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June 18/25, 2019 Circulation. 2019;139:e1082–e1143. DOI: 10.1161/CIR.0000000000000625 e1116

CLINICAL STATEMENTS AND GUIDELINES are not enough data to distinguish the potential for benefit from statin therapy between those on peritoneal dialysis and those on hemodialysis.

4.5.5 Adults With Chronic Inflammatory Disorders and HIV

Recommendations for Adults With Chronic Inflammatory Disorders and HIV Referenced studies that support recommendations are summarized in Online Data Supplement 39.

COR LOE Recommendations

IIa B-NR 1.  In adults 40 to 75 years of age with LDL-C 70 to 189 mg/dL (1.7 to 4.8 mmol/L) who have a 10-year ASCVD risk of 7.5% or higher, chronic inflammatory disorders and HIV are risk-enhancing factors and in risk discussion favor moderate-intensity statin therapy or high-intensity statin therapy.S4.5.5-1–S4.5.5-12

IIa B-NR 2.  In patients with chronic inflammatory disorders or HIV, a fasting lipid profile and assessment of ASCVD risk factors can be useful as a) a guide to benefit of statin therapy and b) for monitoring or adjusting lipid-lowering drug therapy before and 4 to 12 weeks after starting inflammatory disease–modifying therapy or antiretroviral therapy.S4.5.5-12–S4.5.5-20

IIa B-NR 3.  In adults with RA who undergo ASCVD risk assessment with measurement of a lipid profile, it can be useful to recheck lipid values and other major ASCVD risk factors 2 to 4 months after the patient’s inflammatory disease has been controlled.S4.5.5-21–S4.5.5-23

Synopsis

Chronic inflammatory disorders and HIV infection are conditions that often enhance risk. Clinicians should first focus on helping patients with these diagnoses to optimize their lifestyle habits. After a 3- to 6-month trial of lifestyle improvements, including cessation of cigarette smoking, the patient’s 10-year ASCVD risk estimate should be reassessed. If the patient’s ASCVD risk estimate is ≥5% over 10 years, it is reasonable to begin moderate-intensity statin therapy. If the patient or clinician remains uncertain about the need for statin therapy or if the patient has had side effects with a statin in the past, a CAC scan can be used to improve risk assessment. The absence of CAC in a nonsmoking man ≥40 years of age or a nonsmoking woman ≥45 years of age would indicate that the patient is likely at very low risk of an ASCVD event over the subsequent decade. Such patients can then focus on lifestyle habits and delay the decision about statin therapy for about 5 years. Similarly, a CAC score ≥75th percentile for a patient’s age and sex or an absolute score ≥100 Agatston units would support the decision to use statin therapy and intensify lifestyle modifications. Recommendation-Specific Supportive Text

1.	 Inflammation promotes atherosclerosis and is a key feature of many chronic rheumatologic inflammatory joint disorders, such systemic lupus erythematosus, RA, and psoriasis.S4.5.5-1 Inflammation mediates the progression of atherosclerosis, as well as instability, erosion, and rupture of vulnerable atherosclerotic plaques.S4.5.5-2 Among individuals with RA, the risk of an MI has been estimated to be similar to that of an adult with diabetes mellitus or one who is about 10 years older without RA.S4.5.5-3 A large meta-analysis found that persons with RA had an approximately 50% increased risk of CVD death.S4.5.5-4 Individuals with systemic lupus erythematosus and advanced psoriasis have a similarly increased risk of CVD.S4.5.5-5–S4.5.5-7 HIV infection is associated with an increased risk of an ASCVD event even if viremia has been controlled by antiretroviral therapy.S4.5.5-8 There is an increased risk of MI in association with long-term use of antiretroviral therapy, and MI rates are increased in individuals with HIV.S4.5.5-9 Traditional ASCVD risk factors, long-term use of antiretroviral therapy, prolonged immune activation, and inflammation are mediators of atherosclerosis progression and development.S4.5.5-9,S4.5.5-10 Coinfection with hepatitis C virus is frequently present in HIV-infected individuals and further increases ASCVD risk.S4.5.5-11,S4.5.5-12 2.	 The accuracy of the ASCVD risk estimator has not been well validated for adults with chronic inflammatory disorders or HIV infection. Assessment of traditional risk factors often has resulted in underestimation of actual risk and the potential for undertreatment with pharmacological therapy.S4.5.5-13,S4.5.5-14 Traditional risk factors should be assessed early in the disease process and then modified. Rates of smoking in HIV-infected adults have generally been 2 to 3 times that of the general population.S4.5.5-15,S4.5.5-16 Multiple studies have demonstrated underestimation of ASCVD risk in patients with chronic inflammatory conditions or HIV.S4.5.5-15,S4.5.5-16 Antiretroviral therapy may adversely affect lipid levels, glycemic control, and endothelial functionS4.5.5-17–S4.5.5-19 and has been associated with adverse changes in body composition (lipodystrophy). However, use of newer agents may lessen the metabolic derangements of antiretroviral therapy. Similarly, the use of prednisone in chronic inflammatory diseases may worsen glycemic control and dyslipidemia.S4.5.5-20 The most common lipid abnormality phenotype in persons with HIV infection is an elevated triglyceride level with a low HDL-C. In HIV-infected adults,

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