HIV Infection Linked to 40% Increase in Veterans’ Risk of Developing Heart Failure

by U.S. Medicine

June 14, 2017

Risk Manifests Much Earlier in Those Patients

By Annette M. Boyle

WEST HAVEN, CT — Antiretroviral therapy has extended the lives of veterans with human immunodeficiency virus (HIV) by decades, but a new threat could cut back their longevity.

A study published recently in JAMA Cardiology found that veterans with HIV had a 40% increase in heart failure of all types. Those patients had a 61% elevated risk of heart failure with reduced ejection fraction and a 21% increase in heart failure with preserved ejection fraction compared to veterans without HIV infection.1

Veterans with HIV were also found to have a 21% higher risk of borderline heart failure with preserved ejection fraction than other veterans.

During the study, 2,636 heart failure events occurred over a median follow-up period of 7.1 years, with HIV-diagnosed veterans experiencing 941 of those events. Heart failure with reduced ejection fraction accounted for 40% of all events.

“Not only are we seeing a higher rate of heart failure among this group, we are seeing it present decades earlier than expected,” explained lead author Matthew Frieberg, MD, associate professor of Cardiovascular Medicine at Vanderbilt University in Nashville, TN.

The study is touted as the first to show an increased risk of heart failure associated with HIV in the recent antiretroviral therapy (ART) era of HIV. It challenges the assumption that heart failure with reduced ejection fraction had faded as a problem for people living with HIV in high-income countries where ART is available, according to an accompanying editorial.

Still, the authors said they were not surprised to find the increased risk. “Heart failure, like other organ system failures, is often the result of prolonged injury, such as occurs with chronic HIV infection,” pointed out co-author Amy Justice, MD, PhD, lead investigator of the Veterans Aging Cohort Study (VACS) and professor at the Yale School of Public Health in New Haven, CT.

The study used data from VACS, which enrolled 98,015 veterans after April 1, 2003, and followed them through September 30, 2012. Just less than one-third of participants (32.2%) had HIV. Of those, about three-quarters were taking antiretroviral therapy (ART). None of the participants had cardiovascular disease at baseline.

The higher risk for heart failure remained consistent, even when the researchers excluded veterans who had hypertension, had ever smoked or had substance abuse disorders. The findings echoed clinical results for cardiovascular disease more generally.

“Even after adjustment for established risk factors, HIV patients have an increased risk for cardiovascular disease,” Justice said. Veterans in the study who had HIV were less likely to have typical risk factors for heart failure including hypertension, diabetes, hypercholesterolemia and obesity than their uninfected peers.

Click To Enlarge

Some Good News

The study had good news, however, for many of those on ART. Veterans with CD4 cell counts of less than 200 cells/mm or viral loads higher than 500 copies/ml had greater risk for heart failure than veterans who had less severe disease. Both higher CD4 counts and lower viral load generally correlate with ART.

The authors of an accompanying editorial, Gerald Bloomfield, MD, MHS, and Michael Felker, MD, both of Duke University, Durham, NC, advocated taking steps to boost immune system function and increase CD4 cell counts. They also recommended initiating “therapies early in the disease course to mitigate heart failure and total cardiovascular disease risk.”

Justice took a more nuanced approach. “Overall, ART decreases risk by lowering the burden of the virus,” she told U.S. Medicine, but whether more intervention in this population is a good idea across the board is less clear.

“This is a complicated question because people aging with HIV infection also have more polypharmacy. Ideally, we need to personalize management by identifying those at substantial risk of cardiovascular disease so that we can treat those at risk and avoid unnecessary treatments in those at low to no risk,” she said.

While individuals with HIV infection have higher risk of heart failure than those without the infection, within the affected group, the risk differs significantly based on several factors. The authors noted that “the association between HIV infection and types of heart failure varies by age, race/ethnicity, HIV-specific biomarkers, and receipt of antiretroviral therapy.”

