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Implementation Research:

Translating the ABCS into HIV Care

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Use of highly effective, often single pill HIV antiretroviral therapy has dramatically reduced deaths from AIDS-related causes yielding an aging population among people living with HIV (PLH) who increasingly experience cardiovascular (CVD) morbidity and mortality. Age and sex-adjusted deaths from CVD are appreciably higher among PLH than among the general population. This growing CVD risk among PLH can be substantively reduced through use of established interventions, commonly referred to as ABCS, i.e. appropriate use of aspirin, blood pressure control, cholesterol reduction, and smoking cessation, in addition to lifestyle, i.e. diet, physical activity, and safe drinking. Each of these interventions is underused among PLH. There is a fundamental gap in scientific knowledge regarding which strategies will promote shared decision-making regarding ABCS between PLH and their clinicians. Addressing this gap is vital to reducing the growing CVD burden among PLH.

 

      Continuing Medical Education (CME) Online Modules


     Translating the ABCS into HIV Care

ASPIRIN FOR ASCVD PREVENTION AMONG PEOPLE LIVING WITH HIV

Learning Objectives 

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  1. Describe current recommendations regarding aspirin for primary and secondary atherosclerotic cardiovascular disease (ASCVD) prevention.

  2. Understand recent evidence regarding the risks versus benefits of daily aspirin therapy for primary prevention.

  3. Use an online risk calculator to estimate individualized risk versus benefit of aspirin therapy.

Key Messages 

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  1.  Aspirin is recommended for secondary prevention of ASCVD, i.e. for patients who have experienced myocardial infarction or stroke or have established coronary artery, cerebrovascular, or peripheral vascular disease.

  2.  Evidence for aspirin supporting primary ASCVD prevention is comparatively weak. Individual 10-year risk of ASCVD should be carefully considered alongside potential for aspirin-related bleeds before recommending aspirin for primary prevention.

  3.  The online risk calculator (and app) is available to estimate an individualized risks and benefits of aspirin for primary prevention

Introduction

Over the past two decades, effective antiretroviral therapy has prolonged lifespans of people living with HIV (PLH) and shifted mortality from early AIDS-related causes to cardiovascular death. 1,2 Evidence has shown that after adjusting for age, sex, and cardiovascular risk factors, PLH have a higher risk of atherosclerotic cardiovascular disease (ASCVD) than the general population. 3-6 However, PLH are less likely than the general population to receive evidence-based interventions, for ASCVD prevention. 7 This module will review current evidence regarding daily aspirin therapy ASCVD prevention among PLH.


Brief Review

Increased platelet activation has been proposed as a potential mechanism increasing ASCVD among PLH. 8 While preliminary evidence suggests aspirin may attenuate heightened platelet activity, direct evidence of mortality benefit is lacking. To date, aspirin for ASCVD prevention has not been studied specifically among PLH and literature from the general population must be extrapolated to HIV patients.


Secondary Prevention

Evidence supporting the use of aspirin for secondary ASCVD prevention is well-established. 9-12 Among patients with a prior cardiovascular or cerebrovascular event, use of anti-platelet agents have consistently shown reductions in mortality. Accordingly, aspirin or an alternative antiplatelet agents are recommended for secondary prevention. 11,13

Primary Prevention

Evidence supporting the use of aspirin for primary ASCVD prevention has become increasingly controversial and consideration of individualized risk factors and shared decision making should be employed before initiating therapy. Presently, the United States Preventive Services Task Force (USPSTF) states the decision to initiate low-dose aspirin use for primary prevention among adults aged 60 to 69 with a 10-year risk of ≥10% should be made on a case by case basis. 14 Patients who are not at increased risk for bleeding and a life expectancy of at least 10 years may be more likely to benefit. As always, patient preference (i.e. those who place a higher value on potential benefits than the potential harm) may choose to initiate low-dose aspirin (C rating).” Current evidence is insufficient to guide decisions for patients <60 years or >69. 14,15 In general, a 10-year ASCVD risk of 10% is considered a loose benchmark for the benefits of aspirin to outweigh the risks. 16,17

Recently, the American College of Cardiology in partnership with the American Heart Association downgraded recommendations for aspirin for primary prevention based on “weak evidence.” Guidelines released in March 2019 discourage its use for primary prevention stating: “aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit.” 18 These guidelines further state low-dose aspirin (75-100 mg orally daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of bleeding.


Individualized Patient Decision Making

When considering aspirin for primary prevention, clinicians must balance the individual ASCVD against the potential for aspirin-induced bleeding, which is most commonly gastrointestinal or intracerebral in nature.

Risk Factors for Bleeding 19
  • Older age
  • Male gender
  • Smoking
  • Hypertension
  • Diabetes
  • Prior history of bleeding (specifically gastrointestinal or intracerebral)
  • History of peptic ulcer disease
  • Frequent use of NSAIDS, anticoagulants, or other medications than increase bleeds


A helpful web tool is available to estimate patient specific risks of bleeding versus experiencing an ASCVD event. This tool, which is also available as an app, can help weigh the risk reduction from aspirin with the patient risk of bleeding.

Balancing the potential benefits and harms is typically based on the number needed to treat (NNT) and the number needed to harm (NNH). These numbers are based on absolute rather than relative risk. For example, if the aspirin reduces 10-year risk of ASCVD by 3% and is associated with a 10% risk for major GI bleeding over 10 years, the corresponding NNT and NNH are based on the inverse of these percentages, i.e. 1/0.03= 33 and 1/0.1=10. This can be understood as 33 people will need to be treated with aspirin for 10 years in order to prevent one ASCVD event whereas only 10 people will need to be treated with aspirin in order for one person to experience a major GI bleed. While these outcomes are not comparable, the numbers help quantify the relative benefit and harm keeping in mind that aspirin has not been shown to reduce all-cause mortality.

In summary, in the absence of a contraindication, aspirin (or other antiplatelet medication) should be prescribed for PLH with known coronary or cerebrovascular disease for secondary prevention. Use of aspirin for primary prevention is of uncertain benefit and should not be used without careful consideration of benefits versus harms.

HYPERTENSION DIAGNOSIS AND MANAGEMENT AMONG PEOPLE LIVING WITH HIV

Learning Objectives 

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  1. Understand the updated recommendations for classifications of and target goals for hypertension and implications within the HIV population.

  2. Recognize the role of 10-year ASCVD risk in initiating pharmacotherapies.

  3. Discuss strategies to manage hypertension while reducing potential for drug interactions with antiviral agents.

Key Messages 

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  1. Stage I hypertension is defined as a systolic blood pressure of 130 – 139 mmHg or a diastolic blood pressure of 80 – 89 mmHg. For patients with stage I hypertension and a 10-year ASCVD risk, 3 – 6 months of lifestyle management should be attempted prior to starting pharmacotherapy. For those with a 10-year risk ≥10%, CVD, diabetes, or renal dysfunction, one antihypertensive agent should be initiated.

