HIV-Associated Heart Failure: Phenotypes and Clinical Outcomes in a Safety-Net Setting

Abstract

Background: Human immunodeficiency virus (HIV) is associated with increased risk of heart failure (HF) but data regarding phenotypes of heart failure and outcomes after HF diagnosis, especially within the safety-net which is where half of people with HIV in the United States receive care, are less clear.

Methods: Using an electronic health record cohort of all individuals with HF within a municipal safety-net system from 2001-2019 linked to the National Death Index Plus, we compared HF phenotypes, all-cause mortality, HF hospitalization, and cause of death for individuals with and without HIV.

Results: Among people with HF (n=14,829), 697 individuals had HIV (4.7%). Persons with HIV (PWH) were diagnosed with HF ten years younger on average. A higher proportion of PWH had a reduced ejection fraction at diagnosis (37.9% vs 32.7%). Adjusted for age, sex, and risk factors, coronary artery disease on angiography was similar by HIV status. HIV was associated with 55% higher risk of all-cause mortality (HR 1.55; 95% CI 1.37-1.76; P<0.001) and lower odds of HF hospitalization (OR 0.51; 95% CI 0.39-0.66; P<0.001). Among PWH with HF, cause of death was less often attributed to cardiovascular disease (22.5% vs 54.6% uninfected; P<0.001) and more to substance use (17.9% vs 9.3%; P<0.001), consistent with autopsy findings in a subset (n=81).

Conclusions: Among people with HF who receive care within a municipal safety-net system, HIV infection is associated with higher mortality, despite lower odds of HF hospitalization, attributable to non-cardiovascular causes including substance-related and HIV-related mortality.

Keywords: Clinical Outcomes; HIV; Heart Failure; Mortality.

Figure 1.. Primary Underlying Cause of Death among People with Heart Failure as Recorded on Death Certificates by HIV Status

Primary underlying cause of death as reported on death certificates classified by International Classification of Diseases (ICD) codes by HIV status. Liver disease is classified under gastrointestinal diseases.

Central Illustration.. Kaplan-Meier and Adjusted Survival Plots by HIV

Age and sex adjusted survival curves for people with and without HIV from index time of heart failure diagnosis up to 15 years of follow up (main figure) and from 0–12 months (inset). Survival curves separate about 3 months after HF diagnosis (inset), with an adjusted hazard ratio of 1.55 (95%CI 1.37–1.76; p<0.0001).