Yeah, yeah, yeah, yeah. Mm Hi. My name is Carol Trust, and I'm the executive director of the Association of Nurses and Aides Care You are viewing one in a series of learning modules about HIV and aging. We are grateful to Gilead Sciences for supporting this educational program and for our expert panel that includes people living in aging with HIV for their roles in this project. Each module is intended for nurses, nurse practitioners, nursing assistants and students and others who work in settings where people aging with HIV are now entering or receiving their care places such as home care or long term care settings. More than half of people living with HIV in the U. S. In 2020 were over 50.5 of those over 70. That number will increase as new treatments allow for longer lifespans. However, aging with HIV is a complex mix of long term treatment effects, early onset of general aging and other confounding factors. We have a glossary of terms in each module. We encourage you to refer to that Unintended discrimination and mistrust can be spread by the wrong choice of words and contribute to the stigma experienced by people living with HIV. This adds to their experience of social isolation and loneliness that is, unfortunately, all too common. Older people who have been living with HIV have experienced tremendous loss, the loss of friends and partners to the disease, the loss of family from early AIDS hysteria and even stigma and discrimination within the health care system. We have included a short video that explores this from the perspectives of people living with HIV. We strongly encourage you to view them. Each module examines a specific co morbidity or co occurring condition related to HIV and aging. There are deeper dives into each topic in the accompanying resource list that is embedded in each module. We have elected to cover topics that are unique to aging with HIV. However, links to resources on more general aging topics are also provided. Understanding the past trauma and the intersection with the challenges of ageing the many roles of nurses in coordinating care and supporting healthy living while coping and thriving with HIV as people age are so important. Thank you for your interest and for attending these sessions. So hello and welcome to this continuing nurse event on cardiovascular disease, aging and HIV for nurses and nurse practitioner. I'm Alison. Well, well, I'm an associate professor of nursing at Case Western Reserve University in Cleveland, Ohio. The first thing I have to do is disclose that I have no potential conflicts of interest with the content provided today. Our objectives over this next hour are to describe how HIV and aging intersect to increase risk for cardiovascular disease. To discuss strategies to prevent cardiovascular disease in adults aging with HIV and to discuss some general patient assessment and cardiovascular management tools for adults aging with HIV. So cardiovascular disease is a really big topic, and the knowledge base is growing fast. So the scope of today's presentation will focus on the most current available evidence. In this space. It will focus primarily on preventing cardiovascular disease in people living with HIV will focus both on primary and some secondary prevention of cardiovascular disease. This course is designed to introduce nurses and nurse practitioners to these issues. I encourage all learners to review the references that I'll include on each slide and at the end of the presentation, and to reach out to local cardiovascular disease experts in order to learn more about these growing issues, and lastly, cardiovascular disease is very heterogeneous. But in general, many of the cardiovascular diseases share similar risk factors. So I will try to focus the scope of this presentation on those shared risk factors to note about language. We will use a number of abbreviations throughout the course of this presentation. So I wanted to introduce the audience to those especially for those who may not have worked with people living with HIV before. So a R T refers to antiretroviral therapy. Um, these are the HIV medications that individuals take currently daily to help them suppress viral replication. Um, A S C V D refers to a throw sclerotic cardiovascular disease, and we'll use that to describe some of the tools we can use to assess patients. Risk. CBD will refer to cardiovascular disease. HIV stands for the human immunodeficiency virus. Protease P. I stands for protease inhibitor. This is one of the antiretroviral therapy medications that individuals with living with HIV take. We'll use the term P L W H to refer to people living with HIV, and lastly, when we talk about non pharmacological approaches, I will use the abbreviation R P E. That stands for rate of perceived exertion. It refers to how intense, um, someone is exercising. Okay, so with that, let's begin with a little bit of context. Over the past decade, we have made dramatic progress in the prevention and treatments and care of people living with HIV. As such as you can see on this first slide here. More than half of the people living with HIV disease today are over the age of 50 years of age old. This includes a growing number of older adults who are being diagnosed for agent with HIV for the first time, and we can see that the same trends are occurring worldwide. Um, with an estimated seven million people aged 50 years or older today, this is up from 5.7 million about four years ago. So there is a growing number of individuals globally aging with HIV, and as these individuals age, they face higher rates of age related comorbidities, which can be exacerbated by HIV and AIDS treatments. And these include cancer, liver pulmonary diseases as well as cardiovascular diseases. So, a little bit more context in this analysis of the N Accord cohort we can see that multiple morbidity or having more than one co occurring chronic condition has really increased in the decade from 2000 and 2000 and nine. This is a fairly recent analysis that we would expect these trends to continue if we look at subsequent years and then specifically if you If you look at the panel on your left and we drill down on these data, we can see that a significant burden of multi mobility is driven predominantly by cardiovascular risk factors, namely high cholesterol and high blood pressure. And this has been fairly consistent through the decade. Between 4000 and nine, it appears to be the same, continuing past 2010. So with that context, let's review a bit of an overview on cardiovascular disease and HIV. So when we think about cardiovascular disease, I think we should ask ourselves two questions focused on HIV, right? Do people living with HIV actually have an increased risk of cardiovascular disease? And if so, by how much? And for those of you who are familiar with the history of HIV, you might remember in the early pre a r T era we did see a lot of uncontrolled HIV and AIDS, which led to lots of AIDS cardio myopathy. However, when we entered the early art era and individuals were having better controlled HIV, um, we were. We mostly saw increased risk factors due to residual inflammation. Immune dysfunction in dis leukemia, which often lead to a theory. Oh Rombach tick disease. In the modern art era, we've quickly suppressed many of the Bible replication, and so we rarely see cardio myopathy today. But what we have seen is a growth in the burden of myocardial infarction and heart failure among people living with HIV and aging with HIV. So let's return to that first question. Do people living with HIV have an increased risk of cardiovascular disease? And I know this is a bit of a blurry slide, but there was a really wonderful, um, systematic review published in circulation about two years ago, that looked at this specific question, and the answer was, yes, they do. In fact, people living with HIV have approximately 1.52 fold risk of developing cardiovascular disease compared to individuals not living with HIV. This was a global analysis, uh, and what they were What the authors were able to show is that over the past 26 years, the global population attributable fraction from cardiovascular disease that is attributable to HIV infection increase from about 260.36% 2.92% and the disability adjusted life years increased from 0.74 to 2.57 