Epidemiology and Clinical Approach to Heart Failure in Patients with HIV

  • Sadeer G. Al-Kindi
  • Chris T. LongeneckerEmail author


Heart failure (HF) is a major cause of morbidity and mortality globally. Epidemiologic studies have shown that people living with HIV (PLHIV) have 1.5–2-fold higher risk of heart failure compared with uninfected persons. This may be directly related to the level of HIV control and CD4 count. Women with HIV appear to have a higher risk of HF compared to men with HIV. The pathophysiology of HF in PLHIV is likely multifactorial including direct effects of the HIV virus, comorbid conditions, chronic inflammation, and medications. To date, there are no randomized clinical trials focused on the management of HF in PLHIV; therefore, HF management guidelines for the general population may be applied to PLHIV. There are special considerations for PLHIV undergoing device and advanced HF therapies. Studies have shown that HF therapies may be underutilized in PLHIV resulting in increased risk of adverse outcomes. This chapter discusses the epidemiology, pathophysiology, pharmacologic and non-pharmacologic management, and outcomes of heart failure in PLHIV.


Human immunodeficiency virus Heart failure Epidemiology Diagnosis Management 


  1. 1.
    Patel T, Al-Kindi S, Oliveira G. Trends in cardiac imaging in patients receiving cardiotoxic chemotherapy. J Am Coll Cardiol. 2017;11:1498.CrossRefGoogle Scholar
  2. 2.
    Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD, Ferguson JF, Fornage M, Gillespie C, Isasi CR, Jimenez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Lutsey PL, Mackey JS, Matchar DB, Matsushita K, Mussolino ME, Nasir K, O’Flaherty M, Palaniappan LP, Pandey A, Pandey DK, Reeves MJ, Ritchey MD, Rodriguez CJ, Roth GA, Rosamond WD, Sampson UKA, Satou GM, Shah SH, Spartano NL, Tirschwell DL, Tsao CW, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P. American Heart Association Council on E, Prevention Statistics C and Stroke Statistics S. Heart Disease and Stroke Statistics-2018 update: a report from the American Heart Association. Circulation. 2018;137:e67–e492.Google Scholar
  3. 3.
    Gulati G, Heck SL, Ree AH, et al. Prevention of cardiac dysfunction during adjuvant breast cancer therapy (PRADA): a 2 × 2 factorial, randomized, placebo-controlled, double-blind clinical trial of candesartan and metoprolol. Eur Heart J. 2016;37:1671–80.CrossRefGoogle Scholar
  4. 4.
    Cohen IS, Anderson DW, Virmani R, Reen BM, Macher AM, Sennesh J, DiLorenzo P, Redfield RR. Congestive cardiomyopathy in association with the acquired immunodeficiency syndrome. N Engl J Med. 1986;315:628–30.CrossRefGoogle Scholar
  5. 5.
    Remick J, Georgiopoulou V, Marti C, Ofotokun I, Kalogeropoulos A, Lewis W, Butler J. Heart failure in patients with human immunodeficiency virus infection: epidemiology, pathophysiology, treatment, and future research. Circulation. 2014;129:1781–9.CrossRefGoogle Scholar
  6. 6.
    Cerrato E, D’Ascenzo F, Biondi-Zoccai G, et al. Cardiac dysfunction in pauci symptomatic human immunodeficiency virus patients: a meta-analysis in the highly active antiretroviral therapy era. Eur Heart J. 2013;34:1432–6.CrossRefGoogle Scholar
  7. 7.
