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Predicted cardiovascular risk in HIV-infected patients

In a recent case – control study, Kim et al. compared the predicted 10-y cardiovascular mortality between HIV-infected and uninfected patients [1]. Applying the Framingham risk score (FRS), the groups did not differ in predicted 10-y cardiovascular mortality (7% in both groups). While the authors should be commended for their efforts, several concerns remain. Importantly, the study did not control for a family history of cardiovascular disease. Calvo-S á nchez et al. [2] reported that family history is the greatest contributor to cardiovascular risk in HIV patients, higher than diabetes, hypertension, or smoking. Furthermore, the attributable risk of smoking was signifi cantly higher in HIV-infected compared to uninfected patients, which supports the notion that FRS underestimates cardiovascular risk in HIV patients. The inclusion criteria used by Kim et al. limited enrollment to HIV patients who regularly attend appointments at 3-month intervals. This requirement represents an important source of selection bias by selecting for adherent HIV patients, which might not be representative of the greater population [3]. For this cross-sectional study, including all HIV patients would account for variations in patient behavior, thereby improving generalizability. Also, antiretroviral adherence requires behavioral traits that are likely associated with adherence to other interventions, such as cardiovascular risk reduction. Although the inclusion criteria for controls are not mentioned, appointments at 3-month intervals are unlikely in healthy individuals. Greater exposure to healthcare providers in HIV patients compared to healthy controls, might also cause a higher prevalence of statin prescriptions. Discrepancies in statin use would explain the differences in lipid profi les, and therefore FRS. Even with equal rates of statin prescriptions, adherence would likely differ, due to both selection bias and drug interactions [4]. Limitations notwithstanding, Kim et al. provide convincing evidence that traditional cardiovascular risk factors might play a less important role in HIV patients.