Correspondence
Cardiovascular Risk and Body-Fat Abnormalities in HIV-Infected Adults
N Engl J Med 2005; 352:1721-1722April 21, 2005
- Article
To the Editor:
In their review of metabolic and cardiovascular risk factors affecting patients infected with the human immunodeficiency virus (HIV), Grinspoon and Carr (Jan. 6 issue)1 recommend the guidelines of the National Cholesterol Education Program for lipid-lowering therapy in HIV-infected patients with hyperlipidemia. Prediction of coronary heart disease (CHD) with the use of the Framingham equation, however, is based on (and principally predictive for) outpatients free of disease.2 Estimation of the 10-year risk of CHD at any point is based on the person's past and expected future lipid levels (which are best assessed as the area under the curve, as shown in Figure 1Figure 1
Association of Hyperlipidemia and Prediction of the Risk of Coronary Heart Disease over Time.). In many treated HIV-infected patients, however, hyperlipidemia does not follow the 10-year course seen in the population without HIV infection, because frequent changes in therapy3,4 may lower total cholesterol levels, increase high-density lipoprotein cholesterol levels, and reduce the risk of atherogenesis.5 It seems to be inappropriate simply to reduce risk estimates after treatment interventions for hyperlipidemia, as shown in Table 2 of the article by Grinspoon and Carr.1 Effective statin (or antihypertensive) therapy does not result in the same estimated 10-year risk of CHD as for persons with normal lipid levels or normal blood pressure without therapy. HIV-infected patients with hyperlipidemia and risk factors for CHD before receiving highly active antiretroviral therapy might benefit substantially from lipid-lowering therapy, which should be considered first.
5 ReferencesGeorg M.N. Behrens, M.D.
Hannover Medical School, 30625 Hannover, Germany
behrens.georg@mh-hannover. de 1
Grinspoon S ,Carr A . Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med 2005;352:48-62
Full Text | Web of Science | Medline2
Wilson PW ,D'Agostino RB ,Levy D ,Belanger AM ,Silbershatz H ,Kannel WB . Prediction of coronary heart disease using risk factor categories. Circulation 1998;97:1837-1847
Web of Science | Medline3
Mocroft A ,Ledergerber B ,Viard JP , et al. Time to virological failure of 3 classes of antiretrovirals after initiation of highly active antiretroviral therapy: results from the EuroSIDA study group. J Infect Dis 2004;190:1947-1956
CrossRef | Web of Science | Medline4
Mocroft A ,Youle M ,Moore A , et al. Reasons for modification and discontinuation of antiretrovirals: results from a single treatment centre. AIDS 2001;15:185-194
CrossRef | Web of Science | Medline5
van der Valk M ,Kastelein JJ ,Murphy RL , et al. Nevirapine-containing antiretroviral therapy in HIV-1 infected patients results in an anti-atherogenic lipid profile. AIDS 2001;15:2407-2414
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Behrens notes that prediction of the risk of CHD with the use of the Framingham equation is based on outpatients free of disease. The estimates to which we refer,1 which are based on a large outpatient population of HIV-infected adults, indicate that estimating cardiovascular outcomes with the use of baseline risk factors yielded similar estimated and actual rates. Like Dr. Behrens, we emphasize that such modeling can provide only a relative estimate in the case of young patients with changing lipid levels. We used an estimate of a 25 percent reduction in total cholesterol level to calculate the risk of myocardial infarction in Table 2 of our article,2 as suggested by studies of the use of statins in patients with chronic infection and hyperlipidemia who were receiving antiretroviral therapy.3 Dr. Behrens is correct that our calculations assume that lipid levels will remain relatively constant — they remain stable for up to 96 weeks in HIV-infected patients receiving stable antiretroviral therapy.4 Although an area-under-the-curve approach may provide additional information about patients with changing lipid levels, the Framingham equation is useful to estimate risk, particularly among patients with chronically elevated but stable lipid levels.
4 ReferencesSteven Grinspoon, M.D.
Massachusetts General Hospital, Boston, MA 02114
sgrinspoon@partners.org Andrew Carr, M.D.
St. Vincent's Hospital, 2010 Sydney, Australia1
Law MG, D'Arminio Monforte A, Friis-Møller N, et al. Cardio- and cerebrovascular events and predicted rates of myocardial infarction in the D:A:D Study. Presented at the 11th Conference on Retroviruses and Opportunistic Infections, San Francisco, February 8–11, 2004.
2
Grinspoon S ,Carr A . Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med 2005;352:48-62
Full Text | Web of Science | Medline3
Calza L ,Manfredi R ,Chiodo F . Statins and fibrates for treatment of hyperlipidaemia in HIV-infected patients receiving HAART. AIDS 2003;17:851-859
CrossRef | Web of Science | Medline4
Opravil M ,Hirschel B ,Lazzarin A , et al. A randomized trial of simplified maintenance therapy with abacavir, lamivudine, and zidovudine in human immunodeficiency virus infection. J Infect Dis 2002;185:1251-1260
CrossRef | Web of Science | Medline
- Citing Articles (3)
Citing Articles
1
Bin Wang, Dominic E. Dwyer, Choo Beng Chew, Chenda Kol, Zhong Ping He, Hemal Joshi, Megan C. Steain, Anthony L. Cunningham, Nitin K. Saksena. (2009) Sensitive detection of the K103N non-nucleoside reverse transcriptase inhibitor resistance mutation in treatment-naïve HIV-1 infected individuals by rolling circle amplification. Journal of Virological Methods 161:1, 128-135
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E. Morales, E. Gutierrez-Solis, E. Gutierrez, R. Gonzalez, M. A. Martinez, M. Praga. (2008) Malignant hypertension in HIV-associated glomerulonephritis. Nephrology Dialysis Transplantation 23:12, 3901-3907
CrossRef3
Georg MN Behrens. (2008) Treatment options for lipodystrophy in HIV-positive patients. Expert Opinion on Pharmacotherapy 9:1, 39-52
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