Heart Failure Risk in Patients With HIV

In this podcast, Alan S. Go, MD, discusses the results of his recent study, which examined the relationship between HIV, heart failure, and patient demographics.

Additional Resource: 

• Go AS, Reynolds K, Avula HR, et al. Human immunodeficiency virus infection and variation in heart failure risk by age, sex, and ethnicity: the HIV HEART study. Mayo Clin Proc. 2022;97(3):P465-479. doi:10.1016/j.mayocp.2021.10.004

Alan S. Go, MD, is the regional medical director for the Clinical Trials program and an associate director, Cardiovascular and Metabolic Conditions, for the Division of Research at Kaiser Permanente Northern California, in Oakland, CA.

TRANSCRIPTION: 

Leigh Precopio: Hello everyone, and welcome to another installment of Podcasts360, your go-to resource for medical news and clinical updates. I'm your moderator, Leigh Precopio, with Consultant360.

Individuals with HIV are often at high risk of other health conditions and comorbidities. As the treatment and management of HIV has improved drastically over the past few decades, individuals with HIV are living longer and facing new concurrent health complications in old age that have been previously uncommon in this patient population, such as heart failure. Authors of a recent study sought to investigate the relationship between HIV and heart failure, and how demographics such as age sex and ethnicity impacted this relationship.

To learn more about the study results and their implications, we are joined today by lead study author, Dr Allen S. Go, regional medical director for the Clinical Trials Program and associate director for the Division of Research at Kaiser Permanente Northern California.

Thank you for taking the time to join me today, Dr Go. To begin, could you provide some background on the rationale that prompted this study?

Alan Go: Yes. The background for the study really involves a recognition that with a growing population of people living with HIV, that because of the effective treatment, and they're living the older and older ages. And because of that, they're starting to experience a lot of conditions and complications that are associated with aging. And 1 in particular have been cardiovascular complications. Specifically there's been a lot of focus about the risk of things like a heart attack or stroke, very appropriately, that could be linked to the virus or even to the treatments for the virus. But what was receiving less attention is actually the risk of heart failure. And for many in the field, I think there may have been some assumptions that the risk that may be showing up for heart failure is really linked primarily to things like early heart attacks or just narrowing of the blood vessels to the heart. And we wanted to look at that and specifically to see whether or not it varied across different sociodemographic characteristics.

Leigh Precopio: Your study notes that the risk of heart failure was not primarily mediated through atherosclerotic disease, pathways or differential use of cardio preventative medicine. Did the results surprise you or were they anticipated? And what are the clinical implications of these findings?

Alan Go: So, as I alluded to, there were some in the field that would think that because there was a higher risk of developing heart attacks in patients living with HIV, that naturally there would be just more heart failure. And we wanted to dissect that out.

We know that there are common risk factors for either having a heart attack or stroke or heart failure. Those include things like high blood pressure, abnormal cholesterol levels, and certain behaviors like smoking or excess alcohol intake, and things like that. We also thought that maybe that there might be potential for differential use of some of these medications because they may have some contraindications to other medications that these individuals take. So our study is 1, I think, of the first to try to tease that out. And so we certainly went into this thinking that it's possible that if we observe people living with HIV experiencing more heart failure, that in large part it may be due to the fact that they suffer from more heart attacks and narrowing in the blood vessels.

It turns out that we did not find that. That the risk of heart failure was still present and largely not explained by that. And so that's very important clinically because even if we do a lot of the things we would normally do to reduce the risk for heart attack, it may not eliminate the risk for heart failure. And that's important given that we wanna maximize everything we can do to reduce overall risk of complication with the heart. But it also tells us that we have some unanswered questions about how we can specifically reduce the risk of heart failure. And particularly cuz we noticed that it varied across different groups.

Leigh Precopio: Did your study consider any patient specific factors, such as family medical history or other comorbidities?

