People with uncontrolled HIV infection are significantly
more likely to suffer heart failure than people without HIV infection,
according to results of a large cohort study of US military veterans published this
week in Archives of Internal Medicine.
The study adds to the accumulating evidence that untreated
HIV infection may increase the risk of heart disease.
Heart failure is a gradual weakening of the heart that leads to increasing breathlessness and weakness, and requires medication or surgery as the condition becomes more severe.
Previous studies have looked at myocardial infarction,
stroke or other cardiovascular events. Heart failure is a cardiovascular
outcome that may occur for a variety of reasons, including heart attack, high
blood pressure, disease of the heart muscle (cardiomyopathy), alcohol or
cocaine abuse, and represents a progressive condition that requires active
management rather than a one-off event.
The study evaluated heart failure in a large cohort of male US military
veterans, and excluded anyone with pre-existing cardiovascular disease or
A total of 8,846 participants were evaluated, of whom 28.2%
were HIV-infected. All participants were part of the Veterans Aging Cohort
Study Virtual Cohort.
Participants had a median age of 48 years, and around 39%
With regard to risk factors for heart disease those with HIV
were more likely to smoke (55% vs 45%, p<0.001), to have a history of
cocaine use (21.9% vs 15.7%, p<0.01) or hepatitis C coinfection (30.5% vs
11.4%, p<0.001). HIV-negative participants were more likely to have diabetes
(24.8% vs 16.7%, p<0.001) or hypertension (28.8% vs 18.7%, p<0.001).
Rates of alcohol dependence and elevated lipid levels were
similar in the two groups, but HIV-positive people had a lower mean body mass.
People with HIV infection were almost twice as likely to
experience heart failure (incidence 7.2 vs 4.82 per 1000 person-years of
follow-up, hazard ratio 1.81, 95% confidence interval 1.39-2.36).
Among individuals without chronic heart disease or a history
of alcohol abuse HIV was second only to hypertension as a risk factor for heart
failure, and tended to show a stronger association with heart failure than
traditional risk factors such as smoking, high body mass and older age.
Individuals who had a detectable viral load on recruitment
to the cohort (HR 2.28 vs HIV-uninfected), or who subsequently experienced
viral load rebound after joining the cohort (HR 2.39), had a significantly
higher risk of heart failure than those who had an undetectable viral load
throughout their follow-up time in the cohort (HR 1.10) (p> 0.01 and >0.03
The authors say that their analysis is limited in its
ability to fully quantify any effects of antiretroviral treatment by lack of
data on antiretroviral drug regimens and adherence.
The authors suggest that ongoing HIV replication is an
important risk factor, but also note that secondary infections of the
myocardium (heart muscle) by opportunistic pathogens present in people with
HIV, such as cytomegalovirus, Toxoplasma
gondii and Cryptococcus neoformans
could be responsible for some portion of heart failures.
They say that traditional risk factors for heart failure
should not be ignored in people with HIV infection. Age, obesity, hypertension,
diabetes, alcohol abuse and African-American race all remained significant
predictors of heart failure even after individuals with chronic heart disease
were excluded from the analysis, suggesting the extent to which modification of
lifestyle factors is advisable in advance of any development of symptomatic heart
“Interventions to minimize the modifiable traditional risk
factors, including glycemic and blood pressure control, weight reduction and
abstinence from alcohol are prudent strategies that should be emphasized,” the
They say more work is needed to determine whether heart
failure in persons with HIV is chiefly systolic or diastolic, and to look at the
effects of interventions such as glycemic control and anti-hypertensive
medication on the risk of heart failure.