million, with market variation in dailies loss mostly in sub Saharan Africa, where we tend to see much of the much of the HIV epidemic. So the risk factors for cardiovascular disease and HIV. I think we've historically thought that HIV, particularly the residual inflammation and immune dysfunction, um, led to a lot of risk for cardiovascular disease as well as some risk associated with the HIV medications themselves. This was challenged in the paper published last year by Altaf and colleagues and Lance It, or what they were able to demonstrate again using the N A. A core data was that the population attributable fractions from myocardial infarction of people living with HIV were predominantly driven by three traditional risk factors, namely high cholesterol at 44% high blood pressure at 42% and smoking at 37% in fact. HIV specific factors. Things like CD for Nader Less than 200 un suppressed HIV viral load really accounted for a very small fraction of the of the myocardial infractions. So that leads us to re conceptualize, um, how much of the risk factors for cardiovascular disease are HIV specific? And I think this is probably a much more accurate representation of the risk today in the modern a R T era where traditional risk factors and we will get into these and a lot more in the in the in the neck Coming slides, um, really do count for much of the risk associated with cardiovascular disease in a much smaller risk is associated to HIV, HIV and residual inflammation and antiretroviral therapy. When we think about the implications, uh, this epidemiology has for aging. Uh, what I would say is that it's incredibly important to recognize that your patients living with HIV are at increased risk on the patients themselves may recognize it, or they may not so helping them to understand that they might be at increased risk and to understand their other underlying risk factors. For example, a family history or high cholesterol high blood pressure is an important part of helping this population to age well, additionally, Um, and I'll get into this in a little bit more in the coming slides and management. But it also is critically important to help patients understand that by taking their HIV medications and suppressing their HIV viral load, they are improving their heart health. This is probably the first step we can take to really helping patients living with HIV, uh, start their journey to better cardiovascular health. However, it's also important to emphasize that traditional risk factors smoking sex age are are also play here and to work to treat those risk factors to guideline levels using both non pharmacological and pharmacological strategies. And we will discuss that in much more detail in the coming slides. When minimizing cardiovascular disease risk in your HIV patients, What are the primary goals Reducing smoking, HIV viral suppression, systolic blood pressure less than 120 or all of the above? The answer is D all of the above. HIV viral suppression is a primary goal in all aspects of HIV treatment and improves overall health and lessons inflammatory response that may contribute to cardiovascular disease traditional risk factors, including hypertension and smoking, also confer even more significant risk of cardiovascular disease and cardiovascular events in HIV primary care. It is important to address all three of these risk factors with patients using a shared decision making approach. So our second module today is focused on the prevention of cardiovascular disease in adults aging with HIV in a really great framework for helping to think about many of the risk factors individuals based when confronting a cardiovascular disease is what's one that we use. A lot is called Life Simple seven, and this is a tool that's put out by the American Heart Association. And it refers to the seven most common risk factors that individuals have for developing cardiovascular disease. Many of these will be familiar things like stopping smoking, losing weight, eating healthier and being more physically active, as well as reducing uh, LDL, reducing high blood pressure and improving blood glucose levels. So we will first start with some of those lifestyle strategies, most mainly physical activity, healthy eating in which should often result in weight loss. So when we think about physical activity, one of the first questions all of our patients ask us is how active do we really have to be? And the good news is, um, the guidelines for people living with HIV have been shown to be safe and effective as as as the same guidelines for individuals who do not live with HIV. And those guidelines recommend 150 minutes of moderate intensity physical activity per week or 75 minutes of moderate to vigorous physical activity per week and at least two days of strength based training per week. And this really is a minimum because we know as people age in addition to cardiovascular disease, there are increased risk for things like fractures and Sarka pina. So strength based training is a really important component of physical activity and one that's often neglected in thinking about the minimum amount of physical activity. In each week we have a little over 10,000 minutes, Um, and if we're all doing what we're supposed to do and sleeping about eight hours per night, we have to use about third of those minutes on sleeping. But that leaves almost 7000 minutes per week to help meet these guidelines, right, so this is actually less than 2% of our non sleeping time that we should be spending on physical activity. And that's really not a lot considering the benefit derived from even just meeting these minimal, minimal guidelines. So what, I often tell people is to really think of these guidelines as a starting place. They are the minimum. But the more we do know now that the more exercise and the more physical activity individual can participate in the better benefit they derive from that activity. Another question I sometimes get is about intensity. So what is moderate intensity? Physical activity? And you know, this is generally how we describe it. Moderate activity is something that feels hard, right? Our heart rates up for a little bit out of breath, but we can absolutely carry on a conversation with someone who were working out with, even if that person is about 6 ft away. Um, in terms of perceived heart rate or or maximum heart rate, this is really about 50 to 70% of one's age, predicted maximum heart rate. On the other hand, the vigorous activity is is just what it says. It's a vigorous right. Our heart rate is very elevated the individual doing the exercises, breathing deep and rapid, they start sweating, usually pretty quickly. Um, and they can't say more than a couple of words without pausing and getting or gasping for breath. Um, this is really about 70 to 85% of one's age predicted maximum heart rate, and it tends to fall somewhere between the 17 and 20 range on this R P scale. Here, this is a fairly common, uh, scale of perceived exertion. I don't know why it starts at six instead of one, but does go from 6 to 20. And so a good guideline of patients can download this onto their phone. Or, if you have some in the offices to tell them that moderate activity is somewhere between like an 11 and a 14, and then vigorous activity really starts around 15 and goes all the way up to about 19 twenties is really giving 100%. And that's not often something we would want someone to do unless they were training for a specific event. There are different types of activities by intensity. If we want to think about moderate activity, this would be something like, um, power walking or biking individuals happen to have access to a bike. Vigorous activity is playing sports. So whether it's soccer or basketball or other sports, anything that really raises the heart rates dramatically would be considered vigorous activity. Turning to the second strategy, which is a heart healthy diet, I think it's a reasonable question for patients to ask. You know, look, we hear lots of things every day in the news. What exactly is a heart healthy diet? And, um, you know, the truth is that similar to those physical activity guidelines? Whether you are from South Africa, has shown here or from the United States or even from the United Kingdom, the guidelines for eating and drinking for