Coronary heart disease and HIV

Coronary heart disease is when fatty substances build up on the walls of your coronary arteries (the blood vessels that supply your heart with blood). This process is called atherosclerosis. Atherosclerosis makes your arteries narrower, so it’s harder for blood to travel through them. If blood clots form in these arteries it can cause a heart attack (sometimes called a myocardial infarction, or MI). Coronary heart disease can also cause a type of chest pain called angina.

Coronary heart disease is the most common type of cardiovascular disease (CVD). It’s a major cause of death around the world. You might also hear coronary heart disease called ischaemic heart disease (IHD) or coronary artery disease (CAD).

Your lifestyle and heart disease

You can reduce your risk of developing coronary heart disease by making changes to your lifestyle. These changes will generally improve your heart health.

• Don’t smoke. If you are a smoker, giving up smoking is the single best thing you can do to improve your overall health and to live longer. You can get support to stop smoking from your doctor.
• Eat a healthy, balanced diet that contains plenty of fruits, vegetables and whole grains such as brown rice.
• Eat fewer foods that contain saturated fats, such as butter, cheese, and coconut oil. Instead, replace them with foods that contain unsaturated fats, such as vegetable oils and nuts.  
• Avoid highly processed foods wherever possible as these tend to contain large amounts of salt, sugar, and trans fats.
• Eat less than 6g of salt a day (about 1 teaspoon). Try to cut down or remove salt when you’re cooking from scratch and check the labels of the foods you’re buying.
• Get regular exercise. Try to aim for 150 minutes of moderate-intensity exercise, such as cycling or brisk walking, each week. If you have very high blood pressure you should speak to a doctor about what type of exercise is safe for you.
• Limit your intake of alcohol. In the UK, the recommended limit is no more than 14 units a week.
• Limit your intake of caffeine. Try and avoid drinks and foods that contain a lot of caffeine such as coffee, Coca-Cola, and Red Bull.
• Find ways to manage or cope with stress. This might involve exercise, mindfulness, or making time to do the things you enjoy.
• Manage any health conditions, such as type 2 diabetes or high blood pressure, by taking any medications you are prescribed and following your doctor’s advice.

Who is at risk?

Many of the causes of coronary heart disease are linked to people’s lifestyles. However, some people are at higher risk for other reasons.

• Having other health conditions such as high blood pressure, high cholesterol and diabetes.
• Having a close family member who has or had heart disease.
• Your risk increases as you age, so older people are at higher risk. 
• Men are more likely to develop heart disease than women. However, heart disease is common in women too.

Heart disease in people living with HIV

There is evidence that people with HIV are at higher risk of coronary heart disease than the general population and that it happens at a younger age.

The main reason for this seems to be the impact that HIV has on your body. This is because HIV causes chronic inflammation. Chronic inflammation is when your immune system has an unhelpful reaction to the virus over a long time. It seems that this inflammation can contribute to the hardening of your arteries which increases your risk of heart disease.

This risk is likely to increase the longer you have been living with HIV, even if you are on HIV treatment and have an undetectable viral load. However, the risk is higher in people with a high viral load and a low CD4 count. This means that taking effective HIV treatment is an important way of keeping your risk of heart disease as low as possible.

Anti-HIV medications

Some anti-HIV medications have been linked to an increased risk of heart disease in people living with HIV compared to the general population. However, the benefits of taking anti-HIV medication far outweigh this risk. The risk of developing heart problems is much higher if you don’t take anti-HIV treatment. It’s also important to know that newer anti-HIV medications generally cause fewer problems than older medications.

There are different ways that anti-HIV medications can affect your heart health. This includes changes to your blood lipid levels and your blood pressure.

The anti-HIV medications that have been linked to changes in the amount of fats (lipids) in your blood are:

• efavirenz (Sustiva, also in Atripla)
• elvitegravir (Vitekta) when taken with cobicistat, also included in the combination pills Stribild (with cobicistat, tenofovir disoproxil fumarate and emtricitabine) and Genvoya (with cobicistat, tenofovir alafenamide and emtricitabine)
• protease inhibitors such as darunavir (Prezista, also in Rezolsta and Symtuza), atazanavir (Reyataz, also in Evotaz) and lopinavir (Kaletra) when they are taken with ritonavir (Norvir) or cobicistat (Tybost). You might take a booster separately, or it may be included in a combination pill.

When your blood lipid levels aren’t in the healthy range this is sometimes called ‘dyslipidaemia’. There is more information about this on our cholesterol page.

One study has found that people taking integrase inhibitors are more likely to develop high blood pressure than people taking medications from the NNRTI class. Integrase inhibitors include:

• dolutegravir (Tivicay, also in Triumeq, Juluca, and Dovato)
• raltegravir (Isentress)
• elvitegravir (Vitekta, also in Stribild and Genvoya)
• bictegravir (Biktarvy).

High blood pressure can lead to coronary heart disease over time. For more information see our page High blood pressure and HIV.

Some studies have also found that abacavir (Ziagen, also in Kivexa, Epzicom, Triumeq, and Trizivir) is linked to an increased risk of heart attack and heart disease. It’s not known for sure why this link might exist.

If you’re worried about the way your medication might affect your heart, speak to your doctor.

Symptoms of heart disease

Many people don’t have any symptoms before they are diagnosed with heart disease. Some people will only be diagnosed with heart disease after they have a heart attack. The most common symptoms of heart disease are breathlessness and angina.

Angina is a type of chest pain that is caused when your heart can’t get enough blood. This happens because of the build-up of fatty substances in your arteries. Many people find that they experience angina when they exercise or when they are stressed, but it goes away after a few minutes.

It’s important to know that the symptoms of angina, such as chest pain and pain in your arm, are often the same as a heart attack. This means that if you experience these symptoms and you haven’t been diagnosed with angina you should call an ambulance immediately.