Alan Go: We did. So in this particular study we were able to match up patients who were living with HIV and those who were not. And we were able to account for any differences in things like age and other risk factors and also other kinds of comorbidity. And it turns out that in fact, not surprisingly, even after we did that, there's still differences between the patients. And yet when we fully accounted for everything, there was still clearly an excess risk of heart failure that we could not explain by things we measured. And so that includes importantly, that the use of these medications that people would normally take to prevent heart disease actually was not different between the groups, and therefore that was not an explanation.

And again, even when we accounted for differences in known risk factors for heart failure or other forms of heart disease, it did not explain away the excess risk we saw in people living with HIV. We also looked to account for different things like geography, et cetera. And we found that did not explain our findings. And again, in all of that, we found that patients who are younger, women and particular racial/ethnic groups seem to be at even higher risk than just overall living with HIV.

Leigh Precopio: Significant demographic health care disparities exist among individuals with HIV and individuals with heart failure. How do you hope that your study findings will help health care practitioners better address these disparities?

Alan Go: So I do think that there are clear opportunities with regard to traditional cardiovascular risk factors. We know that we need to systematically search for them in people living with HIV. Because we actually have proven therapies for those and they are gonna help to reduce the risk of things like again, heart attack and stroke. The other part, I think to reduce disparities is to have a greater sensitivity about possible symptoms that may reflect underlying heart failure. And that's 1 of the things in clinically, we may not just appreciate as much prior to the study that there is this underlying higher risk of heart failure, independent, again, of having a heart attack or stroke.

So I think that our providers need to be more sensitive to those symptoms and to have a fairly low threshold to evaluate whether or not the heart is working properly. That could be done through imaging tests like echocardiograms and also just working through the evaluation of the symptoms and doing a thorough workup for them. Because I think that's important that if we can identify people who have early heart failure, we have thankfully a number of medications that allow us to healthily intervene and allow them to have a longer and healthier life, even if they develop heart failure.

Leigh Precopio: What knowledge gaps remain on the relationship between HIV and heart failure, and what are the next steps for research?

Alan Go: There are several things I think that come out of our study to highlight, you know, where we still need to do work. I think number 1 is, as I mentioned earlier, is that we went in thinking that maybe a significant part of the excess risk for heart failure really came from just having more heart attacks, and that wasn't the case. So it raises the question about whether there are specific things that HIV does to the body and the heart that we need to figure out and identify those mechanisms, because then we can actually start targeting treatments.

The other thing that we're active exploring is whether or not some of the therapies we use to treat HIV, some of the antiretroviral therapies, maybe those might be contributing as well. And so we're actively exploring that right now because we might be able to identify the people who are particularly high risk and tailor their antiretroviral therapy regimen to not increase their chance of having heart failure. The other aspect is it gets to the prior question, which is now that we know that there is a high risk among certain demographic groups, again younger patients, women, Asian and Pacific Islanders in particular, that those are opportunities for us to improve clinical care by particularly again having greater surveillance and seeing where that really works. Meaning if we're actually actively pursuing symptoms in those particular groups, maybe we can identify cases of heart failure earlier and begin to see whether we can reduce the overall risk in the population.

Leigh Precopio: Was there anything else that you would like to add?

Alan Go: I think that the important part here is that our study was done across 3 Kaiser Permanente regions. Which as fully integrated health care delivery systems, 1 of the important things in prior research was they couldn't tease out whether access to care was a major contributor to why we might find either disparities in care or disparities in the risk of heart failure. So I think by having populations that were receiving comprehensive care through this sort of integrated health care delivery framework, there were 2 important things.

One is that we took care of that factor. All of these patients had access to care and they actually have robust population health management programs for people living with HIV. So I think that tells us that number 1, having that kind of systematic access care is really important overall.

Secondly, we found that by having that integrated health care, we can remove actually a lot of the potential disparities in how people get cardiopreventive treatment. And so I think that's important because that begins to, again, tell us where we need to focus our next efforts, both in research as well as in care by getting people systematic access to care and then ensuring that we're maximizing guideline based recommendations.

Leigh Precopio: Great. Thank you so much for speaking with me today, Dr Go.

Alan Go: Thank you. Yeah, I really appreciate the opportunity to share about our study and appreciate the interest in helping to reduce the disparities in heart failure in people with HIV.