Is there a place for the prevention of atherosclerosis in HIV patients care

1
Is there a place for the prevention of
atherosclerosis in HIV patients care?
Cardiovascular risk of HIV therapy
Bruno Caramelli, MD, PhD Associate Professor of
Medicine Director, Interdisciplinary Medicine in
Cardiology Unit Heart Institute
INCOR University of Sao Paulo, Brazil bcaramel_at_usp
.br
2
Causes of Death - Brasil 2002
32.1
17.5
14.9
14.6
10.9
5.5
4.5
CV
Infection
Pulmonary
External
Cancer
Other
Infant
Health Authorities, Brazil, 2002
3
Help comes too late...
WHO Monica Project - Circulation, 1997
4
SmokingRelative Risk for Death
135,036 men
1.9
2
1.8
1.4
1
Relative Risk
1
0
gt 15 CIGAR.
NO SMOKERS
SMOKELESS
lt 15 CIGAR.
DAY
TOBBACO
DAY
Bolinder, G. et al. Am J Public Health199484399
5
Hypertension Framingham Heart Study
Macmahon,S. Lancet 1990335765
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LDL/HDL ratio Framingham Heart Study
3.0
2.5
2.0
Relative risk
1.5
25
1.0
45
HDL-C (mg/dL)
0.5
65
85
0
100
160
220
LDL-C (mg/dL)
Castelli W. Can J Cardiol 19884(supl)5A-10A
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How to estimate risk? Framingham score (Men) -
Absolute total CHD risk in 10 years
SBP DBP
Pts lt 120 lt 80
0 120 - 129 80 - 84
0 130 - 139 85
- 89 1 140 - 159
90 - 99 2 gt 160
gt 100 3
Absolute CHD risk
total pts
10 yrs CHD risk
lt-1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 ?14
2 3 3 4 5 7 8 10 13 16 20 25 31 37 4
5 ? 53
HDL-C (mg/dL)
Pts lt35
2 35-44
1 45-49
0 50-59
0 gt60
- 1
Idade Diabetes Fumante PA HDL-C Colesterol Total
Wilson PWF et al. Circulation. 1998971837-1847.
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Risk of Acute Coronary EventsFramingham score
index

• High
• Absolute risk ? 20 in 10 years
• Intermediate
• Absolute risk 10-20 in 10 years
• Low
• Absolute risk lt 10 in 10 years

• High risk independently of Risk Score
• Clinical atherosclerosis (CHD, PTCA, CABG,
  Stroke/TIA, PAD, Genetic dyslipidemia, DM)

9

• DAD Study Group,NEJM 349 1993-2003, 2003

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Treatment of Dyslipidemia
Hypertension
Diabetes
Smoking
Dyslipidemia

• DAD Study Group,NEJM 349 1993-2003, 2003

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Atherogenic profile in HIV
Hypertriglyceridemia increasing the LDL/HDL
ratio related risk - PROCAM study
plt0,0001
plt0,0001
LDL/HDL
mg/dl
plt0,0001
plt0,0001
plt0,0006
Spósito A, Caramelli B Braz J Infect Dis., v. 6,
p. 275-86, 1997.
Caramelli B. Braz J Infect Dis
20015(6)332-338.
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Cardiovascular risk according to Framingham risk
score219 HIV patients receiving HAART and 438
HIV -
with Framingham score gt 20 in 10 years
Bergensen BM. Eur J Clin Microbiol Infect Dis
2004. 23 625-630
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Switching X hipolipemic agents
L. Calza. AIDS, Jul 2005 19 1051-8.
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Average Framingham risk score (FRS) in 105 HIV
Influence of intervention
Preliminary data
Changes on FRS related to intervention

3 mo. Intervention (LSM drugs)
Baseline
Oliveira E, Caramelli B
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Carotid Intima-Media Thickness9 yrs, HIV CIMT
0.545 mm (expected for age 0.431 mm)
Preliminary data
Giuliano I
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Progression of carotid thickening in one year in
121 HIV and 27 HIV-

• Independent predictors of carotid thickening
  progression
• age (plt0.001)
• CD4 lt 200 cels/mm3(p0.0082)
• HIV infection (p0.002)

P0.0001
0.074mm
P0.0034
P0.002
-0.006mm
18.75 of HIV whithout plaque at baseline,
developed it at one year
Hsue, P. Circulation 109, 2004
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Risk factors in HIV children
Preliminary data
Giuliano I
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Is there a place for the prevention of
atherosclerosis in HIV patients care?
YES
Quit Smoking
Exercise
Blood pressure control
Glucose control
We need multiple task tools to individualize risk
assessment and prevention strategies.
Diet
?
Decrease body weight
Metabolic syndrome
CRP
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Prevention of Atherosclerosis must be
FUN

• Feasible
• Urgent
• Necessary