  2. Stage II hypertension is defined as a systolic blood pressure ≥140 mmHg or a diastolic blood pressure ≥90 mmHg. Two antihypertensive agents from different classes should be initiated in patients with stage II hypertension along with lifestyle changes.

  3. The pooled cohort calculator may underestimate ASCVD risk among PLH; true risk may be 50 – 100% higher than that estimated by the calculator. Therefore, pharmacologic treatment may be appropriate for PLH with stage I HTN and a 10-year risk <10%.

  4. ACE-inhibitors, ARBs, dihydropyridine calcium channel blockers, e.g. amlodipine, and thiazide/thiazide-like diuretics are considered first line therapies. Blood pressure should be assessed monthly after initiation and the regimen should be adjusted as needed to achieve a goal blood pressure of <130/80 mmHg.

Introduction

The success of antiretroviral therapy (ART) has transformed morbidity and mortality among people living with HIV (PLH) from early AIDS-related causes to later cardiovascular causes. Age and sex-adjusted deaths from cardiovascular disease among PLH are appreciably higher than the general population. The association between antiretroviral therapies and development of dyslipidemia and insulin resistance is well established, and there is also some evidence suggesting a higher incidence of hypertension (HTN) in PLH. 1,2 The higher prevalence among PLH may be a reflection of ART side effects and/or HIV itself. 3-5 In addition, PLH are at higher risk for chronic renal diseases such as HIV-associated nephropathy and ART associated renal toxicity. 6 Similarly, PLH are at higher risk for systolic and diastolic cardiac dysfunction, including heart failure. 7 Appropriate blood pressure control among PLH is important for minimizing progression of renal and cardiovascular disease.


Brief Review

Classification & Blood Pressure Goals

One of the most controversial aspects of the 2017 American College of Cardiology/American Heart Association HTN guideline is classification of hypertension as a blood pressure ≥130/80 mm Hg. 8 The impetus behind this recommendation largely is a result of a well cited meta-analysis of 61 prospective studies in which the risk of CVD increased in a log-linear fashion from systolic BP levels <115 mm Hg to >180 mm Hg and from diastolic BP levels <75 mm Hg to >105 mm Hg. 9

The updated guideline recommends using the baseline blood pressure and 10-year ASCVD risk to guide decisions about medication therapy (Table 2). Stage I hypertension is defined as a systolic BP 130 – 139 mmHg or a diastolic BP 80 – 89 mmHg and treatment decisions are stratified based on 10-year ASCVD risk. If the 10-year risk is <10%, start with healthy lifestyle recommendations and reassess the BP in 3-6 months. 8 Among antihypertensive patients, lifestyle changes have been shown to reduce systolic BP by 4 - 11 mmHg, with the largest improvements stemming from dietary changes and increased exercise. 10 Approximate reductions in systolic blood pressure following lifestyle changes are displayed in Table 2. 8, 10


Table 2: Updated Classification of High Blood Pressure*

BP Category
Systolic BP
Diastolic BP
Normal
<120 mmHg
and
<80 mmHg
Elevated
120 – 129 mmHg
and
<80 mmHg
Stage I Hypertension
130 – 139 mmHg
or
80 – 89 mmHg
Stage II Hypertension
≥140 mmHg
or
≥90 mmHg

*Individuals with SBP and DBP in 2 categories should be designated to the higher BP category. BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2 occasions, as detailed in DBP, diastolic blood pressure; and SBP systolic blood pressure.)


Table 3: Reductions in Systolic Blood Pressure by Lifestyle Change

Lifestyle Change
Approximate Change in Systolic Blood Pressure
Aerobic exercise (150 minutes per week)
↓ 5 – 8 mmHg
Resistance training (150 minutes per week)
↓ 4 mmHg
Isometric hand grips (4 x 2 minutes, 3 time weekly for 8 – 10 weeks)
↓ 5 mmHg
Limiting alcohol intake (≤2 drinks per day for men and ≤1 drink per day for women)
↓ 4 mmHg

Patients with stage I hypertension and a 10-year ASCVD risk ≥10% or CVD, diabetes mellitus, or kidney disease (defined as estimated glomerular filtration rate <60 mL/min/1.73 m2 and/or urine albumin:creatinine ≥300 mg/g), an antihypertensive agent should be initiated along with lifestyle changes. Patients with stage 2 hypertension, which is defined as a BP ≥140/90, should be initiated on 2 antihypertensive agent should be initiated along with lifestyle changes. Patients with stage 2 hypertension, which is defined as a BP ≥140/90, should be initiated on 2 antihypertensive agents of different classes along with lifestyle changes. For all patients, including those with HIV, target BP <130/80 mmHg.


Therapy Selection

Patients who do not have a compelling indication for a specific antihypertensive agent, should initially be treated with one or more agents from the following classes: thiazide/thiazide-like diuretics, dihydropyridine calcium channel blockers, angiotensin converting enzyme inhibitors, or angiotensin receptor blockers. While, HIV alone is not a compelling indication for a specific class of antihypertensive agents lowering medication, considering the potential for drug interactions is essential when initiating therapy in patients on antiretrovirals. Common interactions between antiretroviral and antihypertensives are presented in Table 4.


Adapted from DHHS Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV. 11

Table 4: Common Interactions Between Antiretroviral and Antihypertensives

Concomitant Drug Class/Name Effect on INSTI or Concomitant Drug Concentrations Dosing Recommendations and Clinical Comments
Interactions with Integrase Strand Transfer Inhibitors (INSTIs)
Beta Blockers

(e.g., metoprolol, timolol)

BIC, DTG,RAL ↔ expected No dose adjustment necessary.
EVG/c ↑ beta-blockers possible

Beta-blocker dose may need to be decreased; adjust dose based on clinical response.

Consider using beta-blockers that are not matebolized by CYP450 enzymes (e.g., atenolol, labetalol, nadolol, sotalol).

CCBs BIC ↑ BIC possible with diltiazem

↔ expected for all other CCBs

No dose adjustment necessary.
DTG, RAL ↔ expected No dose adjustment necessary.
EVG/c ↑ CCBs possible

Coadminister with caution. Titrate CCB dose and monitor for CCB efficacy and toxicities.

Refer to Table 19a for diltiazem plus ATV/r recommendations.

