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Heart Failure among People with HIV: Evolving Risks, Mechanisms, and Preventive Considerations

  • Complications of HIV and Antiretroviral Therapy (GA McComsey, Section Editor)
  • Published:
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Abstract

Purpose

People with HIV (PHIV) with access to modern antiretroviral therapy (ART) face a two-fold increased risk of heart failure as compared with non-HIV-infected individuals. The purpose of this review is to consider evolving risks, mechanisms, and preventive considerations pertaining to heart failure among PHIV.

Recent Findings

While unchecked HIV/AIDS has been documented to precipitate heart failure characterized by overtly reduced cardiac contractile function, ART-treated HIV may be associated with either heart failure with reduced ejection fraction (HFrEF) or with heart failure with preserved ejection fraction (HFpEF). In HFpEF, a “stiff” left ventricle cannot adequately relax in diastole—a condition known as diastolic dysfunction. Diastolic dysfunction, in turn, may result from processes including myocardial fibrosis (triggered by hypertension and/or immune activation/inflammation) and/or myocardial steatosis (triggered by metabolic dysregulation). Notably, hypertension, systemic immune activation, and metabolic dysregulation are all common conditions among even those PHIV who are well-treated with ART. Of clinical consequence, HFpEF is uniquely intransigent to conventional medical therapies and portends high morbidity and mortality. However, diastolic dysfunction is reversible—as are contributing processes of myocardial fibrosis and myocardial steatosis.

Summary

Our challenges in preserving myocardial health among PHIV are two-fold. First, we must continue working to realize UNAIDS 90-90-90 goals. This achievement will reduce AIDS-related mortality, including cardiovascular deaths from AIDS-associated heart failure. Second, we must work to elucidate the detailed mechanisms continuing to predispose ART-treated PHIV to heart failure and particularly HFpEF. Such efforts will enable the development and implementation of targeted preventive strategies.

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Authors and Affiliations

  1. Metabolism Unit, Endocrine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, 5 LON 207, Boston, MA, 02114, USA

    Mabel Toribio & Markella V. Zanni

  2. Cardiac MR PET CT Program, Division of Cardiology and Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Tomas G. Neilan

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  1. Mabel Toribio
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Dr. Toribio has no conflicts of interest. Dr. Neilan has participated in a Scientific Advisory Board Meeting for BMS and has served as a consultant for Aprea Therapeutics, Parexel, and Intrinsic Imaging. Dr. Zanni received investigator-initiated research grant support from Gilead Sciences to her institution (Massachusetts General Hospital).

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Toribio, M., Neilan, T.G. & Zanni, M.V. Heart Failure among People with HIV: Evolving Risks, Mechanisms, and Preventive Considerations. Curr HIV/AIDS Rep 16, 371–380 (2019). https://doi.org/10.1007/s11904-019-00458-1

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