1. health and fitness
2. disease
3. cholesterol

National HIV Nurses Association (NHIVNA)
Study Day
‘Health Promotion’
Scott McLean
Royal Infirmary of Edinburgh
Linda Panton
Western General Hospital, Edinburgh
18 November 2009, Surgeons Hall, Edinburgh
Cardiovascular disease and HIV infection
Implications, assessment and interventions
Scott McLean
Nurse Consultant
The Edinburgh Heart Centre
NHS Lothian
Linda Panton
Clinical Nurse Specialist
Infectious Diseases Unit
NHS Lothian
1
National HIV Nurses Association (NHIVNA)
Study Day
‘Health Promotion’
Scott McLean
Royal Infirmary of Edinburgh
18 November 2009, Surgeons Hall, Edinburgh
Cardiovascular disease and HIV infection
Introduction to Cardiovascular Disease
Scott McLean
Nurse Consultant
The Edinburgh Heart Centre
NHS Lothian
2
The burden of cardiovascular disease
Diseases of the heart and circulatory system
(CVD) are the main cause of death in the UK
Account for approximately 200,000 deaths
per annum.
More than one in three UK deaths are as a
result of CVD
The burden of cardiovascular disease
Almost half (48%) of deaths from CVD are as
a result of it’s most common manifestation –
Coronary Heart Disease (CHD).
CHD caused almost 94,000 deaths, of which
31,000 were premature deaths in the UK in
2006.
3
Coronary Heart Disease in ages <75
Mortality per 100,000 population in Scotland
Almost half (48%) of deaths from CVD are as
a result of it’s most common manifestation –
Coronary Heart Disease (CHD).
CHD caused almost 94,000 deaths, of which
31,000 were premature deaths in the UK in
2006.
Coronary Heart Disease statistics (2008)
available at http://www.heartstats.org/datapage.asp?id=7998
4
UK deaths by cause (2006)
Reports of longstanding illness by sex
and condition (2006)
5
Absolute gap in CVD death rates
between 5th most deprived
areas vs. population as a whole
CHD death rates by social class in men
and women aged 35-64
6
Age standardised CHD death rates per
100,000 population for men <65yrs (2006)
CHD death rates from ages 35-74 (2000)
7
Prevalence of disease across England,
Scotland and Wales (2007)
Prescriptions used in the prevention and
treatment of CVD
8
CABG and PCI per annum
Prevalence of cigarette smoking by sex
9
Proportion of men smoking
by region (2006)
Regular daily smokers aged over 15yrs
10
Fruit and veg consumption in adults
aged over 16
No moderate-intensity physical activity
in a typical week (2005)
11
More alcohol than the recommended
daily maximum in adults aged over 16
Alcohol consumption by country in
adults aged 15 and over (2003)
12
High blood pressure by sex and age in
adults aged over 16 (2006)
Adults with serum cholesterol
>5.0mmol/l (2006)
13
Obesity by sex in adults
aged over 16
Obese children aged 2 to 15
14
Diagnosed diabetes in adults
Healthcare costs of CHD in the UK (2006)
£14.4 billion
15
The United Kingdom (2009)?
The United Kingdom (2009)?
CHD mortality
Social deprivation gap (mortality)
CVD prescriptions
CABG + PCI
Cigarette smoking
Fruit and Veg consumption
Physical activity
16
The United Kingdom (2009)?
Alcohol consumption
High blood pressure
Hypercholesterolaemia
Adult obesity
Child obesity
Diabetes mellitus
National HIV Nurses Association (NHIVNA)
Study Day
‘Health Promotion’
Linda Panton
Western General Hospital, Edinburgh
18 November 2009, Surgeons Hall, Edinburgh
17
Why should HIV nurses know
about heart disease?
Linda Panton
Clinical Nurse Specialist
Infectious Diseases Unit
NHS Lothian
HIV and cardiovascular disease
In HIV, cardiovascular disease
ranks 4th for cause of death behind
opportunistic infections, cancers
and liver disease.
18
HIV and cardiovascular disease
The HIV population is ageing and therefore
at increased risk of CVD
10% are aged over 50yrs
40% over 40yrs
HIV and cardiovascular disease
Uncontrolled HIV infection increases the
risk of heart attack
Risk of MI 7070-80% higher in HIV positive
people
Some lifestyle habits attributable to CVD
more common in people with HIV
19
HIV and cardiovascular disease
Uncontrolled HIV can show similar lipid
changes found to be associated with
increased risk of CVD in general
population.
