COMPETING INTEREST OF FINANCIAL VALUE

Transcription

1 BHIVA AUTUMN CONFERENCE 2012 Including CHIVA Parallel Sessions Dr Duncan Churchill Royal Sussex County Hospital, Brighton COMPETING INTEREST OF FINANCIAL VALUE > 1,000: Speaker Name Statement Duncan Churchill None Date 22 September October 2012, Queen Elizabeth II Conference Centre, London

2 Cardiovascular disease and antiretrovirals Duncan Churchill Brighton and Sussex University Hospitals NHS Trust

3 Should we start ARVs earlier in people with high CVD risk? How should we measure CVD risk? Should we modify ARVs in people with high CVD risk?

4 New HIV and AIDS diagnoses and deaths People living with diagnosed HIV infection New HIV and AIDS diagnoses, people living with diagnosed HIV, and deaths: United Kingdom, Numbers with diagnosed HIV infection HIV diagnoses AIDS diagnoses Deaths HIV and AIDS Reporting System HIV and STI Department, Health Protection Agency - Colindale

5 Persons seen for HIV care HIV diagnosed persons seen for HIV care by age group*: UK, ,000 70,000 60,000 50,000 40, <15 30,000 20,000 10, *Excludes persons with age not reported, 15 in 2002 and 0 in HIV and AIDS Reporting System HIV and STI Department, Health Protection Agency - Colindale

6 Brighton cohort HIV and ageing 100% 90% 15% 17% 17% 19% 20% 22% 23% 23% 25% 27% 28% 80% 30% 32% 70% 60% 50% 72% 70% 72% 70% 70% 40% 70% 68% 67% 66% 65% 63% 61% 59% 30% 20% 10% 0% 13% 13% 10% 10% 10% 9% 9% 9% 9% 9% 9% 8% 8% % HIV cohort aged <30 % HIV cohort aged % HIV cohort aged >50

7 Bozzette et al., NEJM 2003; 348:

8 Increased risk of CVD in HIV Islam et al. HIV Medicine 2012, 13:

9 Should people with high CVD risk start antiretrovirals earlier?

10 % with a Major CVD Event SMART Study Risk of CVD with ART Interruptions DC Death from CVD 7 4 VS Non-fatal clinical MI Non-fatal silent MI 11 5 Non-fatal stroke 8 3 Coronary artery disease requiring surgery for invasive procedure All major CVD events DC No. at Risk DC VS VS Years from Randomization Phillips A, et al. 14th CROI, Los Angeles, CA, February 25-28, Abst. 41.

11 Baseline characteristics of deaths + controls in SMART Deaths (n=85) Controls (n=170) P-value Age (median) CD4 (median) Prior AIDS (%) Current smoker (%) Diabetes (%) Antihypertensive medication (%) Prior CVD (%) /85 deaths due to AIDS Kuller et al. CROI 2008

12 Should people with high CVD risk start SMART ARVs earlier? Virological suppression associated with reduced CVD events (not significant) HOPS CD4 <350 greater risk of CVD CD no increased risk D:A:D Treated HIV associated with increased risk of MI Longer treatment associated with increased risk

13 NEJM 2003; 349:

14 Islam et al. HIV Medicine 2012, 13:

15 Should we start ARVs earlier in people with high CVD risk? Probably not How should we measure CVD risk?

16 Managing cardiovascular risk

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18 Assessment of CVD risk Framingham CHIP Q risk BHIVA monitoring guidelines 2011

19 cvrisk.mvm.ed.ac.uk/calculator/framingham.htm

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22 41 year old MSM Ex-smoker (stopped 10 cigarettes/day 10 years ago) BP 120/82 Total cholesterol 4.3 HDL cholesterol 1.3

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24 JBS2 - Thresholds for intervention Everyone: Stop smoking Increase aerobic exercise Achieve optimal weight and weight distribution Make healthier food choices Clinical evidence of CVD Diabetes mellitus CVD risk of >20% BP > 160 systolic, or >100 diastolic or target organ damage Cholesterol: HDL >6.0 Familial dyslipidaemia

25 Incidence rate ratio of MI related to smoking history in the D:A:D study HIV Medicine 2011; 12:

26 How would you assess CVD risk? Framingham calculator JBS/BNF calculator CHIP CVD risk assessment tool Qrisk Other Don t know I wouldn t his risk is low Vote

27 Which calculator? Framingham JBS2 ASSIGN CHIP Qrisk Advantage Different time scales Different end points Corresponds to JBS guidance Tailored to Scottish population Uses family history, deprivation Developed for HIV Incorporates drug history Widely used in general practice Incorporates postcode, rheumatoid, diabetes, renal disease etc. Disadvantage Not validated for other populations

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33 Should we start ARVs earlier in people with high CVD risk? Probably not How should we measure CVD risk? That depends Should we modify ARVs in people with high CVD risk?

34 Managing cardiovascular risk

35 RR of cumulative exposure/year 95%CI RR of recent* exposure yes/no 95%CI RR of cumulative exposure/year 95%CI D:A:D: Recent and/or Cumulative Antiretroviral Exposure and Risk of MI 1.9 NRTI ZDV ddi ddc d4t 3TC ABC TDF # PYFU: 138,109 74,407 29,676 95, ,009 53,300 39,157 # MI: PI NNRTI IDV NFV LPV/RTV SQV NVP EFV # PYFU: 68,469 56,529 37,136 44,657 61,855 58,946 # MI: *Current or within last 6 months. Approximate test for heterogeneity: P = 0.02 Lundgren JD, et al. CROI Abstract 44LB. Graphics reproduced with permission.

36 Lancet 2008; 371:

37 41 year old MSM Ex-smoker (stopped 10 cigarettes/day 10 years ago) BP 120/82 Total cholesterol 4.3 HDL cholesterol 1.3 On Kivexa and Kaletra for 9 years

38 Would you Leave him on Kivexa/Kaletra Switch Kivexa only Switch Kaletra only Switch both drugs

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