Interactions with non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Dihydropyridine CCBs EFV, ETR, NVP ↓ CCBs possible Titrate CCB dose based on clinical response.
Diltiazem, Verapamil EFV Diltiazem AUC ↓69%

↓ verapamil possbile

Titrate diltiazem or verapamil dose based on clinical response
Interactions with protease inhibitors (PIs)
Beta-Blockers

(e.g., carvedilol, metoprolol, timolol)

All PIs ↑ beta-blockers possible

May need to decrease beta-blocker dose; adjust dose based on clinical response.

Consider using beta-blockers that are not metabolized by CYP450 enzymes (e.g., atenolol, labetalol, nadolol, sotalol).

Key: BIC=Bictegravir; DTG= Dolutegravir; RAL= Raltegravir; EVG/c=Elvitegravir/cobicistat; EFV=Efavirenz; ETR=Etravirine; NVP=Nevirapine; PI=Protease Inhibitor; CCB= Calcium Channel Blocker; ATV/r= Atazanavir/ritonavir; CYP=Cytochrome; AUC=Area Under the Curve

Hypertension & HIV

Literature evaluating management of hypertension specifically among PLH is scarce. However, HIV infection, even in the presence of full HIV viral suppression, is considered a “risk-enhancing” factor associated with ASCVD. HIV status is not included in the pooled cohort calculator and therefore may underestimate risk among PLH. Studies have shown that HIV may increase ASCVD 50 – 100% above what is estimated by the pooled risk calculator.12,13 Consideration of HIV is particularly relevant for patients with an ASCVD risk estimate that is borderline for pharmacologic therapy. In these instances, true 10-year risk might be >10% suggesting that the patient may benefit from initiation of pharmacologic therapy.

CHOLESTEROL MANAGEMENT IN PEOPLE LIVING WITH HIV

 Learning Objectives

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  1. Recognize when to perform screening for dyslipidemia in persons living with HIV (PLH).

  2. Explain best practice prescribing guidance for the treatment of lipid disorders, including preferred initial treatment agents and statin dose intensity.

  3. Identify clinically significant drug-drug interactions between antiretroviral and cholesterol medications.

Key Messages

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  1. Patients with existing ASCVD, history of multiple major ASCVD events, or one major ASCVD event and multiple high-risk conditions should be prescribed statin therapy unless contraindicated for secondary prevention.

  2. Patients 40 to 75 years of age with severe hypercholesterolemia (LDL-C ≥190 mg/dL) or who have diabetes and an LDL-C ≥ 70 mg/dL, should be started on statin therapy without further need for calculating 10-year ASCVD risk.

  3. Patients 40 to 75 years of age without clear indication for statin therapy (i.e., clinical ASCVD, very-high risk for ASCVD, severe hypercholesterolemia, or elevated LDL-C and diabetes) should be evaluated for primary ASCVD prevention using a risk scoring tool to help guide shared decision-making for management.

  4. PLH who are/will be prescribed ARVs should have a careful evaluation for drug-drug interactions prior to the initiation of statin (or ARV) therapy.

Introduction

Elevated blood lipids are a well-established risk factor for atherosclerotic cardiovascular disease (ASCVD), people with high cholesterol have twice the risk of heart disease as those with lower levels. One-third of people in the U.S. have elevated LDL cholesterol, but only 1 in 3 adults are controlled. 1 Statin therapy, demonstrated to reduce cardiovascular (CV) mortality, 2 remains widely underutilized, with only half of medically eligible patients in the U.S. receiving treatment. 1 In people living with HIV (PLH), dyslipidemia is highly prevalent (up to 80% of patients) in those with and without antiretroviral therapy (ART) and contributes to the increased CVD risk in this population. Factors that may contribute to underuse of statin therapy in PLH (reported to be as low as 5.9% in patients on ART) include concerns regarding statin safety and clinically significant drug-drug interactions when co-prescribed with ART. 3

Diagnosis and management of dyslipidemia has become an important part of overall care for PLH. The ACC/AHA Cholesterol Guidelines were updated in 2018 to allow for more individualized treatment interventions, detailed risk assessment (including the introduction of risk-enhancing factors) and new drug options for those at the highest risk for ASCVD. 4 This brief discusses the role of cholesterol management (with an emphasis on statin therapy) in reducing CVD risk among PLH.


Brief Review

Clinicians should assess a patient’s cardiovascular risk factors, including a baseline lipid panel at the initial visit, prior to the initiation of ART, and then annually. Dyslipidemia is considered a modifiable risk factor for ASCVD and should be reassessed over time; at baseline, prior to starting ART, then every 6-12 months for patients on ART 5 and at least every five years for patients ages 40-75 not on ART.6 The clinician’s risk factor assessment, including results of the lipid panel, should be used to estimate a patient’s risk for developing ASCVD using the ASCVD Risk Estimator Plus Calculator. Though this calculator underestimates CV risk in PLH (by not accounting for underlying increased risk associated with ART or HIV 7,8) experts support its use as a reasonable starting point for assessing risk.

The 2016 WHO Antiretroviral Guidelines provided advisement that the assessment and management of cardiovascular risk of PLH should be the same as the general population. 9 Indications for the use of cholesterol-lowering agents includes evaluation for the need to initiate secondary or primary prevention for ASCVD based on patient specific factors. Patient specific factors include: cardiovascular history, LDL-C results, diagnosis of diabetes, 10-year ASCVD risk, and presence of risk enhancers (Figure 1).

Patients with existing ASCVD or those at very-high risk for ASCVD (history of multiple major ASCVD events, or 1 major ASCVD event and multiple high-risk conditions) should be prescribed statin therapy unless contraindicated for secondary prevention. These patients should be prescribed maximally tolerated, high, or moderate statin therapy (Table 1), based on the treatment algorithm outlined in Figure 1. In patients with stable clinical ASCVD, the goal of therapy is to reduce baseline LDL-C by ≥ 50%. In patients at very-high risk for ASCVD, an LDL-C of 70 mg/dL can be used to consider the addition of non-statin therapy, such as Ezetimibe, to a maximally tolerated statin. 4


Table 1: High and Moderate Intensity statin therapy
  • High Intensity*
  • Lower LDL-C by ≥ 50%
  • Atorvastatin 40-80 mg daily
  • Rosuvastatin 20-40 mg daily
  • Moderate Intensity*
  • Atorvastatin 10-20 mg daily
  • Rosuvastatin 5-10 mg daily
  • Simvastatin 20-40 mg daily (do not use >40 mg)
  • Pravastatin 40-80 mg daily
  • Lovastatin 40 mg daily
  • Fluvastatin 40 mg daily
  • Fluvastatin XL 80 mg daily
  • Pitavastatin 2-4 mg daily

*Dose may need to be increased or decreased based on the presence of other co-prescribed interacting drugs.


