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 1. UNAIDS. Joint United Nations Programme on HIV/AIDS. Ending AIDS: progress towards the 90-90-90 targets. Global AIDS Update . [Accessed in 2017 Dec 27]. Available from http://www.unaids.org . 2. Brasil. Ministério da Saúde. Bol EpidemiológicoHIVAIDS.[Accessed in 2017 Dec 8]. Available fromwww.aids.gov.br. 3. Smith CJ, Ryom L, Weber R, Morlat P, Pradier C, Reiss P, et al. Trends in underlying causes of death in people with HIV from1999 to 2011 (D:A:D): a multicohort collaboration. Lancet. 2014;384(9939):241-8. 4. Hanna DB, Ramaswamy C, Kaplan RC, Kizer JR, Anastos K, Daskalakis D, et al. Trends in cardiovascular disease mortality among persons with HIV in New York City, 2001-2012. Clin Infect Dis. 2016;63(1):1-9. 5. Triant VA. Epidemiology of Coronary Heart Disease in HIV Patients. Rev Cardiovasc Med. 2014;15(1):S1–8. 6. Malvestutto CD, Aberg JA. Coronary heart disease in people infected with HIV. Cleve Clin J Med. 2010;77(8):547-56. 7. Hsue PY, Lo JC, Franklin A, Bolger AF, Martin JN, Deeks SG, et al. Progression of Atherosclerosis as Assessed by Carotid Intima-Media Thickness in Patients With HIV Infection. Circulation. 2004;109(13):1603-8. 8. Pirš M, Jug B, Eržen B, Šabović M, Karner P, Poljak M, et al. Cardiovascular risk assessment inHIV-infectedmale patients: a comparison of Framingham, SCORE, PROCAM and DAD risk equations. Acta dermatovenerol Alp Pannonica Adriat. 2014;23(3):43–7. References To compare scores, a correlation was made between them and medium-intimal thickness, besides the calculation of degree of agreement between them, and ROC curve discrimination analysis. Scores were shown to be correlated with medium-intimal thickening. Kappa index was statistically significant and showed 49% of total agreement between scores, but substantially between high-risk patients. The intermediate risk category did not present statistically significant agreement and the low risk category presented low agreement. There was no statistically significant difference in the ROC curve discrimination analysis between scores. Importantly, these scores present differences in time and composition of type of predicted cardiovascular events. In addition, the Kappa coefficient may have limitations, and even low coefficients may show a good degree of agreement. 19 In the present observational, cross-sectional study with a small and random sample, we performed risk stratification and the presence of subclinical atherosclerosis was assessed by carotid Doppler ultrasonography; however, the occurrence of clinical events was not evaluated. These data suggest that HIV-positive patients classified as intermediate risk by the Framingham 2008 and reduced DAD scores could be reclassified as high risk in up to 62.5% and 30.8% of cases, respectively, due to the presence of subclinical atherosclerosis detected by carotid Doppler ultrasonography. These results are relevant because high-risk patients demand more aggressive therapeutic goals and subclinical atherosclerosis could indicate the need for other classes of drugs such as platelet antiaggregants. More appropriate risk stratification methods are highly desirable for this population, as this group, has risk factors inherent to chronic HIV infection itself in addition to increased risk of cardiovascular events, which leads to a systemic inflammatory process, and the use of ART increases the prevalence of metabolic syndrome. In addition to more accurate scores, new diagnostic tools or biomarkers may lead to stratification that allows better identification of high-risk patients. Thus, cardiovascular prevention measures can be reinforced not only by decrease in events, but also avoiding unnecessary use of medications that could cause adverse reactions and drug interactions. Conclusion Although this study shows a correlation between the Framingham 2008 and the reduced DAD scores and medium-intimal thickening, as well as high agreement between patients classified as high risk, we could not find a statistically significant difference between them by ROC curve discrimination analysis. In addition, the results suggest that HIV-positive patients sorted as intermediate risk by Framingham 2008 and reduced DAD scores could be reclassified as high risk in up to 65.5% and 30.8% of cases, respectively, due to the presence of subclinical atherosclerosis detected by carotid Doppler ultrasonography. Author contributions Conception and design of the research and Writing of the manuscript: Silva AG, Paulo RV, Silva-Vergara ML; Acquisition of data: Silva AG, Paulo RV; Analysis and interpretation of the data and Critical revision of the manuscript for intellectual content: Silva AG, Silva-Vergara ML; Statistical analysis: Silva AG. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This article is part of the thesis of master submitted by Achilles Gustavo Silva, fromUniversidade Federal do TrianguloMineiro. Ethics approval and consent to participate This study was approved by the Ethics Committee of the Universidade Federal do Triângulo Mineiro under the protocol number 1.464.324. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study. 74