ABC | Volume 114, Nº1, January 2019

Original Article Subclinical Carotid Atherosclerosis and Reduced DAD Score for Cardiovascular Risk Stratification in HIV-Positive Patients Achilles Gustavo Silva, 1 Rafael Vieira Paulo, 1 M ario León Silva-Vergara 1 Universidade Federal do Triangulo Mineiro, 1 Uberaba, MG – Brazil Mailing Address: Achilles Gustavo Silva • Universidade Federal do Triangulo Mineiro - Rua Frei Paulino, 30. Postal Code 38025-180, Uberaba, MG – Brazil E-mail: dr.achillesgustavo@gmail.com Manuscript received September 24, 2018, revised manuscript January 21, 2019, accepted March 10, 2019 DOI: 10.5935/abc.20190227 Abstract Background: HIV-positive patients are twice as likely than the general population to have a heart attack and are four times at greater risk of sudden death. In addition to the increased risk, these individuals present with cardiovascular events on average approximately 10 years earlier than the general population. Objective: To compare Framingham and reduced DAD (Data Collection on Adverse Effects of Anti-HIV Drugs Cohort) scores for cardiovascular risk assessment in HIV-positive patients and potential impact on clinical decision after evaluation of subclinical carotid atherosclerosis. Methods: Seventy-one HIV-positive patients with no history of cardiovascular disease were clinically evaluated, stratified by the Framingham 2008 and reduced DAD scores and submitted to subclinical carotid atherosclerosis evaluation. Agreement between scores was assessed by Kappa index and p < 0.05 was considered statistically significant. Results: mean age was 47.2 and 53.5% among males. The rate of subclinical atherosclerosis was 39.4%. Agreement between scores was 49% with Kappa of 0.735 in high-risk patients. There was no significant difference between scores by ROC curve discrimination analysis. Among patients with intermediate risk and Framingham and reduced DAD scores, 62.5% and 30.8% had carotid atherosclerosis, respectively. Conclusion: The present study showed a correlation between the scores and medium-intimal thickening, besides a high correlation between patients classified as high risk by the Framingham 2008 and reduced DAD scores. The high prevalence of carotid atherosclerosis in intermediate risk patients suggests that most of them could be reclassified as high risk. (Arq Bras Cardiol. 2020; 114(1):68-75) Keywords: Carotid Artery Diseases; HIV; Acquired Immunodeficiency Syndrome/complications; Indicators of Morbidity; Antiretroviral Therapy, Highly Active; Risk Factors. Introduction Currently, about 36.7 million people are infected with HIV worldwide, and 1.8 million cases are diagnosed every year, while 1 million deaths occur. 1 In Brazil, estimates say that 813,000 people are infected with HIV, with 48,000 new cases and 14,000 deaths in 2016. 2 Over the last decades, the use of antiretroviral therapy (ART) has led to a progressive decrease in mortality caused by opportunistic diseases and, consequently, there has been a considerable increase in the survival of these patients. AIDS has become a chronic disease and permanent immune activation, caused by the HIV virus, which translates into a systemic inflammatory process with significant repercussions in various organs and systems, especially cardiovascular system, brain, kidneys and bones, which leads to premature aging. Cardiovascular diseases emerged as an important cause of morbidity and mortality in this group of patients. Data from the DAD study (Data Collection on Adverse Effects of Anti‑HIV Drugs), published in 2014, indicate that 11% of deaths of HIV‑positive patients are caused by cardiovascular diseases. 3,4 HIV-infected patients are at twice as high risk of having a heart attack than the general population and four times more likely to have sudden death. 5,6 In addition to the increased risk, people with HIV experience cardiovascular events approximately 10 years before the general population, on average. 7 Although traditional cardiovascular risk scores, such as Framingham, have been developed for the general population, their use in HIV-positive patients is not well defined. 8 Based on the prospective multicenter DAD study, which was a collaboration of 11 cohorts of HIV-positive patients treated at 212 clinics in the United States, Europe, Argentina and Australia, algorithms were developed specifically for this population. The DAD score was first published in 2010, and considered CD4 count, use of Abacavir, and time of exposure to protease inhibitors and nucleoside reverse transcriptase inhibitors in addition to classic cardiovascular risk factors. 9 In order to simplify risk stratification of HIV positive patients and due to the difficulty of assessing previous antiretroviral therapy regimens, a modification in the DAD score was proposed and published in 2016, assessing the same clinical outcomes in 5 years, but not using the classes and time of exposure to ART. 10 68