HIV感染者之降血脂藥物使用與血脂目標達成情形

Abstract

隨著抗反轉錄病毒治療的進步，HIV感染者之預期壽命顯著延長，心血管疾病已成為其重要的相關共病之一。研究顯示，HIV感染者相較於未感染者，其心肌梗塞風險約增加50%。近年的大型臨床試驗也證實，於心血管風險屬低至中度之HIV感染者中，使用pitavastatin降血脂藥物可顯著降低重大心血管事件發生率。然而，在台灣HIV感染者族群中，降血脂藥物之使用率仍偏低，僅約39%，且血脂治療目標達成情形相關資料有限。因此，本研究旨在評估台灣HIV感染者之心血管風險分布，降血脂治療使用率，以及低密度脂蛋白膽固醇（LDL-C）目標達成情形。 本研究為橫斷式研究，於亞東紀念醫院進行，納入2023年7月1日至12月31日之間，年齡大於或等於40歲且持續接受HIV照護之HIV感染者。蒐集資料包括人口學特徵、動脈粥樣硬化性心血管疾病（ASCVD）風險評分、代謝症候群、心血管疾病或慢性腎臟病病史、血脂數值，以及 HIV 相關指標（CD4 細胞數與病毒量）。依 ASCVD風險分級與2022年台灣血脂治療指引進行風險分類，並分析不同風險族群之statin使用率與低密度脂蛋白膽固醇（LDL-C）目標達成率，並且以邏輯斯迴歸分析方式，分析低密度脂蛋白膽固醇（LDL-C）達標之相關因子。 本研究共納入600位HIV感染者，年齡中位數為46歲，其中男性占93.2%，90.7%的個案達到HIV抑制狀態。然而，整體statin使用率僅有23.2%，若依據ASCVD風險分級，低風險、邊緣風險、中度風險以及高風險族群當中，有處方statin的比例分別為20.8%、25.9%、31.4%以及28.6%；依據2022年台灣血脂初級預防指引的分類方式，「零個風險因子」、「一個風險因子」、「兩個以上的風險因子」族群以及高風險族群，有處方statin的比例分別為8.7%、16.3%、27%以及52.6%。顯示不論是使用ASCVD風險分級，或是使用2022年台灣血脂初級預防指引的分類方式，都發現到隨著心血管風險等級上升，statin 使用率呈現顯著增加趨勢。 依據2022年台灣血脂初級預防指引，根據不同風險分級建議的LDL-C標準，在600名個案中，109名個案（18.2%）未達到LDL標準，474名個案（79%）達到LDL標準，17名個案（2.8%）無LDL-C數值故無法評估。在139名有使用statin的個案中，114名個案（82%）有達到LDL-C標準。依據風險高低以及是否有使用statin進行分析，在沒有風險因子的族群，不論有無使用statin，LDL-C達標比率皆為100%，相較下，在高風險族群中有使用statin的LDL-C達標比率僅為72.4%，沒有使用statin的LDL-C達標比率則為54.2%。進一步分析顯示，「兩個以上風險因子」與「高風險」兩組其LDL-C達標率顯著低於其他低風險組別。整體而言，未達到LDL標準的109名個案當中，有82.6%屬於「兩個以上風險因子」或者高風險族群。此結果顯示，在高風險族群中，降血脂治療與治療目標達成仍有明顯不足。 在多變項分析中，依據年齡、性別、吸菸、糖尿病、高血壓及HIV抑制狀態進行調整後，使用statin與LDL-C目標達成呈顯著正相關（adjusted OR 1.81，95% CI 1.05–3.24，p = 0.038）。相較於未吸菸者，吸菸者達到LDL-C目標之勝算顯著較低（adjusted OR 0.59，95% CI 0.38–0.91，p = 0.018）；此外，合併糖尿病者之LDL-C目標達成勝算亦顯著降低（adjusted OR 0.32，95% CI 0.16–0.64，p = 0.001）。因本研究採用橫斷面研究設計，其結果僅能解釋為相關而非因果。另外，糖尿病個案會被歸類在高風險族群，LDL-C目標較為嚴格，亦可能影響達標率。然而，吸菸與糖尿病皆為重要的心血管風險因子，對於患有糖尿病或者有吸菸的HIV感染者，更應加強心血管風險衛教與管理，適當給予降血脂藥物，並積極追蹤血脂達標情形。 台灣40歲以上HIV感染者之statin使用率仍不理想，約為23.2%，雖然statin使用率隨著心血管風險分級上升而呈現增加趨勢，但高心血管風險族群之LDL-C目標達成率最低，且LDL-C未達治療目標與吸菸行為及糖尿病相關。未來應加強以風險分級為基礎之血脂管理策略，用以降低HIV感染者發生心血管疾病之風險。

