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Table 1 Take home messages

From: Statins and aspirin in the prevention of cardiovascular disease among HIV-positive patients between controversies and unmet needs: review of the literature and suggestions for a friendly use

(a) Statins (1) Which guidelines to adopt between American and European ones?
ACC/AHA guidelines, being simple to use and cost effective, should be adopted in the management of PLWH and use of statins, when indicated, should be encouraged
(2) Which algorithm to adopt to estimate the CV risk of PLWH?
The current prediction models seem to underestimate the CV risk, However, the ACC/AHA PCE score seems to estimate more accurately the CV risk among PLWH. In addition ACC/AHA PCE is well validated, its calculation is simple, and evaluates also non-fatal events
(3) At what percentage of risk should we start a statin therapy?
We suggest to start statin therapy in all patients with a calculated 10-year risk of a cardiovascular event of 10% or greater. Considering the increase of pill burden, the treatment is optional if the calculated 10-year risk is between 7.5 and 10%
(4) Which statin to use?
In line with ACC/AHA guidelines, we suggest to chose the appropriate intensity of statin therapy to lower LDL-c by the requested percentage. When a statin is prescribed to PLWH the problem of drug–drug interactions must be attentively evaluated consulting the current guidelines for the use of antiretrovirals
(5) Should we use statins in patients with subclinical atherosclerosis?
We encourage the use of a high intensity statin (atorvastatin or rosuvastatin) in PLWH with a subclinical atherosclerosis
(b) Aspirin (1) Should we use aspirin in primary CV prevention?
The balance between cost and benefit should be attentively evaluated considering that there are no strong evidences of a benefit, and that the increasing of the pill burden could determine a decrease of the adherence to antiretroviral therapy. Moreover the risk of bleeding should be considered, especially in patients with liver disease and uncontrolled hypertension. Consequently the addition of aspirin should be reserved only to patients with ≥ 20% 10-year CVD risk that are particularly adherent to treatments, and with low risk of bleeding
(2) Should we use aspirin in secondary CV prevention?
Aspirin should be always used in secondary CV prevention, in association with a statin. The HIV physicians should strongly encourage the prescription and the adherence to these drugs. We suggest to start with a dose of 100 mg/day
(c) Antiplatelet agents or novel oral anticoagulants (1) How to manage the co-medication with antiplatelet agents or novel oral anticoagulants?
Potential drug interactions between antiretroviral therapy and these molecules have been demonstrated. Consequently, management of these drugs may include selecting antiretrovirals with a lower potential for drug interactions or choosing antiplatelet agents or novel oral anticoagulants least likely to interact with antiretrovirals