Hello esteemed colleagues,
I've encountered several patients undergoing prolonged ARV therapy, spanning from their adolescent years through to their senior years, across various ARV regimens. An annual evaluation I often conduct is the lipid profile test. I've observed diverse results, with some patients displaying LDL levels exceeding 130mg/dl and others showcasing high triglycerides, some beyond 400mg/dl.
Traditionally, I employ the ASCVD risk score to determine the necessity of statin administration for primary ASCVD prevention. While this has been my routine approach, I'm curious about the practices and experiences of other physicians in our community.
Are there alternative lipid cut-offs you consider before initiating statin or other lipid-lowering therapies?How do you navigate the decision-making process when it comes to managing lipid profiles in long-term ARV patients?I believe that by pooling our collective knowledge and experiences, we can provide enhanced care to our patients. I appreciate any insights or strategies you can share, and I'm eager to learn from our community's diverse range of experiences.
Warm regards,Nuntana Chumpa
I am not a physician, but I do cardiovascular risk reduction regularly for people with HIV in my practice. Here is my approach:
I've historically used the ASCVD 10 yr and lifetime risk scores as well as the 2019 ACC/AHA guidelines on primary prevention of CVD. These guidelines consider HIV to be a risk enhancer and have had this nice algorithm to follow:I discussed their score and their risk enhancers with patients if they don't already have the "compelling indications for a statin" listed at the top right (LDL > 190mg/dL or diabetes). Given that HIV is shown to increase risk of cardiovascular disease, I've favored starting a statin earlier vs. later if the patient is amenable. (I prefer more hydrophilic statins- rosuvastatin, pravastatin- as these have lower passive diffusion into muscle cells and tend to have less muscle side effects.)
Now that the REPRIEVE trial data is published supporting the use of a moderate-intensity statin in all people with HIV (primary prevention with pitavastatin lowered incidence of new major CV events by 35% in PWH ages 40-75), I'm moving more to start statins (at least a moderate intensity) once people are over 40 and targeting the goal LDL reductions based on intensity of statin (moderate: goal reduction of LDL 30-49%, high: goal reduction of LDL >50%). Under 40 years old, I'm using the 10 yr and lifetime ASCVD risk scores to have a patient-centered discussion about starting a statin. I also love to focus on assisting people in quitting smoking as a means to reduce CV risk!
The REPRIEVE trial was great, but there are still unanswered questions like what to do for people <40, how long people should stay on a mod-intensity statin, will other statins be as effective as pitavastatin, etc. I know we will be learning a lot more in the years to come. :)