-hypercholesterolemia
-low levels of high density lipoprotein
-elevated levels triglycerides
MEASUREMENTS
HDL = good fat – blood transports this cholesterol
from peripheral tissues to liver, and deposits as
bile.
LDL = bad fat – lipoprotein transports cholesterol
and deposits in blood vessel wall – plaques
Total cholesterol = LDL + HDL = TGLs + lipoprotein a
20
HIV ITSELF CAUSES
Pro-inflammatory states
ProEndothelial dysfunction
Increased carotid artery thickness
Decreased arterial elasticity
ALL CORRELATE WITH TRADITIONAL RISK
FACTORS FOR ATHEROSCLEROSIS AND CVD
EVIDENCE
SMART study – treatment interruption increased
likelihood of CVD
FIRST study – lower CD4 count associated with
higher risk of CV events
21
DO ANTIRETROVIRALS
AFFECT THE HEART?
The SMART study -being on ARV therapy and having an undetectable
viral load (VL) is protective for heart disease, compared to not being on
ARVs and having a detectable VL
Some ARVs affect the blood lipids (increases)
These include some of the protease inhibitors
D:A:D study - increase of risk of cardiac events such as heart attack
(myocardial infarction or MI) with certain drugs such as PIs and some
nucleoside analogues
THESE DRUGS WILL STILL BE USED, BUT WITH CAUTION AND
CAREFUL MONITORING
Largest observational study to date linked
myocardial infarction to ART exposure
MIs per 1000 PYFU
(IC95%)
8
D:A:D study
7
6
5
4
3
RR per year of ART:
Univariate: 1.16 [1.11-1.21]
Adjusted:
1.16 [1.09-1.23]
2
1
0
No
<1
1-2
2-3
3-4
4-5
5-6
6-7
>7
Exposure to ART(years)
D:A:D study group. NEJM 2003; 349: 1993-2003
22
Higher risk of MI with PI exposure (but not
with NNRTI exposure)
D:A:D study
Number of MIs per 1000
PYFU (IC 95%)
Adjusted relative rate/year of PI: 1.15 (1.06, 1.25)
Adjusted relative rate/year of NNRTI: 0.94 (0.74, 1.19)
10
8
6
4
2
0
0
<1 1–2 2–3 3–4 4–5 5–6 >6
Years of exposure to PI or NNRTI
Friis-Møller N et al. N Engl J Med 2007;356:1723-35
Recent Use of ABC Associated with Increased Risk of MI;
TDF Not Associated with Increased Risk of MI
D:A:D
580 MIs in 33,308 patients (178,835 person-years of follow-up)
ABC
TDF
Relative rate [95% Cl]
Relative rate [95% Cl]
Recent Use1
1.68 [1.33, 2.13]
1.14 [0.85, 1.52]
Cumulative Use
1.07 [ 1.01, 1.14]
1.05 [0.92, 1.19]
1Recent
use is defined as still using or stopped within last 6 months
Lundgren J, CROI 2009; 44LB
23
D.A.D. STUDY – RECENT AND
CUMMULATIVE EXPOSURE TO NRTIs
1.9
1.68
RR
95% CI
1.5
1.2
1.14
RR per
year
95% CI
**
1
0.8
0.6
ZDV
#PYFU: 138,109
#MI:
523
Lundgren J, CROI 2009; 44LB
ddI
ddC
d4T
3TC
ABC
TDF
74,407
29,676
95,320
152,009
53,300
39,157
331
148
405
554
221
139
* Recent use defined as still using or stopped within last 6 months.
** Not shown (low number of patient currently on ddC)
Host-related factors
Higher prevalence of metabolic abnormalities –impaired glucose
tolerance & fasting glucose, diabetes
drug consumption (tobacco, alcohol, cocaine, others)
Higher smoking rates in HIV+ vs HIVHIV-
Body fat changes (lipoatrophy and visceral accumulation) associated
with dyslipidemia and insulin resistance
Degree of immune deficiency (eg, low CD4 count)
ALL ABOVE INCREASE RISK OF CVD
24
Conclusions
Increasing importance of CV ischemic disease as a
health problem in HIVHIV-infected persons
Higher risk of CV disease in HIVHIV-infected persons
relative to nonnon-HIV
HIV--infected ones
Uncontrolled HIV and other concurrent infections
further increase the risk for CV disease.
