Expert Conversations: Are Patients With HIV Being Screened for ASCVD?

In this podcast, Mark Liotta, Peter Cangialosi, and Diana Finkel, DO, discuss their latest research study, which examined the rate of adherence to the American College of Cardiology guideline on atherosclerotic cardiovascular disease prevention among people with HIV. 

Additional Resources:

• Liotta M, Cangialosi P, Ho J, Finkel D, Swaminathan S, Keller S. Overlooking those at intermediate risk? ASCVD prevention measures among people living with HIV at an urban academic medical center. Paper presented at: IDWeek 2020; October 21-25, 2020; Virtual. https://www.eventscribe.net/2020/IDWeek/fsPopup.asp?efp=VFhWUUpXVFA2ODg4&PosterID=291967&rnd=4.642189E-03&mode=posterinfo
• Cangialosi P, Liotta M, Finkel D, Swaminathan S, Keller S. Disparities in diabetes care: smoking cessation among women and minorities living with HIV at an urban academic medical center. Paper presented at: IDWeek 2020; October 21-25, 2020; Virtual. https://www.eventscribe.net/2020/IDWeek/fsPopup.asp?Mode=posterinfo&PosterID=290847 

Mark Liotta is a fourth-year medical student at Rutgers New Jersey Medical School in Newark, New Jersey.

Peter Cangialosi is a fourth-year medical student at Rutgers New Jersey Medical School in Newark, New Jersey.

Diana Finkel, DO, is an assistant professor of medicine in the Division of Infectious Disease at Rutgers New Jersey Medical School in Newark, New Jersey.

TRANSCRIPT:

Amanda Balbi: Hello everyone, and welcome to a special installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator, Amanda Balbi with Consultant360 Specialty Network.

Heart disease is a leading cause of death in the world, and it is a common comorbidity in patients with HIV. A new study presented at IDWeek 2020 examined the rates of American College of Cardiology guideline adherence for atherosclerotic cardiovascular disease prevention among people with HIV who have calculated risk scores in the low-, intermediate-, and high-risk ranges.

Here with us today to discuss their study are the lead authors:

Peter Cangialosi: My name is Peter Cangialosi. I'm a fourth-year medical student at Rutgers New Jersey Medical School.

Mark Liotta: My name is Mark Liotta. I’m also a fourth-year medical student at Rutgers New Jersey Medical School.

Diana Finkel: My name is Diana Finkel. I'm an assistant professor of medicine, division of infectious disease, at New Jersey medical school in Newark.

Amanda Balbi: Thank you all for joining me today. To start, can you give us a brief overview of your study and its findings?

Mark Liotta: We've been aware that HIV is kind of a risk factor for people developing some sort of atherosclerotic cardiovascular disease, whether that's risk for a stroke or MI. But a lot of these guidelines don't really address what to do specifically for these people with HIV or how to address this.

So, the point of the study was to look at University Hospital in Newark, New Jersey, infectious disease clinic and look at how we're managing the HIV patients there based on the current guidelines for ASCVD prevention. The American College of Cardiology has these calculators that they use and that they recommend clinicians take into account lipid levels, high blood pressure, diabetes, and smoking to determine a person’s risk of developing ASCVD over the 10-year range.

And then, based on this, develop some sort of risk score and then can determine if it's appropriate to give some sort of therapy. Most the time it's some sort of statin therapy. We used these similar guidelines to this HIV population to see how well the clinic with adhering to these guidelines based on the risk factors of these patients.

And so overall, we looked at over 1000 patients from the clinic. After accounting for potential reasons for not giving a statin, such as interactions with other types of medications or adverse effects that it may have caused the patient.

We checked, basically, how well they were following the guidelines and found that for the low-risk group that the ASCVD risk score groups of men and the high-risk actually had okay adherence rates. They were pretty good.

But when compared to the high- and the low-risk, the intermediate group was significantly less than that of the high- and the low-risk. Basically, the main points of the study was that, within this group, we were kind of lacking compared to the other groups. Next steps for us for this will be to look at how to improve within a specific group range and why they necessarily may or may be overlooked.

Diana Finkel: Our study was done in the Infectious Disease practice outpatient clinic of University Hospital in Newark, New Jersey. Our clinic is a Ryan-White funded clinic, and we serve over 3000 patients.

