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Protease inhibitors may increase risk of death in people with HIV and heart failure

Ritonavir-boosted protease inhibitors associated with doubled risk of hospital readmission and cardiovascular death

Ingrid Torjesen

Tuesday, 24 July 2018

Patients with both HIV infection and heart failure whose antiretroviral regimen includes ritonavir-boosted protease inhibitors may be at greater risk of worsening of heart failure and cardiovascular death than patients with HIV taking non-protease-inhibitor-based regimens, a study* published in the Journal of the American College of Cardiology has shown.

People with HIV have twice the risk of developing heart failure compared to those without the infection, and as the number of persons with HIV aged over 50 grows, largely due to the success of antiretroviral therapy, the rates of heart failure in this group are projected to increase.

Previous research by the research group found that people with both HIV and heart failure are at four times the risk of needing to be hospitalised for worsening heart failure symptoms and three times the risk of cardiovascular death, so they decided to look at why heart failure outcomes were worse in HIV and specifically when there was ritonavir-boosted protease inhibitor use.

The US research team examined the records for 394 people with HIV and heart failure who were receiving antiretroviral therapy and were admitted for worsening heart failure symptoms to hospital. During that hospital admission, the 145 patients whose antiretroviral therapy included ritonavir-boosted protease inhibitors were more likely than those not taking protease inhibitors to have elevated blood lipids, diabetes, coronary artery disease, elevated pulmonary artery pressure and a reduced left-ventricular emission fraction.

In the two years after hospital admission, 35 per cent of those taking ritonavir-boosted protease inhibitors died from cardiovascular causes, compared with 17 per cent of those on non-protease-inhibitor antiretroviral regimens. Controlling for the severity of heart failure upon original hospitalisation or for the specific type of protease inhibitors taken did not significantly change the association between ritonavir-boosted protease inhibitor treatment and cardiovascular death. Taking a protease inhibitor also doubled - from 34 to 68 per cent - the risk that a patient would need to be readmitted to the hospital within 30 days of discharge.

"The use of protease inhibitors - specifically in combination with ritonavir - is an important treatment strategy for some persons with HIV," said senior author of the study Tomas Neilan, associate professor of Medicine at Harvard Medical School.

"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."

He added: "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. We also need to better understand why persons with HIV have higher rates of heart failure and why their outcomes are worse."

*Alvi RM, Neilan AM, Tariq N, et al. Protease Inhibitors and Cardiovascular Outcomes in Patients With HIV and Heart Failure. Journal of the American College of Cardiology. Volume 72, Issue 5, 31 July 2018, Pages 518-530, doi: 10.1016/j.jacc.2018.04.083

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