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Prediction of Cardiovascular Risk Among People with HIV Using the PREVENT Equations Compared to the Pooled Cohort
Matthew S Durstenfeld1,2,3, Megan M McLaughlin4, Monica Gandhi4,5
1Department of Medicine, University of California San Francisco, San Francisco, USA. matthew.durstenfeld@ucsf.edu.
Insights
New PREVENT equations underestimate atherosclerotic cardiovascular disease (ASCVD) risk in people with HIV (PWH), potentially leading to fewer statin recommendations and increased disparities. Further research is needed to refine risk prediction for this population.
Area of Science:
- Cardiology
- Public Health
- Infectious Diseases
Background:
- People with HIV (PWH) face higher atherosclerotic cardiovascular disease (ASCVD) risks.
- Existing risk calculators often underestimate ASCVD risk in PWH.
- The American Heart Association's PREVENT equations have not been evaluated in PWH.
Purpose of the Study:
- Compare 10-year ASCVD risk predictions between PREVENT and Pooled Cohort Equations (PCE) in PWH.
- Assess the impact of PREVENT on statin therapy recommendations for PWH.
- Identify potential disparities in ASCVD risk assessment among PWH.
Main Methods:
- Cross-sectional observational study utilizing real-world electronic health records.
- Included PWH aged 40-75 without pre-existing cardiovascular disease.
- Compared ASCVD risk predicted by PREVENT and PCE, and analyzed statin eligibility based on current guidelines.
Main Results:
- PREVENT predicted significantly lower 10-year ASCVD risk (median 3.3%) compared to PCE (median 7.7%) in PWH.
- 97% of individuals had lower predicted risk with PREVENT.
- Statin recommendations decreased from 67.3% with PCE to 28.6% with PREVENT using a 5% ASCVD risk threshold.
Conclusions:
- The PREVENT equations underestimate ASCVD risk in PWH compared to PCE.
- This underestimation could lead to 58% fewer PWH being recommended for statins, potentially increasing cardiovascular disease events.
- Lowered risk prediction may exacerbate healthcare disparities among PWH.
Background:
People with HIV (PWH) are at elevated risk of atherosclerotic cardiovascular disease (ASCVD), and current risk prediction tools underestimate risk among PWH. The American Heart Association developed new risk prediction equations, Predicting Risk of cardiovascular disease EVENTs (PREVENT), which have not been studied among PWH.
Objective:
To compare predicted 10-year ASCVD risk using PREVENT with the pooled cohort equations (PCE) and the implications for statin recommendations among PWH.
Design:
A cross-sectional observational study using real-world, electronic health records PARTICIPANTS: All people with HIV ages 40 to 75 without cardiovascular disease at 23 primary care and HIV clinics affiliated with two health systems in San Francisco, California from 2019 to 2024 MAIN MEASURES: We compared predicted 10-year ASCVD using the PREVENT equations and the PCE. Then we considered implications of PREVENT for statin therapy using current guidelines.
Key Results:
Among 3357 PWH (median 57 years old; 73% male,12% female, 15% transgender/nonbinary/nondisclosed; 20% Black and 25% Latino), 91% were on antiretroviral therapy and 86% had virologic suppression. Among 2853 PWH with complete data for both calculators, the median predicted risk was 7.7% (interquartile range (IQR) 3.7, 14.0) using the PCE and 3.3% (IQR 1.9, 5.4) using PREVENT. Predicted risk was lower for 97% of individuals using PREVENT. Using a 10-year ASCVD risk threshold of 5%, only 28.6% of PWH would be strongly recommended for statins with PREVENT compared to 67.3% with PCE. The difference in predicted risk between the two equations varied across sex and race/ethnicity.
Conclusions:
The PREVENT equations predict lower 10-year ASVCD risk for PWH compared to the PCE, which underpredicts risk for PWH. Underprediction of ASCVD risk, which -using new guidelines -would translate to 58% fewer PWH strongly recommended for statins using PREVENT compared to PCE, has the potential to increase cardiovascular disease and worsen healthcare disparities among PWH.
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