Michos ED et al. Lipid management for the Prevention of Atherosclerotic Heart Disease.
N Engl J Med 2019;381(16):1557-67. DOI: 10.1056/NEJMra1806939

Because of the growing importance of prevention and treatment of cardiovascular disease in persons with HIV, I have decided to cite an excellent review article on this topic. The content is mainly based on the 2019 ACC-AHA guidelines for cholesterol management for primary prevention of CVD. Here are some key take-home points from the article.

• • It has been known since 1961 from Framingham data that an elevated level of low-density lipoprotein (LDL) is a major contributor to atherosclerotic CVD
  • Although the general assumption regarding LDL cholesterol is “lower is better,” 40% of persons with coronary artery disease have normal total cholesterol levels (< 200 mg/dL)
  • As a starting point, all adults 40-75 years old should have their overall CVD assessed by using the ACC-AHA risk calculator (cvriskcalculator.com). This should NOT include persons with diabetes or whose LDL is > 190 mg/dL as statin therapy is recommended for these patients
  • A low risk ACC-AHA score is < 5%, intermediate risk is 5-20%, and high-risk is > 20%
  • Statin therapy is recommended for high-risk patients to reduce LDL by 50%
  • Statin therapy is recommended for intermediate-risk patients to lower LDL by 30%
  • The presence of risk-enhancing factors, including HIV infection and chronic kidney disease, favor initiation of statin therapy for intermediate risk patients
  • For patients at intermediate risk who are statin-intolerant or have concerns about side-effects, coronary artery CT to calculate a calcium score is reasonable. Patients with scores of 0 may defer a statin (except for smokers)

Author’s Commentary:

The above is a summation of the key points regarding primary prevention of CVD. The article also includes a discussion of secondary prevention and of non-statin therapies including ezetimibe, PCSK9 inhibitors, and N-3 fatty acids. These latter drugs still play a role in persons with elevated triglyceride levels – something that was seen very commonly in the past in patients on boosted-protease inhibitors. Life-style modifications remain very important for primary and secondary prevention of CVD. Shared decision-making regarding risks and benefits of statins is also emphasized in this article.  

Readers are also referred to the comprehensive review by Feinstein and Hsue – Characteristics, Prevention, and Management of Cardiovascular Disease in People Living with HIV: A Scientific Statement From the AHA. Circulation. 2019; 140: e98–e124; DOI: 10.1161/CIR.0000000000000695