Conclusions
Individual antiretroviral agents associated with
increased risk of CV
Rationale for choosing ART components
depending on CV risk.
From a purely cardiovascular perspective, the
benefits of ART clearly outweight the potential
risks.
25
Cardiovascular disease and HIV infection
Risk assessment
Scott McLean
Nurse Consultant
The Edinburgh Heart Centre
NHS Lothian
26
Risk assessment tools
Different:
Tools
Populations
Recommendations re. Rx
Results!
Russell T, Burns LA.
Cardiovascular risk assessment and management
guidelines for HIV – what are we using in practice?
Framingham
ASSIGN
JBS2
Q-Risk
Total
Chol:HDL
ratio
Mean %
risk
8.1
6
8
3
4.1
Median %
risk
11.3
8.4
11.4
5.4
4.5
% at
“high-risk”
20
9
21
4
27
SIGN 97 (2007)
available at http://www.sign.ac.uk/pdf/sign97.pdf
28
SIGN 97
5-yearly riskrisk-assessment on adults
aged >40yrs
High-risk (10yr risk > 20%) assumed
Highwithout using any scoring system:
Pt with previous cardiovascular event
Diabetics aged >40yrs
Pt with familial hypercholesterolaemia
Clinical history
Age
Gender
Cigarette smoking
Family history of premature CVD
Socioeconomic status
29
Clinical measurements
Blood pressure
Weight, BMI and waist circumference
Total serum cholesterol and HDL
Blood glucose
Renal function
SIGN 97 (2007)
RECOMMENDATIONS
30
(A) Diets low in total and saturated fats should
be recommended to all for the reduction of
cardiovascular risk
(C) Increased fruit and vegetable consumption
is recommended to reduce CV risk for the
entire population
(B) Pts and individuals at risk of CVD who are
overweight should be targeted with
interventions designed to reduce weight and
maintain reduction
(A) Physical activity of at least moderate
intensity (enough to make the person slightly
out of breath) is recommended for the whole
population
(B) All people who smoke should be advised
to stop and offered support in order to
minimise CV and general health risks
(B) Exposure to passive smoking increases
CV risk and should be minimised
31
(B) Pts with no evidence of CHD may be
advised that light to moderate alcohol
consumption may be protective against the
development of CHD
(A) Adults >40yrs with 10yr risk >20% should
be considered for Rx with Simvastatin 40mg
(B) All pts with established symptomatic CVD
should be considered for more intensive statin
Rx
(√) The existing target of <5mmol/l in
individuals with established symptomatic CVD
should be regarded as the minimum standard
of care
(A) Pts with hypertriglyceridaemia (>1.7
mmol/l) and/or low HDL (<1 mmol/l in men)
should be considered for Rx with a fibrate or
nicotinic acid
(A) Pts with sustained SBP of >140 mmHg
and/or DBP of >90 mmHg, and clinical
evidence of CVD should be considered for BP
lowering Rx
32
(B) Individuals without symptomatic CVD who
have a BP of greater than 160/100 mmHg
should have drug Rx and lifestyle advice to
lower their BP and risk of CVD
(√) Targets defined by JBS state optimal BP
control for pts at high CVD risk (established
CVD or 10 yr risk of >20%) as <140/85 mmHg
(√) For individuals with established CVD,
chronic renal disease or end organ damage, a
lower BP of <130/80 mmHg is recommended
(A) Cognitive behavioural therapy should be
considered for increasing physical function
and improving mood in pts with CHD
(√) Targets defined by JBS state optimal BP
control for pts at high CVD risk (established
CVD or 10 yr risk of >20%) as <140/85 mmHg
(√) For individuals with established CVD,
chronic renal disease or end organ damage, a
lower BP of <130/80 mmHg is recommended
33
SIGN 97 (2007)
SIGN 97 (2007)
34
SIGN 97 (2007)
SIGN 97 (2007)
35
Cardiovascular disease and HIV infection
Guidelines and management strategies
Linda Panton
Clinical Nurse Specialist
Infectious Diseases Unit
NHS Lothian
GUIDELINES
All HIV guidelines recommend screening
for CVD in patients with HIV
-at diagnosis
-before initiation of HAART
-annually
36
What do we use?