Patients 40 to 75 years of age with severe hypercholesterolemia (LDL-C ≥190 mg/dL) or who have diabetes and an LDL-C ≥ 70 mg/dL, should be started on statin therapy without further need for calculating a 10-year ASCVD risk. These patients should be prescribed high or moderate statin therapy (Table 1), based on the treatment algorithm outlined in Figure 1. In patients with severe hypercholesterolemia, an LDL-C of 100 mg/dL can be used to consider the addition of non-statin therapy, such as Ezetimibe, to a maximally tolerated statin. In diabetic patients without other underlying risk factors, the goal of therapy is to reduce baseline LDL-C by 30-49%. 4

Patients 40 to 75 years of age without clear indication for statin therapy (i.e., clinical ASCVD, very-high risk for ASCVD, severe hypercholesterolemia, or elevated LDL-C and diabetes) should be evaluated for primary ASCVD prevention using a risk scoring tool to help guide shared decision-making for management. Shared-decision making includes discussion of potential benefits from risk reduction and potential harms. This discussion should review: all major risk factors (e.g., elevated blood pressure, smoking, and calculated 10-year ASCVD risk); benefits of lifestyle modifications and statin therapy; the potential for adverse events (e.g., myopathies with statins) and drug-drug interactions (e.g., with statins and ART); cost considerations of statin therapy (most are affordable and covered on insurance plans); and patient preferences and values. In addition, the presence of risk-enhancing factors (which includes chronic HIV infection) should be considered during patient shared decision-making and favors statin initiation for patients with intermediate (7.5-19%) or may favor initiation in those at borderline (5-7.4%) risk. In patients at intermediate risk, coronary artery calcium scores from CT can also be used to improve individualized decision making (especially in those with unclear risk); however, the utility of these tests continues to be hindered by limited insurance coverage. For patients at high (>20%) risk, risk discussion should include high intensity statins to reduce LDL-C ≥ 50%. 4 There are tools available that can help guide shared-decision making around statin therapy, including those developed by the Mayo Clinic, available at: statindecisionaid.mayoclinic.org . In all individuals, clinicians should emphasize the importance of a heart-healthy lifestyle as the foundation of ASCVD risk reduction.

After starting therapy, follow-up lipid panels are necessary every 4-12 weeks until goal is reached, and then at least every 12 months, to assess adherence, response to therapy, and need for dose titration.4

PLH who are/will be prescribed ARVs should have a careful evaluation for drug-drug interactions (Table 2) prior to the initiation of statin (or ARV) therapy. Drug interactions between statins and ARVs are often clinically significant interactions that can lead to either statin induced rhabdomyolysis (when co-prescribed with potent CYP3A4 inhibitors such as PIs, cobicistat or ritonavir) or suboptimal statin dosing (when co-prescribed with potent CYP3A4 inducers such as efavirenz). 5 Practically this means that often in practice the dose of statins may be/need to be reduced when co-administered with protease inhibitors to account for clinically significant drug interactions, but the drug exposure is anticipated to be the same based on pharmacokinetic studies.

To review the 2018 Guidelines in more detail, further test your knowledge, or access recommended patient resources and education, please refer to the ACC “Guideline Hub” available at: www.acc.org/guidelines/hubs/blood-cholesterol


Figure 1. Summary of 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol
EVALUATE CLINICAL ASCVD
YES
Secondary Prevention
NO
Primary Prevention (age 40 -75 yo)
History of multiple major ASCVD events or 1 major ASCVD event + multiple high risk conditions
LDL-C
> 190 mg/dL
LDL-C 70 - 189 mg/dL
LDL-C
< 70 mg/dL
YES
Very high ASCVD risk
NO
Stable ASCVD
YES
NO
Diabetes
Assess 10-yr ASCVD risk to begin risk discussion
≥20%
High
Risk
≥7.5 - <20% Intermediate Risk
5 -< 7.5% Borderline Risk
<5%
Low
Risk
Evaluate risk enhancers & CAC if uncertain
Risk/benefit discussion for statin; use risk enhancers
Treatment
Maximal tolerated statin
High or moderate-intensity statin
Maximal tolerated statin
Moderate-intensity statin
High-intensity statin
Moderate-intensity
Lifestyle; selective moderate statin
Lifestyle and risk discussion
Assess lifetime risk
Evaluation
LDL-C ≥70 mg/dL, ezetimibe* Reasonable LDL-C ≥70 or non-HDL ≥100 mg/dL PCSK9-I** Reasonable after risk discussion
High-intensity statin Aim for LDL-C lowering ≥50% Moderate-intensity Aim for 30-49%
LDL-C ≥100 mg/dL, ezetimibe* Reasonable LDL-C ≥100 mg/dL Consider PCSK9-I**
Aim for LDL-C lowering 30-49% If multiple ASCVD risk factors, 50-79y: High-intensity statin
Aim for LDL-C lowering ≥50%
Aim for LDL-C lowering 30-49%

*on maximally tolerated statin

**on maximally tolerated statin and ezetimibe


Adapted from: Grundy, S.M., et al J Am Coll Cardiol. Central Illustration Available at: www.onlinejacc.org/guidelines/cholesterol

Table 2. Summary of Statin Drug-Drug Interactions with Commonly Used ARVs

Statin
Antiretroviral*
Statin Recommendation
Atorvastatin
  • Atazanavir/cobicistat
Avoid use
  • Atazanavir/ritonavir
Titrate dose carefully

Use lowest dose necessary

Monitor for toxicities

  • Darunavir/cobicistat
  • Darunavir/ritonavir
  • Elvitegravir/cobicistat
  • Lopinavir/ritonavir
Titrate dose carefully

Use lowest dose necessary

Monitor for toxicities

Do not exceed 20 mg

  • Efavirenz
  • Etravirine
Adjust dose according to lipid response

(do not exceed maximum dose)

  • Bictegravir
  • Dolutegravir
  • Doravirine
  • Raltegravir
  • Rilpivirine
No dose adjustment necessary
Lovastatin Simvastatin
  • ALL Protease Inhibitors Elvitegravir/cobicistat
Contraindicated
  • Bictegravir
  • Dolugetravir
  • Raltegravir
No dose adjustment necessary
  • Efavirenz
  • Etravirine
Adjust dose according to lipid response

(do not exceed maximum dose)