heart health are really kind of the same. This includes eating a variety of nutritious foods across different food groups, trying to draw heavily on the fruit and vegetable food groups. Uh, it does include, and this is particularly important, as people age does include high protein sources and high fiber foods. This can be challenging for individuals as they age because they may lose teeth. They may have dentures so it can be hard to consume. For example, meat sources of protein. So working with patients to help them understand that high protein, high fiber um, foods that are also soft and easier to choose things like lentils and beans can be really helpful in meeting these heart healthy goals. Additionally, this includes eating less nutrient poor foods, and this can often be very challenging with patients. Um, but easy way to eat and consume less nutrient poor foods really is to cut back on food and beverages with added sugars, as well as choosing foods that have reduced salt. And this is gonna be critically important for individuals who have high blood pressure, um, choosing foods that have less than 1500 mg of salt per day. I will say one of the strategies that we've often recommended to patients when they're trying to cut back on food and beverages with added sugar is to substitute just plain water. People will say they don't like plain water, but plain drinking lots of clean, safe water is a really helpful way of helping individuals get off, say, soda and reducing calories. In that way, and also depending on the context in which you practice, um, portion size, maybe more, or less a challenge for your patients. So it's also about reminding patients in ourselves that we only need to eat until our bodies are full. If we want to save the rest of the meal for the next meal or take it home, that's that's a perfectly good and healthy strategy to do to really maximize our heart healthy eating. So when we talk about maybe integrating nutrition into HIV care, I do think that there are some specific concerns that are more prevalent in this population. Um, the first. Unfortunately, what we know is that people living with HIV are at much higher risk for food and security, and that's a that's a That's a large structural problem. Um, but what? You know, if you happen to work in a setting that either works with the Ryan White nutritionist or has access to nutrition consults, um, really, really doing a full understanding of of what? How they obtain food if it's enough to meet their daily caloric needs safely, Um, and if not, where some places the individual can be referred to just really help obtain that healthy food. The other one, um, and I can't tell you we've We've actually been able to do studies helping folks to switch off of sugar sweetened beverages. But sometimes there's a misunderstanding. Um, I think sometimes people think sugar sweetened beverages is just soda. Um uh. In fact, things like fruit juices and Gatorade's and those high caffeinated drinks can also be sources of very high sugar content added sugar content. So just helping patients to understand what added sugar is and where some of the less obvious sources where that hides out. And lastly, and I mentioned this a little bit in the previous slide. But really, as patients age to try to make sure they are getting enough quality protein and fiber, and here are some guidelines here, um, for the amount per day that they should be consuming third and perhaps the hardest lifestyle strategy to improve cardiovascular health and patients aging with HIV is smoking cessation and again, just like physical activity. This is a really big topic, and it's one area that is incredibly important but also incredibly difficult to address in our population. We now know from several large studies that smoking seems to have an even greater effect on mortality and cardiovascular disease in people with HIV than it does in the HIV uninfected population. But look, quitting is really hard. I mean, people will often tell you it feels like you're just pushing a boulder up a hill, and it's and and and it's it's so hard. The mythology around smoking is so prevalent that it can be daunting for people even to think about what it would mean for them to quit smoking. But luckily, um, there have been a number of of behavioral studies that have demonstrated that short term success in smoking cessation is possible. Um, but unfortunately, long term success is hard to achieve. And these data are from a Cochran data. Um, what? One of the interesting studies here is this been dream study from 2012. It was the largest of these studies. That was a cellphone intervention. So there is a lot of promising research looking at em, health interventions to really support smoking cessation for people living with HIV. So in the absence of a lot of evidence, we are left trying our best with the evidence based approaches for the general population. Uh, and the National Cancer Institute and others have suggested a practical approach for clinicians to address smoking cessation with your patients, and many of you have probably heard of it. It's called the Five Days, Um so the first day stands for ask, and this means that clinicians really need to ask about tobacco use at every patient visit. This can be done systematically by the use of a patient reported question there that they might fill out while they're in the waiting room. Um, or it can be done just by asking them in the in the patient visit and then, of course, documenting it in the medical record. Uh, the second way is to advise, and this is really advising anyone who says that they are currently using tobacco to quit. Um, as clinicians, I think sometimes it can be hard for us to use simple language. But this is one space where it's critically important to speak in very simple, compelling language. A message such as besides taking your HIV medicines, quitting smoking is the most important thing you can do to protect your heart. Health is something that does resonate with patients. The third, a here is assess. This really refers to assessing the individuals readiness to quit if they happen to be smoking. Um, the fourth is to assist. And this looks different for every patient. Um, but really assisting all tobacco users with a quick plan. Uh, this could include, for some discussing nicotine replacement, referring others to a smoking cessation counselor or other groups to support, um, they're smoking cessation, and then the last day is really to arrange for follow up. So even if even if you're the only person assisting them or your team is the only group assisting them with their smoking cessation, really arranging follow up with them is critical to showing that this is important. That is a critical component of their health and that you're there as a team to support them in this journey. And truly it is a journey. Quitting smoking is hard, and it really is about taking it one day at a time and helping individuals to get through that day to celebrate the success and to have what they need to keep keep on that smoking cessation journey for the rest of their lives. When non pharmacological strategies don't work because they are not potent enough to overcome individual risk or because an individual has a hard time completing them. There are many evidence based pharmacological strategies to reducing cardiovascular risk in patients aging with HIV, and we'll talk about them both in this module and then in the next module as well. So let's start with, uh, with the Big One's status, right? Statins are cholesterol lowering medications, and they have been shown to lower bad cholesterol by up to 60%. This translates into an evidence based, um, decreased risk of myocardial infarction of stroke and have all cause mortality. Um, they do have some side effects, and we'll discuss those a little bit more in the next module. So who should get a statin? Well, um, certainly anybody with an LDL above 190 these were the American Heart Association guidelines for a couple of years ago. Anyone who has had a prior diagnosis of coronary artery disease, anybody who has diabetes and is between the ages of 40 and 75 and anyone who's calculated 10 year A s CVD risk is greater than or equal 7.5%. Then we'll talk about a lot more in detail about this in the next match, the other types of medications