The Use of First Line Highly Active Anti-Retroviral Therapy (HAART) is Not Associated with Qtc Prolongation in HIV Patients

Prevention of sudden cardiac death in persons living with HIV infection

Persons living with HIV infection (PLWH) have been recognized to have an increased risk of sudden cardiac death (SCD). Prevention of this risk should theoretically be included in their long-term management. However, only a few approaches have been proposed to optimize such interventions. Targeting detection of the commonly associated conditions such as coronary artery disease, left ventricular dysfunction, heart failure, QT interval prolongation and ventricular arrhythmias is the first step of this prevention. However, although detection of the risk of SCD is a suitable challenge in PLWH, it remains uncertain whether optimized treatment of the identified risks would unequivocally translate into a decrease in SCD rates.

Association between exposure to Efavirenz and substrates of dysrhythmia in HIV-infected young adults

Background

Dysrhythmia and sudden cardiac arrest occur more likely in HIV patients than healthy subjects. Thus, we need to examine dysrhythmias adverse effects of medications including Efavirenz as early as possible especially in young subjects.

Hypothesis

Efavirenz might have contributed to increased risk of developing common types of dysrhythmia in young HIV infected patients.

Methods

We performed a retrospective cohort study among 62 patients on Efavirenz and 38 controls. All participants were under 40 years old without cardiovascular disease. Total significant dysrhythmia in 24‐hour ECG monitoring was the primary endpoint determined as the composite of high premature ventricular contraction (PVC) (>500 beats per 24 hours), high premature atrial contraction (PAC) (>500 bp24h), sinus pause, atrioventricular blocks, ventricular tachycardia, prolonged QTc, and low heart rate variability (HRV). Modified composite dysrhythmia consisted of low HRV (SD of normal‐to‐normal [SDNN]), high PVC and prolonged QT.

Results

Mean heart rate, Efavirenz regimen, male gender, and CD4 count predicted total dysrhythmia. Odds ratios were 1.108, 2.90, 4.36, and 0.96, respectively. The incidence of total dysrhythmia, high PVC, high PAC, low HRV(SDNN), and prolonged QTc were 54.8%, 41.85%, 9.71%, 45.2%, and 12.9% in patients on Efavirenz against 42.11%, 31.64%, 0%, 34.2%, and 7.91% in controls, respectively (p‐values: .031, .001, <.0001, .063, and .043 respectively). Modified composite dysrhythmia was also more frequent in Efavirenz group than that of control group (69.42% vs. 52.60%, respectively p = .032).

Conclusions

We found that patients with Efavirenz had higher prevalence of frequent PVC, frequent PAC, total significant dysrhythmia, Low HRV and prolonged QTc than controls.

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

HIV‐infected individuals have an increased risk of sudden cardiac death compared to the general population; yet the mechanisms underlying this increased risk remain unclear. The mechanisms underlying the heightened sudden cardiac death risk in HIV‐infected individuals is likely multifactorial. We reviewed the literature to elucidate and summarize the potential mechanisms contributing to sudden cardiac death in the HIV patient population. There is biologic plausibility that the following mechanisms may be contributing to the significantly heightened risk of sudden cardiac death in HIV to varying degrees: ventricular arrhythmias, myocardial fibrosis and scar, prolonged QTc interval (both as a direct effect of HIV on repolarization as well as a result of concurrent medications/antiretroviral therapies), substance abuse, structural heart disease, and premature atherosclerosis. Further understanding of the mechanisms underlying the increased sudden cardiac death risk in HIV can lead to identification of modifiable risk factors, implementation of public health programs, and potential revision of ICD implantation guidelines to ultimately reduce the incidence of sudden cardiac death in HIV‐infected patients. Further studies are needed to assess the relative contribution of each of these mechanisms and risk factors.