Human Immunodeficiency Virus Infection-Associated Cardiomyopathy and Heart Failure

Abstract

The landscape of human immunodeficiency virus (HIV) epidemiology and treatment is ever-changing, with the widespread and evolving use of antiretroviral therapy (ART). With timely ART, people living with HIV (PLWH) are nearing the life expectancies and the functionality of the general population; nevertheless, the effects of HIV and ART on cardiovascular health remain under investigation. The pathophysiology of HIV-related cardiomyopathy and heart failure (HF) have historically been attributed to systemic inflammation and changes in cardiometabolic function and cardiovascular architecture. Importantly, newer evidence suggests that ART also plays a role in modulating the process of HIV-related cardiomyopathy and HF. In the short term, newer highly active ART (HAART) seems to have cardioprotective effects; however, emerging data on the long-term cardiovascular outcomes of certain HAART medications, i.e., protease inhibitors, raise concerns about the potential adverse effects of these drugs in the clinical course of HIV-related HF. As such, the traditional phenotypes of dilated cardiomyopathy and left ventricular systolic failure that are associated with HIV-related heart disease are incrementally being replaced with increasing rates of diastolic dysfunction and ischemic heart disease. Moreover, recent studies have found important links between HIV-related HF and other clinical and biochemical entities, including depression, which further complicate cardiac care for PLWH. Considering these trends in the era of ART, the traditional paradigms of HIV-related cardiomyopathy and HF are being called into question, as is the therapeutic role of interventions such as ventricular assist devices and heart transplantation. In all, the mechanisms of HIV-related myocardial damage and the optimal approaches to the prevention and the treatment of cardiomyopathy and HF in PLWH remain under investigation.

Keywords: HAART; cardiomyopathy; heart failure; human immunodeficiency virus.

Figure 1

Pooled prevalence of cardiac impairment in adults with HIV infection. Reproduced with permission from: Erqou et al., J Am Coll Cardiol HF 2019;7:98–108 [11]. CI: confidence interval; DCM: dilated cardiomyopathy; DD: diastolic dysfunction; LVSD: left ventricular systolic dysfunction; PH: pulmonary hypertension; RVSD: right ventricular systolic dysfunction.

Figure 2

Meta-regression analysis of left ventricular systolic dysfunction (LVSD) and diastolic dysfunction (DD) by various characteristics. Reproduced with permission from: Erqou et al., J Am Coll Cardiol HF 2019;7:98–108 [11]. ALL_DD: All diastolic dysfunction; ART: antiretroviral therapy; ADV_DD: advanced diastolic dysfunction; CD4: CD4 T cell count; CI: confidence interval; DD: diastolic dysfunction; LVSD: left ventricular systolic dysfunction.

Figure 3

Proposed mechanisms of systolic and diastolic cardiac dysfunction in HIV-infected persons. ART = Antiretroviral therapy; LV = left ventricular.