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Underutilization of Recommended Interventions for Prevention of Cardiovascular Disease in HIV-infected Patients with Established Cardiovascular Disease or Diabetes
Caroline Sabin*1, R Weber2, E Fontas3, F Dabis4, P Reiss5, S De Wit6, O Kirk7, S Worm8, N Friis-Møller8, J Lundgren8, and The D:A:D Study Group
1Royal Free Ctr for HIV Med, Royal Free and Univ Coll London, UK; 2Swiss HIV Corhort Study, Univ Hosp Zuric; 3Nice Cohort, Ctr Hosp Univ Nice, Hosp de l'Archet, France; 4INSERM E0338 & U593, ISPED, Univ Victor Segalen Bordeaux 2, France; 5ATHENA, HIV Monitoring Fndn, Academic Med Ctr, Amsterdam, The Netherlands; 6Ctr Hosp Univ St Pierre, Brussels, Belgium; 7EuroSIDA, Copenhagen HIV Prgm, Hvidovre Univ Hosp, Denmark; and 8Copenhagen HIV Prgm, Hvidovre, Denmark
Background: In HIV–
populations with established cardiovascular disease (CVD) or diabetes, various
interventions are recommended for the prevention of CVD events and CVD-related
mortality. Few data are available on the use of these interventions, particularly
lipid-lowering drugs (LLD) and smoking cessation, in HIV-infected
individuals.
Methods: We
identified all individuals who had a first CVD event (myocardial infarction,
stroke, invasive CVD procedure) or were diagnosed with diabetes mellitus during
follow-up in the D:A:D Study (December 1999 to February 2006). Use of LLD prior
to the CVD event/diagnosis and over the next 6 months, as well as CVD risk
factors (including use of protease inhibitors [PI]) was assessed among patients
with >6 months follow-up. Statistical analysis was by χ2
test.
Results: Of the
total, 348 patients had a first CVD event (204 myocardial infarction, 73
stroke, 71 invasive procedure); 9% male, median age 49 years, 14% family
history of CVD. At the time, 149 (43%) were smokers (244 (70%) had ever
smoked), 80 (23%) were receiving LLD and 184 (53%) PI. Overall, 149 (56%) of
those not on LLD started these drugs in the next 6 months; LLD initiation
increased from 17% in 1999/2000 to 71% in 2005/2006 (p = 0.007), and was more common after a myocardial infarction (52%)
or invasive procedure (46%) than after stroke (28%, p = 0.007). Rates were similar after restricting the analysis to
those with a total cholesterol of >3.5 mmol/L. Only 24 of 149 (16%) stopped
smoking (myocardial infarction 21%, stroke 4%, invasive procedure 0%) and 38 of
184 (21%) stopped their PI. Among 626 patients diagnosed with diabetes (82%
male, median age 46 years, 10% family history of CVD), only 32 of 512 (6%) not
on LLD started these drugs in the next 6 months, 10 of 193 (5%) smokers ceased
smoking, and 86 of 316 (27%) on protease inhibitors stopped this drug class.
There was no difference in the initiation of LLD over time in patients
diagnosed with diabetes (p = 0.27).
Conclusions:
Initiation of LLD following a CVD event has increased over time,
although was only 70% in the most recent time period and was less common in
those with stroke than myocardial infarctions or invasive procedures. Only a
fifth of diabetics, a group at high risk for CVD mortality, not on LLD initiated
such primary prevention. Smoking cessation was rare in both groups. Greater
emphasis should be placed on increasing use of LLD and reducing modifiable risk
factors such as smoking.
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