are high blood pressure medications, right? And I think, you know, in order to understand who should be on the high blood pressure medication, we have to understand the new blood pressure guidelines, and these were revised a couple of years ago, so some of these numbers might look a little bit different than what you trained with. But the guidelines were revised based on existing evidence that showed that, in fact, a normal blood pressure is less than 120 millimeters of mercury systolic and less than 80 diastolic, uh, individuals start to have elevated blood pressure 100 and 20 and the systolic less than 80 stage one hypertension starts at 100 and 30 to 139 systolic, or a diastolic of 80 to 89. And then stage two. High blood pressure is really 100 and 40 systolic or higher or a diastolic of 90 or higher. Um, I'll just also note the hypertensive crisis would be anything between 180 higher than 180 or higher than 120 systolic, and that that is an emergency when individual has to see a doctor or often emergency seek out emergency treatment right away. So who should we treat or and how should we treat them for high blood pressure? Well, for someone who has a normal blood pressure, really, it's about just promoting those optimal lifestyle habits we just reviewed and then really reassessing their blood pressure risk in about a year, if not more frequently. Um, for individuals who have an elevated blood pressure. So that is a blood pressure systolic between 1 21 29 a diastolic less than 80. Uh, certainly maximizing non pharmacological lifestyle approaches is critical, but because they're elevated, they need to be reassessed more frequently. So this could be between three and six months, as opposed to one year when the individual's blood pressure has been shown to be above 130 they're in stage one hypertension. There, a little bit more information is necessary to help derive appropriate treatment plan. So and we'll talk a little bit more about the clinical a s CVD risk estimator. But if this is this is a estimator of 10 year A S C. D events. If an individual is in stage one hypertension and has a 10 year A s CVD risk of greater than 10%. Um, certainly they should be on both non pharmacological therapy, really maximizing those lifestyle strategy as much as possible. Then it's also really worth having a discussion with the patients about adding a blood pressure lowering medication. Um, this is a is a category of individuals who would likely benefit from having medication as well, and certainly if they're in Stage two high blood pressure. Um, both blood pressure medications and non pharmacological therapy are something that really should be emphasized as a way to reduce that risk with this, uh, there are a lot of key pearls to educate both patients and their caregivers and families on um first, even though an important part a cornerstone of aging well with HIV is to have a suppressed HIV viral load. Aging well with HIV is more than just having a suppressed HIV viral load. Helping patients to understand their own unique increased risk due to their HIV disease as well as their personal or family history can often be a nice way of initiating these conversations about their increased risk for example, I often hear that individuals have their mother was sick with heart disease or their father died of a stroke. Patients talk about that. That's a great way of saying of also starting a conversation about you know, that's that's important because not only do you have an increased risk due to your family history, but you also have an increased risk for cardiovascular disease because of your HIV. And use that as a conversation to start to emphasize, um, some of the potential lifestyle and pharmacological options that they have additionally, and this is true for anyone caring for patients living with HIV throughout the lifespan. Um, really emphasizing the importance of heart healthy habits right from the beginning, Right? If you're if you see patients who are diagnosed with HIV at 21 years old, start emphasizing smoking cessation, healthy eating, physical activity, healthy weight, um, so that they can maintain those behaviors throughout the lifespan because we do know there's very good evidence that shows maintaining these behaviors throughout the lifespan can reduce the need for pharmacological treatments later on in life. Also for those higher risk patients. So for those over the age of 40 with high blood pressure or they're currently smoking, help the patient to make up a cardiovascular health plan of action with them, and this can be a list of strategy that they want to try. You can help them have the resources or access that, um, consultants or the referrals that they may need to follow this plan of action and then follow up with them, throw in the medical record and then follow up on it with them regularly. That follow up is key to really helping them understand how important to these actions are to maintaining their overall health. And lastly, and this is a message that you know, in our work we we've seen again and again as being critical. Really, adherence to medication is just as important for cardiovascular medications as it is for one's HIV medications. So if someone is taking, um, a high blood pressure medication or a statin medication, emphasizing to that individual that we may not have like a viral load like metric with which to evaluate how successful these medications are. But adherence to them is just as important for your health as it is for your HIV medications, so I wanted to give you guys a few great patient education resources we use. They also can be wonderful for providers to use, especially if you're new to kind of understanding cardiovascular resources. Um, so the American Heart Association has a website called the heart dot org, and it has so much information that is highly accessible to patients. This includes things like recipes, patient testimonials. They have YouTube channels both for heart disease and stroke, and all kinds of different conditions that individuals might be your patients might be dealing with. So using those and taking a look at those and helping patients to navigate those can be really useful sources because they are really developed to be at the patient level. Additionally, the Centers for Disease Control and Prevention have great education. Uh, this is CDC dot gov backslash heart disease going there and just getting some information for patients. If you're noticing that they have, for example, increasing blood pressure levels can be helpful for helping them to understand what they can do to reduce that blood pressure. Uh, and then also the new campaign. The new Million Hearts 2020 campaign has some great, um, great information about how patients can can take better care of their heart health. In addition to this more general information, I would say one of the things that we don't always think about in HIV clinics is really helping our patients understand symptoms of a cardiovascular event. And much of this talk has been about prevention. But what? We're hoping to prevent our heart attacks and strokes. Um, so we know that individual experiences symptoms of a heart attack or stroke. The single best thing they can do is to get help immediately. But patients don't always understand what those symptoms are. So really helping patients to understand these symptoms and how they might vary both by sex and age is critical. So just I'll review some of the symptoms of a heart attack with you just so you can take that back to your patients. Um, so for men, we tend to think of these as classic heart attack symptoms, right? Nausea and vomiting, um, jaw, neck or back pain, um, squeezing, squeezing, chest pressure or pain right here and all the chest and shortness of breath. But for women, these symptoms look different. It's important that women know that they might present with different symptoms and to still be attuned to those symptoms. So again includes the classic symptoms. Nausea, vomiting, John neck or upper back pain. Chest pain, but not always. Also pain or pressure in the lower chest or upper abdomen might present with women. Additionally, shortness of breath Women also sometimes present with symptoms of fainting, indigestion or extreme fatigue. The message should be if you're experiencing a