In the JournalsPerspective

Sudden cardiac death risk elevated in adults with HIV hospitalized for HF

Tomas G. Neilan

Risk on sudden cardiac death is markedly increased in adults with HIV who are hospitalized with HF. In particular, risk was increased in those with lower left ventricular ejection fraction, lower CD4 count, and higher viral load, according to data published in the JACC Heart Failure.

Cardiology Today discussed these findings with Tomas G. Neilan, MD, MPH, director of the cardio-oncology program at Massachusetts General Hospital, as well as the implications for clinical cardiologists.

“Our hope was to heighten awareness of the increased risk for sudden cardiac death among persons with HIV who also have heart failure,” Neilan said. “In patients without HIV who have heart failure, the risk for sudden death is mostly observed in those with a reduced ejection fraction. Among patients with HIV and heart failure the risk for sudden death was also noted in those with a higher ejection fraction.”

In this retrospective study, researchers analyzed data from 2,578 patients hospitalized with HF at a single center. Of these patients, 344 were living with HIV. The primary outcome was rate of sudden cardiac death (SCD). The researchers also performed subgroup analyses stratified by viral load and LVEF (< 35%, 35-49%, 50%).

Over a mean follow-up of 19 months, there were 191 occurrences of SCD. In comparison, patients with HIV had a threefold increase in SCD compared with those without HIV (21% vs. 6.4%; adjusted OR = 3; 95% CI, 1.78-4.24). The rate of SCD was similar among patients with HIV with an undetectable viral load and those without HIV, and also similar when the researchers evaluated this outcome by LVEF strata, according to the results.

Neilan told Cardiology Today cardiologists should, “[recognize] this as a higher-risk group and consider HIV status when discussing standard measures to prevent sudden death such as placement of a defibrillator. “Decades ago, there was a hesitation to place ICDs in this group. In contemporary cohorts with HIV and on [antiretroviral therapy], HIV status should act as a reason to place an indicated ICD and not to a reason not to place one.”

Among patients living with HIV hospitalized for HF, predictors of increased risk for SCD included cocaine use, lower LVEF, no beta-blocker prescription and viral load.

“Once individuals with HIV develop heart failure, their cardiac outcomes — sudden death and heart failure hospitalizations — are worse,” Neilan said. “We need to better understand why and come up with plausible ways of both reducing the risk for heart failure and improving outcomes in this at-risk population.”

Additionally, 86% of the study population did not have an ICD. that the rate of SCD was 10% per year among patients living with HIV who are hospitalized with HF, without a conventional indication for an ICD.

“We are performing additional studies to better understand the pathophysiology behind the heightened risk of sudden death in HIV,” Neilan said. One area of research, he said, is using the unique tissue characterization features of cardiac MRI to better understand why these patients are at a heightened risk. – by Scott Buzby

For more information:

Tomas G. Neilan, MD, MPH, can be reached at 55 Fruit St., Boston, MA 02114; email: tneilan@mgh.harvard.edu.

Disclosures: Neilan reports he is a consultant for Aprea Therapeutics, Bristol-Myers Squibb, Parexel Imaging and Intrinsic Imaging. The other study authors report no relevant financial disclosures.

Tomas G. Neilan

Risk on sudden cardiac death is markedly increased in adults with HIV who are hospitalized with HF. In particular, risk was increased in those with lower left ventricular ejection fraction, lower CD4 count, and higher viral load, according to data published in the JACC Heart Failure.

Cardiology Today discussed these findings with Tomas G. Neilan, MD, MPH, director of the cardio-oncology program at Massachusetts General Hospital, as well as the implications for clinical cardiologists.

“Our hope was to heighten awareness of the increased risk for sudden cardiac death among persons with HIV who also have heart failure,” Neilan said. “In patients without HIV who have heart failure, the risk for sudden death is mostly observed in those with a reduced ejection fraction. Among patients with HIV and heart failure the risk for sudden death was also noted in those with a higher ejection fraction.”

In this retrospective study, researchers analyzed data from 2,578 patients hospitalized with HF at a single center. Of these patients, 344 were living with HIV. The primary outcome was rate of sudden cardiac death (SCD). The researchers also performed subgroup analyses stratified by viral load and LVEF (< 35%, 35-49%, 50%).

Over a mean follow-up of 19 months, there were 191 occurrences of SCD. In comparison, patients with HIV had a threefold increase in SCD compared with those without HIV (21% vs. 6.4%; adjusted OR = 3; 95% CI, 1.78-4.24). The rate of SCD was similar among patients with HIV with an undetectable viral load and those without HIV, and also similar when the researchers evaluated this outcome by LVEF strata, according to the results.

Neilan told Cardiology Today cardiologists should, “[recognize] this as a higher-risk group and consider HIV status when discussing standard measures to prevent sudden death such as placement of a defibrillator. “Decades ago, there was a hesitation to place ICDs in this group. In contemporary cohorts with HIV and on [antiretroviral therapy], HIV status should act as a reason to place an indicated ICD and not to a reason not to place one.”

Among patients living with HIV hospitalized for HF, predictors of increased risk for SCD included cocaine use, lower LVEF, no beta-blocker prescription and viral load.

“Once individuals with HIV develop heart failure, their cardiac outcomes — sudden death and heart failure hospitalizations — are worse,” Neilan said. “We need to better understand why and come up with plausible ways of both reducing the risk for heart failure and improving outcomes in this at-risk population.”

Additionally, 86% of the study population did not have an ICD. that the rate of SCD was 10% per year among patients living with HIV who are hospitalized with HF, without a conventional indication for an ICD.

“We are performing additional studies to better understand the pathophysiology behind the heightened risk of sudden death in HIV,” Neilan said. One area of research, he said, is using the unique tissue characterization features of cardiac MRI to better understand why these patients are at a heightened risk. – by Scott Buzby

For more information:

Tomas G. Neilan, MD, MPH, can be reached at 55 Fruit St., Boston, MA 02114; email: tneilan@mgh.harvard.edu.

Disclosures: Neilan reports he is a consultant for Aprea Therapeutics, Bristol-Myers Squibb, Parexel Imaging and Intrinsic Imaging. The other study authors report no relevant financial disclosures.

    Perspective
    Chris Longenecker

    Chris Longenecker

    People with HIV appear to be at high risk for sudden cardiac death (SCD), although this statement is based on only a handful of observational studies. This study is the first to provide more granular detail on SCD in the population of patients at highest risk — those with HF. As expected, those with more advanced immunosuppression and detectable viral load were at highest risk for SCD. As with most observational studies of people with HIV in high-income countries, drug use is an important confounder. In this study, cocaine, in particular, was an important risk factor. Although there is biological plausibility that increased myocardial fibrosis and scar is one mechanism by which chronic treated HIV infection, and untreated infection even more so, may increase arrhythmic death, this study does not prove this.

    Clinicians should not be hesitant about recommending ICDs for patients with HIV and HF, but this is a personalized discussion that must take into account patient preferences and potential risks for complications such as inappropriate shocks and device infection.

    • Chris Longenecker, MD
    • Cardiology Today Next Gen Innovator
      Director, Research and Innovation Center
      University Hospitals Harrington Heart and Vascular Institute
      Director, HIV Cardiometabolic Risk Clinic
      University Hospitals John T. Carey Special Immunology Unit
      Assistant Professor of Medicine
      Case Western Reserve University School of Medicine, Cleveland

    Disclosures: Longenecker reports no relevant financial disclosures.