Several Risk Factors for Heart Problems Can Be Changed by People With HIV
A study of almost 700 people with HIV found high rates
of heart function problems at an earlier age than would
be expected in the general US population.1 Several of the factors that contributed to these heart problems --
like smoking, high weight, high blood pressure, and
diabetes -- can be avoided or changed with the help of
health care professionals.
As HIV-positive people live longer because of antiretroviral
therapy, heart disease has emerged as a more frequent
cause of sickness and death. Research shows that
HIV itself and certain antiretrovirals can raise the risk
of heart disease. Heart problems occur in people taking
antiretrovirals2-4 and in untreated people with low CD4
counts.5 It is clear that the overall benefits of antiretroviral
therapy far outweigh any heart-related risk. Still, it is
important to understand how antiretrovirals and other
factors affect the risk of heart disease in HIV-positive
Echocardiography is a type of scan that can detect heart
abnormalities that cannot be felt, for example, as chest
pain. But in time these abnormalities can lead to serious
heart disease. This study used echocardiography to
look for heart abnormalities in almost 700 people with
HIV -- many more than earlier echocardiography studies
in HIV-positive people.
- How the study worked. From March 2004 through
June 2006, the SUN Study signed up 700 HIV-positive
people in four cities: Denver, Minneapolis, Providence,
and St. Louis. The goal is to check SUN Study members
regularly to measure rates of problems such as heart disease
and to identify factors that make those problems
more or less likely.
This analysis involved 656 people who had echocardiography
when they entered the SUN Study. A single echocardiography
expert analyzed these scans to look for five
abnormalities in heart structure or function:
- Left ventricular systolic abnormalities. (The left
ventricle is the lower heart chamber on a person's
left side. See Figure 1. Systole is the heart-pumping
phase in which the left and right ventricles push
- Diastolic abnormalities. (Diastole is the heartpumping
phase in which the heart fills with blood.)
- Pulmonary hypertension. (Pulmonary hypertension
is abnormally high blood pressure in the arteries
of the lungs.)
- Left ventricular enlargement.
- Left atrial enlargement. (The left atrium is the
upper heart chamber on a person's left side.
See Figure 1.)
Figure 1. During the systolic phase of pumping, the
heart contracts to push blood upward from the left
ventricle and the right ventricle. (Illustration courtesy
of Servier Medical Art: www.servier.com/Smart/ImageBank.aspx?id=729.)
SUN Study researchers used standard statistical methods
to identify factors that raised the risk of these five
abnormalities, regardless of whatever other risk factors
a person had.
- What the study found. Of the 656 people studied, 24%
were women, 59% white, 29% black, and 10% Hispanic.
The study group's age averaged 41 years, and a median
of 6 years had passed since they tested positive for HIV.
Three quarters of these people were taking antiretrovirals
when they entered SUN, median treatment duration
was 2.3 years, median CD4 count was 462, and 91%
of study participants had a viral load below 400 copies.
While 44% of these people smoked tobacco when they
entered the SUN Study, 31% smoked marijuana, 13%
used cocaine, and 10% used heroin or amphetamines.
Thirty percent of these people had hypertension (high
blood pressure), and 7% had diabetes.
Half of the SUN Study group had borderline or mild
pulmonary hypertension, 7% had moderate or severe
pulmonary hypertension, 40% had left atrial enlargement,
6% had left ventricular enlargement, 26% had abnormal
diastolic function, and 18% had abnormal systolic
function. (See the bullet list above and Figure 1 for
descriptions of these problems.) Only one third of these
people had no detectable heart structure problems or
heart function abnormalities.
Figure 2. Three factors independently raised the risk of
abnormal left ventricular systolic function. One of these
factors -- current smoking -- can be changed by the affected
person. hsCRP, or high-sensitivity C-reactive protein,
is an indicator of ongoing inflammation in the body,
which may be caused by HIV or other infections.
Figure 3. Hypertension and high hsCRP (a marker of
inflammation) independently raised the risk of abnormal
diastolic function. Currently taking a protease inhibitor
(PI) boosted by Norvir independently raised the
risk of pulmonary hypertension.
Figure 4. Six factors independently raised the risk of left
ventricle enlargement, including overweight in women
(a body mass index at or above 25), diabetes, and current
use of Ziagen. hsCRP, or high-sensitivity C-reactive
protein, is an indicator of ongoing inflammation in the
body, which may be caused by HIV or other infections.