new onset of any of these symptoms, to really call your health care provider immediately and seek immediate care. Stroke is a fate can be a fatal event. And again, really, time to treatment is critical in preventing some of the longer term morbidity and mortality associated with so strokes. So because patients living with HIV are at increased risk for strokes, reminding them that they were to experience or their their their family or loved one notices in them experiencing a face drooping and arm weakness or difficulty with speech. A new onset of any of those things should warrant to call right away, either to 911 or to your doctor. If it's during a time when you can get a hold of your doctor, but those are all emergency situations. Those are symptoms that patients need to be made aware of, particularly as they age with HIV. Um, and hopefully you can if these these resources are available on the American Heart Association and the American Stroke Association websites. When would you initiate conversations with your patient about increased cardiovascular disease in people living with HIV at their HIV intake visit? When they have an elevated lipid level when they mention a family history of cardiovascular disease, or BNC, the correct answer is D, meaning BNC. Patients who mention a family history or are presenting with an elevated lipid level have a documented risk factor for cardiovascular disease, which can be used as an opportunity to help the patient understand their risk and advise appropriate risk reduction strategies. So our third module is about assessing and managing cardiovascular disease in patients aging with HIV. And when I think about, um, cardiovascular assessment tools and primary care, I really think about two tiers of cardiovascular assessment tools. The first are tools that you probably all use in your routine practice right. This includes things like standardized vital signs, um, annual lipid levels and fasting hemoglobin a one c levels, and it also includes using these to generate the 10 year A S C B D event, uh, risk using using a standardized calculator. However, the next bucket of tools is slightly more invasive, and these typically require, um, some additional orders, right? And these include things like home blood pressure monitoring and coronary calcium scoring. Beyond this, things like you know, EKGs or echocardiograms or maximum stress stress, you may want to consider working either with a referring cardiologist or someone who specializes in these assessment tools. So let's start with those tier one assessment tools. So vital signs. And really, uh, the key here is to assess them correctly and obtain an accurate blood pressure every time the patient comes in. And if you've ever worked in a busy primary care clinic or any clinical setting, we all know that this is one of the hardest things to accomplish. Um, so when whether you're assessing or your training someone to assess blood pressure in your clinic, remember these seven tips right? Remind the patient not to talk, to empty their bladder first to make sure they're back, and they're feet are supported legs uncrossed arms are at the heart level cuff on the bare arm, and then maybe the most challenging part of all is to make sure that we use the correct blood pressure cuff size. I will say the other important thing to make sure of is when assessing glucose and hemoglobin, a one C is to ensure that they are drawn when the patient is fasting. Um, if you are, if you're seeing the last patient of the day and you're asking to draw a fasting glucose at 4 p.m. It might be worth they might not be fasting. Um, so it might be worth the extra trip to the to the clinic or to the lab to have an accurate lab draw. So some of the Tier two assessment tools the first one is home blood pressure monitoring. And there is an increasing amount of evidence supporting the use of home blood pressure monitoring for patients. Um, but the indications for home blood pressure monitoring are for, um, all those patients who are receiving antihypertensive medications, too. Uh, either uncover white coat hypertension or to evaluate masked hypertension. Many of us have heard of white coat hypertension when someone's blood pressure comes up when they come into the clinical setting because they're anxious or nervous. Um, but maths, hypertension, uh, you may not be as familiar with, and this is really when a patient has a normal blood pressure in the office, but it's elevated when they get home, so their normal baseline at home really is an elevated blood pressure. Um, we do know that this masked hypertension is associated with an increased risk of cardiovascular events, and it's similar to that uncontrolled hypertension. Um, so really, if you if you suspect the patient does have, uh, this masked hypertension to really try to work with them to get a home blood pressure monitor to help uncover that The second assessment tool I mentioned here is coronary calcium scoring, and this is really most helpful and risk stratify ng and determining the need for pharmacological therapy in patients who are aging with HIV, especially those who are ages 40 to 75. And you have a family history of a cardiovascular disease event. If you do order this, um, and you can see um, and you get a result. Generally, coronary calcium score less than 100 is really no or low risk. Um, something between for a score between 401 and 400 is moderate. Risk in a score greater than 400 really is high risk for an A F C B D event, Um, and that usually would indicate starting a patient on therapy. So if a patient does most, much of this has been about prevention. But if the patient does present with cardiovascular disease or at risk for cardiovascular disease in the HIV clinical setting, there really are three major strategies for helping these patients. The first is those prevention strategies we've been talking about, plus medication. The second is really targeted. They come in with hypertension, stage one or two hypertension to really target that blood pressure with antihypertensive medications. And the third is to target high cholesterol with statin medications or, if they need to some of the more advanced, newer medications. So I'll just briefly remind you of these lifestyle prevention strategies that we've discussed them at length and the second module, so I won't go into too much more detail here. But certainly, physical activity in consuming a healthy diet can lead to losing and maintaining a healthy weight. Um, these strategies can be used, and they should be considered first line strategies to reduce cholesterol blood pressure, both of which contribute to significant cardiovascular morbidity in patients living with HIV. As I mentioned, these were discussed in detail earlier. So now let's turn to some additional strategies in detail to consider when managing blood pressure and cholesterol in patients aging with HIV when we turn to the slide. Um, so this slide, uh, illustrated the different blood pressure categories. We said that anything less than 120 over 80 was considered normal. Um, but some of the newer evidence shows that individuals who have a blood pressure between 121 29 systolic the diastolic still less than 80 is elevated. There's a little bit higher risk with those patients, Um, so a little bit more frequent assessment is warmed. Stage one hypertension starts with a systolic between 131 139 in a diastolic between 80 and 89 then stage two is 140 over 90 or higher. So how do we treat these patients? Um, as we mentioned. We treat folks with normal blood pressure by optimizing lifestyle habits and reassessing in about a year. Those with elevated blood pressure certainly need to maximize again those non pharmacological options and then reassess a little bit more frequently. 