Pitavastatin
  • Atazanavir
  • Bictegravir
  • Darunavir/ritonavir
  • Dolutegravir
  • Doravirine
  • Efavirenz
  • Etravirine
  • Lopinavir/ritonavir
  • Raltegravir
  • Rilpivirine
No dose adjustment necessary
Pravastatin
  • Atazanavir/cobicistat
  • Atazanavir/ritonavir
  • Darunavir/cobicistat
  • Darunavir/ritonavir
Titrate dose carefully

Monitor for toxicities

  • All other Protease Inhibitors
No dose adjustment necessary
  • Bictegravir
  • Dolutegravir
  • Doravirine
  • Efavirenz
  • Etravirine
  • Raltegravir
  • Rilpivirine
No dose adjustment necessary
Rosuvastatin
  • Atazanavir/cobicistat
  • Atazanavir/ritonavir
Titrate dose carefully

Use lowest dose necessary

Monitor for toxicities

Do not exceed 10 mg
  • Darunavir/cobicistat
  • Lopinavir/ritonavir
Titrate dose carefully

Use lowest dose necessary

Monitor for toxicities

Do not exceed 20 mg
  • Darunavir/ritonavir
  • Elvitegravir/cobicistat
Titrate dose carefully

Use lowest dose necessary

Monitor for toxicities

  • Efavirenz
  • Etravirine
Adjust dose according to lipid response

(do not exceed maximum dose)

  • Bictegravir
  • Dolutegravir
  • Raltegravir
No dose adjustment necessary
Adapted from: 2018 DHHS Guidelines for the use of antiretroviral agents in adults and Adolescents living with HIV. Available at: aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/367/overview

SMOKING CESSATION FOR ASCVD PREVENTION AMONG PEOPLE LIVING WITH HIV

 Learning Objectives

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  1. Utilize the 5 A’s for smoking cessation counseling.

  2. Utilize the 5 R’s for tobacco users who are not ready to quit.

  3. Understand appropriate use of smoking cessation pharmacotherapy for patients receiving antiretroviral therapies.

Key Messages

Click to Expand Key Messages

  1. The 5 A’s is a quick and effective method to assess smoking cessation readiness and provide counseling.

  2. Counseling using the 5As promotes smoking cessation; adding pharmacotherapy to the 5As is more effective than counseling alone, while combined pharmacotherapy, e.g. varenicline plus nicotine replacement, can be used in those previously unsuccessful.

  3. Pharmacotherapy increases quit success rate. Combination NRT therapy, varenicline, and bupropion are considered first line and selection should be guided by patient preference and comorbidities.

Introduction

The success of antiretroviral therapy has transformed morbidity and mortality among people living with HIV (PLH) from early AIDS-related causes to later cardiovascular causes.1,2 Age and sex-adjusted deaths from cardiovascular disease (CVD) among PLH are appreciably higher than the general population. 3-5 Moreover, one in three patients with HIV smoke, and smoking accounts for 60% of all deaths among PLH. 6 While the benefits of smoking cessation among patients with and without HIV are clear, the literature suggests evidence-based treatment for smoking is underused, particularly among PLH. 6-9 This brief discusses the role of smoking cessation treatment in reducing CVD risk among PLH.


Brief Review

The 5 A’s is an evidence-based method of assessing a patient’s willingness to quit smoking. This approach, which can be delivered in as little as 3 minutes, incorporates motivation interviewing to guide patients towards smoking cessation. 10 The 5A’s approach is displayed in Figure 1.


Figure 1: The 5 A’s for Smoking Cessation Assessment

Ask

  • Ask about current and prior tobacco use habits. Prior tobacco users should be congratulated and reminded of the importance of avoiding triggers to prevent relapse.
  • Current smokers: assess frequency of use and type(s) of tobacco products used and any prior attempts to quit. Proceed to “Advise”.

Advise

  • Advise current users to quit and provide clear, strong, and personalized suggestions to help ensure success.

Assess

  • Assess willingness to quit.
  • For patients in pre-contemplative or contemplative states, aim to understand barriers and use motivational interviewing techniques and the 5 R’s to promote cessation considerations.

Assist

  • For patients ready to quit, assist patient in setting a quit date in the near future (i.e. 2 – 4 weeks).
  • Encourage patient to elicit support from family, friends and co-workers.
  • Offer pharmacotherapy to all patients attempting to quit.

Arrange

  • Schedule follow up within 1 – 2 weeks of quit date. This can be in person or via phone.
  • Remain mindful relapses are common, but the majority of patients who relapse are willing to make another quit attempt within 30 days.

The 5 A’s begin by asking patients about current and past tobacco use. Never smokers should be encouraged to continue healthy patterns and prior users should be commended and educated on avoidance of triggers, including the importance of avoiding “just one cigarette”. Current smokers should be asked about frequency and type of tobacco products used. Annual assessments are reasonable for non-smokers while more frequent assessments may be appropriate for prior or current smokers.

After the initial assessment, the clinician should encourage all current users to quit and provide personalized education and recommendations which could assist in their efforts. Even this brief interaction may have a positive impact on cessation rates. 11 At this point, the clinician should assess the patient’s willingness to quit. The stages of change model is commonly used to describe a patient’s attitude towards quitting: 12

  • Pre-contemplative: Not considering quitting in the near future.
  • Contemplative: Considering a quit attempt within 6 months.
  • Preparation: Considering a quit attempt within 30 days.

Clinicians should aim to understanding motives and barriers to cessation for patients in pre-contemplative and contemplative states and motivational interviewing strategies should be employed to move patients towards an actionable state. The 5 R’s is another useful technique to help move patients towards the preparation state: 13


Figure 2: 5 R’s for Patients Who Are Not Ready to Quit

Relevance

  • Collaborate with patient to identify reasons why quitting is personally relevant to them (i.e. comorbidities, costs, other life goals).

Risks

  • Ask patient to explain their perceived risks of smoking or tobacco use. Explain that:
    • 20 minutes after quitting, heart rate and blood pressure drop
    • 12 hours after quitting, carbon monoxide levels drop to normal
    • 2 weeks to 3 months after quitting, circulation and lung function improve
    • 1 year after quitting, risk of coronary heart disease is cut in half
    • 5 years after quitting, stroke risk is the same as for nonsmokers

Rewards

  • Ask patients to identify potential benefits of smoking cessation (i.e. improved breath, whiter teeth, improved sense of smell and taste, everyday activities do not result in shortness of breath, improved skin tone, overall health improvements, reducing loved ones exposure to second hand smoke, money saved that is not spent on tobacco products).

Roadblocks

  • Ask patients to identify barriers to quitting (e.g., previous failures, weight gain, depression) and offer solutions to mitigate concerns. Remind patients that many tobacco users make repeated attempts before they are successful.

Repetition

  • Repeat this process at each visit.

