Current Events in ID 8/24/23

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In the ID news, making note of the NJEM headliner August 24, 2023, Pitavastatin to Prevent Cardiovascular Disease in HIV Infection,

https://www.nejm.org/doi/full/10.1056/NEJMoa2304146

Should we consider statins routinely in HIV+ individuals with low-to-moderate risk for cardiovascular disease on a traditional disease calculator? REPRIEVE suggests that we should. This phase 3 Randomized trial to prevent vascular events in HIV used the American Heart Association and the American College of Cardiology Pooled Cohort Equation risk calculator and specific thresholds for low-density lipoprotein (LDL) cholesterol to identify patients at-risk for cardiovascular disease. Consider that HIV+ individuals have 2x the risk for cardiovascular disease compared to those without HIV, a risk that is not eliminated by successful antiretroviral therapy (ARV) and viral suppression. 

The statin used was pitavastatin at 4 mg, chosen to avoid drug-drug interactions with key ARV. The patient population included 7769 participants from multiple sites globally with 65.2% non-white and 31.1% women. 

The primary outcome was incidence of major adverse cardiovascular events at 4.81 per 1000 person-years in the pitavastatin group and 7.32 per 1000 person-years in the placebo group (hazard ratio, 0.65; 85% confidence interval, 0.48-0.90; P=0.002). Myocardial infarction was diagnosed in 63 participants. Secondary outcomes were major adverse cardiovascular event or death from any cause. 

Interestingly, patients with chronic active hepatitis C and those who use alcohol and drugs and those with psychiatric conditions - often excluded from such landmark trials, were included. Though fewer than 200 participants ere hepatitis C co-infected or active substance users, the risks and benefits of pitavastatin are not clear in these populations. 

Stay-tuned for a substudy that remains underway, the Effects of Pitavastatin on Coronary Artery Disease and Inflammatory Biomarkers: Mechanistic Substudy of REPRIEVE. 

Pitavastatin targets LDL and systemic inflammation, both risk factors for atherosclerotic cardiovascular disease. Let's talk about how this study may or may not change our practice!

Do you routinely use a risk calculator to determine your patient's HIV risk? What prevention measures do you recommend? Does this job lie int he realm of the ID visit or should you engage Primary Care? Would you consider prescribing a statin based on the results of this study? If so, in which population?

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