Cardiovascular Manifestations of HIV

Aka: Cardiovascular Manifestations of HIV, HIV related Cardiovascular Complications, Hyperlipidemia Management in HIV

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II. Causes: Medication Adverse Effects

  1. Direct cardiotoxicity
    1. Abacavir (Ziagen)
    2. Lopinavir/Ritonavir (Kaletra)
  2. Dyslipidemia or Lipodystrophy
    1. Protease Inhibitors (especially boosted Protease Inhibitors)
    2. Abacavir
    3. Efavirenz
    4. Elvitegravir/Cobicistat

III. Associated Conditions: Common

  1. Coronary Artery Disease
    1. Longstanding HIV carries a coronary disease equivalent risk similar to Diabetes Mellitus
    2. HIV-Related Contributing Factors to accelerated atherogenesis
      1. Chronic inflammatory changes
      2. Virus infected Macrophages
      3. Endothelial dysfunction
      4. CD4 Count <500 is associated with an increased risk of coronary events (even if it rebounds)
      5. Patients with HIV also have higher rates of Tobacco Abuse and Hypertension
      6. Protease Inhibitors also increase dyslipidemia and Insulin Resistance
    3. References
      1. Frieberg (2013) JAMA Intern Med 173(8):614-22 [PubMed]
  2. Cerebrovascular Disease
    1. Secondary to direct HIV neurotoxicity, opportunistic infections, Coagulopathy, chronic inflammation
    2. Patients with HIV also have higher rates of Tobacco Abuse, IVDA, CAD, Hypertension, CKD
    3. Strokes occur at younger ages in HIV patients (esp. with lower CD4 Counts, higher viral loads)
    4. D'Ascenzo (2015) J Cardiovasc Med 16(12):839-43 [PubMed]
  3. Dyslipidemia
    1. Obtain lipid panel and Serum Glucose at time of HIV diagnosis
    2. Repeat lipid panel and Glucose screening at perioidic intervals
    3. Protease Inhibitors provoke Hypertriglyceridemia and Low HDL
    4. Consider Statins if indicated (based on non-HIV Infection guidelines)
      1. Risk of Statin-related Drug Interactions with Protease Inhibitors, NNRTI agents
      2. Pitavastatin has the least Drug Interactions and may be preferred in HIV patients
  4. HIV Cardiomyopathy
    1. See HIV Cardiomyopathy

IV. Associated Conditions: Other HIV-Related Cardiovascular Conditions

  1. Less common
    1. Myocarditis
    2. Pericardial Effusion
      1. May develop from HIV Infection or Immunocompromised state
      2. Opportunistic infections (e.g. Mycobacterium, HSV, CMC, Toxoplasmosis, Histoplasmosis, Cryptococcus)
      3. Malignancy (Kaposi Sarcoma, Lymphoma)
    3. Pericarditis
    4. Arrhythmias
    5. Autonomic Dysfunction
  2. Rare Conditions
    1. Endocarditis
      1. In addition to Bacteria (staph, strep, HACEK), fungal organisms (e.g. Candidiasis, Cryptococcus)
    2. Primary Pulmonary Hypertension (plexogenic pulmonary arteriopathy)

V. Management

  1. In those with Cardiac Risk Factors, avoid agents with cardiotoxicity risk (see above)
  2. See Cardiac Risk Management
  3. Tobacco Cessation
  4. Hyperlipidemia Management in HIV
    1. Obtain lipid profile (and Serum Glucose)
      1. Baseline at HIV diagnosis
      2. Obtain at 2-8 weeks after starting Antiretroviral therapy
      3. Obtain at least annually (more often when elevated)
    2. Statin indicated for 10 year Cardiac Risk >5 to 7.5%
      1. Risk of Statin-Induced Myopathy
      2. Pitavastatin start 2 mg orally daily (preferred for least Drug Interactions)
      3. Atorvastatin (Lipitor) start 10 mg orally daily
      4. Rosuvastatin (Crestor) start 5 mg orally daily

VI. References

  1. Baloor (2018) Exam Preparatory Manual for Undergraduates Medicine, Jaypee Brothers, India, p. 242
  2. (2019) Presc Lett 26(8): 46
  3. Mathieu (April, 2000) Federal Practitioner, p. 18-20
  4. Swaminathan and Bafuma in Herbert (2017) EM:Rap 17(3): 2
  5. Chu (2017) Am Fam Physician 96(3): 161-9 [PubMed]
  6. Jaqua (2026) Am Fam Physician 113(1): 71-9 [PubMed]

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