    Butt AA, Chang CC, Kuller L, et al. Risk of heart failure with human immunodeficiency virus in the absence of prior diagnosis of coronary heart disease. Arch Intern Med. 2011;171:737–43.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Al-Kindi SG, ElAmm C, Ginwalla M, Mehanna E, Zacharias M, Benatti R, Oliveira GH, Longenecker CT. Heart failure in patients with human immunodeficiency virus infection: Epidemiology and management disparities. Int J Cardiol. 2016;218:43–6.CrossRefGoogle Scholar
  9. 9.
    Thiara DK, Liu CY, Raman F, Mangat S, Purdy JB, Duarte HA, Schmidt N, Hur J, Sibley CT, Bluemke DA, Hadigan C. Abnormal myocardial function is related to myocardial steatosis and diffuse myocardial fibrosis in HIV-infected adults. J Infect Dis. 2015;212:1544–51.CrossRefGoogle Scholar
  10. 10.
    Oliveira GH, Al-Kindi SG, Hoimes C, Park SJ. Characteristics and survival of malignant cardiac tumors: a 40-year analysis of >500 patients. Circulation. 2015;132:2395–402.CrossRefGoogle Scholar
  11. 11.
    Al-Kindi SG, Kim CH, Morris SR, Freeman ML, Funderburg NT, Rodriguez B, McComsey GA, Dalton JE, Simon DI, Lederman MM, Longenecker CT, Zidar DA. Elevated Red Cell Distribution Width (RDW) identifies elevated cardiovascular disease risk in patients with HIV infection. J Acquir Immune Defic Syndr. 2017;74:298–302.Google Scholar
  12. 12.
    Daley BG, Miranda DF, Tetekpor N, Baker JV, Simegn M. Abstract 11608: characteristics of incident heart failure in HIV disease at an urban HIV clinic and hospital from 2007–2014. Circulation. 2015;132:A11608.Google Scholar
  13. 13.
    Reinsch N, Neuhaus K, Esser S, Potthoff A, Hower M, Brockmeyer NH, Erbel R, Neumann T. Prevalence of cardiac diastolic dysfunction in HIV-infected patients: results of the HIV-HEART study. HIV Clin Trials. 2010;11:156–62.CrossRefGoogle Scholar
  14. 14.
    Hsue PY, Hunt PW, Ho JE, Farah HH, Schnell A, Hoh R, Martin JN, Deeks SG, Bolger AF. Impact of HIV infection on diastolic function and left ventricular mass. Circ Heart Fail. 2010;3:132–9.CrossRefGoogle Scholar
  15. 15.
    Felker GM, Thompson RE, Hare JM, Hruban RH, Clemetson DE, Howard DL, Baughman KL, Kasper EK. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med. 2000;342:1077–84.CrossRefGoogle Scholar
  16. 16.
    Reinsch N, Neuhaus K, Esser S, Potthoff A, Hower M, Mostardt S, Neumann A, Brockmeyer NH, Gelbrich G, Erbel R, Neumann T. Are HIV patients undertreated? Cardiovascular risk factors in HIV: results of the HIV-HEART study. Eur J Prev Cardiol. 2012;19:267–74.CrossRefGoogle Scholar
  17. 17.
    Janjua SA, Triant VA, Addison D, Szilveszter B, Regan S, Staziaki PV, Grinspoon SA, Hoffmann U, Zanni MV and Neilan TG. HIV Infection and Heart Failure Outcomes in Women. J Am Coll Cardiol. 2017;69:107–108.Google Scholar
  18. 18.
    Holloway CJ, Ntusi N, Suttie J, et al. Comprehensive cardiac magnetic resonance imaging and spectroscopy reveal a high burden of myocardial disease in HIV patients. Circulation. 2013;128:814–22.CrossRefGoogle Scholar
  19. 19.
    Howard LC, Liu CY, Purdy JB, Walter P, Bluemke DA, Hadigan C. Lipolytic rate associated with intramyocardial lipid in an HIV cohort without increased lipolysis. J Clin Endocrinol Metab. 2016;101:151–6.CrossRefGoogle Scholar
  20. 20.
    Engstrom K, Garcia M. Initial antiretroviral therapy with protease inhibitors is associated with increased risk of heart failure in HIV-infected patients. J Am Coll Cardiol. 2014;63:A955.CrossRefGoogle Scholar
