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JAMA Cardiol. 2017 May 1;2(5):536-546. doi: 10.1001/jamacardio.2017.0264.

Association Between HIV Infection and the Risk of Heart Failure With Reduced Ejection Fraction and Preserved Ejection Fraction in the Antiretroviral Therapy Era: Results From the Veterans Aging Cohort Study.

Author information

1
Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee2Geriatric Research Education and Clinical Centers, Veterans Affairs Tennessee Valley Healthcare System, Nashville.
2
Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
3
Research Division, Veterans Affairs Connecticut Health Care System, West Haven Veterans Administration Medical Center, West Haven.
4
Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City6Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City.
5
Research Division, Veterans Affairs Connecticut Health Care System, West Haven Veterans Administration Medical Center, West Haven7Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut.
6
Division of General Internal Medicine, Boston University, Boston, Massachusetts.
7
Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.
8
Department of Medicine, University of Maryland School of Medicine, Baltimore11Division of Infectious Diseases, Baltimore Veterans Affairs Health Care System, Baltimore, Maryland12Division of Cardiology, Baltimore Veterans Affairs Health Care System, Baltimore, Maryland.
9
Department of Medicine, University of Maryland School of Medicine, Baltimore.
10
Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles.
11
Department of Medicine, Baylor College of Medicine, Houston, Texas15Division of Infectious Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
12
Department of Pathology and Laboratory Medicine, University of Vermont College of Medicine, Burlington.
13
Department of Medicine, George Washington University School of Medicine, Washington, DC18Division of Infectious Diseases, Washington DC Veterans Affairs Medical Center, Washington, DC.
14
Department of Medicine, Emory University School of Medicine, Atlanta, Georgia20Division of Infectious Diseases, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia.
15
Department of Medicine, Veterans Affairs North Texas Health Care System, Dallas.
16
Division of Infectious Diseases, James J. Peters Veterans Affairs Medical Center, Bronx, New York23Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
17
Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles24Division of Infectious Diseases, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California.
18
Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles25Division of Cardiology, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California.
19
Department of Medicine, University of Washington School of Medicine, Seattle.
20
Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
21
Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.
22
Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
23
Research Division, Veterans Affairs Connecticut Health Care System, West Haven Veterans Administration Medical Center, West Haven29Department of Medicine, Yale School of Medicine, New Haven, Connecticut.
24
Department of Medicine, Weill Cornell Medical College, New York, New York.

Abstract

Importance:

With improved survival, heart failure (HF) has become a major complication for individuals with human immunodeficiency virus (HIV) infection. It is unclear if this risk extends to different types of HF in the antiretroviral therapy (ART) era. Determining whether HIV infection is associated with HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), or both is critical because HF types differ with respect to underlying mechanism, treatment, and prognosis.

Objectives:

To investigate whether HIV infection increases the risk of future HFrEF and HFpEF and to assess if this risk varies by sociodemographic and HIV-specific factors.

Design, Setting, and Participants:

This study evaluated 98 015 participants without baseline cardiovascular disease from the Veterans Aging Cohort Study, an observational cohort of HIV-infected veterans and uninfected veterans matched by age, sex, race/ethnicity, and clinical site, enrolled on or after April 1, 2003, and followed up through September 30, 2012. The dates of the analysis were October 2015 to November 2016.

Exposure:

Human immunodeficiency virus infection.

Main Outcomes and Measures:

Outcomes included HFpEF (EF≥50%), borderline HFpEF (EF 40%-49%), HFrEF (EF<40%), and HF of unknown type (EF missing).

Results:

Among 98 015 participants, the mean (SD) age at enrollment in the study was 48.3 (9.8) years, 97.0% were male, and 32.2% had HIV infection. During a median follow-up of 7.1 years, there were 2636 total HF events (34.6% were HFpEF, 15.5% were borderline HFpEF, 37.1% were HFrEF, and 12.8% were HF of unknown type). Compared with uninfected veterans, HIV-infected veterans had an increased risk of HFpEF (hazard ratio [HR], 1.21; 95% CI, 1.03-1.41), borderline HFpEF (HR, 1.37; 95% CI, 1.09-1.72), and HFrEF (HR, 1.61; 95% CI, 1.40-1.86). The risk of HFrEF was pronounced in veterans younger than 40 years at baseline (HR, 3.59; 95% CI, 1.95-6.58). Among HIV-infected veterans, time-updated HIV-1 RNA viral load of at least 500 copies/mL compared with less than 500 copies/mL was associated with an increased risk of HFrEF, and time-updated CD4 cell count less than 200 cells/mm3 compared with at least 500 cells/mm3 was associated with an increased risk of HFrEF and HFpEF.

Conclusions and Relevance:

Individuals who are infected with HIV have an increased risk of HFpEF, borderline HFpEF, and HFrEF compared with uninfected individuals. The increased risk of HFrEF can manifest decades earlier than would be expected in a typical uninfected population. Future research should focus on prevention, risk stratification, and identification of the mechanisms for HFrEF and HFpEF in the HIV-infected population.

PMID:
28384660
PMCID:
PMC5541383
DOI:
10.1001/jamacardio.2017.0264
[Indexed for MEDLINE]
Free PMC Article

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