVD in PLHIV
• Sudden cardiac death
- SF clinic: 4.5 fold increased risk of SCD compared to expected city-wide rate1
• Heart Failure
– VA cohort: compared with HIV-uninfected veterans, those who were HIV infected
had an increased risk of HF (adjusted HR, 1.81). Those with baseline HIV RNA>500
had increased risk of HF while those with baseline or most recent HIV RNA<500 did
not2
• Atrial Fibrillation
– VA Cohort: lower CD4(+) cell count (<200 compared with >350; HR: 1.4) and higher
viral load (>100,000 compared with <500 copies/ml; HR: 1.7) were independently
associated with increased risk of AF. Additional RFs: older age, White race, CAD,
CHF, etoh, proteinuria, reduced kidney function, and hypothyroidism3
• Stroke
– Boston Cohort: HR of ischemic stroke 1.21 in HIV vs non-HIV. Increased HIV RNA
was associated with an increased risk of IS4
– In US from 1997 to 2006 stroke hospitalizations with coexisting HIV infection rose
60% (888 to 1425)5
• PAD6
1 Tseng ZH er al. J Am Coll Cardiol 2012, 2 Butt AA et al. Arch Intern Med 2011, 3 Hsu JC et al. J Am Coll Cardiol 2013,
4 Chow FC et al. JAIDS 2012, 5 Ovbiagele B et al. Neurology 2011, 6 Ye Y et al. JAIDS 2010
20. Life Expectancy at Age 20 among Treated
HIV+ North Americans
• Estimate temporal changes
in life expectancy among
HIV+ adults on ART from
2000-2007 in US and
Canada
• 22,937 participants from
NA-ACCORD Cohort
• 1622 deaths; crude
mortality rate 19.8/1000 py
• Life expectancy was lower
for individuals with a history
of IVDU, non-whites, and in
patients with baseline CD4
counts <350 cells/mm3
Samji J, et al. PLOS ONE 2013
21. Causes of Death in PLHIV on ART
• Retrospective
classification of deaths
in 39,272 European
and NA patients who
initiated ART from
1996-2006 and were
enrolled in one of 13
HIV cohort studies
• 1597/1876 deaths a
definitive cause of
death identified
Antiretroviral Therapy Cohort Collaboration CID 2010
22.
23. Traditional CVD Risk Factors in HIV vs Non-HIV
a
statistically significant comparison of HIV and non-HIV proportions, with X2 (P<0.0001)
Triant VA, et al. J Clin Endocrinol Metab 2007
24. Other Risk Factors for CVD in PLHIV
• Low CD4 count:
– HOPS COHORT:
Baseline CD4<500 was an
independent RF for CVE
and risk of CVE attributable
to baseline CD4<500 was
comparable to smoking
and dyslipidemia1
• Detectable Viral load
– SMART TRIAL:
Hazard Ratio for risk of
CVD events for DC vs VS
was 1.57 (95% CI 1.00 –
2.46; P=0.05)2
1Lichtenstein KA, et al. CID 2010, 2Phillips N, et al. Antiviral Therapy 2007
25. Antiretrovirals and MI Risk
• Abacavir:
– Meta-analysis of observational studies indicate increased
risk of MI with <6 months of exposure to abacavir (RR 1.92,
95% CI 1.51-2.42)
– Meta-analysis of RCTs found no association between
abacavir use and MI
• Protease inhibitors:
– Meta-analysis of observational studies found increase in
risk of MI with recent PI exposure (OR 2.13, 95% CI 1.06 –
4.28) and cumulative exposure to indinavir (RR 1.11, 95%
CI 1.05 – 1.17) and lopinavir (RR 1.22 (95% CI 1.01 – 1.47)
– Meta-analysis of RCTs failed to demonstrate an association
between PI use and MI
C Bavinger PLOS One 2013
29. Mortality attributable to Smoking in
PLHIV
• Danish cohort
• 2921 HIV+ patients, 10,642 HIVcontrols
• Among PLHIV 47.4%, 17.7%,
34.9% were current, former and
never smokers and among HIVcontrols corresponding rates
were 20.6%, 32.8%, 46.6%
• Among PLHIV relative MR from
CVD in smokers 4.3 higher than
in never smokers
• Excess mortality of smokers is
tripled (17.6 vs 4.8/1000 py) and
population-attributable risk of
death associated with smoking is
doubled (61.5% vs 34.2%) among
HIV+ patients compared to HIVcontrols
Helleberg, M et al. CID 2013
30. Smoking Cessation Reduces
Risk for Cardiovascular Events
• D:A:D Cohort
• More than 27,000
patients had a total of
1778 CVEs or mortality
• Adjusted incidence rate
ratio of CVD in patients
who stopped smoking
decreased from 2.3
within the first year of
stopping to 1.5 after > 3
years compared with
those who never
smoked. Similar trends
were observed for the
MI and CHD endpoints
Petoumenos et al, HIV Medicine 2011
31.