Patient in the preparation phase should be encouraged to set a quit date within 2 – 4 weeks. Encourage patients to share this date with family, friends, and coworkers, and request support. Establishing a clear date with patients prepared to quit is an important but often omitted aspect of cessation counseling. 9,14 Pharmacotherapy should be offered to all patients attempting to quit as assistive medications increase their likelihood of success. First line agents include nicotine replacement therapies (NRT), varenicline (Chantix®) and bupropion (Wellbutrin XR®, Zyban®).15 Choice of medication should be based on patient preference and comorbid disease states. In general, initial regimens should consist of one of the following: short and/or long NRT, varenicline, or bupropion. Varenicline is a nicotine receptor blocker and therefore use in combination with an NRT is theoretically without benefit. Evidence supporting use of bupropion in combination with NRT is mixed, with some studies showing positive results and others indicating no additional benefits. 16,17 Use of two NRTs has been shown to be more effective than a single NRT alone. 8,18,19 A common NRT combination regimen consists of the long acting nicotine patch with a short acting NRT (i.e. gum or lozenges). The role of electronic cigarettes (“e-cigarettes”) in smoking cessation remains unclear and is limited by lack of long-term safety data. 20

In general, pharmacotherapies for smoking cessation are well tolerated. Both varenicline and bupropion should be initiated at least 7-10 days before the quit date. To improve tolerance, both agents should be started at a low dose and titrated to therapeutic doses; varenicline is available as a “starter pack” whereas bupropion may be started at 150 mg daily and increased to 300 mg daily after 3 – 7 days.

Common side effects, HIV-specific drug interactions, and other contraindications are displayed in Table 1.

Table 1. Pharmacotherapies for Smoking Cessation 8

Drug
Common Side Effects
Interactions with Anti-Retrovirals
Other Considerations
Nicotine Replacement Therapy
  • Patch
  • Gum
  • Lozenges
  • Inhaler
  • Nasal spray
  • Patch: location irritation, insomnia, vivid dreams
  • Gum & lozenges: local irritation, GI upset (worsened with vigorous chewing)
  • Inhaler/nasal spray: irritation to eyes, nose, and throat
No clinically significant interactions expected.
  • Patch: can be removed prior to bed if needed, but may take up to 3 hours to return to therapeutic levels
  • Gum: GI effects correlate with chewing intensity
Varinscile Varenicline (Chantix®)
  • GI upset
  • Insomnia, vivid dreams
No clinically significant interactions expected.
  • Concurrent use with NRT may result in additive adverse effects
  • A large randomized controlled trial showed no significant increase in neuropsychiatric effects relative to NRT or placebo and the Black Box Warning for neuropsychiatric effects was removed in 2016.16
  • While the body of evidence is mixed, there appears to be little to no excess cardiovascular risk associated with varenicline. Nevertheless, the FDA encourages weighing the risks vs. benefits of therapy in patients with known CVD.21
Bupropion (Zyban®, Wellbutrin®)
  • Insomnia
  • Reduced seizure threshold (dose-dependent)
Ritonavir boosted PIs, efavirenz, or nevirapine may result in reduced bupropion concentrations. Elvitegravir/cobicistat may increase bupropion concentrations. Titrate bupropion dose based on clinical response.
  • Avoid in patients with history of seizure
  • Use with caution in patients who are at risk for seizures or using other agents (including alcohol) that reduce seizure threshold

A critical but often overlooked step is arranging follow up. Ideally, follow up should be scheduled within 1 – 2 weeks of the quit date and can be accomplished in person or via phone. The is an important opportunity to evaluate response to pharmacotherapies, identify early barriers, and provide reinforcement. Subsequent visits should focus on congratulating success, evaluating continued need for pharmacotherapies, and proactively identifying potential triggers for relapse. Remain mindful that relapse is common, particularly in the initial months to years and that the literature shows nearly two-thirds of those who relapse wish to make another quit attempt within 30 days. 22,23

MEDICATION ADHERENCE

Learning Objectives

Click to Expand Learning Objectives

  1. Understand the prevalence of poor medication adherence.

  2. Know how to ask patients about medication adherence in ways that improve honest answers.

  3. Recognize common strategies for improving medication adherence once recognized.

Key Messages

Click to Expand Key Messages

  1. Consider non-adherence as a leading cause of treatment failure prior to increasing doses or adding additional medications.

  2. Patients often under-estimate the degree to which they do not take medications as prescribed; this may be intentional or unintentional.

  3. Create a non-judgmental atmosphere to identify and address underlying cause(s) of poor adherence.

Introduction

Poor medication adherence is understood to be a leading cause of treatment failure. In trials, patients take approximately 40 – 80% of doses as prescribed and it is likely that real-world rates of poor adherence exceed what has been reported in these closely-monitored settings. 1 Moreover, non-adherence often goes unrecognized. One survey found that while 64% of patients believed they had good medication adherence (defined as followed prescriber instructions “extremely closely”), 31% reported not filling a prescription they were given and 24% admitted to taking less than the prescribed dose. 2 Likewise, physicians tend to over-estimate the degree to which patients are taking medications as prescribed. 3 The combined unawareness among patients and providers has caused non-adherence to become a common but often unrealized reason that patients fail to achieve treatment goals.


Brief Review

Intentional vs. Unintentional Non-Adherence

Poor adherence can be an intentional or unintentional process. Unintentional non-adherence may most commonly be thought of as simple forgetfulness (i.e. a patient inadvertently misses doses) but there are several other underlying causes. It often suggests that the patient has failed to establish an adherence habit in which taking medication has been integrated into a person’s daily routine to the point where adherence becomes automatic.4 In addition, patients with poor health literacy or cognitive impairment may lack the ability to follow the prescribed instructions for medication use needed to develop an adherence habit. Even in patients with adequate health literacy, complex regimens, such as those with multiple daily doses and/or a high number of medications, can also prove problematic for adherence. Transportation to and from the pharmacy may also present barriers, particularly among low-income patients and older adults. Increasingly, cost is another barrier to taking medications as prescribed.

Intentional non-adherence refers to patients who are making a conscious decision as to how they are going to take their medications. Typically, intentional non-adherence reflects the patient’s beliefs about the relative benefits vs harms and side effects. 5 Adverse effects, including actual and fear of potential ones, is a common contributor. Similarly, lack of perceived benefit may also contribute to intentional non-adherence, particularly if patient develops (or are is concerned about developing) adverse effects to a medication used to treat an asymptomatic condition. Increasingly, cost is becoming a significant barrier to medication adherence; 6 it is not uncommon for patients, particularly those with deductibles or in the Medicare Part D coverage gap, to “ration” medications due to affordability concerns.