If you have been diagnosed with angina you might be given medication to take when you have these symptoms. If the pain doesn’t stop after you’ve rested and taken your medicine then you should call for an ambulance, as you could be having a heart attack.

Other symptoms of heart disease can include feeling sick, feeling faint, or having pain all over your body.

Diagnosis and monitoring

There is no single test to measure your heart health. If you’re over 40, you will have some aspects of your heart health monitored as part of your regular HIV check-ups. For example, your blood fats (lipids) should be tested once a year.

If you’re concerned about your heart, speak to a doctor. You can also have your heart health checked by your GP. To get an idea of your risk of heart disease your doctor might do some simple tests such as:

• checking your blood pressure and pulse
• measuring your weight and height
• measuring your waist with a tape measure
• listening to your heart
• blood tests to measure your blood fats.

They might also ask you about your background and lifestyle, such as whether you smoke and if anyone in your family has had heart disease. In the UK, people aged 40 to 74 will be invited to an NHS health check every five years which includes these tests.

If your doctor thinks that you are having heart problems, you are likely to be asked to have further tests. These might include:

• an electrocardiogram (ECG), which involves having small sensors stuck to different points on your body to measure your heart’s rhythm and its electrical activity
• an exercise ECG, which uses the same sensors to monitor how well your heart is working while you walk or run on a treadmill
• wearing a portable heart monitor for a longer period of time (usually 24 hours, but sometimes it can be longer)
• an angiography, which involves dye being injected into an artery before an X-ray is taken
• other types of chest X-rays or scans to see if there is any damage to your heart.

Treatment and management

Heart disease can’t be cured but there are ways to manage it and reduce the risk of other problems. You might be advised to make lifestyle changes, be prescribed medication, or need to have surgery, depending on how serious your heart disease is.

Lifestyle

If you are at risk of heart disease, you might first be advised to make some changes to your lifestyle. More information on these can be found in the section at the top of the page called 'Your lifestyle and heart disease'.

Medication

There are different types of medication you may be prescribed to manage your coronary heart disease and reduce the risk of complications in the future.

• Medications to reduce your cholesterol (also called lipid-lowering medication).
• Medications to reduce your blood pressure.
• Blood thinning medication, such as antiplatelet and anticoagulant medicine.
• Medication for angina.

You might also be given some of these medications in a small dose, even if you have normal blood pressure or cholesterol. This is because they can reduce your risk of death from a heart attack or stroke.

For more information about lipid-lowering medication and blood pressure medication see our pages Cholesterol and HIV and High blood pressure and HIV. 

Blood-thinning medication can reduce your risk of having a heart attack or a stroke. Aspirin and prasugrel can be prescribed for you no matter what anti-HIV medication you are taking. However, it’s important to know that some anti-HIV medication interacts with some other blood-thinning tablets.

For this reason, you shouldn’t be prescribed the blood-thinning medications clopidogrel (Grepid, Plavix), rivaroxaban (Xarelto) or ticagrelor (Brilique) if you are taking:

• elvitegravir (Vitekta) when taken with cobicistat, including in the combination pills Stribild (with cobicistat, tenofovir disoproxil fumarate and emtricitabine) and Genvoya (with cobicistat, tenofovir alafenamide and emtricitabine)
• protease inhibitors such as darunavir (Prezista, also in Rezolsta and Symtuza), atazanavir (Reyataz, also in Evotaz) and lopinavir (Kaletra) when they are taken with ritonavir (Norvir) or cobicistat (Tybost). You might take a booster separately, or it may be included in a combination pill.

If you have angina you might be prescribed a type of medication that contains nitrate. There are different types of nitrate medications: isosorbide dinitrate (Isoket Retard), isosorbide mononitrate (Chemydur, Isotard, and Elantan), and glyceral trinitrate (Rectogesic and Minitran).

Some anti-HIV medications might affect how well isosorbide dinitrate works. If you’re prescribed this medication you might need to be monitored more closely if you’re also taking:

• elvitegravir (Vitekta) when taken with cobicistat, including in the combination pills Stribild (with cobicistat, tenofovir disoproxil fumarate and emtricitabine) and Genvoya (with cobicistat, tenofovir alafenamide and emtricitabine)
• protease inhibitors such as darunavir (Prezista, also in Rezolsta and Symtuza), atazanavir (Reyataz, also in Evotaz) and lopinavir (Kaletra) when they are taken with ritonavir (Norvir) or cobicistat (Tybost). You might take a booster separately, or it may be included in a combination pill.

Isosorbide mononitrate and glyceryl trinitrate, also known as GTN, can be taken with all anti-HIV treatments.

Surgery

If medication isn’t working well for you then you might be offered surgery. There are two main types of surgery used to treat coronary heart disease.

• A coronary angioplasty. A balloon is inserted into your artery to make it wider. Usually, you’ll also have a thin tube put into your artery at the same time. This tube is called a stent. A stent keeps your artery open to allow blood to flow more easily.
• A coronary artery bypass graft (CABG). You might have heard this called a 'heart bypass'. A blood vessel from somewhere else in your body is used to divert blood around a blockage in your artery. This means the blood has a new way to flow into your heart.

Extremely rarely, people with significant heart failure due to heart disease need a heart transplant. In the UK, this is only around 30 to 40 people each year out of 2.3 million people who have heart disease.

You will only be considered for a heart transplant if your symptoms are very severe, and all other treatments haven’t worked for you. Living with HIV doesn’t stop you from receiving a heart transplant.

Other sources of information

You may find the British Heart Foundation helpful. Visit their website www.bhf.org or call their helpline (from the UK) on 0300 330 3311.

You can check for interactions between your anti-HIV medication and other medications here: www.hiv-druginteractions.org