Statistical analysis that calculated the impact of many factors
that may affect heart structure and function found
12 that raised the risk of abnormalities independently
(that is, they raised the risk regardless of whatever other
risk factors a person might have) (Figure 2, 3, and 4).
Some of these factors -- such as race and having a heart
attack before the study -- cannot be changed. But many of the risk factors can be changed. For example, smoking
tobacco independently raised the risk of abnormal left
ventricular systolic function more than 1.5 times (Figure
2). High blood pressure almost doubled the risk of
abnormal diastolic function (Figure 3) and more than
tripled the risk of left ventricle enlargement (Figure 4).
Being overweight raised the risk of left ventricle enlargement
more than 3 times in women (Figure 4). In this
study group, most of the overweight women were non-Hispanic African Americans. Hypertension and smoking
marijuana in the last 6 months independently raised the
risk of left atrial enlargement.
Among people who smoked marijuana, a lowest-ever
CD4 count under 200 raised the risk of systolic abnormalities
more than 75%. Otherwise, the risk of these
heart abnormalities was not independently affected by
lowest-ever or current CD4 count, viral load, or a previous
diagnosis of an AIDS disease.
- What the results mean for you. This study found relatively
high rates of abnormalities in heart structure and
function in middle-aged HIV-positive people with fairly
high CD4 counts. Although these heart abnormalities
could not be felt (for example, they did not cause chest
pain), they could lead to serious heart disease later. The
heart problems could be detected only by echocardiography,
a scan that makes a picture of the heart.
Further analysis identified risk factors for the five abnormalities
detected (Figures 2, 3, and 4). Five of these risk
factors are conditions or behaviors that can be avoided
- High blood pressure
- High body weight (in women)
- Current tobacco smoking
- Current marijuana smoking
Heart trouble is only one of many problems caused by
smoking cigarettes or marijuana. People who smoke
should get help stopping from health care professionals,
community groups, or friends who have managed
to stop. Even people who have smoked for years can
stop, sometimes with the help of nicotine gum or patches
that help break the addiction to nicotine. High blood
pressure, diabetes, and high weight are common causes
of heart disease in the general population. All of them
can be avoided or successfully treated with your doctor's
High-sensitivity C-reactive protein (hsCRP) is a marker
of ongoing inflammation in the body. HIV and other
viruses and bacteria can cause low-level inflammation
even when those viruses and bacteria are not causing
noticeable disease symptoms.
The study also found links between certain types of antiretroviral
therapy and a higher risk of heart abnormalities.
Current use of Ziagen (abacavir) raised the risk of
left ventricle enlargement almost 4 times. And a protease
inhibitor -- such as Prezista (darunavir) or Reyataz (atazanavir) --
boosted by Norvir (ritonavir) raised the risk of
pulmonary hypertension. The SUN Study researchers
warn that these findings must be viewed with caution.
The contribution of any single drug to heart disease
may be very small, they note. And recommendations to
change antiretrovirals just to prevent heart disease "cannot
be made on the basis of this study alone."
Considering all of their findings, the SUN Study team
makes the following suggestion: HIV infection itself or
use of certain antiretrovirals might speed up changes in
heart structure and function that usually occur later in
life in people without HIV. It will take further study to
see if that suggestion proves true. In the meantime, people
with HIV should do everything possible to control
known heart risk factors, like high weight, high blood
pressure, diabetes, and smoking.
- Mondy KE, Gottdiener J, Overton ET, et al. High prevalence of echocardiographic abnormalities among HIV-infected persons
in the era of highly active antiretroviral therapy. Clin Infect Dis. 2011;52:378-386.
- The DAD. Study Group. Class of antiretroviral drugs and the risk of myocardial infarction. N Engl J Med. 2007;356:
- Holmberg SD, Tong TC, Ward DJ, et al. Protease inhibitor drug use and adverse cardiovascular outcomes in ambulatory
HIV-infected persons. Lancet. 2002;360:1747-1748.
- Grinspoon S, Carr A. Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med. 2005;352:48-62.
- The Strategies for Management of Antiretroviral Therapy (SMART) Study Group. CD4 count-guided interruption of
antiretroviral treatment. N Engl J Med. 2006;355:2283-22896.
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