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Arterial Schlerosis and Protease -- Diagnostic and preventitive strategies
Aug 4, 2003

What test(s) can a doctor run to see if a patient is developing arterial schlerosis from protease and in the absence of high triglycerides and high cholesterol? What drugs can a patient take to open clogged arteries?

Earlier this year an edition of the body suggested a possible test for evaluating contributions to arterial schlerosis from protease. I recall the article indicating that arterial schlerosis could be caused from protease -- even in the absence of high cholesterol or high triglycerides.

I recall from the past hearing about a drug that is supposed to unclog arteries. What is this drug called and can this drug be taken as a prophylactic to prevent or reduce arterial schlerosis in patients on protease?

ZCorker

Response from Dr. Pierone

Since you asked this question you are probably aware that treatment with HIV medications, particularly protease inhibitors, has been associated with metabolic changes that include higher cholesterol and triglyceride levels. Protease inhibitors also increase the risk of insulin resistance and diabetes, known risk factors for atherosclerosis.

Do these metabolic changes translate into higher rate of development of atherosclerosis with resultant heart attacks and strokes? The final answer is not yet in, but the early answer is probably yes. The very large D:A:D study showed a 27% increase risk of heart attacks per year of exposure to HIV medications. In our practice over the last twp months 2 of our patients have had strokes and one had unstable angina, so this is a serious concern. Risk of vascular disease does not outweigh benefits of treatment, but must be addressed.

The best way to address this risk is through a strategy of multiple risk factor assessment. This means determining for every person their estimated risk of heart disease based on age, cholesterol, smoking, family history of heart disease, blood pressure, etc. There is actually an online calculator that can be used for those aged 35-70.

Beyond this risk factor assessment there are tests such as ultrafast or electron beam CT scan of the heart that can estimate the presence of atherosclerosis non-invasively. Ultrasound of the carotid arteries can also give an early estimate of atherosclerotic plaque, especially if carotid intima-media thickness is measured. These tests are most helpful for those with higher risk scores based on the Framingham calculations.

In terms of prevention or treatment we can turn to the National Cholesterol Education Program (NCEP) guidelines. These guidelines help us determine who should start lifestyle modification (diet, exercise, fish oil, etc.) and cholesterol lowering therapy. The medications that lower cholesterol are statins and include simivastatin (Zocor) and atorvastatin (Lipitor) and pravastatin (Pravachol). Zocor should not be used with protease inhibitors because of an interaction that raises its levels too high. So we usually use Lipitor or Pravachol for those on PIs. The medication used to lower triglycerides is usually a fibrate such as fenofibrate (Tricor). The decision to use these medications should be made after taking into consideration of your personal risk and after a discussion with your doctor. Good luck!



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