Heart disease
CVD = cardiovascular disease (cardio = heart; vascular = veins and arteries); CHD = coronary heart disease.
Why discuss heart disease?
Just as in the general population, the many factors linked to the risk of heart disease can often be reduced by changes in life choices.
For HIV positive people, ART is a good thing and the risk of heart disease is likely to be lower by being on treatment. However, even on effective ART, HIV itself still increases som erisks associated with heart disease. Moving to healthier life choices is also important on ART.
Very few HIV meds have been linked to heart disease (abacavir, lopinavir/r and ddI in the D:A:D study for example) and your doctor will chose alternatives if this is important for you.
There is a lot of information and research about risk factors for heart disease in HIV negative people. This has often come from very large studies (Framingham, Caerphilly etc) that followed a large group of people for many decades. These studies led to the development of risk calculators that are easy to access online.
It is easy to check your risk of heart disease. If you put in your age, gender, cholesterol and triglyceride levels and other risk factors such as smoking, you get your 5-year or 10-year risk of heart disease.
People with high risk factors for heart disease who need HIV treatment, should use HIV drugs that are least likely to increase the risk of cardiovascular disease any further. Support for lifestyle changes should also be provided.
Risk factors for heart disease
The following factors increase the risk of heart disease; some of which are fixed and some are modifiable by lifestyle.
Fixed risk factors
- Older age (men over 45, women over 55).
- Gender (men are at higher risk at the same age).
- Family history of heart disease.
Risk factors you can change
- Smoking.
- High lipids – ie high cholesterol and/or triglyceride levels.
- Lack of exercise.
- High blood pressure, especially diastolic blood pressure (the second reading).
- High levels of sugar in blood, insulin resistance and diabetes.
Symptoms of heart attack or stroke
Symptoms of cardiovascular disease include:
- Shortness of breath.
- Fatigue.
- Feeling dizzy or light-headed.
- Fainting.
- Chest pains (that can extend to the shoulders, back, arms, head and jaw).
- Chest pains after exercise or exertion.
Additional symptoms for a stroke include:
- Sudden numbness.
- Paralysis of the face or limbs, especially affecting just one side of the body.
- Difficulty speaking.
- Loss of balance or coordination.
- Severe headache.
- Brief loss of consciousness.
If you experience these symptoms, you should seek urgent medical attention.
Rapid treatment after a stroke (within 2-3 hours) can limit permanent brain damage.
D:A:D study
The D:A:D study is the largest study to look at the risk of heart disease in relation to HIV treatment.
It has been running for over ten years and has collected results from almost 50,000 patients from Europe, the US and Israel.
This diversity is one of the study’s strengths. D:A:D found that some HIV drugs are related to a small but significant increased risk of heart disease. This was found in different countries and in both men and women.
These drugs include recent use of abacavir, ddI and cumulative use (from each year) of abacavir, indinavir and lopinavir/r (Kaletra).
Relative rate and actual risk
The D:A:D study showed that the relative rate for an increased risk of heart disease form using a drug depends on your other risks factors.
If you have a low cardiovascular risk, then a relative increase, even by 50% still remains a low real (absolute) risk. However, for someone with a high cardiovascular risk relating to other factors (age, smoking etc) then an increase in the relative risk from an HIV drug would be much more significant.
For someone who has a high risk because of factors that can’t be changed (ie a family history of heart disease) then it is more important not to add to these risks by using any HIV drug with this potential side effect.
How to make lifestyle changes
Changing the risk factors for heart disease can have a direct impact on future risk. By implication, this will also make HIV drugs safer to use.
The advice given to the general population is even more important if you are using HIV treatment.
Stopping smoking is the most important lifestyle change in terms of general health and risk of heart disease. Support groups and other interventions including replacement therapy like nicotine patches are now available on the NHS.
It is more effective to try a range of products over the first weeks to cope with nicotine withdrawal – patches, gum, inhalers and sprays – so you find the ones that work best for you.
Your HIV doctor can refer you to specialist services to help you quit.
- Diet changes can significantly reduce your risk for heart disease.
- Reducing fatty foods can reduce lipids to some extent. Cutting down on salt reduces blood pressure. Eating less processed sugars reduces your risk of developing insulin resistance and diabetes.
- Eat more fruit and vegetables, fish and lean meat and reduce use of processed foods.
- Exercise is the other main factor that you can change. Regular exercise and being more active in your day-to-day life, by walking more and using the lift less, is more important than very vigorous exercise.
- Any change in level of activity will probably have to start gradually. People who start an exercise programme report benefits in quality of life. This can include increased well-being and energy levels.
The website for the North Central London Cardiac Network includes detailed guidelines for managing heart disease:
North Central London Cardiac Network
This study reported higher risk of factors linked to heart disease, even with an undetectable viral load on ART.
McLaughlin MM et al. Association of viral persistence and atherosclerosis in adults with treated HIV infection JAMA Netw Open. 2020.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2772338
Glossary (heart disease)
Arteries are the blood vessels that take blood from the heart.
Veins are blood vessels that delivery blood back to the heart again.
Arrhythmia is the medical terms for a disturbance of the heart’s natural rhythm. Tachycardia refers to when the heart beats too fast. Bradycardia is when the heart beats too slowly.
Atherosclerosis refers to a narrowing or hardening of large and medium sized arteries. The narrowing is caused by a build-up of plaque, and usually takes many years. As the walls of the artery thicken, the heart has to work harder to pump the same amount of blood through a narrower gap.
Cardiovascular refers to the heart and blood vessels.
Cardiovascular disease (CVD) is the general term for disease to the heart and related blood vessels.
Cerebrovascular refers to the blood vessels taking blood to the brain. A blockage that restricts blood to the brain is called a stroke. Strokes can occur when blood vessels in the brain block, or when a clot formed in another part of the body is carried to the brain.
Coronary heart disease (CHD) refers to the three main arteries that supply blood from the heart. A coronary by-pass is a surgical operation to provide a new route for blood to reach the heart when coronary arteries become blocked.
Hypertension is the medical name for high blood pressure (BP). Blood pressure is measured as two numbers ie 120/80. The first number is systolic BP – the pressure when your heart beats. The second number is diastolic BP, which is the pressure when you heart rests between beats.
Target range for BP is usually 120/80. Drugs to reduce BP are sometimes recommended if this is above 130/85 or 140/90. This also depends on other risk factors for heart disease, including age, sex, ethnicity ajd other health factors.
Hypertension increases the risk of a heart attack or stroke, particularly when diastolic BP is high.
Hypotension is the medical name for low blood pressure.
Pulmonary hypertension refers to high blood pressure in the arteries taking blood from the heart to the lungs. HIV-positive people are more likely to develop pulmonary hypertension than HIV-negative people.
Myocardial Infarction (MI) is the medical term for ‘heart attack’.
Peripheral arterial disease refers to atherosclerosis in the arteries in the arms or legs.
Last updated: 1 March 2023.