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Canadian Journal of Cardiology

Cardiomyopathy and Heart Failure in Patients With HIV Infection

Published:October 19, 2018DOI:https://doi.org/10.1016/j.cjca.2018.10.009

      Abstract

      With the advent and widespread use of antiretroviral therapy (ART), the epidemiology of cardiomyopathy and heart failure (HF) associated with HIV infection is changing. Near-normal life expectancy in contemporary HIV-infected populations has been associated with prolonged exposure to increased cardiometabolic burden and chronic immune activation and systemic inflammation. Therefore, the pre-ART phenotype of HIV-associated cardiomyopathy with overt left ventricular systolic dysfunction and poor prognosis has been replaced over time by cardiomyopathy with a more insidious course, more frequent ischemic background, and highly prevalent left ventricular diastolic dysfunction. Patients with HIV are more prone to development of coronary artery disease and development of HF after myocardial infarction. The role of ongoing immune activation and systemic inflammation, despite highly active ART (HAART), appears to be central in this process. The role of HAART toxicity is controversial, as HAART itself appears to be protective for the development of HF, but recent data suggest that protease inhibitors might adversely affect the course of HIV-associated HF. Because of these unique features, the optimal therapeutic approach for HIV-associated cardiomyopathy remains unknown. The current therapeutic approaches are an extrapolation from noninfected populations. Importantly, the significance of the highly prevalent diastolic abnormalities among HIV-infected patients is not known. Therefore, further research is needed to identify its prognostic implications. Considering the prevalence of structural and functional cardiac abnormalities in HIV-infected persons and the lack of evidence on how to best screen and treat these patients, systematic research on this topic is a public health priority.

      Résumé

      Avec la mise au point et l’utilisation généralisée du traitement antirétroviral (TAR), les caractéristiques épidémiologiques de la cardiomyopathie et de l’insuffisance cardiaque (IC) associées à l’infection par le VIH sont en train de changer. L’espérance de vie quasi normale des populations contemporaines infectées par le VIH a été associée à une exposition prolongée à une augmentation du fardeau métabolique, à une activation immunitaire chronique et à une inflammation généralisée. Par conséquent, le phénotype pré-TAR de la cardiomyopathie associée au VIH, une dysfonction systolique ventriculaire gauche manifeste de pronostic défavorable, a été remplacé au fil du temps par une cardiomyopathie caractérisée par une évolution plus insidieuse, un contexte ischémique plus fréquent et une dysfonction diastolique ventriculaire gauche extrêmement prévalente. Chez les patients vivant avec le VIH, la probabilité de survenue d’une coronaropathie et d’une IC après un infarctus du myocarde est plus élevée. L’activation immunitaire chronique et l’inflammation généralisée, malgré un TAR hautement actif (TARHA), semblent jouer un rôle central dans ce processus. L’effet de la toxicité du TARHA est une question controversée, car alors que le TARHA semble protéger contre l’apparition de l’IC, des données récentes laissent croire que les inhibiteurs de la protéase pourraient avoir un effet défavorable sur l’évolution de l’IC associée au VIH. En raison de ces caractéristiques uniques, l’approche thérapeutique optimale de la cardiomyopathie liée au VIH demeure incertaine. Les schémas thérapeutiques actuels ont été élaborés par extrapolation des résultats obtenus dans des populations non infectées. Fait important, on ignore quelle est la portée des anomalies diastoliques hautement prévalentes chez les patients infectés par le VIH. Par conséquent, il est important de poursuivre les recherches afin de déterminer les conséquences pronostiques d’une telle situation. Compte tenu de la prévalence des anomalies cardiaques structurelles et fonctionnelles chez les personnes infectées par le VIH et l’absence de données probantes sur les méthodes les plus appropriées de dépistage et de traitement de ces patients, la recherche continue sur cette question est une priorité de santé publique.
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