From the Guidelines
HIV-associated cardiomyopathy should be managed with standard guideline-directed medical and device therapies for patients with systolic heart failure, in addition to optimizing antiretroviral therapy (ART) to suppress viral replication. The condition typically presents as dilated cardiomyopathy with systolic dysfunction, characterized by left ventricular enlargement and reduced ejection fraction 1. According to the American Heart Association, treatment of HIV with antiretroviral therapy is useful in prevention and treatment of DCM related to HIV, and patients with HIV cardiomyopathy should be treated with standard therapies for systolic heart failure 1.
The pathophysiology of HIV-associated cardiomyopathy involves direct viral infection of cardiac myocytes, chronic inflammation, autoimmune responses, nutritional deficiencies, and potential cardiotoxicity from some older antiretroviral medications 1. Some key points to consider in management include:
- Optimizing antiretroviral therapy (ART) to achieve viral suppression
- Using standard heart failure therapies such as ACE inhibitors, beta-blockers, and diuretics as needed
- Regular cardiac monitoring with echocardiography, especially for patients with risk factors like low CD4 counts, high viral loads, or prolonged infection
- Lifestyle modifications including sodium restriction, regular exercise as tolerated, smoking cessation, and limiting alcohol consumption
Early detection and management are essential, as HIV-associated cardiomyopathy can progress to severe heart failure if untreated, with a poor prognosis and high mortality rate if left untreated 1. Therefore, it is crucial to prioritize the management of HIV-associated cardiomyopathy with a comprehensive approach that includes both standard heart failure therapies and optimized antiretroviral therapy.
From the Research
Definition and Prevalence of HIV-Associated Cardiomyopathy
- HIV-associated cardiomyopathy is a significant cause of morbidity and mortality among HIV-infected individuals, with a prevalence of clinical heart failure of 6.5% 2.
- It is often clinically occult or attributed incorrectly to other noncardiac disease processes, highlighting the need for routine screening for cardiovascular involvement in HIV-infected patients 3.
Pathogenesis and Causes
- The pathogenesis of HIV-associated cardiomyopathy involves direct viral infection, cytokine activity, focal myocarditis, HAART side effects, immune system dysregulation, and/or ischemia 4.
- Myocarditis from direct HIV toxicity, opportunistic infections, and nutritional deficiencies are implicated in causing HIVAC when HIV viral replication is unchecked, whereas cardiac autoimmunity, chronic inflammation, and ART cardiotoxicity contribute to HIVAC in individuals with suppressed viral loads 5.
Clinical Manifestations and Diagnosis
- The clinical manifestations of HIV-associated cardiomyopathy depend on the degree of host immunosuppression, with myocarditis and opportunistic infections being more common in individuals with unchecked HIV viral replication 5.
- The initiation of ART has dramatically changed the clinical manifestation of HIVAC in high-income countries from one of severe, left ventricular systolic dysfunction to a pattern of subclinical cardiac dysfunction characterized by abnormal diastolic function and strain 5.
Treatment and Management
- The therapy of HIV-associated cardiomyopathy comprises standard medical treatment for heart failure, with the initiation of ART being crucial in reducing HIV-associated diseases 3.
- Patients with HIV-associated cardiomyopathy should be started or continued on HAART and initiated on guideline-directed medical therapy (GDMT) per the ACC/AHA guidelines 4.
- Advanced heart failure therapies, such as left ventricular assist device (LVAD) support or orthotopic heart transplantation (OHT), should also be considered in carefully selected HIV-positive patients, as current data indicates that these therapies are safe and effective in this population 2.