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Low Aspirin or Statin Use for Primary MI/Stroke Prevention at HIV Clinic
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53rd ICAAC, September 10-13, 2013, Denver
Mark Mascolini
About half of HIV-positive adults in care at New York's SUNY Downstate Medical Center had a high risk of coronary heart disease (CHD) or stroke, according to Framingham and DAD algorithms [1]. But only half of these people had an aspirin or statin prescription for primary prevention of myocardial infarction (MI) or stroke.
The US Preventive Services Task Force recommends aspirin for men 45 to 79 when their MI risk outweighs the risk of gastrointestinal bleeding, and for women 55 to 79 when their stroke risk outweighs the GI bleeding risk [2]. HIV-positive people run a higher risk of MI or stroke than the general population, which may encourage some clinicians to be more aggressive in prescribing aspirin or statins for primary prevention. But HIV/heart expert James Stein advises HIV clinicians to rely on general-population recommendations and seriously consider the risk of GI and intracranial bleeding [3]. "We can't just give patients aspirin and think it's a completely benign drug," Stein says.
SUNY Downstate investigators conducted this single-center retrospective analysis to determine rates and predictors of aspirin or statin prescription for primary prevention in their HIV population. In accordance with USPSTF guidelines [2], they considered men between 45 and 79 and women between 55 and 79. They included only patients who did not miss more than two consecutive outpatient appointments between January 1, 2012 and December 31, 2012.
The researchers considered patients to qualify for aspirin if they had a Framingham Risk Score for 10-year CHD risk at or above 10% or a DAD 5-year CHD risk score at or above 5%. People qualified for aspirin or a statin to prevent stroke if they had a Framingham 10-year stroke risk at or above 10%.
The analysis focused on 258 people with HIV, including 130 (50%) with a high MI risk by Framingham and/or DAD criteria and 36 (14%) with a high stroke risk. Median age stood at 59 (range 45 to 78) in the high MI risk group and at 65 (range 55 to 78) in the high stroke risk group. Men accounted for two thirds of both groups, about one quarter in each group was obese, and both groups had HIV infection for a median of 14 years. All but 1 of these high-risk people were taking antiretroviral therapy. In the high-risk MI and stroke groups, rates of hypertension were 78% and 100%, abnormal lipids 55% and 47%, diabetes 39% and 44%, and current smoking 39% and 33%.
Among the 130 people with a high MI risk, 56 (43%) were taking aspirin. And among the 36 people with a high stroke risk, 12 (33%) were taking both aspirin and a statin, 6 (17%) were taking aspirin only, and 1 (3%) was taking only a statin. So 17 people (47%) were taking nothing to prevent stroke.
Age, gender, CD4 count, and HCV infection did not affect chances of primary prevention with aspirin or a statin. Surprisingly, smokers were almost 75% less likely to get an aspirin or statin prescription for primary prophylaxis. People with a viral load below 48 copies were 60% less likely to be taking aspirin or a statin. Factors that raised chances of primary prevention were hypertension, abnormal lipids, and diabetes. The following list spells out the odds ratios (OR) (and 95% confidence intervals) for each association:
Lowered chances of aspirin or statin prophylaxis:
Current smoking: OR 0.26 (0.11 to 0.55), P < 0.001
Viral load below 48 copies: OR 0.4 (0.17 to 0.9), P = 0.024
Raised chances of aspirin or statin prophylaxis:
Hypertension: OR 3.8 (1.5 to 10.9), P = 0.006
Abnormal lipids: OR 2.5 (1.2 to 5.2), P = 0.017
Diabetes: OR 5.6 (2.6 to 12.4), P < 0.001
A similar analysis of 397 people at the University of Alabama HIV clinic who qualified for MI prevention with aspirin found that only 66 (17%) got an aspirin prescription [4]. As in the New York study, diabetes and out-of-line lipids resulted in higher odds of aspirin prophylaxis, but smokers were more likely--rather than less likely--to get an aspirin prescription.
The New York investigators did not speculate on why prescribers at their center tended not to prescribe aspirin or statins for smokers or people with an undetectable viral load. These researchers suggested "interventions are needed to improve provider awareness in the use of aspirin and statins for the primary prevention of MI and stroke."
References
1. Park TE, Sharma R, Yusuff J, et al. Use of aspirin and statins for the primary prevention of myocardial infarction and stroke in patients with human immunodeficiency virus. 53rd ICAAC. September 10-13, 2013. Denver. Abstract H-1257.
2. US Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease. March 2009. http://www.uspreventiveservicestaskforce.org/uspstf/uspsasmi.htm
3. Pointers on cardiovascular disease risk, screening, and management in patients with HIV. An interview with James H. Stein, MD. Research Initiative, Treatment Action. 2013;18(1):Summer. http://centerforaids.org/pdfs/rita0613.pdf
4. Burkholder GA, Tamhane AR, Salinas JL, et al. Underutilization of aspirin for primary prevention of cardiovascular disease among HIV-infected patients. Clin Infect Dis. 2012;55:1550-1557.
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