Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy.
Clinica Malattie Infettive, Azienda Ospedaliero-Universitaria di Perugia, Perugia, Italy.
AIDS Res Ther. 2019 May 24;16(1):11. doi: 10.1186/s12981-019-0226-2.
As in non-infected subjects, statins and aspirin have a pivotal preventive role in reducing the cardiovascular related morbidity and mortality in HIV infected patients. The persistence of immune activation in these subjects, could contribute to accelerate atherosclerosis, therefore, these treatments that reduce inflammation could provide additional cardiovascular protection. However the current guidelines for the use of these drugs in general population are dissimilar, with important differences between American and European ones. Aim of the present position paper is to provide recommendations aimed to overcome the actual differences and limitations among the current ones and to adapt them to the needs of HIV infected patients.
We propose to adopt the new ACC/AHA guidelines, simple to use and cost effective, to use the ASCVD score that seems to estimate more accurately the cardiovascular risk among these patients. We suggest to start statin therapy in all patients with a calculated 10-year risk of a cardiovascular event of 10% or greater. Rosuvastatin and atorvastatin should be preferred. LDL-C target may be adopted. Aspirin should be always associated with a statin, in secondary prevention, while in primary prevention it should be reserved only to patients with ≥ 20% 10-year risk particularly adherent to treatments, and with low risk of bleeding. We suggest to start with a dose of 100 mg/day. Finally, management of antiplatelet agents or novel oral anticoagulants may include selecting antiretrovirals with a lower potential for drug interactions or choosing agents least likely to interact with antiretrovirals.
As demonstrated in surveys, HIV physicians are generally highly committed regarding CVD and autonomous in prescribing statins and ASA. Consequently, in the light of the previously discussed discrepancies among the different guidelines and of the incomplete indications regarding HIV-positive persons, the present suggestions could overcome the actual differences and limitations among the current ones.
与非感染者一样，他汀类药物和阿司匹林在降低 HIV 感染者心血管相关发病率和死亡率方面具有重要的预防作用。这些患者的免疫激活持续存在，可能会加速动脉粥样硬化，因此，这些可以减轻炎症的治疗方法可以提供额外的心血管保护。然而，目前这些药物在普通人群中的使用指南并不相同，美国和欧洲的指南之间存在重要差异。本立场文件的目的是提供建议，旨在克服当前指南之间的实际差异和局限性，并使其适应 HIV 感染者的需求。
我们建议采用新的 ACC/AHA 指南，该指南简单易用且具有成本效益，可以使用 ASCVD 评分更准确地评估这些患者的心血管风险。我们建议在所有计算出 10 年内发生心血管事件风险为 10%或更高的患者中开始使用他汀类药物治疗。建议优先选择瑞舒伐他汀和阿托伐他汀。可以采用 LDL-C 目标。阿司匹林应始终与他汀类药物联合使用，在二级预防中，如果患者 10 年风险≥20%且治疗依从性高、出血风险低，也可用于一级预防。建议起始剂量为 100mg/天。最后，抗血小板药物或新型口服抗凝剂的管理可能包括选择药物相互作用潜力较低的抗逆转录病毒药物，或选择与抗逆转录病毒药物相互作用可能性较小的药物。
正如调查所示，HIV 医生通常非常关注 CVD 并自主开具他汀类药物和阿司匹林的处方。因此，鉴于不同指南之间存在的差异以及针对 HIV 阳性患者的不完全适应证，本建议可以克服当前指南之间的实际差异和局限性。