The majority of the individuals living with HIV in our practice, over 80% are African American or Black and another 20% are Latinx. It is an urban population, and many of our patients also receive primary care from us. So, the study was done to evaluate patients in our clinic, who are aged between 40 to 79 years and had a clinic visit over the last year to see whether we were managing adequately their risk factors and treating them appropriately for cardiovascular risk.

In 2019, the American College of Cardiology did add that HIV is a promoter, but it's not really considered—it's still debatable, and that data is still ongoing on whether or not it by itself is a risk factor for cardiovascular disease. So there have been several large studies currently in progress that would suggest that it is so.

Peter Cangialosi: Right. I was just, again, reviewing those guidelines prior to this, and yes, it’s listed as a risk-enhancing factor is how they refer to it. So not maybe fully on the level of diabetes or something like that, as a risk factor, but being officially recognized on the guidelines as a risk-enhancing factor.

Importantly, in the risk-estimator tool and the calculator that we use for creating a risk score and deciding what kind of management these patients need, this risk-enhancing factor—and many of them aren't incorporated into that calculator—so, on top of the fact that we're still figuring out how much of a risk-enhancer it is, the risk scores we use also likely underestimate that risk further by not being able to incorporate HIV at this point.

Amanda Balbi: Definitely a great point. So we all know that cardiovascular disease is a common comorbidity among patients with HIV. What knowledge gaps does your study fill?

Diana Finkel: The study fills the gap of or even background knowledge on whether or not we're doing the same kind of care for everybody living with HIV and evaluating them for statin therapy in the medium-, high-, or low-risk groups that we have.

Our study suggested, though, that while we certainly are aware of cardiac risk factors, perhaps we're not managing the group with intermediate risk, which is the group that might not be right away noted to have increased cardiovascular risk, meaning maybe they're not very overweight.

As we found in the group who had diabetes, we tended to not be as aware of risk factors for cardiovascular disease and the group who was thin and other criteria that might not immediately suggest that this person is at increased risk without calculating their risk with the calculator tool that we were using.

It suggests that perhaps we should be using more of the tools that are available to calculate risk factors and to also remember that we should evaluate everybody for their cardiovascular risk, whether or not they're overweight, whether or not they're thin, male, female—no matter how they're presenting. That way we’d be able to capture some of the people who might not be adequately being treated for their increased risk for cardiovascular disease.

Peter Cangialosi: I was just going to say that right now that we recognize cardiovascular disease as a common comorbidity among patients with HIV, that's becoming more of an accepted fact, the study adds into answering the question of, “Are we using that in our everyday practice and are we managing those patients with that fact in mind?”

As Dr Finkel was mentioning, it seems like in that intermediate-risk population or maybe right they don't jump out at you as a person has diabetes and I'm definitely worried about parts of these with them, are we still taking the time to calculate the risk score and make sure that they're getting the appropriate management they need?

Amanda Balbi: Based on your experience with this study, what are some of the best practices for screening as CVD among patients with HIV?

Diana Finkel: The standard guidelines that are published by the American College of Cardiology apply to our patients as well as the Diabetes Association guidelines as well. So, patients living with HIV should be screened as those who are not living with HIV.

However, we should be paying more careful attention to some to comorbidities in general in our population, because, as previous studies have suggested, persons living with HIV have more co-morbidities such as diabetes, hypertension, and cardiovascular risk.

Additionally, to try to perhaps not overlook some of the risk factors that might not be as obvious to us when we're doing the histories, but they are in the system—since all of us almost use electronic medical records—perhaps we would be best served by also using the tools that are provided in many of our EMRs to calculate cardiovascular risk factors, through the ASCVD calculator score. That was actually something Mark and Peter had suggested after they completed this quality analysis that they did as well.

Mark Liotta: Yeah, I think the screener tool does a pretty good job of addressing at least cardiovascular risk.

Like Dr Finkel said, with or without HIV, we should be looking at those populations in a similar light. I think one thing that I thought was particularly interesting while going through the data, or at least a chart reviews, is that there were quite a number of patients that we really couldn’t calculate a risk score for, or screen them even, just because they were missing some pertinent information like lipid values for the calculator or their values were out of range.

