Lipid Screening and Cardiovascular Risk
Clinicians should assess human immunodeficiency virus (HIV)-infected patients for cardiovascular risk factors at least annually.
Table
Major Risk Factors Exclusive of Low-Density Lipoprotein (LDL) Cholesterol that Modify LDL Goals*
|
- Cigarette smoking
- Hypertension (blood pressure ≥140/90 mm Hg or on antihypertensive medication)
- Low high-density lipoprotein (HDL) cholesterol (<40 mg/dL)**
- Family history of premature coronary heart disease (CHD) (CHD in male first-degree relative <55 years; CHD in female first-degree relative <65 years)
- Age (men ≥45 years; women ≥55 years)
|
From the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP). Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol.
Refer also to the Framingham risk prediction calculator, available at: http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof.
* Diabetes is regarded as a coronary heart disease risk equivalent.
**HDL cholesterol ≥60 mg/dL counts as a "negative" risk factor; its presence removes one risk factor from the total count.
Monitoring Lipid Profile
Clinicians should monitor patients receiving antiretroviral (ARV) therapy for dyslipidemia by obtaining a fasting lipid profile before initiation of ARV therapy, between 3 and 6 months after starting or changing ARV treatment, and at least annually thereafter. More frequent monitoring may be indicated by the presence of persistent lipid elevation, cardiovascular risk factors, or cardiovascular symptoms.
Management of Lipid Disorders
Lifestyle Modifications
Clinicians should recommend lifestyle modifications, such as smoking cessation, increased exercise, weight loss, nutrition therapy, and substance use treatment (refer to the table below for information about "LDL and non-HDL cholesterol goals and thresholds for therapeutic lifestyle changes and drug therapy in different risk categories").
Table
LDL and Non-HDL Cholesterol Goals and Thresholds for Therapeutic Lifestyle Changes and Drug Therapy in Different Risk Categories
|
| Risk Category |
LDL Goal (mg/dL) |
LDL Level at Which to Initiate Lifestyle Changes (mg/dL) |
LDL Level at Which to Consider Drug Therapy (mg/dL) |
Non-HDL Goal (mg/dL)* |
| CHD or CHD risk equivalents: diabetes mellitus, atherosclerotic disease (CAD or stroke), or multiple risk factors (10-year risk >20%) |
<100 |
>100 |
>130 (100-129: drug optional)** |
<130 |
| 2+ risk factors: HDL <40 mg/dL, strong family history, age >45 years, and smoking (10-year risk >20%) |
<130 |
>130 |
10-year risk 10%–20%: >130
10-year risk <10%: >160
|
<160 |
| 0-1 risk factor*** |
<160 |
>160 |
>190 (160-189: LDL-lowering drug optional) |
<190 |
Modified from the Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol.
LDL, low-density lipoprotein; CHD, coronary heart disease; CAD, coronary artery disease; HDL, high-density lipoprotein.
* Non-HDL cholesterol = (total cholesterol – HDL). When LDL cannot be measured because the triglyceride level is >200 mg/dL, non-HDL cholesterol may be used as a secondary goal. The non-HDL cholesterol goal is 30 mg/dL higher than the LDL cholesterol goal.
** Some authorities recommend use of LDL-lowering drugs in this category if an LDL cholesterol level of <100 mg/dL cannot be achieved by therapeutic lifestyle changes (dietary and exercise intervention). Others prefer use of drugs that primarily modify triglycerides and HDL (e.g., nicotine acid or fibrate). Clinical judgment also may suggest deferring drug therapy in this subcategory.
***Almost all people with 0 or 1 risk factors have a 10-year risk <10%; thus, 10-year risk assessment in people with 0 or 1 risk factors is not necessary.
Pharmacologic Treatment of Dyslipidemia
Pharmacologic treatment of dyslipidemia should be guided by currently available clinical guidelines.
When a statin is indicated, clinicians should avoid using simvastatin and lovastatin in patients who are concurrently receiving protease inhibitors (PIs).