3 to 6 months, um, those with stage one hypertension and have a A s CVD risk score greater than 10% should start to be considered for therapy. Uh, pharmacological therapy and really helping the patient to understand that risk and have some of those discussions about the risks and benefits of starting therapy are important at this. At this stage, if a patient has has progressed or has presented with Stage two hypertension, really, they need to adopt both non pharmacological and pharmacological strategies to really reduce this blood pressure, because this is a blood pressure that places them at really high risk for a cardiovascular event. So because we're talking about patients aging with HIV, one of the key considerations here is poly pharmacy and drug drug interactions and anti hypertensive medications. Um, there's a lot of different categories, and they're listed here. Um, but thankfully, these IEDs in Al das Cerone do not seem to have any significant interactions with antiretroviral therapy, however, UM, ace inhibitors, calcium channel blockers and beta blockers. Some of the medications in these categories do interact with some of the HIV medications, so really working either with the pharmacist in your clinic online or consulting pharmacists over the phone to understand what some of those potential interactions are when determining which medication might be appropriate given, given the patient's blood pressure is critical to really maintaining their health and well being. The next group of medications that we sometimes think about and managing cardiovascular risk in these patients is, uh, anti cholesterol medications, and here are mostly talking about statins, and this is a very busy slide, but these are the updated cholesterol guidelines, so I wanted to give you all of them. But because the focus of our C and the event today really is patients aging with HIV, we're really going to focus on on just this group of patients who are between the ages of 40 and 75 and what to know here about these patients. If individuals do present with an LDL greater than 70 but less than 90 they should be risk stratified using the A s DVD risks for But please note that in these new guidelines, HIV was considered an A s CVD risk enhancer. So, really, if they really should start with someone being a borderline risk in these in this age group and really helping them to at least start with lifestyle modifications, if they have this cholesterol, the cholesterol levels and then consider medication anything higher than that really is a risk discussion about medications, statins and really trying to reduce the LDL by 30 to 49% if they do have an A s CVD risk for greater than 20% the risk discussion really is about reducing their LDL to at least 50% what it normally is or what it was it baseline. Uh, so those were patients who had LDL less than 1 90. If they happen to have an LDL greater than 190 a few additional risk assessment is not needed. They should start on a Staten right away if if they're willing to do so, uh, and then really having the same will be true of diabetes and those between the ages of 40 and 75 because this group does tend to be at higher risk. Now if you do care for patients over the age of 75. Um, this is this is a group where there's not as much data as we need. So really doing a clinical assessment, having a discussion with them about their own cares of goal and what matters to them at the stage and their treatment is important and really tailoring that discussion and then those treatments. Recommendations based off of that discussion, just like with the antihypertensive statins, do have the potential for drug drug interactions. Um particularly, um, individuals who might be taking protease inhibitors, especially those that are boosted with ritonavir or Kobe CitiStat, will have increased levels in the blood. So being aware that some of the medications are contraindicated with these protease inhibitors, there are groups of Medicaid statins that are much more appropriate and are at much lower risk for interaction compared us on those higher risk. Now, when we talk about status, one of the things patients will often tell us in our focus groups is, you know, they've you know, their cousin told them that status caused X, Y, or Z, and So there is an evidence base, a growing evidence based around the side effects associated with statins. Um, and I think given it's important to emphasize that if someone's at risk for an A S c B D event and they have high cholesterol status, first and foremost have been shown to improve mortality in patients taking them. So, um, there is a clear benefit to taking these medications for patients who are at higher risk with the side effects are there is an evidence base and probably the number one side effect many of our patients talk about are really, um, muscle symptoms. So this is often nostalgia's, which tend to present a lot more frequently, usually when someone is started during that initiation period of the new medication. But they also can include things more severe, like grabbed a dialysis. So this is why again, when starting a patient on the statin is important to check for potential drug drug interactions and a check, um uh, their c K. To make sure that if they do present with a, uh with a symptom that it can be addressed in a timely way. There is also a literature around UM, stands being associated with new onset diabetes. This tends to be predominantly in patients who already presents with symptoms for diabetes or risk factors for diabetes, including a higher B M. I elevated fasting blood glucose, those with metabolic syndrome in those with elevated hemoglobin. Anyone sees a liver injury has been described. Um, it's rare, but it's possible. And so it really, um, checking liver function prior to starting a patient on Staten and then, you know, after the initiation period to make sure that their liver functioning is, um is not been impaired. And then sometimes patients will talk about statins affecting their memory or their cognition. And this is not a side effect that is supported by the literature right now. But it is often something that patients will be concerned about. So having a conversation with them about what the literature says, it can help them to adhere to these medications. Just a few kind of minor statin notes, because I do know that there is a lot of um, yeah, let's say here say about statins are a lot of rumors about status from that you will often hear from patients. Uh, so statins um, typically are recommended at night, but that's not always necessary. Um, patients can certainly take it in the morning. It helps them with it here. And so there are some medications that are kind of longer acting, um, statins. That might be more appropriate if they want to take them out in the morning. And it helps them out here. By all means, they should do so. Um, you know, statins may interact with supplements or vitamins, and I think what's important here to remember is really conducting. A thorough assessment of all medications and supplements is necessary. Patients don't always. We ask them to reconcile their medications at the beginning of the visit. They don't always recognize that supplements and vitamins should be part of that. So really prompting them with. Are you taking any additional supplements? Are you taking any medications? Anything else over the counter I should I should know about this is important. It will help us to make sure that there's no potential interactions or adverse events. Uh, and lastly, um uh, simvastatin is a longer acting statin, and there is some support for doing, um, giving the statin every other day or once a week and patients who might not be able to tolerate it otherwise, Um, if you're going to adopt this strategy of the patients suggests a strategy. I think working closely with the pharmacist to make sure kind of maximizing the effect of the statin while helping the patient to adhere to whatever the regimen is, uh would probably be most helpful. And I did. This is a very busy, sly and much of it we've already talked about already. What I what I mostly wanted you all to recognize or to know was that last year in 2019, the American Heart Association did publish a pragmatic approach to assessing and treating A S CVD risk specifically and people living with HIV. Um, Dr Matt Feinstein and his team reviewed the all of the evidence. Uh, and they did create this algorithm. That's really a pragmatic approach, covering much of what we've already said, with an emphasis on lifestyle optimization, um, lipid lowering medications and then blood pressure medications. I started this talk by saying, It's a really big topic, and I hope I hope I've convinced you of that and what this has led us to believe, really is the best cardiovascular care for people living with HIV really is adopting a team