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 53: Lifestyle Interventions
See page 55: Hypertension: Diagnosis, Grading and Management
See page 56: Hypertension: Drug Sequencing Management
See page 55-57: Drug-drug Interactions between Antihypertensives and ARVs
See page 59: Type 2 Diabetes
See page 60: Dyslipidaemia

 
* Fasting or non-fasting samples may be used
** and ≥ 50% reduction from baseline

  1. Use the Framingham equation or whatever system local National Guidance recommends; a risk equation developed from HIV populations 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. See discussion on drug treatment of persons with lower CVD risk at ESC/EAC Guidelines for the Management of Dyslipidaemias EHJ September 2019 [5]
  5. Age 65+: Target 130-139 SBP.
    Age 18-65: 120-129 SBP
  6. Target levels are to be used as guidance and are not definitive – expressed as mmol/L with mg/dL in parenthesis. In case LDL 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 (65) but the independent contribution from TG to CVD risk is uncertain
  7. In acute settings (Post-MI, ischemic, stroke or stent insertion) dual anticogulation is recommended for up to 1 year

See online video lecture CVD, CKD, Endocrinology from the EACS online course Clinical Management of HIV.