Boston—HIV patients who also have heart failure appear to be at a greater risk of cardiovascular death if they are on antiretroviral regimens including ritonavir-boosted protease inhibitors than those on nonprotease-inhibitor–based regimens.

The report in the Journal of the American College of Cardiology discussed the risk of worsening heart failure in the patients taking ritonavir-boosted protease inhibitors, which previous studies have associated with other vascular events.

Massachusetts General Hospital (MGH)–led investigators note that people with HIV have twice the risk of developing heart failure (HF) than others. The urgency of the issue is heightened as successful antiretroviral therapy keeps more of those patients alive past the age of 50 years, they add.

“The use of protease inhibitors—specifically in combination with ritonavir—is an important treatment strategy for some persons with HIV,” explained senior author Tomas Neilan, MD, MPH, in an MGH press release. “While studies have demonstrated associations between some protease inhibitors and events such as heart attack and stroke, this is the first to note an effect of ritonavir-boosted protease inhibitor regimens on heart failure events.”

In previous research, the study team found that HIV patients with heart failure have quadruple the risk of hospitalization for heart failure exacerbations and triple the risk of cardiovascular death. In the current study, the researchers sought to understand why heart failure outcomes were worse in HIV and specifically investigated the association between ritonavir-boosted protease inhibitor use (PI) and worsening heart failure outcomes in those patients.

To do that, study authors conducted a retrospective single-center study of all 394 antiretroviral therapy–treated HIV patients who were hospitalized with HF in 2011, stratified by type of therapy. Cardiovascular (CV) mortality was designated as the primary outcome; the secondary outcome was 30-day HF readmission rate.

Of the 394 participants in the study, 53% with a mean age of 60 years and an average CD4 count of 292, 37% were prescribed a PI, whereas 63% were prescribed nonprotease-inhibitor–based (NPI) regimens. All PI-based antiretroviral therapy contained boosted-dose ritonavir, researchers note.

Results indicate that patients treated with 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, the study team also found that PI use was associated with increased CV mortality (35% vs. 17%; P <.001) and 30-day HF readmission (68% vs. 34%; P <.001), effects seen in all HF types. Predictors of CV mortality included PI use, CAD, PASP, and immunosuppression. Overall, study authors point out, PIs were associated with a twofold increased risk of CV mortality.

“Persons with HIV and heart failure on any regimen warrant close monitoring with regular follow up with their cardiologists and their HIV treatment providers, as well as tight control of cardiovascular risk factors such as hypertension, hyperlipidemia and diabetes,” Neilan emphasized. “We also need to better understand why persons with HIV have higher rates of heart failure and why their outcomes are worse. This study is a small step toward that better understanding.”
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