Cholesterol , HDL, LDL, BP
Chol:HDL ratio
Framingham equation
10yr risk of CVD
Checked at every visit
MEASUREMENTS
HDL = good fat – blood transports this cholesterol
from peripheral tissues to liver, and deposits as
bile.
LDL = bad fat – lipoprotein transports cholesterol
and deposits in blood vessel wall – plaques
Total cholesterol = LDL + HDL = TGLs + lipoprotein a
37
CVD screen on all patients
Use both Framingham
& chol:HDL ratio scores
High Risk:
Moderate risk:
≥20% CV risk
10-20% CV risk
Low risk:
<10% CV risk
And/ or
Chol:HDL ≥6
Lifestyle intervention –
Smoking, diet, exercise, treat hypertension
3-6 month F/U
Consider change
of ART or statin/
antihypertensive
therapy
Repeat lipids and blood pressure
And CVD risk as above
Improvement
in lipid profile
Yes
No
Continue to encourage lifestyle throughout
TARGETS
What determines ‘Targets met’
met’
Need to look at different factors
if total cholesterol is high but risk is <10% and ratio ≤6
then check LDL and aim for LDL < 5mmol/l
If risk is moderate - 10
10--20%, then aim for a %
reduction to <10%, check LDL and try to get LDL
<4mmol/l
If risk high - ≥20% or cholesterol:HDL ratio ≥6 then
aim for a % reduction to <10%. Check LDL level and
aim for <3mmol/l.
If you cannot get LDL levels below recommendation
with lifestyle advice then consider statin or change
therapy
38
WHAT WE WANT TO
ACHIEVE
HDL > 1mmol/l(men)
>1.3(women)
LDL< 3 mmol/l
Total cholesterol <5mmol/l
Triglycerides < 1.7mmol/l
LIFESTYLE CHANGES
SMOKING
52% HIV patients are smokers
DAD study – 42% of those reporting MI
were smokers
BHIVA guidelines – access to smoking
cessation
39
LIFESTYLE CHANGES
SMOKING
– increased risk of heart disease, hypertension
and stroke
Stopping smoking decreases risk of MI by
65%
40
SMOKING CESSATION
GUIDELINES
BRIEF – no more than 3 mins
OPPORTUNISTIC – a suitable, appropriate
time to raise issue
DELIVER – message that smoking is bad for
health, and stopping is worthwhile
OFFER – factual information
ALLOW – person to make own choice
RECOMMEND – they seek local support
DOES NOT INVOLVE OFFERING ONGOING
SUPPORT
SMOKING
Nicotine replacement therapy
NHS Stop Smoking Services
Smoking cessation advisors in nursenurse-led
clinics
41
EXERCISE
Prevents build up of plaques
Blood less sticky
Strengthens heart – needs less oxygen
BP drops, HDL rises, LDL lowers, total fat
decreases
In HIV patients ↓cholesterol, ↓TGLs, improves
insulin resistance, improves CV parameters
EXERCISE
30 mins exercise a day, 5 days a week
Incorporate exercise into everyday life
Waverley Care -walking groups
-allotments
Community physio/OT
42
DIET
Cardioprotective diet to ↓LDL
5 a day fruit and vegetables
Reduction of saturated fats
Omega 3 fish oils
Unrefined CHOs
High fibre
Moderate alcohol consumption
LIFESTYLE MANAGEMENT
Maintain weight
BMI 1919-24
Waist circumference
Stress management
Hypertension – low salt, medication
Good diabetic control
Reduction of alcohol/recreational drug use
43
FOLLOW UP
Recalculate CV risk every visit
Refer to dietician
Refer to consultant if change in therapy is
considered best option
DRUG INTERVENTION
Review of lipids
Statins
Fibrates
Benecol drinks
Metformin
Omacor
44
NHIVNA competencies
Assessment of health and well-being
Level2 –
“participates in assessments of clinically stable
patients on and off therapy as part of routine
follow--up care…..”
follow
Level 4 –
“works autonomously, in partnership with MDT, to
assess a case load of clinically stable patients with
complex care needs, on or off therapy, on ongoing
basis….
