What is the treatment for HIV (Human Immunodeficiency Virus) myocarditis?

Treatment for HIV Myocarditis

The cornerstone of treatment for HIV myocarditis is immediate initiation of antiretroviral therapy (ART) combined with standard guideline-directed medical therapy for heart failure, while avoiding immunosuppression in most cases. 1

Primary Treatment Strategy

Antiretroviral Therapy (Essential)

• ART is the definitive treatment and should be initiated urgently, as it directly addresses the underlying HIV infection that drives myocardial inflammation and prevents progression to dilated cardiomyopathy. 1
• Untreated HIV myocarditis carries a grave prognosis with >50% mortality within 2-3 years, making ART initiation critical for survival. 1
• The American Heart Association explicitly states that "treatment of HIV with antiretroviral therapy is useful in prevention and treatment of DCM related to HIV." 1

Heart Failure Management (Concurrent)

• All patients with HIV myocarditis should receive standard guideline-directed medical and device therapies for systolic heart failure, including ACE inhibitors/ARBs, beta-blockers, aldosterone antagonists, and diuretics as indicated. 1
• This dual approach—treating both the underlying HIV infection and the cardiac manifestations—is essential for optimal outcomes. 1

Diagnostic Workup Before Treatment

Essential Testing

• Cardiac troponin levels should be obtained for diagnosis and risk stratification. 1
• 12-lead ECG is mandatory to assess for conduction abnormalities, particularly high-grade AV block or ventricular arrhythmias. 1
• Transthoracic echocardiography should be performed to evaluate ventricular function and exclude other causes of cardiomyopathy. 1

Advanced Diagnostic Considerations

• Endomyocardial biopsy (EMB) should be performed in patients requiring inotropic support or mechanical circulatory support, those with Mobitz type 2 or higher-degree heart block, sustained ventricular tachycardia, or failure to respond to standard therapy. 1
• EMB can distinguish between viral myocarditis, autoimmune myocarditis, and other etiologies, which has important therapeutic implications. 2
• Screen for coinfections and other potential causes including ischemic heart disease, substance abuse, and nutritional deficiencies. 1

Critical Treatment Caveat: Immunosuppression

When to AVOID Corticosteroids

• Corticosteroids are generally contraindicated in viral myocarditis, including HIV-associated myocarditis, as they can reactivate viral infections and lead to ongoing inflammation. 3
• The risk of increased inflammation and mortality makes routine immunosuppression dangerous in this population. 1

Exception: Biopsy-Proven Autoimmune Myocarditis

• If EMB demonstrates autoimmune (non-viral) myocarditis with HLA-DR overexpression and negative PCR for cardiotropic viruses, steroid therapy may be considered and can result in complete resolution. 2
• This represents a distinct subset requiring biopsy confirmation before immunosuppression is attempted. 2

Supportive and Advanced Therapies

Arrhythmia Management

• Acute arrhythmia management is primarily supportive, as arrhythmias often resolve with resolution of acute inflammation. 1
• For drug-refractory ventricular arrhythmias, endocardial and epicardial radiofrequency catheter ablation can be effective. 1

Advanced Heart Failure Support

• Mechanical circulatory support (MCS) may be required in patients developing cardiogenic shock despite optimal medical management. 1
• Some patients can be bridged to recovery with MCS, though the role of immunosuppression in this setting remains uncertain. 1
• Cardiac transplantation outcomes for HIV myocarditis are similar to other causes of cardiac failure in adults. 1

Pathophysiological Context

The myocardial involvement in HIV is multifactorial, involving direct HIV infection of myocardial cells, coinfection with other viruses, postviral autoimmunity, drug cardiotoxicity, nutritional deficiencies, and prolonged immunosuppression. 1 Autopsy studies show histological evidence of myocarditis in approximately 50% of patients who died of AIDS, with HIV nucleic acid sequences detected in cardiac tissue in about one-third of cases. 1

Common Pitfalls to Avoid

• Do not delay ART initiation while awaiting cardiac stabilization—early ART is protective and therapeutic. 1
• Do not empirically use corticosteroids without biopsy confirmation of autoimmune etiology, as this can worsen viral myocarditis. 3, 2
• Do not attribute all cardiac dysfunction to HIV alone—screen for ischemic disease, substance abuse (particularly cocaine and methamphetamine), and medication cardiotoxicity. 1
• Do not overlook immune reconstitution inflammatory syndrome (IRIS) as a potential cause of myocarditis worsening after ART initiation, particularly in patients with advanced immunosuppression. 4