Cardiovascular Medicine Q26

Answer & Critique

Correct Answer: E

Educational Objective: Recognize the potential for underestimation of cardiovascular risk in patients with HIV infection.

Key Point

In patients with HIV infection, there is a 1.5- to 2-fold increased risk for coronary artery disease.

This patient's HIV status will contribute most to the underestimation of his risk for atherosclerotic cardiovascular disease (ASCVD). This young patient has both traditional risk factors (hypertension and smoking) and a nontraditional risk factor (HIV) for ASCVD, which is defined as coronary death or nonfatal myocardial infarction, or fatal or nonfatal stroke. The Pooled Cohort Equations are a risk assessment instrument developed from multiple community-based cohorts; their use as a primary risk assessment tool is recommended in the 2018 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline on the Management of Blood Cholesterol. The AHA/ACC ASCVD risk calculator based on the Pooled Cohort Equations includes age, sex, race, total and HDL cholesterol levels, systolic blood pressure, blood pressure–lowering medication use, presence of diabetes mellitus, and smoking status. Calculated 10-year ASCVD risk can be classified as low (<5%), borderline (5% to <7.5%), intermediate (≥7.5% to <20%), or high (≥20%). This patient's calculated 10-year ASCVD risk of 6.2% is categorized as borderline. However, this patient has HIV infection, an ASCVD risk-enhancing factor. According to the AHA/ACC guideline, patients with borderline risk plus risk enhancers should be engaged in a discussion about initiating moderate-intensity statin therapy.

Large observational studies have demonstrated a 1.5- to 2-fold increase in the risk for ASCVD among patients with HIV infection. The increased risk for ASCVD in HIV-infected patients is likely the result of interactions among the viral infection, host factors, traditional risk factors, and therapies for HIV. Traditional risk models, including the AHA/ACC ASCVD risk calculator based on the Pooled Cohort Equations, underestimate the risk for ASCVD in patients with HIV. Alternative risk models, including one based on the D:A:D (Data Collection on Adverse events of Anti-HIV Drugs) study, have been developed, but they lack validation and have not been widely adopted.

This patient's age, blood pressure, use of antihypertensive medications, and HDL cholesterol level are accounted for in the AHA/ACC ASCVD risk calculator and are not factors responsible for underestimating his ASCVD risk.

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