HIV and Cardiomyopathy: Unraveling the Heart’s Hidden Risk

For decades, human immunodeficiency virus (HIV) has been recognized as a significant global health challenge. Whereas advancements in antiretroviral therapy have dramatically improved survival rates for people living with HIV (PLWH), a new wave of health concerns is emerging: cardiovascular complications, particularly cardiomyopathy. This review examines the complex relationship between HIV and cardiomyopathy, exploring the underlying mechanisms, clinical presentations, diagnostic approaches and treatment strategies.

Understanding Cardiomyopathy

Cardiomyopathy refers to a group of diseases that affect the heart muscle, making it harder for the heart to pump blood effectively. There are several types of cardiomyopathy, including dilated, hypertrophic, and restrictive cardiomyopathy. HIV-associated cardiomyopathy often presents as a dilated cardiomyopathy, where the heart chambers enlarge and weaken ¹.

The Rising Prevalence of Cardiac Involvement in HIV

Cardiac involvement is increasingly recognized in individuals with HIV, with prevalence rates ranging from 28% to 73% ². This increased risk is likely due to a combination of factors, including direct effects of the virus on the heart, chronic inflammation, and the effects of antiretroviral therapy.

Pathogenesis: How HIV Impacts the Heart

The pathogenesis of HIV-associated cardiovascular disease (CVD) is complex and multifaceted. Advances in cardiac imaging and immunology are continually deepening our understanding ³. Key mechanisms include:

• Direct Viral Infection: HIV can directly infect heart muscle cells, leading to inflammation and damage.
• Chronic Inflammation: HIV is associated with chronic immune activation and inflammation, which contribute to the development of CVD. ⁴ Trained immunity and pro-inflammatory lipids may exacerbate this inflammation.
• Antiretroviral Therapy: While life-saving, some antiretroviral drugs have been linked to cardiovascular side effects.
• Shared Risk Factors: PLWH often have a higher prevalence of traditional CVD risk factors, such as hypertension, hyperlipidemia, and diabetes.

Clinical Manifestations

HIV-associated cardiomyopathy can manifest in various ways, including:

• Shortness of breath
• Fatigue
• Swelling in the legs and ankles
• Irregular heartbeat
• Chest pain

Diagnosis and Monitoring

Diagnosing HIV-associated cardiomyopathy requires a comprehensive evaluation, including:

• Echocardiogram: An ultrasound of the heart to assess its structure and function.
• Electrocardiogram (ECG): To detect abnormal heart rhythms.
• Cardiac Magnetic Resonance Imaging (MRI): Provides detailed images of the heart muscle.
• Biomarkers: Blood tests to measure cardiac enzymes and markers of inflammation.

Treatment Strategies

Treatment for HIV-associated cardiomyopathy focuses on managing symptoms, improving heart function, and addressing underlying risk factors. This may include:

• Antiretroviral Therapy: Maintaining viral suppression is crucial.
• Medications: Standard heart failure medications, such as ACE inhibitors, beta-blockers, and diuretics.
• Lifestyle Modifications: Dietary changes, exercise, and smoking cessation.

The Future of HIV and Heart Health

As PLWH live longer, the prevalence of HIV-associated cardiomyopathy is expected to rise. Continued research is needed to better understand the underlying mechanisms, develop targeted therapies, and improve outcomes for this vulnerable population. Early detection, comprehensive management, and a focus on cardiovascular risk reduction are essential for protecting the heart health of individuals living with HIV.

References

1. Awoyemi, T., et al. (2025). The hidden link between HIV and cardiomyopathy: unraveling HIV’s impact on the heart. *Frontiers in Cardiovascular Medicine*, *12*.
2. Cardiac Manifestations of Acquired Immunodeficiency Syndrome. (n.d.). *JAMA Internal Medicine*.
3. HIV-Associated Cardiovascular Disease Pathogenesis: An Emerging… (n.d.). *Circulation Research*.
4. HIV and cardiovascular disease: the role of inflammation. (n.d.). *PMC*.