32. Question #4
• Which guidelines do you use to determine
who should go on lipid lowering therapy?
– 2013 ACC-AHA
– NECP ACT III
– IDSA/ACTG
– Other
– Do not use any
34. NCEP ATP III Cholesterol Guidelines
http://my.americanheart.org/professional/StatementsGuidelines/PreventionGuidelines/Prevention-Guidelines_UCM_457698_SubHomePage.jsp
35. NCEP ATP III Guidelines
TLC: low saturated fat diet, increase physical activity and weight management
Consider drug simultaneously with TLC for CHD and CHD equivalents
Consider adding drug to TLC after 3 months for other risk categories.
http://my.americanheart.org/professional/StatementsGuidelines/PreventionGuidelines/Prevention-Guidelines_UCM_457698_SubHomePage.jsp
36. NCEP ATP III Cholesterol Guidelines
If TG>500 treat TG first
Non-HDL goal 30 mg/dL higher than LDL goal
http://my.americanheart.org/professional/StatementsGuidelines/PreventionGuidelines/Prevention-Guidelines_UCM_457698_SubHomePage.jsp
40. D:A:D 5 year Estimated Risk
Calculator*
• BMI, lipodystrophy, TGs, CD4
and VL were assessed and
excluded based on
nonsignificance
• Risk of CHD over 5 year
period:
–
–
–
–
Low (<1%)
moderate (1-5%)
high (6-10%)
very high (>10%)
• DAD model better predicted
CVE than an older FRAM
equation (one used did not
include variable for treated
HTN and had differences in
outcomes measured)
• Not validated externally
*http://www.cphiv.dk/TOOLS/DADRiskEquations/tabid/437/Default.aspx
Friis-Moller N, et al. Eur J Cardiovasc Prev & Rehabil 2010
41. Updated D:A:D risk models
• Additional 80,000 PY of follow-up (total
180,000 PY)
• One outcome only: Global CVD risk
• Based on baseline rather than time-updated
risk parameters (Cox Model)
• Full and Reduced D:A:D models (+/- ARVs)
• Updated Models will be available at
www.CPHIV.DK (updated models still currently
unavailable)
N Friis Moller et al. 14th European AIDS Conference 2013
42. 3 CVD Risk Models
N Friis Moller et al. 14th European AIDS Conference 2013
43. 5-year CVD risk by Age and Diabetes
N Friis Moller et al. 14th European AIDS Conference 2013
44. UpToDate Treatment of Lipids in
Primary Prevention Guidelines
• Counsel all patients to exercise, eat a prudent diet and
lose weight as appropriate
• Calculate pt’s baseline risk for CVE (using FRC) and
treating with statin in pts for whom 20-30% reduction
in events translates into absolute reduction in events
worth costs and burdens of daily therapy
• Do not recommend specific LDL target or calculated CV
risk cutoff to determine use of statin
• If decision made to treat then use moderate statin
dose (eg, pravastatin 40 mg, atorvastatin 20 mg,
rosuvastatin 5-10 mg)
45. UpToDate Cholesterol Guidelines
• Recommend measuring LDL 6 weeks after
starting statin and every 6-12 months thereafter
to assess med adherence only
• Do not recommend monitoring LDL response to
therapy or intensifying dose to achieve any
particular LDL goal
• Do not recommend nonstatin lipid-lowering
therapy in pts who do not tolerate statins or
adding them in pts who do not achieve a
particular LDL level on a statin alone.
46. 2013 Cochrane Review of Statins for
primary prevention of CVD
Incidence of cancers, myalgia, rhabdomyolysis, LFT elevation, renal dysfunction, or arthritis and rates of
adverse events (17%) and stopping treatment (12%) did not differ between statin and placebo groups. An
increase risk of incident of diabetes (RR 1.18 [95% CI, 1.01-1.39], NNT 198) found in 1/2 trials reporting this
outcome. No long term data on health related QOL outcomes.