care approach. Um, this includes, um, you know, potentially referring the patient to a cardiologist if necessary. But one additional model that we've actually been testing and our lab here is the collaborative care model. So this model includes having a consulting pharmacist and a cardiologist who specialize in HIV who consult with the team as an even now. This is a model that has worked quite well in mental health care, specifically in managing depression in people living with HIV. So we're trying to adapt it now to a cardiovascular context. And also, um, uh, it is something that we are currently investigating as part of the n h L B I funded Preclude initiative. Um, it does require specialized knowledge, but I think especially given the last six months and the growth of telemedicine and some of the strong innovations that are happening in that space, I do think it's it's a viable method in the future, and one that is possibly quite scalable, particularly as patients with HIV are living longer and their need for specialized cardiovascular treatment could become could increase my summary slide of kind of the general prevention, monitoring and treatment strategies. We started by saying people living with HIV are in fact, at 1.5 22 fold greater risk for developing cardiovascular disease compared to those who are not living with HIV in the modern a r T R. And that may diminish as we get better and better therapies, and we start patients earlier and earlier on medications. But right now the risk is elevated at 1.5 to 2 fold. Greater risk. We've talked about reduce ways to prevent it by reducing hypertension, reducing high cholesterol, reducing blood sugar, reducing weight, certainly helping patients to quit smoking, and then also to prevent cardiovascular disease by increasing physical activity and consuming a healthier diet. There are a number of monitoring and assessment strategies that we've discussed, including blood pressure monitoring um, routine weight and waist circumference assessments, as well as annual smoking assessments, checking fasting, lipid and glucose levels. Using this information to calculate the A s CVD risk score for patients who are over the age of 40 potentially assessing exercise as a vital sign at each visit. And then we talked about some more advanced monitoring strategies, including coronary calcium scoring and cardiovascular fitness testing. How often should you check lipid levels in a 40 year old person living with HIV twice a year at every patient visit? Whenever the patient is fasting once a year, the correct answer is D. Once a year, fasting lipid levels should be assessed once a year in persons living with HIV. If a patient is starting on a lipid lowering medication, it can be assessed more frequently to gauge the patient's response to the new therapy. But in general, once a year is sufficient. So thank you for attending the see any event today? Um, in summary. I just like to say, You know, we talked a lot about how aging well with HIV means, among other things, improving cardiovascular health in those patients. Um, but to accomplish this, we will have to adopt help our patients to adopt a combination of strategies including non pharmacological and pharmacological strategies in clinic and home based interventions. We believe that team based cardiovascular care may help to improve these outcomes in patients, and we also believe that a strength based approach to really developing a cohesive cardiovascular health message at the HIV clinic is both possible and will help to improve the quality of life and the growing population of adults aging with HIV. Thank you. And now it's my pleasure to introduce Ronald Johnson to help us better understand what it is like for a patient to live in a judge. Well with HIV and cardiovascular disease. After a career spanning over 40 years, Ronald S. Johnson retired at the end of 2017. As the vice president of policy and advocacy at AIDS United, he continues to consult with AIDS United as a senior policy fellow. Johnson spent the latter half of his career responding to the HIV epidemic, starting in 1984 as a volunteer with the Gay Men's Health Crisis in New York City. His career includes serving as New York City's first citywide coordinator for AIDS policy, associate executive director, director for policy at the Gay Men's Health Crisis. In directing the policy activities of AIDS Action, which merged with the National AIDS Fund in 2011 to become AIDS united, Johnson has served on numerous boards of directors of non profit agencies and was a member of the president's advisory Council on HIV and AIDS from 1996 to 2000 and one. He currently serves as the chair of the steering committee for the U. S. People living with HIV Caucus and his treasurer for the National Black Gaiman's advocacy coalition. Johnson also serves as the board president of Point Source Youth, which is focused on ending youth homelessness, especially among LGBT. Q. Ronald, thank you so much for speaking with us today about your experiences. Thank you very much for inviting me. It's a pleasure. Thank you. Would you would you mind starting by just telling us a little bit about how you learned that you were at risk for cardiovascular disease? Well, pretty much for my entire adult life. I've known I was at risk for cardiovascular disease because of my family history. My mother had bypass surgery, a heart surgery and my father and just about all of his brothers and sisters my aunts and uncles died as a result of heart disease or cardiovascular disease. In my father's case, it was an aneurysm, so the risk the fear of hot issues was a constant even before well before my HIV diagnosis, Uh, and in my case. My I was diagnosed pretty much in my, uh, early adult life maybe in my twenties and thirties with high blood pressure, and that's been a chronic and continues to be a chronic, uh, issue for me and taking medications for high blood pressure. So the fact of cardiovascular disease are preceded my HIV diagnosis. And when I was diagnosed, uh, and the attention obviously shifted to HIV and about two or three years, uh, into my care and HIV care. My doctor just noticed or going through my records that she hadn't taken and e k g in about two or three years, and she laughed and said, Wouldn't it be funny if I took care of your HIV? But then you died of heart disease? I didn't see the humor in that, uh, but it did signal for both my doctor and me that we also need to pay attention to the CVD issues. And I think that's a common experience because it's so for so many folks, especially those who are diagnosed in the early days of HIV, it has been the primary focus of their health care for so long. So we do hear from a lot of patients that shifting to that focus to chronic comorbidities like cardiovascular disease is it's actually sometimes harder for the providers. It is for the patients to think about it, because for patients like you who have lived with this awareness all their life, it makes a lot more sense. In the first years of my being diagnosed, heart disease and HIV were separate issues. I mean, I saw them as separate issues. Uh, it wasn't until the past, uh, maybe 10 years or five or 10 years that the relationship or possible relationship between, uh the C V cardiovascular issues and the HIV and the aging issues became more prominent. As I said previously, I treated them as completely separate issues. Yeah, thank you so much round. Can you seem to have such a acute awareness about your own risk for cardiovascular disease? Can you? Can you tell us about your experience? Is trying to reduce this risk using either non pharmacological or pharmacological approaches? Well, yes, uh, and I, through both coaches, I am under Medicaid. I have medications for my blood pressure. I also was diagnosed with peripheral arterial artery disease, so I'm taking medications for that also. But certainly I really have been cognizant of the non medical, non pharmacological issues I try to exercise. Uh, covid has, I think, as this has, many people, uh, interfered with the exercise regimen that I had been used to. So it's still even after this many months. I'm still trying to get into a a physical exercise routine, uh, to help me, my diet is a constant struggle. Uh, I No. All of the risks associated with high blood pressure and