  21. 21.
    Lundgren JD, Battegay M, Behrens G, et al. European AIDS Clinical Society (EACS) guidelines on the prevention and management of metabolic diseases in HIV. HIV Med. 2008;9:72–81.CrossRefGoogle Scholar
  22. 22.
    Baker JV, Huppler Hullsiek K, Prosser R, Duprez D, Grimm R, Tracy RP, Rhame F, Henry K, Neaton JD. Angiotensin converting enzyme inhibitor and HMG-CoA reductase inhibitor as adjunct treatment for persons with HIV infection: a feasibility randomized trial. PLoS One. 2012;7:e46894.CrossRefGoogle Scholar
  23. 23.
    Wever-Pinzon O, Bangalore S, Romero J, Silva Enciso J, Chaudhry FA. Inotropic contractile reserve can risk-stratify patients with HIV cardiomyopathy: a dobutamine stress echocardiography study. JACC Cardiovasc Imaging. 2011;4:1231–8.CrossRefGoogle Scholar
  24. 24.
    Romero-León JM, Gálvez-Contreras MC, Díez-García LF. Symptomatic bradycardia and heart failure triggered by ivabradine in a patient receiving antiretroviral therapy. Rev Esp Cardiol. 2016;69:529–30.CrossRefGoogle Scholar
  25. 25.
    Tseng ZH, Secemsky EA, Dowdy D, Vittinghoff E, Moyers B, Wong JK, Havlir DV, Hsue PY. Sudden cardiac death in patients with human immunodeficiency virus infection. J Am Coll Cardiol. 2012;59:1891–6.CrossRefGoogle Scholar
  26. 26.
    Boersma L, Burke MC, Neuzil P, Lambiase P, Friehling T, Theuns DA, Garcia F, Carter N, Stivland T, Weiss R. Infection and mortality after implantation of a subcutaneous ICD after transvenous ICD extraction. Heart Rhythm. 2016;13(1):157–64.CrossRefGoogle Scholar
  27. 27.
    Jessup M, Brozena S. Heart failure. N Engl J Med. 2003;348:2007–18.CrossRefGoogle Scholar
  28. 28.
    Uriel N, Nahumi N, Colombo PC, Yuzefpolskaya M, Restaino SW, Han J, Thomas SS, Garan AR, Takayama H, Mancini DM, Naka Y, Jorde UP. Advanced heart failure in patients infected with human immunodeficiency virus: is there equal access to care? J Heart Lung Transplant. 2014;33:924–30.Google Scholar
  29. 29.
    Pamboukian SV, Baddley JW, Kirklin JK, Cantor RS, Naftel DC, Miller JD, Teuteberg JJ. Outcomes of mechanical circulatory support in HIV infected patients from the INTERMACS registry. J Heart Lung Transplant. 2014;33:S209.Google Scholar
  30. 30.
    Calabrese LH, Albrecht M, Young J, McCarthy P, Haug M, Jarcho J, Zackin R. Successful cardiac transplantation in an HIV-1–infected patient with advanced disease. N Engl J Med. 2003;348:2323–8.CrossRefGoogle Scholar
  31. 31.
    Agüero F, Castel MA, Cocchi S, et al. An update on heart transplantation in human immunodeficiency virus–infected patients. Am J Transplant. 2016;16:21–8.CrossRefGoogle Scholar
  32. 32.
    Muller E, Barday Z, Mendelson M, Kahn D. HIV-positive–to–HIV-positive kidney transplantation – results at 3 to 5 years. N Engl J Med. 2015;372:613–20.CrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Medicine/Cardiology, Cardiovascular MedicineUniversity Hospitals Cleveland Medical CenterClevelandUSA
  2. 2.Department of Cardiovascular Medicine, Harrington Heart and Vascular InstituteUniversity Hospitals Cleveland Medical CenterClevelandUSA
  3. 3.Case Western Reserve University School of MedicineClevelandUSA

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