From the Guidelines
HIV-associated cardiomyopathy significantly increases the risk of heart complications, including a greater than 50% mortality rate in 2 to 3 years if left untreated, emphasizing the need for prompt diagnosis and treatment. This condition involves damage to the heart muscle that can lead to heart failure, arrhythmias, and other cardiac complications. People with HIV have a higher risk of developing cardiovascular disease compared to the general population. The pathogenesis of cardiomyopathy associated with HIV includes infection of myocardial cells with HIV type 1, postviral cardiac autoimmunity, autonomic dysfunction, cardiotoxicity from illicit drugs and pharmacological agents, nutritional deficiencies, and prolonged immunosuppression 1.
Management and Treatment
Management includes optimizing antiretroviral therapy (ART) with regimens that have fewer cardiac side effects. Treatment of HIV with antiretroviral therapy is useful in prevention and treatment of DCM related to HIV 1. Standard heart failure medications are also used, including ACE inhibitors, beta-blockers, and diuretics as needed. Regular cardiac monitoring is essential, including echocardiograms every 1-2 years and more frequently if symptoms develop. Lifestyle modifications are crucial, including smoking cessation, moderate exercise, limiting alcohol, maintaining a heart-healthy diet low in sodium and saturated fats, and managing comorbidities like hypertension and diabetes.
Key Recommendations
- Patients with DCM and risk factors for HIV should be screened for HIV as a possible cause of DCM 1.
- Patients with HIV cardiomyopathy should be treated with standard guideline-directed medical and device therapies for patients with systolic HF 1.
- The prognosis of HIV cardiomyopathy when untreated remains poor, with a >50% mortality rate in 2 to 3 years, especially among patients in sub-Saharan Africa 1.
Pathophysiology and Risk Factors
The pathophysiology involves direct viral effects on cardiac tissue, chronic inflammation, ART-related metabolic changes, and traditional cardiovascular risk factors, all contributing to progressive cardiac dysfunction. HF is seen in approximately one half of these patients with myocardial involvement 1. Other than treatment for HIV, the treatment of HF in patients with symptomatic HIV cardiomyopathy is the same as the conventional treatment for patients with DCM 1.
From the Research
HIV-Associated Cardiomyopathy
- HIV-associated cardiomyopathy is a significant cause of morbidity and mortality among HIV-infected individuals, despite antiretroviral therapy (ART) 2, 3.
- The pathogenesis of HIV-associated cardiomyopathy involves direct viral infection, cytokine activity, focal myocarditis, HAART side effects, immune system dysregulation, and/or ischemia 2.
- The clinical manifestations of HIV-associated cardiomyopathy depend on the degree of host immunosuppression, with myocarditis from direct HIV toxicity, opportunistic infections, and nutritional deficiencies implicated in causing HIVAC when HIV viral replication is unchecked 3.
Risk of Heart Disease
- HIV-infected individuals are at an increased risk for heart disease, specifically HIV-associated cardiomyopathy, due to the direct effects of the virus, immune activation, and inflammation 4, 5.
- The risk of heart disease in HIV-infected individuals is also influenced by traditional cardiovascular risk factors such as tobacco smoking, as well as HAART toxicity 5, 6.
- Early and effective ART can blunt the risk for cardiovascular diseases (CVDs) among individuals with HIV, but questions remain regarding how to optimally predict, prevent, and treat CVDs among individuals with HIV 6.
Diagnosis and Treatment
- Clear diagnostic and treatment guidelines for HIV-associated cardiomyopathy are currently lacking, but should be prioritized given the global burden of HIVAC 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 2.
- The safety and efficacy of mechanical circulatory support and heart transplant in this population has been repeatedly demonstrated, but it remains less available compared with the general advanced heart failure population 2.