Pulmonary arterial hypertension in HIV is rare and is possibly linked to inflammatory mediators, growth factors, and vasoconstrictors. Patients may present with progressive dyspnea, chest discomfort, dizziness, and syncope. The investigators noted that patients with HIV have shown higher pulmonary artery systolic pressures than patients without HIV, but screening is not recommended in patients who are asymptomatic.2

“The effect of cART on patients with HIV-PAH (pulmonary arterial hypertension) is controversial,” they wrote. “Retrospective studies have suggested a decrease in pulmonary artery systolic pressures after introduction of cART.3,4 However, 2 later retrospective studies5,6 demonstrated an increase in pulmonary artery pressures or no changes in right heart hemodynamics after the introduction of cART.”


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Sudden cardiac death has significantly contributed to mortality in patients with HIV. In one study,7 13% of patients met the criteria for sudden cardiac death, which is 4-fold higher than in the general population. Of note, CD4 cell count and viral load levels did not appear to affect the risk; therefore, even if patients have high CD4 cell counts and low viral loads, they still have an increased risk of sudden cardiac death.7

Conversely, lower CD4 count and higher viral load were independently associated with incident atrial fibrillation risk, which suggests the pathogenesis may be related to inflammation.8 Warfarin and cART do have potential drug interactions, and patients who are receiving cART need a higher mean warfarin maintenance dose.9 In addition, the effects of rivaroxaban and apixaban are likely to be increased by most protease inhibitors. Bleeding risks may be increased with both of these agents but not with dabigatran.10

CHD and HIV

In “HIV and Ischemic Heart Disease,”2 the researchers noted that patients with HIV have a “stepwise increase” in their risk of myocardial infarction (MI) depending on the number of CVD risk factors (eg, smoking, dyslipidemia, hypertension, central obesity) present.11 Women with HIV have double the risk of developing CHD compared with men, which the investigators noted may be related to higher levels of immune activation in women.12

The immune system itself plays a crucial role in the development and progression of atherosclerosis in patients with HIV. Higher levels of C-reactive protein, interleukin-6, and tumor necrosis factor have been detected in these patients.13-15

Traditional risk factor calculators like the Framingham Risk Score may not accurately predict CHD risk in a patient with HIV. HIV-specific risk calculators have been in development, but none are currently validated or in widespread use.16,17 However, noninvasive imaging techniques (eg, stress echocardiography, computed tomographic coronary angiography, and carotid intima-media thickness testing have been successful at identifying the increased risk of CHD in patients with HIV.18

CHD typically presents in patients with HIV as an episode of acute coronary syndrome (ACS), specifically MI.19 These patients experience such an episode about 10 years younger than the general population (mean age: 50 years). However, little is known about patients who present with ACS in developing nations. The cause of ST-segment elevation MI there is usually documented as “related to a large thrombus burden in the infarct-related artery, with angiographically normal underlying coronary arteries.”19-23

“It is possible that the HIV virus subtype infection may play a role, as [it] differs in various regions,” the authors wrote. “The major subtype infection in Africa is HIV-1, subtype C, whereas in developed countries, the infection is with HIV-1 subtype B.”22,23

As with heart failure and atrial fibrillation therapies, clinicians should be aware of possible drug interactions when prescribing medication for HIV-related ACS, particularly with thienopyridines and clopidogrel. Prasugrel is considered a good alternative for the latter, but should not be used in combination with ritonavir because prasugrel’s activity will decrease. In addition, ticagrelor should not be used in patients who receive protease inhibitor therapy.24,25

In the event of surgical intervention, drug-eluting stents can be implanted in patients with HIV, and coronary artery bypass grafting outcomes are similar between patients with and without HIV.26 There may be higher rates of stent thrombosis, but the data are limited.27 Finally, in-hospital mortality from ACS is similar in patients with and without HIV.28