Current Tools Underestimate CVD Risk in People with HIV

The elevated cardiovascular disease (CVD) risk among people with HIV is even greater than predicted by a standard risk calculator in several groups, including Black people and cisgender women, according to analyses from a large international clinical trial primarily funded by the National Institutes of Health (NIH). The risk of having a first major cardiovascular event was also higher than previously predicted for people from high-income regions and those whose HIV replication was not suppressed below detectable levels.

Researchers examined the incidence of major adverse cardiovascular events in people who did not take pitavastatin or other statins during the Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE) trial, a large clinical trial to test whether pitavastatin could prevent CVD in people with HIV. The scientists compared the incidence of cardiovascular events in the trial to the incidence predicted by standard estimates, which use the American College of Cardiology and American Heart Association’s Pooled Cohort Risk Equations (PCE) score.

Risk factors contributing to cardiovascular events

They found that the rate of cardiovascular events occurring in many groups of people differed from predicted rates, even considering that people with HIV have a higher overall risk of CVD than people without HIV, including double the risk of major adverse cardiovascular events. Notably, in high-income regions, including North and South America and Europe, cardiovascular event rates were higher overall, with cisgender women experiencing about two and a half times more events than predicted, and Black participants having more than 50 percent higher event rates than predicted.

A second, related analysis defined risk factors contributing to the occurrence of major adverse cardiovascular events, such as heart attacks and strokes, in people with HIV in the trial. The study team assessed risk factors contributing to these events and found that the risk of experiencing a first major adverse cardiovascular event was higher for people:

• with HIV from high-income regions,

• who are Black and older than 50 years,

• current or former cigarette smokers,

• with hypertension or a family history of early CVD onset, or 

• with a detectable HIV viral load.

The REPRIEVE trial was the largest trial to test a strategy for primary prevention of major adverse cardiovascular events in people with HIV and enrolled 7,769 people with HIV aged 40 to 75 years across five continents. The participant group was diverse in terms of race and gender and was assessed to be at a low-to-moderate risk of CVD using PCE scores. 

The primary analysis of this trial showed that people with HIV who took pitavastatin calcium had a 35 percent lower risk of major adverse cardiovascular events than those taking a placebo. These results led to the release of recommendations for the use of statin therapy in people with HIV in the HHS clinical practice guidelines.

Underestimated cardiovascular risk

As demonstrated by these new analyses, data from the trial continue to address knowledge gaps about cardiovascular health in people with HIV.

The results of these two analyses reveal that while all people with HIV are at an elevated risk of cardiovascular events, the cardiovascular risk for some people may be underestimated by the current standard tools. 

The authors note that both traditional and HIV-related risk factors are associated with an increased CVD risk among people with HIV. They suggest that updated tools are needed to facilitate precision, high-quality care for the diverse population living with HIV. Importantly, these studies underscore the necessity for representative inclusion in clinical trials.

- This press release was originally published on the National Institutes of Health website