salt. And yet my craving for salt is also a lifetime, uh, issue, Uh, and it's, uh that is a daily continues to be a daily struggle for me in terms of my salt trying to control my salt intake and as well as my craving for sweets. Uh, a bowl of ice cream is a bowl of ice cream, a bag of potato chips as a bag of potato chips. So I struggled with that, Uh, this past week was my earlier, uh, my husband's birthday, So I took that as a perfect reason to get some night ice cream to celebrate. Uh, so those are issues that I know are important to me and important to helping me control my cardiovascular issues. But I also know that it's a struggle. It's, you know, it's a struggle because we can't We can't live just for our disease or to mitigate our health risk. We have to think about the larger quality of life issues, and I think your story really illustrates that nicely. Thank you for sharing all of that. I think you also really illustrated just how complex it can be for patients to enact so many of the recommendations that we talked about during this presentation. And I was wondering, um, can you tell us what you've learned from your healthcare providers or others that you've worked with about how to best navigate the many different types of doctors and health care providers that helped to keep you in such great shape over these last few decades? Thank you for that question, because that is a really a challenge. I know for myself, and I know from listening and talking to other people a lot, I realized that I've been watching it in both. When I was living in New York, my original, uh, primary care doctor who also, uh, was my took care of my HIV care. She was very knowledgeable and and and very good in helping me deal with that. And again, once she realized she forgot the e k g. So we got back on a track like that. And when I moved to Washington, um, I was again fortunate to find a physician, a primary care physician who was very knowledgeable about HIV, uh, most HIV specialist in many ways, but also monitored my health care. By that time, I was under, uh, medication for blood pressure. So I entered into his care with that as a known factor. So he has, uh, scheduled me for stress echo stress exams, uh, and then growing when I had to go to see a cardio that, uh, cardiologist, uh, staying on top of that. But managing the cardiology cardio cardiologist visit, uh, my primary care. Uh, it's an issue, and it's a problem. I have worked with my cardiologist so that my stress exams are around the time of my birthday. So that helps me remember, uh, that it's my birthday. It's time for my, uh, stress echo stress exam. Uh, but, uh, and and then when I was also diagnosed with P a. D the perfect peripheral artery disease. Fortunately, the same cardiologist, So that care is combined, but it is a sort of a management issue of dealing with with all those those. My primary care doctor is also very much on top of my cholesterol levels. So I am taking medication to control my cholesterol also, uh, so the poly pharmacy issues related to that care are challenging. And again, my doctor and my primary care doctor was very aware of that. And when I see a special specialist outside of the primary care, I always tell him what medications My primary. I tell my primary care doctor what medications have been prescribed before I take them. So to get his clearance to make sure that, uh, there's nothing, uh, no issues. So I don't just depend upon the HIV knowledge of the specialists, the non HIV specialist I checked back with my doctor to make sure there are no problems with any medications that have been prescribed outside of my HIV care. Mr. Johnson, thank you so much for sharing that, and I think I have to say, I love how you describe taking care of your heart health around the time of your birthday. I think that's a really great way of thinking about how we can live Well as we get older and something I'm definitely going to share with our patients in the coming years, I just want to say the other thing that really struck me by what you were saying is you really are what we call this this very active self manager of all your chronic diseases. And I just want to commend you for, you know, taking taking that on and kind of working both with your specialist and your HIV primary care doctor to make sure you're getting what you need to age. Well, in conclusion, I just want to ask if there's anything that you would recommend that patients living with HIV who may either be diagnosed with cardiovascular disease for the first time or are concerned about their risk for her developing cardiovascular disease. Since we're now starting to realize that HIV is one of the risk factors for developing severe cardiovascular disease, well, I think it's my advice and I think it's some of it is just plain common sense and but also to make sure that you're in conversation with your primary care doctor. About all of the the risk of cardiovascular, uh, disease. And don't wait. I mean, bring them up. Uh, just make sure that your heart health and your circulatory health is a part of the discussions. Uh, even if they have not been an issue in the past, particularly for those of us who are older, we need to make sure that we're on top of that. Uh, and also, um, if there are issues that arise, Uh, and if you need to see a specialist, make sure that the the specialist is aware of your HIV, uh, conditions, uh, don't rely on Don't assume that they are knowledgeable. Uh, they hopefully they are. They should be, But make sure they know your issues and including your HIV issues. And then, uh, and again, speaking from a person from the point of view of a person who knows the challenges of dieting and exercise and the importance of it, But to be mindful of the impact and the relationship between your level of exercise and your diet are on your health and heart health, Uh, and that you have control you. You have power to, uh, to help maintain your health and wellbeing, and particularly in terms of cardiovascular issues. There are so many issues that are are completely in your control and you should be aware of them and take advantage of them. I've never smoked, but certainly are realizing that smoking is it is an issue or your alcohol consumption. And all of these things are also issues you should feel empowered to talk to your physician about. Don't don't wait for your doctor to bring them up. You should bring them up. And you should make sure that your care includes all of those issues that might impact or might impact your HIV care or that HIV might impact your heart and other, uh, cardio related issues. So, uh, be and feel that you are empowered, Uh, and when you need help, seek help. And because I know the issues of managing all of this are not easy, but they can be done and there's a there's growing help, so don't be afraid to seek help. Uh, don't be afraid to bring up issues with your doctor. You think of no better way of ending this. We've been speaking with Ronald Johnson. Ronald, thank you so much for your time today. Thank you. I hope this presentation and the discussion between Alison and Ronald was helpful in understanding some of the complexities of managing cardiovascular disease and people aging with HIV. The most important messages, of course, prevention, regardless of age or severity of disease coordination and communication between the patient subspecialty visits and primary care is critical for optimal patient outcomes. It was so well managed in Ronald's experience, but often requires the assistance of nurse care coordination for others, understanding medications for hypertension and cholesterol, including working with the pharmacist to track and manage the full range of all of the patients. Medications is important and to also synchronize the timing and avoid drug drug interactions so critical with statins and anti retrovirals. Working with patients on risk reduction, including diet, exercise and smoking, cessation or even reduction, is likely to be more successful within the context of a trusting relationship and an understanding of the patient's goals, capabilities and lifestyles, and an approach that is the definition of nurse care coordination. We hope you join us for other parts of this HIV and aging program. Thank you
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