Incidence, Predictors, and Outcomes of Implantable Cardioverter‐Defibrillator Discharge Among People Living With HIV

Abstract

BackgroundPeople living with HIV (PHIV) are at an increased risk for sudden cardiac death, and implantable cardioverter‐defibrillators (ICDs) prevent SCD. There are no data on the incidence, predictors, and effects of ICD therapies among PHIV.Methods and ResultsWe compared ICD discharge rates between 59 PHIV and 267 uninfected controls. For PHIV, we tested the association of traditional cardiovascular risk factors and HIV‐specific parameters with an ICD discharge and then tested whether an ICD discharge among PHIV was associated with cardiovascular mortality or an admission for heart failure. The indication for ICD insertion was similar among groups. Compared with controls, PHIV with an ICD were more likely to have coronary artery disease and to use cocaine. In follow‐up, PHIV had a higher ICD discharge rate (39% versus 20%; P=0.001; median follow‐up period, 19 months). Among PHIV, cocaine use, coronary artery disease, QRS duration, and higher New York Heart Association class were associated with an ICD discharge. An ICD discharge had a prognostic effect, with a subsequent 1.7‐fold increase in heart failure admission and a 2‐fold increase in cardiovascular mortality, an effect consistent across racial/ethnic and sex categories.Conclusions ICD discharge rates are higher among PHIV compared with uninfected controls. Among PHIV, cocaine use and New York Heart Association class are associated with increased ICD discharge, and an ICD discharge is associated with a subsequent increase in admission for heart failure and cardiovascular mortality.

Heart failure and adverse heart failure outcomes among persons living with HIV in a US tertiary medical center

“…In the same cohort, we have previously shown that PLHIV who are prescribed protease inhibitors are associated with significantly increased CV mortality compared to the PLHIV who were prescribed a non-protease inhibitor ART regimen 8 . In another study, our group has also demonstrated that PLHIV with an ICD have a higher rate of ICD firing and subsequently an increased risk of CV mortality compared to the non-HIV individuals 14 . Therefore, from the previous results, it may be plausible that the poor HF outcomes among PLHIV are multifactorial, contributed by different elements.…”

“…These findings with respect to increased CV and all-cause mortality rates among PLHIV with HF (including preserved as well as reduced ejection fraction) expand upon previous findings by Freiberg et al based out of the US Veterans Aging Cohort Study-Virtual Cohort (VACS-VC) cohort (~97% male) suggesting that individuals with HIV and HF face increased mortality as compared with non-HIV-infected individuals with HF 4 especially those with a detectable VL/lower CD4 count. HIV is associated with increased CV mortality because of traditional CV risk factors, residual virally mediated inflammation despite of HIV treatment, side effects of ART 8,[14][15][16][17] . In the same cohort, we have previously shown that PLHIV who are prescribed protease inhibitors are associated with significantly increased CV mortality compared to the PLHIV who were prescribed a non-protease inhibitor ART regimen 8 .…”

Sudden cardiac death in HIV‐infected patients: A contemporary review

“…Alvi et al 4 demonstrated in 2018 that among HIV‐infected subjects with concomitant heart failure, the rate of appropriate ICD discharges was higher than in uninfected controls. Additionally, ICD discharge was associated with increased cardiovascular mortality among both HIV‐infected and uninfected controls with heart failure 4 . However, this study was limited to only subjects who had been admitted to the hospital for decompensated heart failure, which may represent a higher‐risk subgroup.…”

“…Ventricular arrhythmias that arise after cocaine use can be due to sodium channel blockade by the drug itself, a surge of sympathetic stimulation, and/or due to cocaine‐induced myocardial infarction 28 . Alvi et al 4 found that history of cocaine use was associated with greater likelihood of appropriate ICD discharge even after adjustment for history of coronary artery disease, CD4 count, use of beta blockers, QRS duration and higher NYHA class ( p = .011). Furthermore, cocaine use has been found to not only lead to decreased ART adherence but also to directly affect HIV disease progression independent of adherence to ARVs 29 .…”

Outcomes of implantable cardioverter‐defibrillator implantation in HIV‐infected patients: A single‐center retrospective cohort study

“…Furthermore, ICD data provides an objective surrogate for risk of sudden arrhythmic death, which would otherwise be presumed in studies without ICD data and/or autopsy data. Alvi et al 8 demonstrated that among HIV‐infected subjects with concomitant heart failure, rates of both appropriate and inappropriate ICD shock were higher than in uninfected controls. Additionally, ICD discharge was associated with increased cardiovascular mortality amongst both HIV‐infected and uninfected controls with heart failure 8 .…”