Veterans with HIV who were younger than 40 years of age when the study started, for instance, had a particularly elevated risk of heart failure with reduced ejection fraction—nearly  3.6 times the risk of uninfected young veterans. The authors noted that the risk of this type of heart failure “can manifest decades earlier than would be expected in a typical uninfected population.”

Learning more about which individuals are at risk for which type of heart failure requires further research, as the mechanisms, appropriate therapies and typical outcomes differ between the three subtypes.

They encouraged adoption of a strategy that includes the risk of heart failure in developing treatment plans for individuals with HIV. “We want providers to think about heart failure in this population. It’s imperative that they understand that the risk is there and that we begin to develop guidelines for prevention and management for this high-risk population,” Frieberg said.

  1. Freiberg MS, Chang CH, Skanderson M, Patterson OV, et. al. Association Between HIV Infection and the Risk of Heart Failure With Reduced Ejection Fraction and Preserved Ejection Fraction in the Antiretroviral Therapy Era: Results From the Veterans Aging Cohort Study. JAMA Cardiol. 2017 May 1;2(5):536-546. doi: 10.1001/jamacardio.2017.0264. PubMed PMID: 28384660.

Comments are closed here.

Related Articles

Low to No Alcohol Use Optimizes Health Outcomes in HIV Patients

SEATTLE—For years, physicians have encouraged patients diagnosed with human immunodeficiency virus to minimize or avoid drinking alcohol. But how much does it really matter? “Controlled alcohol use over time, especially nonuse or very low-level use,... View Article

Army Researchers Identify a CV Bonus from Early ART Initiation in HIV

SAN ANTONIO, TX—ART has never looked better, at least if you’re an individual recently diagnosed with human immunodeficiency virus.  Researchers at the Brooke Army Medical Center in San Antonio recently determined that antiretroviral therapy reverses... View Article

U.S. Medicine Recommends

More From department of veterans affairs

Department of Veterans Affairs (VA)

VA Manages Drug Costs Better than Medicare Part D

ST. LOUIS – Medicare Part D could save more than $14 billion annually if it paid the same prices for top medications as the VA, according to a new study. A research letter published earlier... View Article

Department of Veterans Affairs (VA)

House Passes Bill to Create Education/Employment Arm of VA

WASHINGTON,—Legislators have reintroduced plans to create a fourth administration within the Department of Veterans Affairs—one dedicated to overseeing veterans’ education, transition and employment benefits. Currently these operations fall under the Veterans Benefits Administration, with VBA... View Article

Department of Veterans Affairs (VA)

Administrative Confusions Results in Little Oversight of VA’s Police Force

Suicides, Violence at VMACs Put Spotlight on Security WASHINGTON—As the number of suicides and other violent incidents at VA facilities grows, a spotlight is being thrown on VA’s internal police force and its ability to... View Article

Department of Veterans Affairs (VA)

Veterans Using Dual Health Systems Have More Problems With Medications

CHARLESTON, SC—More than half of the patients treated by VA are also Medicare eligible, and that is increasing the risk for a range of prescription medication problems—from chronic disease medication nonadherence to opioid overdoses—among dual... View Article

Department of Veterans Affairs (VA)

All VA Healthcare Facilities to Be Completely Smoke-Free by October

New Directive Abolishes Designated Smoking Zones WASHINGTON—Starting in October, all VA healthcare facilities will be official no-smoking zones. While VA now permits smoking in designated areas, the department has issued a new policy restricting smoking... View Article

Subscribe to U.S. Medicine Print Magazine

U.S. Medicine is mailed free each month to physicians, pharmacists, nurse practitioners, physician assistants and administrators working for Veterans Affairs, Department of Defense and U.S. Public Health Service.

Subscribe Now

Receive Our Email Newsletter

Stay informed about federal medical news, clinical updates and reports on government topics for the federal healthcare professional.

Sign Up