Taylor F, et al. Cochrane Database Syst Rev. 2013
47. Statin Affects on Inflammatory
Markers in PLHIV
• Retrospective cohort study
• 151 HIV+, dyslipidemic pts on stable ART who
were started on a statin and followed for ≥12 mo
Calza L, et al. HIV Cin Trials 2012
48. Statin Affects on Immune Activation in
PLHIV
• Randomized, double-blind, placebo-controlled crossover trial to
investigate effect of statin on HIV RNA and cellular markers of immune
activation
• 24 untreated HIV+ pt randomized to receive 8 weeks of atorvastatin 80 mg
or placebo daily. After 4-6 week washout phase, participants switched
treatment assignments
Ganesan A, et al. JID 2011
49. Affect of Rosuvastatin on cIMT and lipids in
PLHIV
• 36 adult (30 M) HIV+
pts, mean age 49 yr,
mean duration of ART
38 mo, mean 10 yr
risk of MI 18.5%.
• Rosuvastatin 10
mgdaily x 24 months
• Well tolerated, no
adverse events
Calza L, et al. AIDS Res Hum Retroviruses 2013
50. Association between Statins and Mortality in
PLHIV
• JH HIV Cohort
• 238/1538 pt fully suppressed on ART
were also taking a statin
• 85 deaths (7 on statins)
– 12 cardiovascular (2 on statin)
• Statin use associated with relative
hazard of 0.33 (95% CI: 0.14-0.76;
P=0.0009) of all cause mortality after
adjusting for multiple factors
Moore RD, et al. PloS One 2011
51.
52. Aspirin
• Aspirin has been shown to be effective in the primary and
secondary prevention of AMI in the general population
• No study looking at the effect of aspirin in prevention of
CVD in PLHIV
• Decrease cardiovascular events via:
– Antiplatelet effects
– Increased nitric oxide formation
– Anti-inflammatory effects
• Heightened platelet activation and immune activation in
treated HIV-infected patients were attenuated by 1 week of
aspirin therapy (325 mg loading dose followed by 81 mg
daily)1
1 O’Brien M, et al. JAIDS 2013
53. Aspirin Primary Prevention of CVD
• Pooled data from RCT in general population
suggest aspirin is associated with:
– ~20% relative risk reduction in non-fatal MI
– No significant effect on non-fatal stroke (including
hemorrhagic stroke)
– ~12% relative risk reduction in cancer incidence
– ~50% increase in relative risk of major non-fatal
extracranial bleed
– ~6% reduction in relative risk in overall mortality
54. Estimated Absolute Benefits and Risks
of Aspirin for Primary Prevention
• Daily aspirin use in a thousand 60 yo HIV
negative pts with avg risk (10-20%) for CAD
and malignancy (~12%) over 10 yr period:
– 6 fewer deaths
– 6 fewer cancers
– 17 fewer non-fatal MI
– No significant reductions in non-fatal strokes
– 16 more major bleeding events (IC, GI or other
requiring hospitalization +/- transfusion)
55. Caveats of Aspirin Use
• Low dose as effective as higher dose with
possibly less side effects
• Do not use concurrently with warfarin
• Avoid concurrent use of NSAIDs (reduces anticardioprotective effects and increases risk of
GIB)
• Avoid use in patients with history of PUD or
other risk factors of GIB
56. Guidelines for Aspirin Use
• UTDOL: individualize assessment of patient’s risk for MI,
cancer and bleeding and discuss results with patient to
determine patient’s preference. For individuals age ≥50 yr
without excess bleeding risk, suggest low dose daily aspirin
• ACCP 2012: suggest low-dose aspirin (75-100 mg) daily over
no aspirin therapy for persons ≥50 yr without symptomatic
CVD
• European Society of Cardiology 2012: advise against use of
aspirin in individuals without CVD due to risk of major
bleeding
• USPTF 2009: recommends for men 45-79 yo for MI
prevention and women 55-79 for stroke prevention if
benefits outweigh risks
• No specific guidelines for HIV+ patients
57. USPSTF Aspirin for Primary CVD Prevention Guidelines
Does not apply to adults taking NSAIDs (4x GIB risk), have upper GI pain or
Hx of GI ulcers (2-3x GIB risk)
USPSTF Ann Intern Med 2009;150:396-404
58. Underutilization of Aspirin for primary
prevention of CVD in qualifying PLHIV
• UAB HIV Clinic: 66/397 (17%) patients who
qualified to receive ASA were prescribed it1
• Spanish Cohort: 2/37 patients who met
criteria for aspirin for primary prevention of
CVD were prescribed it2
1 Burkholder GA, et al. CID 2012, 2 Tornero CA, et al. JAIDS 2010
59. Undertreatment of CVD RFs
• Multicenter German Cohort: Almost half of
patients with DM and HTN were untreated. LDL
appropriately treated <50% in patients at
moderate CHD risk and <70% at high risk 1
• VACS: 39% of HIV+ vs 62% of HIV- vets (OR 0.45)
received appropriate lipid lowering therapy2
• HOPS: 81%-87% treated for elevated LDL but only
2-11% for low HDL (NCEP ATP III guidelines) and
46-59% for HTN3
1Reinsch N, et al. Eur J Prev Cardiol 2012, 2 Freiberg MS, et al. J Gen Intern Med 2009
3Lichenstein KA, et al. Preventing Chronic Disease 2013
60. Case: Statin/ASA for primary MI
prevention?
