What are the cardiac manifestations of HIV (Human Immunodeficiency Virus) and their relative incidence in individuals with HIV?

Cardiac Manifestations of HIV and Relative Incidence

HIV infection causes multiple cardiac complications with dilated cardiomyopathy being the most significant, affecting 40% of untreated HIV-positive patients within 5 years, while coronary artery disease has emerged as the dominant concern in the antiretroviral therapy era with significantly elevated and accelerated risk compared to the general population. 1

Major Cardiac Manifestations and Their Incidence

Dilated Cardiomyopathy (DCM)

• Pre-HAART era incidence: 40% of initially asymptomatic HIV-positive patients developed DCM with significantly depressed left ventricular ejection fraction during 5-year follow-up 1
• Post-HAART era: 7-fold reduction in prevalence compared to pre-HAART period, though DCM remains clinically significant 2
• Higher incidence occurs among patients with AIDS or low CD4 counts 1
• Results in symptomatic heart failure in approximately 5% of HIV patients 2
• Untreated HIV cardiomyopathy carries >50% mortality rate within 2-3 years, particularly in sub-Saharan Africa 1, 3

Myocarditis

• Approximately 50% of patients who died of AIDS-related illnesses demonstrated histological evidence of myocarditis on autopsy 1
• HIV nucleic acid sequences detected in cardiac tissue in approximately one-third of AIDS patients at autopsy using in situ hybridization 1
• Heart failure develops in approximately 50% of patients with myocardial involvement 1

Coronary Artery Disease (CAD)

• Significantly higher risk in HIV-positive population with accelerated disease progression compared to general population 1, 4
• Traditional ASCVD risk calculators consistently underestimate risk in HIV populations, particularly for women and Black/African American individuals 5
• The REPRIEVE trial demonstrated 36% reduction in major adverse cardiovascular events with statin therapy (HR 0.64,95% CI 0.48-0.84) even in patients with median 10-year ASCVD risk of only 4.5% 5

Pericardial Effusion

• Among the most commonly reported cardiac abnormalities in HIV patients, though specific incidence data varies by study 6

Other Manifestations

• Pulmonary hypertension, endocarditis, and coronary vasculopathy occur but with less well-defined incidence 7, 8, 6

Pathophysiological Mechanisms

Direct HIV Effects

• Direct myocardial cell infection with HIV type-1, though human myocardial cells do not express CD4 receptors 1
• Targeted myocardial expression of HIV transactivator causes cardiomyopathy and mitochondrial damage in transgenic mice 1

Indirect Mechanisms

• Coinfection with other viruses (cytomegalovirus, Epstein-Barr virus) 1
• Postviral cardiac autoimmunity 1
• Chronic inflammation, immune activation, and microbial translocation 1, 4
• Endothelial injury and disordered coagulation 1
• Prolonged immunosuppression 1

Treatment-Related Factors

• Cardiotoxicity from illicit drugs and pharmacological agents 1
• HAART-associated metabolic syndrome with hyperlipidemia and accelerated atherosclerosis 7, 4
• Increased incidence of cardiovascular events including myocardial infarction and hypertension with HAART 1
• Nutritional deficiencies and autonomic dysfunction 1

Traditional Risk Factors

• High burden of cigarette smoking, hypertension, metabolic syndrome, and dyslipidemia in HIV population 1

Critical Clinical Implications

Screening Recommendations

• All patients with DCM and HIV risk factors should be screened for HIV as a possible cause 1
• Screen for other potential causes including ischemic heart disease, substance abuse, and medication cardiotoxicity 1, 3

Treatment Priorities

• Antiretroviral therapy is essential for prevention and treatment of HIV-related DCM and should be initiated urgently 1, 3
• Standard guideline-directed medical and device therapies for systolic heart failure apply to HIV cardiomyopathy patients 1, 3
• Statin therapy provides substantial benefit even at lower traditional risk thresholds in HIV patients 5

Common Pitfalls to Avoid

• Do not delay ART initiation while awaiting cardiac stabilization—early ART is both protective and therapeutic 3
• Do not rely solely on traditional ASCVD risk calculators, as they systematically underestimate cardiovascular risk in HIV populations 5, 9
• Do not attribute all cardiac dysfunction to HIV alone without excluding ischemic disease, substance abuse, and medication effects 1, 3
• Corticosteroids are generally contraindicated in HIV-associated myocarditis as they can reactivate viral infections 3