ACC/AHA Cholesterol Guidelines Increased Statin Eligibility for Patients With HIV, But Challenges Persist

Jaime Rosenberg

People living with HIV are twice as likely to develop cardiovascular disease (CVD) and have incident heart failure, underscoring the importance of HIV-specific cardiovascular prevention strategies. However, according to a new study, many patients are still not recommended for or prescribed statin therapy.

In 2013, the American College of Cardiology/American Heart Association (ACC/AHA) released new cholesterol guidelines, replacing the National Cholesterol Education Program Adult Treat Program III (ATPIII) and changing statin eligibility. Based on these new guidelines, it was estimated that in the general population an additional 11% of patients would be eligible and therefore recommended for statin therapy, largely driven by older patients with an elevated risk score.

“However, whether a similarly increased number of all patients infected with HIV would be recommended for statin therapy under the new guidelines has not been explored relative to a control population of all patients infected with HIV,” wrote the researchers. “Moreover, it is not known whether application of the ACC/AHA guidelines would result in improved identification of patients who ultimately experience a CVD event and would benefit from preventative therapy with a statin.”

After examining 1394 patients with HIV between January 1, 2006, and December 31, 2008, the researchers determined that there was improved statin eligibility among the patient population, with 38.6% of patients recommended for the treatment under the ACC/AHA guidelines compared with 20.1% under the ATPIII guidelines. Notably, statins were prescribed for more patients meeting ATPIII guidelines than ACC/AHA guidelines (66.4% vs 42.8%).

However, comparing recommended statin use in this patient population with a group of 6141 uninfected controls, the researchers found that patients with HIV were less likely to actually be prescribed statin therapy compared with the controls (22% vs 33.7%) despite having similar rates of recommendation.

During the study period, there were 71 CVD events among the patients with HIV, of which 42 (59.2%) met criteria for statin use under the ACC/AHA guidelines, indicating that more than 40% of these patients who experienced a CVD event would not have been recommended for statin therapy under the guidelines.

Meanwhile, 29% of controls with a CVD event would not have been identified as statin-eligible. There were 197 CVD events among the group, of which 141 (71.6%) were eligible for statin use under the ACC/AHA guidelines.

“Our findings suggest that although the ACC/AHA guidelines may identify more HIV-infected patients as statin-eligible, the newer cholesterol guidelines still perform suboptimally in HIV patients in terms of identifying patients at high cardiovascular risk who merit preventative therapy,” wrote the researchers.

Mosepele M, Regan S, Massaro J, et al. Impact of the American College of Cardiology/American Heart Association cholesterol guidelines on statin eligibility among human immunodeficiency virus-infected individuals [published online December 13, 2018]. Open Forum Infect Dis. doi: 10.1093/ofid/ofy326.
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