Identifying & Addressing

Identifying Poor Adherence

Reviewing prescription fill histories is a simple way to gauge medication use in patients with suspected non-adherence. While electronic medical records have this technology embedded, this can also be accomplished by contactinged the patient’s pharmacy and requesting the refill dates for a given medication. Though gaps in fill histories suggest a pattern of non-adherence, one must be careful not to assume that filling a medication means a patient is taking a medication. Pill counts may also be used, however this method tends to be time consuming and may be skewed if patients combine the contents of old prescription vials with new ones. Another clue to non-adherence is failing to see an expected effect, e.g. reduction in blood pressure or cholesterol.

Starting the Conversation about Medication Use

There are multiple patient-reported tools that can be used to assess adherence. The Morisky Medication Adherence Scale (MMSAS) is a 4 or 8-item survey that is a validated measure of medication adherence across a number of chronic disease states. 7-9


Figure 1: Morisky Medication Adherence Scale (MMAS)

MMAS – 4
  • Do you ever forget to take your medicine?
  • Are you careless at times about taking your medicine?
  • Sometimes if you feel worse when you take the medicine, do you stop taking it?
  • When you feel better, do you sometimes stop taking your medicine?












MMAS – 8
  1. Do you ever forget to take your pills?
  2. People sometimes miss taking their medications for reasons other than forgetting. Thinking over the past 2 weeks, were there any days you did not take your medicine?
  3. Have you ever cut back or stopped taking your medicine without telling your doctor because you felt worse when you took it?
  4. When you travel or leave home, do you sometimes forget to bring along your medicine?
  5. Did you take all your medicine yesterday?
  6. When you feel like your symptoms are under control, do you sometimes stop taking your medication?
  7. Taking medicine every day is a real inconvenience for some people. Do you ever feel hassled about sticking to your treatment plan?
  8. How often do you have difficulty remembering to take all of your medications?
    1. Never/Rarely
    2. Once in awhile
    3. Sometimes
    4. Usually
    5. Never

Adherence
MMAS Score
High adherence
0
Medium Adherence
1 - 2
Low Adherence
≥ 3

Ultimately, it is important for providers to create a non-judgmental environment where patients feel comfortable discussing their true manner of medication use. A trusting relationship between the patient and the clinician is associated with improved ART adherence.10 Similarly, a trusting relationship increases the chances that the patients will be more forthright about their non-adherence when asked about their adherence in a non-judgmental way. Approaches for addressing intentional and unintentional non-adherence are included in Table 1. Examples of talking points include:


  • "Many people find it hard to take to their medication every day. Tell me about your experience."
  • “What have you read about your medications? Did you come across anything in your research that makes you concerned?”
  • “Do you have any concerns about paying for your medications?”
  • “Before we add a second medication for your blood pressure, let’s talk about how you are taking the first. Your refill history shows you filled this medication about 2 weeks later than we would expect if you were taking it every day. Thinking about the last week, were there any days you missed a dose?”
  • “What do you use to help you to remember to take your medications?”

Table 1: Addressing Intentional and Unintentional Non-Adherence
Underlying Reason for Poor Adherence
Tools to Identify
Tools to Address
Asymptomatic Disease/Lack of Perceived Benefit
  • Ask: “Do you feel this medication helps you?”.
  • Be mindful that embarrassment or social stigma may impact adherence in certain disease states.
  • Address misconceptions around asymptomatic diseases.
  • Empathize with embarrassment and provide access to supportive resources (i.e. patient groups, counselors, etc.).
Medication Cost
  • Ask: “Do you have any concerns about paying for your medications?”.
  • Ask staff to follow up 5 – 7 days after a new medication is prescribed to make sure the patient actually picked it up.
  • Whenever possible, prescribe generic medications.
  • Consider combination products to reduce out of pocket costs.
  • Prescribe agents on $4 programs available at most large retail chains.
  • Use the app “MMIT Formulary” to determine coverage.
  • Even generic medications may be less expensive if the patient uses coupons from www.goodrx.com.
  • For brand name drugs, look for manufacturer coupons or assistance programs:www.needymeds.org.
Lack of Transportation
  • Ask: “Do you have any problems getting to the pharmacy?”.
  • Take advantage of pharmacy delivery programs (many independent pharmacies offer this free of charge).
  • Consider mail order pharmacies.
  • Prescribe 90-day supplies to minimize trips to the pharmacy.
  • Work with the pharmacy to coordinate refills to occur on the same day.
Side Effects (Fear of or Actual)
  • Ask: “How do you feel since starting the medication?”.
  • Ask: “What have you read about your medications? Did you come across anything in your research that makes you concerned?”.

  • Ask staff to follow up 2 weeks and 4 weeks after a medication is started or a dose is changed to make sure the patient is tolerating.
  • Set expectations for adverse effects and be clear that you will work with the patient to manage any tolerance issues. Explain side effects that are expected to improve with time.
  • Advise patients that the leaflet included with their prescription may be written from a medical-legal perspective.
  • Encourage patients to contact the office to discuss concerns rather than conduct internet searches.
  • If patients chose to conduct internet research, encourage use of reputable websites.
Forgetfulness
  • Ask: “What do you use to help you remember your medications?”.
  • For patients on regimens with multiple daily doses, ask which dose they are most likely to miss.
  • Encourage use of pill boxes or other reminder aids (i.e. alarms, apps).
  • Encourage patients to request refills when they have 5 – 7 days of medication remaining or enroll in auto-refill programs.
  • Use once-daily regimens whenever possible.
  • Advise patients to incorporate their medication timing into daily habits (i.e. place medications near coffee maker or on nightstand by bedroom light to be taken first thing in the morning or at night).
  • Simplify regimens as much as possible by eliminating unnecessary medications and optimizing use of once-daily agents and combination pills.
Cognitive Impairment or Low Health Literacy
  • Use teach-back techniques to verify understanding.
  • Simplify regimen as much as possible (once-daily dosing, combination pills, reduce polypharmacy).
  • Engage a caregiver to assist.
  • Consider pre-fill medisets or blister packs.

ASSESSING ASCVD RISK AMONG PEOPLE LIVING WITH HIV

Learning Objectives 

Click to Expand Learning Objectives

  1. Apply atherosclerotic cardiovascular disease (ASCVD) risk assessment in guiding risk reduction strategies for people living with HIV (PLH).

  2. Recognize HIV infection as an ASCVD risk enhancing factor.

  3. Utilize the ASCVD Risk Estimator Plus as a shared decision-making tool for PLH.

Key Messages

Click to Expand Key Messages

  1. Assessing ASCVD risk among PLH is best done using handheld or online risk calculation using the ACC/AHA ASCVD Risk Estimator Plus.

