September 2000
Dr. Egger examined the general recommendations for treating risk factors for coronary artery disease (CAD). He used figures from the MONICA project -- WHO's analysis of coronary artery disease in various parts of the world. He also discussed the decreased risk of women until a period 10 years later than men and showed that this was unrelated to the time of menopause in women.
| Factors | Relative Risk of CAD |
| Increased cholesterol | 1.5 |
| Decreased HDL | 1.4 |
| Increased triglycerides | 1.8 |
| Hypertension | 1.5 |
| Diabetes mellitus | 2.3 |
| Smoking | 2.3 |
Dr. Egger then used a comparison between age, sex and cholesterol-level controls from the Welsh Caerephilly Heart Disease Study, a database of 2,512 men begun in 1979 and followed at five-year intervals. He compared this to data from Andrew Carr's study of 113 patients on HAART.
| Degree of Lipodystrophy | Caerphilly Study | |||||
| 45-49 | >50 | |||||
| Lipodystrophy | 0 | + | + | +++ | ||
| N | 18 | 44 | 31 | 12 | 828 | 1,684 |
| Insulin Resistance | 1.73 | 2.25 | 2.60 | 3.86 | 1.84 | 2.93 |
| TG mmol/L | 1.8 | 3.3 | 3.0 | 5.0 | 2.1 | 2.0 |
| Total Chol mmol/L | 5.6 | 5.9 | 5.7 | 6.2 | 5.7 | 5.7 |
| HDL Chol mmol/L | 1.18 | 1.06 | 0.97 | 0.85 | 1.10 | |
These data demonstrate that patients with severe lipodystrophy have findings more consistent with the older HIV-negative cardiac study group, especially with values like insulin resistance. Dr. Egger concluded that it was very clear that patients with lipodystrophy would be at increased risk of CAD. For men, the relative risk compared to those without lipodystrophy would be 1.5-4.0. In women, the relative risks may be somewhat higher.
However, he cautioned that increased risk must be analyzed in absolute terms and contrasted with the benefit of HAART. Dr. Egger then laid out a model of risk assessment that looked at the number of patients needing to be treated for a good outcome vs. the number of patients needing to be treated to see a toxicity. Comparing the risk of progression in the MACS cohort, reported by John Mellors, with the benefit from HAART treatment reported in the Swiss HIV Cohort, he showed that in patients with advanced disease, benefit outweighed risk, while this might be reversed by treating too early.
Dr. Egger then presented data showing the absolute five-year coronary risk along with the number of patients treated to see one patient harmed (NNTH). Data was presented using the Framingham equations, with separate data presented for the French risk (this as a result of the "French paradox," where despite high levels of risk, the French show decreased CAD compared with other groups):
| Five-Year Risk of CAD | |||
| No Lipodystrophy | Lipodystrophy (Severe) | NNT | |
| % USA/France | % USA/France | % USA/France | |
| MEN | |||
| Nonsmoker | |||
| 30 | 0.5/0.2 | 1.9/6.8 | 71/167 |
| 50 | 3.6/1.7 | 9.1/5.0 | 18/30 |
| Smoker | |||
| 30 | 1.1/0.4 | 3.6/1.7 | 40/77 |
| 50 | 6.3/3.2 | 14.0/8.3 | 13/20 |
| WOMEN | |||
| Nonsmoker | |||
| 30 | 0.048/0.01 | 0.5/0.2 | 217/526 |
| 50 | 2.2/0.93 | 8.8/4.8 | 15/26 |
| Smoker | |||
| 30 | 0.1/0.04 | 1.1/0.4 | 100/278 |
| 50 | 4.1/1.9 | 13.7/8.1 | 10/16 |
Clearly, while we can't do much about our age or our nationality, we can make changes in other risk behaviors that could have a profound impact. Patients with HIV and lipodystrophy must be carefully counseled about these risk behaviors, especially smoking. Stopping smoking can reduce the patient's risk to that of a nonlipodystrophic person.