Noninvasive stress testing should be preceded by a prerequisite history, physical examination, 12-lead ECG, and an assessment of pretest probability of CAD 37. Routine evaluation of CAD in patients infected with HIV/AIDS should be guided by the established clinical practice guidelines and appropriateness criteria for test selection used in patients without HIV/AIDS 37,38. These recommendations are largely based on conventional populations and there is a paucity of data with respect to HIV-specific populations that call the performance of these noninvasive testing modalities into question.
Specific guidelines for the evaluation and management of HAART-related HLD have been developed by the Infectious Disease Society of America, Adult AIDS Clinical Trials Group 39, and the European AIDS Clinical Society. These guidelines recommend estimation of Framingham-predicted 10-year cardiovascular risk 40. Currently, there is no difference in HLD goal treatment between HIV-infected and non-HIV-infected patients. In the choice of specific lipid-lowering therapy, it is critical to consider drug–drug interactions. In general, all PIs and delavirdine, an NNRTI, inhibit CYP3A4. Nevirapine and Efavirenz result in the induction of the enzyme. Therefore, the first-choice agents for lowering LDL are Pravastatin (not metabolized by CYP3A4), with Fluvastatin (metabolized CYP2C9) as the second choice. Rosuvastatin concentrations appear to be increased when used in combination with some NNRTIs; thus, in that setting, 10 mg should be considered the maximum safe dose 41,42. Similarly, Atorvastatin should be used at lower doses in HIV patients. Finally, during PI therapy, Simvastatin and Lovastatin are not recommended because of the high risk of rhabdomyolysis 42,43. Nucleoside reverse-transcriptase inhibitors, integrase inhibitors, and entry inhibitors do not have drug–drug interactions with statins. PIs and NNRTIs can have significant drug–drug interactions with statins and these need to be reviewed before prescribing statins for patients on these regimens 44. Cobicistat-boosted regimens will have similar effects as ritonavir-boosted regimens as cobicistat is a CYP3A4 inhibitor. Lack of data limits the precise estimation of benefits related to anti-inflammatory properties of statins. Clinicians can consider switching HAART in cases of dyslipidemia because of adverse drug effects (Table 3).
The authors thank David J. Schneider, MD, FACC of The University of Vermont Medical Center (UVMMC), Burlington, Vermont, USA, and The Cardiovascular Research Institute of Vermont (CVRI-VT), Burlington, Vermont, USA, for his valuable contribution in reviewing the manuscript.
There are no conflicts of interest.
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