Inotropic Contractile Reserve Can Risk-Stratify Patients With HIV Cardiomyopathy: A Dobutamine Stress Echocardiography Study

Human immunodeficiency virus (HIV) cardiomyopathy is an important cause of heart failure and death. The incidence of HIV cardiomyopathy before the introduction of highly active antiretroviral therapy (HAART) was estimated at 15.9 per 1,000 annually (1). After the introduction of HAART, the prevalence of HIV cardiomyopathy decreased about 30% in developed countries (2,3). However, the access to HAART is limited, and the prognosis of those patients in whom HIV cardiomyopathy develops remains poor, with a median survival in acquired immunodeficiency syndrome (AIDS)–related death of 101 days in patients with left ventricular (LV) dysfunction and 472 days in patients with normal LV function at similar infection stage (4). Furthermore, patients with HIV cardiomyopathy had worse survival when compared with all other causes of dilated cardiomyopathy (ischemic and nonischemic) (adjusted hazard ratio [HR]: 5.86; 95% confidence interval [CI]: 3.92 to 8.77) (5). Recent data suggest that the use of aggressive interventions such as ventricular assist devices and heart transplantation in patients with HIV may have a good outcome in selected patients (6,7). Hence, the ability to identify patients with HIV cardiomyopathy at high risk of cardiac death and who may benefit from early aggressive therapy and referral for specialized care would have important prognostic implications. Dobutamine stress echocardiography (DSE) is clinically useful for distinguishing viable myocardium from scar in both ischemic and nonischemic cardiomyopathy. The presence of inotropic contractile improvement in regional and global LV function on follow-up, and better response to therapy (8 –10). However, whether ICR can risk-stratify and predict left ventricular ejection fraction (LVEF) improvement in patients with HIV cardiomyopathy is not known.