Prevention of Cardiovascular Disease (CVD)

Principles

The intensity of efforts to prevent CVD depends on the underlying risk of CVD, which can be estimated(i). The preventive efforts are diverse in nature and require involvement of a relevant specialist, in particular if the risk of CVD is high and always in persons with a history of CVD

See page 61: Lifestyle Interventions
See page 63 Hypertension: Diagnosis, Grading and Management
See page 64: Hypertension: Drug Sequencing Management
See page 65: Drug-drug Interactions between Antihypertensives and ARVs
See page 68: Type 2 Diabetes
See page 69: Dyslipidaemia

  1. Use the Framingham equation or whatever system local National Guidance recommends; a risk equation developed from HIV populations without history of CVD is available: see https://www.chip.dk/Tools-Standards/Clinical-risk-scores. This assessment and the associated considerations outlined in this figure should be repeated annually in all persons under care, see Assessment of PLWH at Initial & Subsequent Visits, to ensure that the various interventions are initiated in a timely way
  2. Options for ART modification include:
    1. Replace with NNRTI, INSTI or another PI/r known to cause less metabolic disturbances and/or lower CVD risks, see Adverse Effects of ARVs and Drug Classes 
    2. Consider replacing ZDV or ABC with TDF or use an NRTI-sparing regimen
  3. Of the modifiable risk factors outlined, drug treatment is reserved for certain subgroups where benefits are considered to outweigh potential harm. Of note, there is a combined benefit of various interventions in target groups identified. Per 10 mmHg reduction in systolic blood pressure, per 1 mmol/L (39 mg/dL) reduction in TC and with use of acetylsalicylic acid, each reduces risk of IHD by 20-25%; the effect is additive. Observational studies suggest that smoking cessation results in about 50% less risk of IHD – and this is additive to other interventions
  4. Age 65+: Target 130-139 SBP 70-79 DBP Age 18-65: 120-129 SBP 70-79 DBP Ambulatory blood pressure monitoring is recommended using home BP
  5. Persons with DM in the absence of clear contraindications and established CVD or other target organ damage (any proteinuria, UA/C > 3, eGFR < 30 mL/min, left ventricular hypertrophy, or retinopathy) or ≥ 3 major risk factors (age, hypertension, dyslipidemia, smoking, obesity) or early T1DM (> 20 years) or DM ≥ 10 years plus any other risk factor 
  6. In acute settings (Post-MI, ischemic, stroke or stent insertion) dual antiplatelet therapy is recommended for up to 1 year
  7. Target levels are to be used as guidance and are not definitive – expressed as mmol/L with mg/dL in parenthesis. In case LDL-c cannot be measured or calculated because of high triglyceride levels, the non- HDL-c (TC minus HDL-c) target should be used. Target levels for TG are usually < 1.7 mmol/L (150 mg/dL) but the independent contribution from TG to CVD risk is uncertain
  8. Very high-risk persons: Documented atherosclerotic CVD (ASCVD), either clinical [ACS (MI or unstable angina), stable angina, coronary revascularization (PCI, CABG, and other arterial revascularization procedures), stroke and TIA, and peripheral arterial disease] or unequivocal on imaging [significant plaque on coronary angiography or CT scan (multivessel coronary disease with two major epicardial arteries having > 50% stenosis), or on carotid ultrasound]. DM with target organ damage, or at least three major risk factors, or early onset of T1DM of long duration (> 20 years). Severe CKD (eGFR < 30 mL/min). A calculated SCORE ≥ 10% for 10-year risk of fatal CVD. Familial hypercholesterolemia with ASCVD or with another major risk factor
  9. High-risk persons: Markedly elevated single risk factors, in particular TC > 8 mmol/L (> 310 mg/dL), LDL-c > 4.9 mmol/L (> 190 mg/dL), or BP ≥ 180/110 mmHg. Familial hypercholesterolemia without other major risk factors. Persons with DM without target organ damage, a with DM duration ≥ 10 years or another additional risk factor. Moderate CKD (eGFR > 30 - < 60 mL/min). A calculated SCORE ≥ 5% and < 10% for 10-year risk of fatal CVD