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High risk of sudden cardiac death in HIV-positive persons with HF

heartfailure.onlinejacc.org
Literature - Alvi RM, Neilan AM, Tariq et al., - JACC Heart Fail. 2019 DOI: 10.1016/j.jchf.2019.04.025

Introduction and methods

Because patients with heart failure (HF) are at higher risk of sudden cardiac death (SCD), insertion of an implantable cardioverter-defibrillator is indicated [1]. Conventional indications for ICD for primary prevention of SCD in HF patients are imperfect. They may suggest the use of ICD in patients who are not likely to benefit, or fail to identify persons at risk of SCD [2,3]. Hence, better characterization of populations at risk may be of help.

Persons living with human immunodeficiency virus infection (PHIV) are at increased risk for HF [4], and SCD is increased among PHIV without HF [5]. No data are available on the risk for SCD among PHIV with HF. There are, however, epidemiological and pathophysiological data to support the hypothesis that the risk for SCD is increased among PHIV with HF, as compared with uninfected persons with HF [5-7]. This study set out to investigate the incidence of SCD among PHIV with HF and the risk factors associated with it, in an observational registry of all patients admitted with a primary diagnosis of acute decompensated HF. Patients having ICD’s or receiving one during follow-up were excluded from analysis. Follow-up started on the first date of discharge from the first HF hospitalization in 2011. Primary outcome was occurrence of SCD.

Main results

  • Among 2,149 patients hospitalized with HF without ICDs in a single US academic hospital in 2011, 344 were living with HIV infections. 91% (313/344) Of PHIV were prescribed antiretroviral therapy (ART), with a median ART prescription duration of 9 years (IQR: 4-16). 64% (221/344) were virologically suppressed.
  • During a median follow-up duration of 19 months (IQR: 3-24), 191 SCDs (8.8%) occurred.
  • SCD rate was higher in PHIV vs. non-HIV infected HF patients (21% vs. 6.4%, P<0.001, adjOR: 3.0, 95%CI: 1.78-4.24).
  • In PHIV, those with CD4 counts <200 cells/mm³ had a higher SCD rate than those with CD4 counts ≥200 cells/mm³ (37% vs. 8.4%, P<0.001). Similarly, those with detectable viral load (VL) (≥200 copies/ml) showed a higher SCD rate compared with those with suppressed VL (43% vs. 9%, P<0.001).
  • The rate of SCD in PHIV with undetectable VL was not significantly higher than in non-infected subjects with HF (8% vs. 6.4%, P=0.16).
  • In a multivariate model, after adjustment for confounding factors, CAD was the strongest predictor of SCD, followed by lower CD4 count or nonsuppressed VL, cocaine use, non-prescription of betablockers, a low LVEF, wider QRS and increased corrected QT interval duration.
  • In those with preserved LVEF (≥50%) and with LVEF 35% - 49%, SCD rate was similarly higher among PHIV than in non-HIV-infected patients (18% vs 5.4%, P<0.001 and 20% vs. 6.5%, P<0.001). In patients with LVEF<35%, PHIV also had a higher SCD rate compared with non-infected controls (42% vs. 14%, P=0.001). In all LVEF categories, those with low CD4 counts and/or detectable VL showed a higher SCD rate.

Conclusion

This study shows that PHIV with HF show a higher rate of SCD than uninfected control subjects with HF. Moreover, better HIV disease control measures, namely higher CD4 count and undetectable viral load, were associated with lower, but not background rates of SCD among PHIV. CAD, cocaine use, absence of beta-blockers, low LVEF and QRS width and corrected QT interval duration were predictors of SCD, also after stratifying the cohort based on LVEF.

References

1. S.M. Al-Khatib, W.G. Stevenson, M.J. Ackerman, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol, 72 (2018), pp. 1677-1749

2. L. Kober, J.J. Thune, J.C. Nielsen, et al. Defibrillator implantation in patients with nonischemic systolic heart failure. N Engl J Med, 375 (2016), pp. 1221-1230

3 R. Deo, C.M. Albert Epidemiology and genetics of sudden cardiac death Circulation, 125 (2012), pp. 620-637

4. A.A. Butt, C.C. Chang, L. Kuller, et al. Risk of heart failure with human immunodeficiency virus in the absence of prior diagnosis of coronary heart disease. Arch Intern Med, 171 (2011), pp. 737-743

5 Z.H. Tseng, E.A. Secemsky, D. Dowdy, et al. Sudden cardiac death in patients with human immunodeficiency virus infection. J Am Coll Cardiol, 59 (2012), pp. 1891-1896

6. M. Vaduganathan, R.B. Patel, A. Michel, et al. Mode of death in heart failure with preserved ejection fraction J Am Coll Cardiol, 69 (2017), pp. 556-569

7 R.M. Alvi, A.M. Neilan, N. Tariq, et al. Incidence, predictors, and outcomes of implantable cardioverter-defibrillator discharge among people living with HIV. J Am Heart Assoc, 7 (2018), Article e009857

Find this article online at JACC: Heart Failure

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