  2. Clinicians should recognize that HIV infection enhances risk for ASCVD meaning that actual risk often exceeds that calculated based on traditional risk factors.

  3. Use the ACC/AHA ASCVD Risk Estimator Plus for shared decision-making with patients regarding ASCVD risk reduction using the ABCS (Aspirin, Blood pressure control, Cholesterol management, and Smoking cessation) based on National Guidelines for each.

Introduction

The dramatic success of antiretroviral therapy (ART) is transforming morbidity and mortality among people living with HIV (PLH) from early AIDS-related causes to later cardiovascular causes. 1,2 Age and sex-adjusted deaths from cardiovascular disease (CVD) among PLH are appreciably higher than the general population. 3-5 PLH have higher risk for atherosclerotic cardiovascular disease (ASCVD) than the general population after controlling for ASCVD risk factors. 6 Yet, PLH are less likely than the general population to receive proven interventions commonly referred to as the ABCS for aspirin, blood pressure control, cholesterol control, and smoking cessation for prevention of ASCVD. 7-9 Underuse of these interventions in PLH is worse for African Americans. 10

Reasons for underuse of these interventions likely reflects an underestimation of ASCVD risk and lack of knowledge regarding safety of medications (e.g., statins in combination with ART) in this population. In the absence of formal risk calculation, clinician’s estimates are inaccurate and tend to underestimate ASCVD risk. 11 In practice, clinicians tend to emphasize one or two risk factors and fail to appreciate the impact of compounded risk, particularly the impact of age, sex, and other risk factors. 12

Use of risk calculation improves risk assessment beyond clinician estimates 13 and results in greater reduction in risk factors without clinical harm. 14 While risk calculators tend to underestimate risk for PLH,6 their use provides a foundation for shared patient decision-making regarding risk reduction. 15

National Clinical Practice Guidelines for management of hypertension (2017) and also for cholesterol (2018) recommend use of the American College of Cardiology/American Heart Association (ACC/AHA) ASCVD Risk Estimator Plus Calculator to estimate a patient’s 10-year ASCVD risk. 16,17 This calculator has the advantage of including white and black participants in the original cohorts. In addition, the current version allows estimation of treatment with aspirin, antihypertensive agents, statins, and smoking cessation. 18 The ASCVD Risk Estimator Plus can be accessed through the Web. It is also available as an App for free download for IOS and Android phones.


This brief discusses how to assess ASCVD risk among PLH.


Brief Review

The ASCVD Risk Estimator Plus should be used at an initial visit with a patient to establish a reference point and forecast the impact of various interventions on patient risk. 13,19 Risk should be reassessed at follow-up visits (after use of an ABCS) to monitor change in a patient’s 10-year risk. ASCVD risk can be estimated for patients 40-79 years of age. Patients with a history of known ASCVD, i.e. a diagnosis of coronary artery disease, cerebrovascular disease, aortic disease or peripheral vascular disease, are considered high risk, typically 10-year risk >20% for future coronary or cerebrovascular events. Individuals with high risk should be considered for secondary prevention that may include: aspirin prophylaxis, blood pressure control, use of high intensity statins to reduce LDL-C by at least 50%, and smoking cessation counseling/pharmacotherapy.

For primary ASCVD prevention, calculation of ASCVD risk is based on the following risk factors: age, biological sex, race (White, African American, or Other), systolic and diastolic blood pressure, total, HDL, and LDL cholesterol, presence of diabetes, smoking status (current, former, never), current treatment for hypertension and currently on a statin or aspirin therapy.

Most ASCVD related guidelines recommend shared decision making. 17,20 This includes discussion of potential benefits from risk reduction and potential harms. A patient’s risk estimate can be used during the clinician-patient discussion to determine approach to therapy for risk reduction when indicated. In addition to reviewing the risk estimate, consideration should be given to the burden, severity, and control of CVD risk factors along with the presence of any risk-enhancing conditions (Figure 2). HIV infection (even in the presence of controlled viremia) is considered a “risk-enhancing” factor associated with increased risk of an ASCVD event, affecting the 10-year risk estimate. HIV often increases risk 50-100% beyond calculated risk. 6 Consideration of HIV is particularly relevant for patients with a “borderline” ASCVD risk estimate, i.e. 5-7.4%. In these instances, the actual 10-year risk might be closer to 7.5-10%, suggesting the need for firmer recommendation for drug therapy (i.e., statin).

Our online CME modules address each of the ABCS. These include discussion of the U.S. Preventive Services Task Force (USPSTF) for use of aspirin and a calculator to assist in personalizing the benefits and harms of use of aspirin to prevent CVD, discussion of current hypertension guidelines, including a stepped care approach to achieve control, use of statins for PLH, and USPSTF guidelines to address smoking.

Figure 2. Risk-Enhancing Factors
  • Family history of premature ASCVD (males, age <55 yr; females, age <65 yr)
  • Primary hypercholesterolemia (LDL-C, 160–189 mg/dL); non–HDL-C 190–219 mg/dL)*
  • Metabolic syndrome (increased waist circumference, elevated triglycerides [>175 mg/dL], elevated blood pressure, elevated glucose, and low HDL-C [<40 mg/dL in men; <50 in women mg/dL] are factors; three of these makes the diagnosis)
  • Chronic kidney disease (eGFR 15–59 mL/min/1; not treated with dialysis or kidney transplantation)
  • Chronic inflammatory conditions such as psoriasis, RA, or HIV/AIDS
  • History of premature menopause (before age 40 yr) and history of pregnancy-associated conditions that increase later ASCVD risk such as preeclampsia
  • High-risk race/ethnicities (e.g., South Asian ancestry)
  • Lipid/biomarkers: Associated with increased ASCVD risk
  • Persistently* elevated, primary fasting hypertriglyceridemia (≥175 mg/dL);
  • Elevated high-sensitivity C-reactive protein (≥2.0 mg/L)
  • Elevated Lp(a): Lp(a) ≥50 mg/dL
  • Elevated apoB ≥130 mg/dL:
  • ABI <0.9
ABI, ankle-brachial index; apoB, apolipoprotein B; ASCVD, atheroscleroticcardiovascular disease; eGFR, estimated glomerular filtration rate; HDL-C, high-density lipoprotein cholesterol; HIV, human immunodeficiency virus; LDL-C, low-density lipoprotein cholesterol; Lp(a), lipoprotein (a);and RA, rheumatoid arthritis. ¶ Adapted from Grundy et al.17

The Implementation Research: Translating the ABCS into HIV Care Project is supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) under award number 1 U01 HL 142107-01. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.