Even with effective HIV viral suppression, inflammation and immune dysregulation appear to increase risks for myocardial infarction, stroke, and heart failure in patients with HIV infection, according to a scientific statement from the American Heart Association.
“Characteristics, Prevention, and Management of Cardiovascular Disease in People Living With HIV” reviews existing evidence on HIV-associated cardiovascular disease (CVD), in particular atherosclerotic CVD (including myocardial infarction and stroke), and heart failure, and recommends ways to approach CVD prevention and treatment in HIV in the absence of large-scale randomized controlled trial data. The scientific statement was published by Circulation on June 3.
The statement notes that rates of myocardial infarction, heart failure, stroke, and other CVD manifestations, including pulmonary hypertension and sudden cardiac death, are significantly higher for people living with HIV than for uninfected control subjects, even in the setting of HIV viral suppression with effective antiretroviral therapy. Understanding of CVD pathogenesis, prevention, and treatment in HIV relies on large observational studies, randomized controlled trials of HIV therapies that are underpowered to detect CVD end points, and small interventional studies that use surrogate CVD end points, the statement said.
Studies have reported an excess risk of myocardial infarction among patients with HIV compared with uninfected people, the scientific statement said. A lower CD4 cell count is associated with higher risk, while a lower CD4/CD8 ratio is associated with more coronary atherosclerosis. Patients with HIV who achieve sustained HIV viral suppression or have few, if any, cardiovascular risk factors have higher myocardial infarction risks than people without HIV infection, and this risk may be greater in women.
Given the excess risk of coronary heart disease, patients with HIV also have elevated heart failure risks, with current estimates ranging from a 1.5- to 2-fold greater risk. This excess risk is not entirely attributable to myocardial infarction. After adjustment for prior myocardial infarction, patients with HIV still have a more than 1.5-fold higher hazard for heart failure than uninfected individuals.
A chart in the statement offers a pragmatic approach to assessing CVD risk in patients with treated HIV infection. It highlights risk-enhancing factors that are related to HIV, such as low current or nadir CD4 cell count or a history of prolonged viremia, as well as more general risk factors such as family history of premature atherosclerotic coronary vascular disease, chronic kidney disease, or atherosclerosis on imaging. The statement also reviews prevention and treatment of HIV-associated CVD and heart failure, including lifestyle changes, statins, nonstatin prevention strategies, and stroke prevention and treatment.