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 Figure 3 – Correlation between medium-intimal thickening in 71 HIV-positive patients according to the Framingham 2008 and reduced DAD scores. 1,5 1,0 0,5 0,0 0 10 20 30 40 1,5 1,0 0,5 0,0 0 5 10 15 20 r = 0,5404 p < 0,0001 r = 0,5108 p < 0,0001 Medium-intimal thickening (mm) Medium-intimal thickening (mm) Framingham 2008 score Reduced DAD score Figure 4 – Frequency of subclinical atherosclerosis in 71 HIV-positive patients according to the Framingham 2008 and reduced DAD scores. 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 % 77.8 62.5 20.0 6.7 30.8 88.2 Framingham 2008 Reduced DAD Low Intermediate High/very high Table 2 – Degree of agreement between cardiovascular risk scores in 71 HIV-positive patients. Low Intermediate High Category Kappa 0.268 0.084 0.735 p-value of category Kappa 0.001 0.226 < 0.001 95%CI of category Kappa 0.11 a 0.427 -0.052 a 0.22 0.502 a 0.967 95%CI: 95% confidence interval. In our study, aggravating factors for reclassifying the Framingham 2008 score were disregarded as some guidelines recommend, which led to a higher number of individuals in the low-risk category. The inclusion of aggravating factors could overestimate the risk in 10 years and lead to a 10-fold increase in the proportion of patients classified as intermediate risk (3.2% to 39.9%). 14 The use of the Framingham and DAD scores in a recent study conducted with 997 HIV-positive patients concluded that the Framingham score would attribute to this population a greater cardiovascular risk than the DAD full score, and that this could lead to overtreatment of patients and increased risk. 17 Although the Framingham 2008 score underestimates the presence of subclinical atherosclerosis, in the reduced DAD scoremore than 50%of atherosclerosis patients are not classified as high-risk, suggesting that this score may also underestimate cardiovascular risk in HIV-positive patients. Another study evaluating 203 HIV-positive patients reported DAD score as having better performance than Framingham’s, and showed that its accuracy increases when CD4 lymphocyte parameters and albumin levels are incorporated. However, the detection of subclinical atherosclerosis was underestimated by both scores. 18 72