For practices to just continue screening our patients and making sure that those values are recorded somewhere so that they can actually make those calculations, but just reinforcing the idea that the screener tool does its job. Sometimes it's missing the tools it needs.

Amanda Balbi: What prevention measures should be taken in this population, and are patients with HIV managed any differently than patients without HIV?

Diana Finkel: I think patients with HIV do not necessarily need to be managed differently. It’s more trying to understand the risk factors and the barriers your particular population living with HIV vs without HIV has and getting them into appropriate health practices, such as quitting smoking and diet, exercise.

Also because of the higher rate of diabetes and pre-diabetes, we should also probably focus in particular also on nutritional education in our population.

Peter Cangialosi: I agree, I think the same prevention measures that you want to take in any population and lifestyle modification and blood pressure control and things like that.

One other slight difference that we looked at a bit in our study was medication interactions that can come into play when you have patients who are on different antiretroviral therapies. Oftentimes these different combination medicines that may interact with the statins that you would generally prescribe for this ASCVD risk.

And that's something we tried to factor into our assessment of guideline adherence, as well as maybe this patient should be on a high-intensity statin, but that's actually not recommended when they're also taking this other ART medication.

One caveat is having to balance those medication interactions as you would when you're considering any patient with multiple comorbidities.

Diana Finkel: Another thing we picked up, which I'm not sure we discussed, was ownership of the medical care. Sometimes patients will see their HIV provider on a referral and sometimes we are managing them for all their disease states.

We might be missing an opportunity for those that we are only treating for HIV, in terms of decreasing the risk factors, because this is something we might be thinking their primary doctor should be doing. However, this is an opportunity to treat the whole person.

All of us together should be working to decrease our patients’ morbidity and risk factors for cardiovascular disease. The conversation can be done by anybody and should be done by everybody really, in terms of risk factors that might be something we can affect such as diet, exercise, smoking, adherence to antihypertensive treatments and lifestyle changes.

Amanda Balbi: In your opinion, how do you hope your research impacts the future of CVD screening among patients with HIV?

Diana Finkel: Our research further shows that the use of a tool, a calculator tool, might suggest that that would improve screening. If you’re not just relying on perhaps something you have in mind. We should also use the tools that are available to us through our EMRs, the screen, as well as screening and making sure that everything that's needed to be able to use the EMR tools is available.

Also, I think we should use this opportunity to encourage HIV providers, as well as primary care providers and all providers who care for patients who are living with HIV, to try to set in programs and not miss opportunities to help decrease cardiovascular risk factors and improve lifestyle modification adherence.

Peter Cangialosi: And I think kind of one of the big contextual points of the project was now that patients living with HIV, when taking medications, are living longer, healthier lives, the issues of cardiovascular disease and diabetes—the typical chronic conditions that everyone deals with—are going to become more of a prevalent issue.

And so I think we hope that our research and data adds more to that evidence of considering the impacts of HIV is a risk factor for a lot of these other chronic conditions and—you're right—figuring out how to best incorporate these screening practices in the discussion of the care of all of our patients.

Mark Liotta: One other thing that I would just add is, for us, it was pretty impressive that we found that this intermediate group was one of the ones overlooked.

When you look at something that's the low-risk group, as long as you're really not providing them a statin, you need guideline adherence. And for a high-risk group, there's usually some reason or it's kind of more blatantly obvious in these groups, either they're smoking or they have really high blood pressure to begin with. So, even without using this calculator clinicians are more inclined or may start thinking about giving a statin or some other therapy regardless.

It's interesting to note that, like this intermediate group, were may require the calculator or may require it to see some of the hidden risk factors for pretty much any patient that could suffer from some sort of cardiovascular disease.

It emphasizes the point that all clinicians really should take some ownership of this for the patients because there are a lot of impacts of just giving medication or helping them with their lifestyles could have.

Amanda Balbi: Very well said. Thank you all so much for joining me today on this podcast and talking to me about your research.

Mark Liotta: All right, thank you for having us.

Diana Finkel: Yes, thank you very much. We greatly appreciated the opportunity to be able to share our study with you and to have this opportunity, again, to emphasize the need for ongoing studies, as well as care for comorbidities in populations living with HIV