Background: New cholesterol guidelines were issued by the American College of Cardiology (ACC)/ American Heart Association (AHA) in 2013. The impact of the new guidelines on HIV-infected patients is unknown. Our objective was to compare recommendations for statin use under the new guidelines with the established Adult Treatment Panel III (ATPIII) cholesterol guidelines in a large cohort of HIV-infected patients.
Methods: Using the Partners HealthCare System HIV longitudinal cohort, we determined patients’ eligibility for statin therapy under the ACC/AHA and ATPIII guidelines as of 2008. We followed them through 2013 to observe actual statin prescription rates, indication for statin recommendations, and cardiovascular disease (CVD) event rates (CHD for ATPIII and atherosclerotic CVD for ACC/AHA) by statin recommendation status (ACC/AHA only, ATPIII only, both, or neither).
Results: In a clinical care cohort of 2239 HIV-infected patients over age 18, 936 (41.8%) patients were recommended for statin therapy by the ACC/AHA guidelines compared with 575 (25.7%) by the ATPIII guidelines. Actual statin prescription rates for patients meeting guidelines for statin therapy were 47% for ACC/AHA and 65% for ATPIII. Of the 405 (18%) patients with discordant statin recommendations, 95% were recommended to be on statin therapy by ACC/AHA and not ATPIII. The most common indication for statin use under the ACC/AHA guidelines was CVD risk ≥7.5% by the new ACC/AHA risk prediction algorithm, and this was the only indication for 46% of patients recommended for statin therapy. Among the group of patients with a CVD outcome event, statin therapy was recommended for 44% of patients by ATPIII and 62% by ACC/AHA. When only one guideline recommended statin therapy for the group of patients with CVD events, the vast majority of cases (39/40) would have qualified for statin therapy by ACC/AHA but not by ATPIII.
Conclusions: In an HIV clinical care cohort, the new ACC/AHA cholesterol guidelines recommend that a higher proportion of patients be on statin therapy and identify an increased proportion of patients with CVD outcome events compared with ATPIII. Despite this increase, nearly 40 percent of patients with a CVD event would not have qualified for statin therapy by the ACC/AHA guidelines. This gap may reflect the novel mechanism of HIV-associated CVD which is not accounted for in general-population guidelines and underscores the need for HIV-specific primary CVD prevention trials.