Protease Inhibitors and Cardiovascular Outcomes in Patients With HIV and Heart Failure

• Published in: Journal of the American College of Cardiology 2018-07, Vol.72 (5), p.518-530
• Main Authors: Alvi, Raza M., Neilan, Anne M., Tariq, Noor, Awadalla, Magid, Afshar, Maryam, Banerji, Dahlia, Rokicki, Adam, Mulligan, Connor, Triant, Virginia A., Zanni, Markella V., Neilan, Tomas G.
• Format: Article
• Language: English
• Subjects: Aged; Antiretroviral agents; Antiretroviral drugs; Antiretroviral therapy; Antiretroviral Therapy, Highly Active - adverse effects; Antiretroviral Therapy, Highly Active - trends; Blood pressure; Cardiology; Cardiovascular disease; Cardiovascular diseases; CD4 antigen; Cocaine; Coronary artery; Coronary artery disease; Diabetes; Diabetes mellitus; Dosage; Dyslipidemia; Education; Female; Heart; Heart diseases; Heart failure; Heart Failure - chemically induced; Heart Failure - diagnosis; Heart Failure - mortality; heart failure readmission; HIV; HIV Infections - diagnosis; HIV Infections - drug therapy; HIV Infections - mortality; Hospitalization; Human immunodeficiency virus; Humans; Hyperlipidemia; Hypertension; Immunosuppression; Infections; Lung diseases; Male; Middle Aged; Mortality; Mortality - trends; Multivariate analysis; Patient Readmission - trends; Patients; Protease; Protease inhibitors; Protease Inhibitors - adverse effects; Protease Inhibitors - therapeutic use; Proteinase inhibitors; Pulmonary artery; Regression analysis; Retrospective Studies; Ritonavir; Smoking; Systolic pressure; Therapy; Treatment Outcome; Ventricle; Viruses
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2018.04.083

Incident heart failure (HF) is increased in persons with human immunodeficiency virus (PHIV). Protease inhibitors (PIs) are associated with adverse cardiac remodeling and vascular events; however, there are no data on the use of PIs in PHIV with HF. This study sought to compare characteristics, cardiac structure, and outcomes in PHIV with HF who were receiving PI-based versus non-PI (NPI) therapy. This was a retrospective single-center study of all 394 antiretroviral therapy–treated PHIV who were hospitalized with HF in 2011, stratified by PI and NPI. The primary outcome was cardiovascular (CV) mortality, and the secondary outcome was 30-day HF readmission rate. Of the 394 PHIV with HF (47% female, mean age 60 ± 9.5 years, CD4 count 292 ± 206 cells/mm3), 145 (37%) were prescribed a PI, whereas 249 (63%) were prescribed NPI regimens. All PI-based antiretroviral therapy contained boosted-dose ritonavir. PHIV who were receiving a PI had higher rates of hyperlipidemia, diabetes mellitus, and coronary artery disease (CAD); higher pulmonary artery systolic pressure (PASP); and lower left ventricular ejection fraction. In follow-up, PI use was associated with increased CV mortality (35% vs. 17%; p < 0.001) and 30-day HF readmission (68% vs. 34%; p < 0.001), effects seen in all HF types. Predictors of CV mortality included PI use, CAD, PASP, and immunosuppression. Overall, PIs were associated with a 2-fold increased risk of CV mortality. PI-based regimens in PHIV with HF are associated with dyslipidemia, diabetes, CAD, a lower left ventricular ejection fraction, and a higher PASP. In follow-up, PHIV with HF who are receiving a PI have increased CV mortality and 30-day HF readmission. [Display omitted]