NHIVNA COMPETENCIES
Management of ARTs
Level 2 –
“demonstrates ability to recognise longlong-term S/Es of
ARTs such as lipodystrophy, raised lipids, CVD
risk factors….”
Level 3 –
“ ..assesses for LT s/Es and takes action to maximise
preventing and monitoring of S/Es where possible,
incorporating this into nursenurse-led clinics….”
45
NHIVNA COMPETENCIES
Management of ARTs
Level 4 –
“establishes systems for prevention of LT S/Es
where possible, such as smoking cessation,
dietary and exercise interventions.”
NHIVNA COMPETENCIES
Health promotion
Prevention and risk reduction support
Level 2 –
“undertakes nursing assessment in relation to maintaining
health and a healthy lifestyle, including recreational drug
use, smoking and alcohol, diet, exercise, weight, stress
management…”
Level 33“Undertakes risk assessment in relation to smoking, CV
risk….develops action plan and makes onward referrals
based on assessment.”
46
Conclusions
Nurses play an important role in
assisting in the screening for CVD using
appropriate tools.
Nurse--led clinics
Nurse
Supporting patients in lifestyle changes to
decrease risk of CVD
Ensuring good adherence to HAART, to remain
undetectable
Understanding the rationale for choosing ART
components depending on CV risk assessmentassessment-
Cardiovascular disease and HIV infection
Group work
Assessment of the patient with “Chest Pain”
Scott McLean
Nurse Consultant
The Edinburgh Heart Centre
NHS Lothian
47
Case study
54 yearyear-old male in your clinic
HIV for 16 years, “stable”
As part of general discussion discloses that
he has been having “some chest pain”
On further questioning describes an 88-10
week history of (L) sided chest pain
Group work
What questions will you now ask?
If you were able to, what tests (if any) would
you request / arrange?
What options do you have in terms of second
opinion / expert advice?
What are your skills and knowledge deficits?
48
HPC
Previous Medical History
Site
Medications
Onset
Duration
Frequency
Risk Factors
Radiation
Severity
Nature
Relieving/Provoking factors
Associated factors
Cardiovascular disease and HIV infection
Group work
Case study
Linda Panton
Clinical Nurse Specialist
Infectious Diseases Unit
NHS Lothian
49
Jackie
40 year old female
Lawyer
Married
Lives in Manchester
Travels to London for work on a weekly
basis
Twin girls age 13 years
Clinic Presentation
Referred to Dietitian by Clinician who says
her CVD risk is on the ‘lower end of
moderate’ – Framingham risk of 13%
Q1. –
What information do you need to retrieve
for assessment?
50
Information?
Full lipid profile
Total cholesterol 4.0mmol/l
HDL 0.5mmol/l
TG 4.5 mmol/l
? LDL
Blood pressure – 140/80
Family history – yes, father at 50years old
Smoker - yes
Blood glucose - normal
Information
Weight – 85Kg
Height – 1.65m
BMI – 31
31Kg/m2
ART – 3TC/ABV + ATAZ + RTV
Lifestyle – stresses!
51
Q2:
What would you do next?
Re-do CVD screening?
Framingham
JBS2
ASSIGN
Q-Risk
Using JBS2/ Framingham pts risk is 16% and
ratio of 8.0
52
What advice would you
give?
What advice would you
give?
Stop smoking
Cardioprotective diet
Exercise – consider busy lifestyle?
Eating out?
Salt?
Weight reduction
Alcohol
Relaxation
53
What advice would you
consider giving the Clinician?
What advice would you
consider giving the Clinician?
Re
Re--do bloods in 3 months for review
Consider change of ART
Consider Statin if lipid profile not improved
54
Take home messages
Obtain as much info as possible to build up whole
picture
Always carry out your own risk assessment /
screening
Consider risk percentage and ratio
Encourage screening in your area – who will do
this, how often, what to include, decide on what
tool to use and how to monitor
Cardiovascular disease and HIV infection
Questions?
Scott McLean
Nurse Consultant
The Edinburgh Heart Centre
NHS Lothian
Linda Panton
Clinical Nurse Specialist
Infectious Diseases Unit
NHS Lothian
55