From the Guidelines
HIV-associated cardiac disease should be managed by optimizing antiretroviral therapy (ART) with regimens that have fewer metabolic side effects, such as integrase inhibitor-based combinations, and implementing cardiovascular risk reduction strategies through lifestyle modifications and medical management of comorbidities. This approach is supported by the most recent guidelines, including the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease 1. The guideline recommends choosing antiretroviral therapy regimens associated with more favorable lipid and cardiovascular risk profiles, considering drug-drug interactions, and using statins, such as atorvastatin or rosuvastatin, for managing dyslipidemia.
Key considerations in managing HIV-associated cardiac disease include:
- Optimizing ART regimens to minimize metabolic side effects
- Implementing lifestyle modifications, such as smoking cessation, regular exercise, and a healthy diet
- Managing comorbidities, such as hypertension, dyslipidemia, and diabetes
- Regular cardiac screening, including baseline ECG, echocardiogram for symptomatic patients, and lipid profiles every 6-12 months
- Targeted treatments for specific cardiac conditions, such as heart failure, pericardial effusions, and pulmonary hypertension
The underlying mechanism of HIV-associated cardiac disease involves direct viral effects on cardiac tissue, opportunistic infections, chronic inflammation, and medication side effects, making comprehensive HIV management crucial for cardiac health 1. By prioritizing the management of HIV-associated cardiac disease, healthcare providers can reduce the risk of cardiovascular events and improve patient outcomes. The use of newer generation antiretroviral treatment regimens, such as dolutegravir-based regimens, can improve lipid levels and reduce cardiovascular risk 1.
From the Research
HIV-Associated Cardiac Disease
- HIV infection is associated with an increased risk of cardiovascular diseases, including coronary heart disease, myocardial infarction, stroke, peripheral artery disease, heart failure, and sudden cardiac death 2, 3, 4.
- The mechanisms underlying HIV-associated cardiac disease are multifactorial and include traditional cardiovascular risk factors, HIV-related factors such as chronic inflammation and immune dysregulation, and the use of antiretroviral therapy 2, 3, 5.
- Antiretroviral therapy has been shown to reduce the risk of cardiovascular disease in individuals with HIV infection, but the risk remains elevated compared to the general population 2, 3, 5.
- Cardiac disease associated with HIV infection can present as myocarditis, dilated cardiomyopathy, or isolated left or right ventricular dysfunction, and is associated with a poor prognosis 5.
- The introduction of highly active antiretroviral therapy (HAART) has substantially modified the course of HIV disease and reduced the incidence of cardiovascular manifestations of HIV infection 5.
Risk Factors and Management
- Traditional cardiovascular risk factors, such as tobacco smoking, are also important contributors to the increased risk of cardiovascular disease in individuals with HIV infection 3.
- Cardiovascular screening, prevention, and risk factor management are important factors in the management of patients infected with HIV worldwide 4.
- Early and effective antiretroviral therapy can blunt the risk of cardiovascular disease in individuals with HIV infection, but questions remain regarding how to optimally predict, prevent, and treat cardiovascular disease in this population 3.
- Cardiac surgery can be performed safely in selected patients with HIV infection, with acceptable risks and outcomes, especially when combined with highly active antiretroviral therapy 6.