•
•
•
•
PreMI lipids: TC 197, HDL 37, LDL 109, TG 253, nonHDL 160
Traditional RFs: HTN, Smoker, Low HDL, Age
HIV related RFs: CD4<500, abacavir
NCEP ATP III:
– 10-year risk: 16%
– 2+RF, 10-yr risk ≤20%: LDL goal <130, nonHDL goal<160
– At goal LDL, slightly above nonHDL goal, initiate TLC and consider drug
therapy
• ACC/AHA 10-year risk: 12.6%
– Recommend high-intensity statin therapy
• D:A:D 5 year risk: 7.4% (high risk)
• USPSTF Guidelines:
– 10-year risk: 17%
– Recommend aspirin
61. First MI among Owen Clinic Patients
2012+2013
• 11 patients
• All male
• Race: 6 W, 3 L, 1 Asian,
1B
• Mean Age: 49 (range: 3857), 2<45 yo
• 8/11 on ART
• Mean CD4: 488 (1601253)
• Viral Load: 8/11<100
• Mean TC: 188 (126-241)
• Mean HDL: 39 (21-52),
6/11<40
• Mean LDL: 107 (61-175),
3/11<70, x/11<100
• Current Smoker: 6/11
• Hypertension: 4/11
• DM: 2/11
• ACC/AHA Calculator: mean
(range): 7.4% (2.9%-16.2%)
• UTDOL FRAM Calculator:
16.5% (6.7%-33.8%)
62. First MI at Owen Clinic
• Prescribed Aspirin prior to MI: 2/11
– 8/11 met USTSPF criteria
– Of 3 who did not meet criteria:
• 1 calculated risk below threshold
• 2 <45 yr
• Prescribed Statin prior to MI: 1/11
– 4/11 met ACC-AHA criteria
– Of 7 who did not meet criteria:
• 3 had LDL<70
• 4 risk <7.5%
• 10/11 patients had stents
– 8 DES, 2 BMS
– 4 had 1 stent, 6 had 2 stents
• 1 CABG
• All survived MI and are still alive
63. Summary
• Due to advances in ART, the life expectancy of
PLHIV is approaching that of the general
population
• PLHIV are at greater risk for developing CVD due
to HIV-associated inflammation and immune
activation and higher rates of traditional CVD RFs
• Encourage all patients to adopt a healthy life
style
• Treat HIV and identify and manage modifiable
traditional CVD RFs
64. Summary II
• Use of interventions for primary prevention of CVD are underutilized
• Aspirin and statins provide anti-inflammatory and immune deactivation
effects that may provide additional benefits for PLWH
• Current guidelines for use of aspirin and statin therapy for primary
prevention of CVD in the general population use risk calculators that do
not account for the deleterious effect of HIV and therefore likely
underestimate the CVD risk for PLWH
• In 2012 and 2013 most Owen Clinic patients did not meet current
guideline criteria for aspirin or statin use due to young age, low LDL or low
calculated risk prior to their MIs. Consider the following for PLWH:
– account for HIV-related risk factors (e.g, CD4 count, viral load) when
determining risk
– start statins and aspirin at younger ages than currently recommended for
general population
– use statins at lower doses in high risk patients with LDL<70
– use new D:A:D HIV risk calculator when available or if using ACC-AHA
calculator then multiply determined risk by 1.5