Thanks to medical breakthroughs over the years, people with HIV (human immunodeficiency virus) infection live longer now. But they are at a higher risk of cardiovascular complications especially heart attacks and are also prone to developing most health complications faster than people who do not have HIV.
Dr Ragavendra R Baliga, professor and faculty cardiologist, Ohio State University Wexner Medical Center, USA, says HIV-infected (HIV+) persons have a 1.5-fold to two-fold increased risk of having coronary artery disease, and compared to uninfected persons, HIV infected persons presenting the first episode of acute coronary syndromes are, on average, a decade younger.
According to ‘HIV Infection and the Risk of World Health Organization–Defined Sudden Cardiac Death’, a study by Matthew S Freiberg, Meredith S Duncan, et al published in Journal of the American Heart Association in 2021, HIV infection is associated with an increased risk of WHO‐defined SCD (sudden cardiac death). The risk has been observed to be 29 per cent higher among people with HIV with lower CD4 count (which tells the health of the immune system) and 14 per cent higher than people without HIV.
Does HIV affect the heart?
Dr Sunil Chandy, former director of CMC, Vellore, says HIV affects a person’s immunity. “HIV is an immunodeficiency disease,” he says. “It reduces the ability of the body to tackle infection and inflammation.”
Dr Baliga says chronic inflammation and immune dysfunction appear to accelerate the progression of cholesterol plaque erosion and rupture in HIV patients. “Several studies have shown that in HIV-infected patients, rates of heart attack (acute myocardial infarction) are up to twice as high as in non-infected patients,” he says.
Dr Chandy says research also shows that HIV patients are at risk for cardiomyopathy (a disease of the heart muscle), which then leads to ventricular tachycardia (a heart rhythm problem) and sudden death. “The heart muscles get enlarged, which affects [their] pumping function,” he says. “HIV-infected people are also prone to developing complications like myocarditis [inflammation of the heart muscle].”
Dr Chhayakant A Vezare, consultant at DrSafeHands, Mumbai and a former technical expert, Maharashtra State AIDS Control Society, says people with long-term HIV infections are at higher risk of developing plaque in their coronary arteries, regardless of other risk factors. Also, he adds, studies show that non-calcified and partly calcified plaques are more prevalent among HIV-infected people, suggesting increased risk for heart attacks.
Signs of heart problems
The signs and symptoms of heart diseases are similar in HIV patients and those without HIV, but they manifest at a younger age in the former, says Dr Vezare. The symptoms include:
- Chest pain
- Shortness of breath
- Discomfort in the chest
- Fatigue or weakness
- Chest discomfort (angina)
- Pain in the neck, jaw, throat, upper-belly area or back
- Numbness, weakness or coldness in the legs or arms in cases where the blood vessels are narrowed.
HIV effect on heart
Antiretroviral therapy (ART), which involves a combination of medications to treat HIV infection, is also proven to add to the risk of heart problems.
According to Dr Baliga, specific antiretroviral therapeutic regimens can contribute to atherosclerotic disease through dyslipidaemia (unhealthy levels of lipids in blood) and insulin resistance. “The nucleoside reverse transcriptase inhibitor (used to treat HIV) has been associated with elevated rates of heart attacks in studies from the large, multinational data collection on adverse events of anti-HIV drugs cohort and other cohorts,” he says. “But this finding was not reproduced in an analysis of the pooled AIDS clinical trials group cohort.”
Dr Vezare says that some studies show that ART can stimulate the immune system, leading to inflammation. “Inflammation causes swelling and irritation of any body tissues, which will in turn lead to plaque formation in the blood vessels,” he says.
But the use of ART can be a paradox too. “The treatment for heart disease also gets difficult,” Dr Chandy says. “They are exposed to infections when they undergo surgery, and we can’t tell how they will react. They are at higher risk of developing complications.”
When limited to HIV-infected patients on ART, the relative risk of cardiovascular diseases increases twofold compared to the HIV-uninfected, according to ‘Sudden Cardiac Death in Patients with Human Immunodeficiency Virus Infection’, a study published in 2012 by Zian H Tseng, Eric A Secemsky et al.
Some common factors such as high BP, smoking and alcohol also add to the risk for heart problems for people with HIV. “Abnormal lipid profile is also common among HIV+ persons,” Dr Baliga says. “HIV+ persons on antiretroviral therapy, particularly protease inhibitors, tend to have elevated triglycerides and low high-density lipoprotein cholesterol levels.”
Dr Vezare says AIDS-infected people with heart failure experience various physical and emotional symptoms such as dyspnoea (difficulty in breathing), fatigue, edema (swelling due to excess fluid in body tissues), sleeping difficulties, depression and chest pain. “These symptoms limit patients’ daily physical and social activities, and result in poor quality of living,” he says.
Precautions to help prevent heart problems
There are no preventive measures for cardiovascular diseases among HIV-infected people. “People with good immunity will be able to cope with the side-effects of a drug but if you have HIV, you will lose that defence,” says Dr Chandy.
However, Dr Vezare and Dr Baliga suggest a few measures that can help reduce the risk or delay heart problems among people with HIV:
- Take HIV medicines every day
- Eat a healthy diet
- Include lots of vegetables, fruits and whole grains in the diet
- Consume food low in saturated fats, added sugars and salt
- Be physically active on a regular basis
- Avoid or quit smoking and alcohol
- Check lipid profile regularly.
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