When to check for Human Immunodeficiency Virus (HIV) in patients with chronic systolic heart failure?

Reasons to Check HIV in Chronic Systolic Heart Failure

HIV screening is recommended in selected patients with chronic systolic heart failure, particularly those with high-risk factors for HIV infection, as HIV can directly cause cardiomyopathy. 1

Indications for HIV Testing in Heart Failure Patients

• HIV infection is recognized as a potential cause of cardiomyopathy and heart failure, and should be considered in the differential diagnosis of heart failure etiology 1
• HIV screening is specifically recommended as a Class IIa recommendation (reasonable to perform) in selected patients who present with heart failure 1
• HIV-associated cardiomyopathy can occur even before other clinical manifestations of HIV infection become apparent 1

Patient Selection for HIV Testing

Consider HIV testing in heart failure patients with:

• Risk factors for HIV infection 1
• Unexplained cardiomyopathy, especially in younger patients 1
• Dilated cardiomyopathy without other identified causes 1
• Diastolic dysfunction without traditional risk factors 2, 3
• Heart failure with preserved ejection fraction (HFpEF) without typical risk factors 4, 5

Pathophysiology of HIV-Related Heart Disease

• HIV infection itself can directly affect cardiac function, independent of antiretroviral therapy 2, 4
• HIV-infected patients demonstrate higher rates of diastolic dysfunction (43.38%) compared to the general population 6
• HIV infection is associated with chronic immune activation and systemic inflammation that may contribute to cardiomyopathy 4, 5
• The incidence of systolic dysfunction in HIV patients is approximately 8.33%, even in the era of highly active antiretroviral therapy 6

Clinical Considerations

• The phenotype of HIV-associated cardiomyopathy has evolved from overt left ventricular systolic dysfunction in the pre-antiretroviral era to a more insidious course with highly prevalent diastolic dysfunction in the current era 4, 5
• HIV patients have higher rates of heart failure following myocardial infarction compared to non-HIV patients 5
• The incidence of new-onset diastolic dysfunction in HIV patients has been reported at 8.2/100 person-years 3
• Early identification of HIV in heart failure patients allows for appropriate management of both conditions 1

Diagnostic Approach

• HIV testing should be included as part of the initial laboratory evaluation in selected heart failure patients, alongside other routine tests such as complete blood count, electrolytes, renal and liver function tests 1
• Echocardiography remains essential for assessing cardiac structure and function in all heart failure patients, including those with suspected HIV-associated cardiomyopathy 1
• Consider HIV testing particularly when other common causes of heart failure have been ruled out 1

Pitfalls and Caveats

• Most patients with HIV cardiomyopathy already have other clinical signs of HIV infection before heart failure symptoms develop, but exceptions exist 1
• Treatment of HIV-associated heart failure is largely extrapolated from non-HIV populations as specific clinical trials are lacking 4, 5
• The optimal approach to screening and managing HIV-associated cardiac dysfunction remains undefined and requires further research 4
• Diastolic dysfunction is highly prevalent in HIV patients and may represent an early marker of cardiac involvement 2, 3, 6