Background: With advances in antiretroviral therapy, the life expectancy of people with human immunodeficiency virus (HIV) has markedly improved, and cardiovascular disease has emerged as a major comorbidity in this population. Previous studies have shown that people with HIV have an approximately 50% higher risk of myocardial infarction compared with those without HIV. Recent large-scale clinical trials have further demonstrated that lipid-lowering therapy with pitavastatin significantly reduces major adverse cardiovascular events among people with HIV at low to moderate cardiovascular risk. However, in Taiwan, the utilization of lipid-lowering therapy among people with HIV remains suboptimal (39%), and data regarding lipid target attainment are limited. This study aimed to evaluate cardiovascular risk distribution, statin utilization, and low-density lipoprotein cholesterol (LDL-C) target attainment among people with HIV in Taiwan. Methods: This cross-sectional study was conducted at Far Eastern Memorial Hospital and included people with HIV aged ≥40 years who were continuously receiving HIV care between July 1 and December 31, 2023. Collected data included demographic characteristics, atherosclerotic cardiovascular disease (ASCVD) risk scores, metabolic syndrome, history of cardiovascular disease or chronic kidney disease, lipid profiles, and HIV-related parameters (CD4 cell count and viral load). Cardiovascular risk was classified according to ASCVD risk categories and the 2022 Taiwan lipid management guidelines. Statin utilization and LDL-C target attainment were analyzed across different risk groups, and multivariable logistic regression was performed to identify factors associated with LDL-C target attainment. Results: A total of 600 people living with HIV were included in this study. The median age was 46 years, and 93.2% of the participants were male. Overall, 90.7% of the cohort achieved virologic suppression. However, the overall statin utilization rate was low, at only 23.2%. When stratified by ASCVD risk categories, the proportions of patients receiving statin therapy were 20.8% in the low-risk group, 25.9% in the borderline-risk group, 31.4% in the intermediate-risk group, and 28.6% in the high-risk group. According to the 2022 Taiwan lipid guidelines for primary prevention, statin use was observed in 8.7% of patients with zero risk factors, 16.3% with one risk factor, 27.0% with two or more risk factors, and 52.6% of those classified as high risk. Regardless of whether ASCVD risk stratification or the 2022 Taiwan primary prevention guideline was applied, statin use increased significantly with higher cardiovascular risk categories. Based on the LDL-C targets recommended by the 2022 Taiwan lipid guidelines for primary prevention, 109 patients (18.2%) did not achieve their LDL-C targets, 474 patients (79.0%) achieved target levels, and 17 patients (2.8%) lacked available LDL-C data and were therefore not evaluable. Among the 139 patients receiving statin therapy, 114 (82.0%) achieved their LDL-C targets. When further stratified by cardiovascular risk and statin use, LDL-C target attainment was 100% in patients without risk factors, regardless of statin use. In contrast, among high-risk patients, LDL-C target attainment was 72.4% in those receiving statins and only 54.2% in those not receiving statins. Patients with two or more risk factors and those classified as high risk had significantly lower LDL-C target attainment rates compared with lower-risk groups. Overall, 82.6% of patients who failed to achieve LDL-C targets belonged to either the “two or more risk factors” group or the high-risk group. These findings indicate substantial gaps in lipid-lowering treatment and goal attainment among high-risk individuals. In multivariable analysis adjusting for age, sex, smoking status, diabetes mellitus, hypertension, and HIV virologic suppression, statin use was independently associated with LDL-C target attainment (adjusted odds ratio [aOR] 1.81, 95% confidence interval [CI] 1.05–3.24, p = 0.038). Compared with non-smokers, smokers had significantly lower odds of achieving LDL-C targets (aOR 0.59, 95% CI 0.38–0.91, p = 0.018). In addition, patients with diabetes mellitus also had lower odds of achieving LDL-C targets (aOR 0.32, 95% CI 0.16–0.64, p = 0.001). Because of the cross-sectional design, the findings can only be interpreted as associations rather than causal relationships. In addition, individuals with diabetes were classified as high risk group, with more stringent LDL-C targets, which may have influenced the rate of target attainment. Nevertheless, given that smoking and diabetes are well-established cardiovascular risk factors, people with HIV who have diabetes or smoking behaviors warrant intensified cardiovascular risk education and management including lipid-lowering therapy and closely monitoring of LDL-C target attainment. Conclusions: Statin use among people with HIV aged 40 years and older in Taiwan remains suboptimal at approximately 23.2%. Although statin utilization increased with higher cardiovascular risk categories, LDL-C target attainment was lowest among high-risk patients, and failure to achieve LDL-C targets was associated with smoking and diabetes mellitus. Risk-based lipid management strategies should be further strengthened to reduce cardiovascular disease risk in people with HIV.