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Several Risk Factors for Heart Problems Can Be Changed by People With HIV

March 2011

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 people.

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 blood upward.)
    • 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: Heart structure.

    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:

    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: Risk factors for abnormal left ventricular systolic function.

    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: Risk factors for abnormal diastolic function and pulmonary hypertension.

    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: Risk factors for left ventricle enlargement.

    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 or treated:

    • High blood pressure
    • Diabetes
    • 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 help.

    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.


  1. 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.
  2. The DAD. Study Group. Class of antiretroviral drugs and the risk of myocardial infarction. N Engl J Med. 2007;356: 1723-1735.
  3. 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.
  4. Grinspoon S, Carr A. Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med. 2005;352:48-62.
  5. 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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This article was provided by The Center for AIDS Information & Advocacy. It is a part of the publication HIV Treatment ALERTS!. Visit CFA's website to find out more about their activities and publications.
See Also
An HIVer's Guide to Metabolic Complications
HIV and Cardiovascular Disease
High Blood Cholesterol: What You Need to Know
Quiz: Are You at Risk for HIV?
10 Common Fears About HIV Transmission
More on Heart Disease Prevention

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