ABC | Volume 114, Nº1, January 2019

Original Article Silva et al. Risk stratification with reduced DAD Score Arq Bras Cardiol. 2020; 114(1):68-75 The aim of this study was to compare the Framingham and reduced DAD scores for cardiovascular risk assessment in HIV-positive patients and the potential impacts on clinical decision after evaluation of subclinical carotid atherosclerosis. Methods Population Seventy-one asymptomatic HIV-positive patients on regular ART, with no previous diagnosis of cardiovascular disease, and in regular follow-up at the Infectious and Parasitic Diseases Outpatient Clinic of Universidade Federal do Triângulo Mineiro (UFTM), in Uberaba, Minas Gerais, were included. Clinical assessment Clinical, demographic and anthropometric data were obtained by clinical interview and included risk factors for cardiovascular disease, namely: age (≥ 45 years in men and ≥ 55 years in women), smoking (current use or cessation in the last 30 days), family history of early coronary artery disease (CAD) (myocardial infarction or death fromCAD in first-degree relatives, if men < 55 years and women < 65 years), systemic arterial hypertension (previous diagnosis with medication for hypertension and/or blood pressure >140x90 mmHg), dyslipidemia (previous diagnosis with use of lipid lowering drugs and/or laboratory abnormalities according to current guidelines and described in the following), diabetes mellitus (previous diagnosis with use of blood glucose lowering medications and/or blood glucose monitoring > 126 mmHg). Body mass index (BMI) was calculated as the ratio between weight in kilograms and height squared in meters and considered normal from 18.5 to 24.9 kg/m 2 , overweight from 25.0 to 29.9 kg/m 2 and obesity as ≥30.0. Waist circumference was measured in centimeters at the level of the umbilical scar and considered abnormal according to the International Diabetes Federation (IDF)’s metabolic syndrome standards. 11 Blood pressure was measured during clinical evaluation at the outpatient clinic using an OMRON automatic arm blood pressure measuring device (HEM-7113), in compliance with current guidelines for systemic arterial hypertension, and the each individual’s level of activity was assessed by the short version of IPAQ (International Questionnaire on Physical Activity), with those who reported performing physical activity lasting < 10 minutes per week being considered sedentary. Laboratory assessment All patients had 12-hour fasting peripheral venous puncture blood collection. Blood counts, blood glucose (RV = 60 to 99 mg/dL), total cholesterol, triglycerides, HDL-cholesterol, LDL‑cholesterol, urea (RV ≤ 50 mg/dL), creatinine (RV = 0.4 to 1,4 mg/dL), sodium (RV = 136 to 145 mmol/L), potassium (RV = 3.5 to 5.1 mmol/L). Blood glucose, total cholesterol, LDL-cholesterol and triglycerides were considered altered if > 100 mg/dL, 200 mg/dL, 160 mg/dL and 150 mg/dL, respectively, and HDL-cholesterol was considered low when < 40 mg/dL in men and < 50 mg/dL in women. The blood samples were processed at the Laboratory of Clinical Analysis of the UFTMClinics Hospital. Total cholesterol, HDL-cholesterol and triglycerides were determined by colorimetric-enzymatic method in a Roche Cobas 6000 apparatus. LDL-cholesterol was calculated by the formula [(total cholesterol-HDL-cholesterol) – (triglycerides/5)]. Risk stratification Estimates of cardiovascular risk were measured by the reducedDAD and Framingham2008 scores. Framingham2008 considers outcomes such as cardiovascular death, CAD, stroke, heart failure and claudication in 10 years, whereas simplified DAD includes acute myocardial infarction, stroke, coronary and carotid interventions and cardiovascular death in 5 years. According to the Framingham 2008 score, event rate was considered low risk when < 10%, intermediate risk when >10% and <20%, and high risk when >20%. For DAD, values <1% were considered low risk, 1% to 5%moderate risk, 5% to 10% high risk, and >10% very high risk. 9,12 The simplified DAD score was calculated by means of a tool available at https:// www.chip.dk/Tools-Standards/Clinical-risk-scores. Evaluation of subclinical atherosclerosis Exams were performed at the Radiology Department of the UFTM Clinical Hospital with a Toshiba Aplio 400 ultrasound device using a 10-14 MHz linear and multifrequency probe. Patients were evaluated in supine position, in a semi-dark room, with their neck positioned at 45°. The distal portions of the right and left common carotid arteries (1 cm before bifurcation) and proximal segments (2 cm) of the internal carotids were evaluated. The medium-intimal complex (MIC) was measured by the distance between two echogenic lines, the lumen-intima interface and media-adventitia interface, on the vessel’s posterior wall. The MIC was considered thickened if > 0.8 mm in the common carotid artery and the presence of plaques was established by a focal structure extending at least 0.5 mm to the vessel lumen and/or measuring more than 50% of the adjacent MIC value, and/or MIC greater than 1.5 mm. 13 Statistical analysis Qualitative variables were expressed by frequency distribution and quantitative variables with normal distribution, as per the Kolmogorov-Smirnov test, were expressed as mean and standard deviation, and those with non-Gaussian distribution as median and interquartile range. The correlations in which the variables had non-Gaussian distribution were evaluated by the Spearman’s coefficient. Agreement between scores was assessed by Kappa index and discrimination power of scores was assessed by C-statistics, defined by the area below the ROC curve relating to the finding of subclinical atherosclerosis. The statistical software GraphPad Prism version 5 was used in the process. Statistical significance was set at p < 0.05. Results From January 2016 to July 2017, 71 HIV patients under regular treatment were evaluated. All patients had an undetectable viral load, and had been in ART for over a year, asymptomatic and with no history of cardiovascular disease. Mean age was 47.23 ± 9.36m with 53.52% of the sample 69