Patients with Comorbid Heart Failure, HIV Infection Need Optimal HIV Therapy

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People living with HIV are known to be at a heightened risk of developing cardiovascular diseases, including heart failure (HF). However, there has been little research on how HIV status influences HF outcomes.

Tomas G. Neilan, MD, MPH, director of the Cardio-Oncology Program, and colleagues recently conducted the first contemporary U.S. study of this question. In the American Heart Journal, they report that HF patients with HIV had higher rates of hospital readmission and mortality than HF patients without HIV, but only if they had a low CD4 count or detectable viral load during the index hospitalization.

Dr. Neilan's group created a cohort of 2,308 patients with heart failure who were admitted to a tertiary care medical center in the Bronx, New York in 2011. Each patient's HIV status was verified by reviewing their electronic health record. The cohort was found to consist of 374 patients with HIV infection and 1,934 without.

They were stratified according to left ventricular ejection fraction:

• HF with reduced ejection fraction, <40% (HFrEF): 171 patients with HIV, 941 without
• HF with preserved ejection fraction, ≥50% (HFpEF): 164 with HIV, 821 without
• HF with borderline EF, 40%-49% (HFbEF): 39 with HIV, 172 without

Demographic and clinical characteristics were similar in patients with and without HIV, except that those with HIV were significantly more likely to have elevated pulmonary artery systolic pressure, use cocaine and have hepatitis C virus infection.

The primary outcome measure, the rate of HF-related hospital readmission within 30 days of discharge, was 35% overall. The rate was significantly higher among patients with HIV than those without (49% vs. 32%, < .001).

Findings were similar when the researchers calculated 30-day readmission according to type of heart failure:

• HFrEF: 52% of patients with HIV vs. 31% of those without ( < .001)
• HFpEF: 44% vs. 33% ( = .006)
• HFbEF: 53% vs. 33% ( = .01)

The median duration of follow-up was 19 months. Mortality rates were significantly higher in HF patients with HIV than in those without: cardiovascular mortality, 26% versus 13.5%; all-cause mortality, 38% versus 22% (< .001 for both comparisons).

Based on an adjusted multivariable model, factors associated with greater risk of readmission among HF patients with HIV were smoking, history of coronary artery disease, cocaine use, elevated pulmonary artery systolic pressure and low CD4 count or high viral load.

The researchers further determined that HIV control influenced outcomes irrespective of ejection fraction. HF patients with HIV who had a detectable viral load (≥200 copies/mL) or CD4 count (<200 cells/mm³) during the initial hospitalization had a significantly higher readmission rate and significantly higher cardiovascular mortality, compared with those who did not have HIV.

In contrast, rates of 30-day readmission and cardiovascular mortality among patients with an undetectable viral load were similar to those of HF patients without HIV.

Effective antiretroviral therapy that leads to immunologic rebound and viral suppression may partially protect people who have HIV and also have HF against adverse heart failure outcomes, the research team concludes.

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