A Practical Guide to a Healthy Body for People Living with HIV

Cardiovascular Health

Cardiovascular disease refers to many conditions that affect the heart and blood vessels. These include heart attack (damage to the heart muscles) and stroke (damage to the brain due to limited blood flow), angina (chest pain due to coronary artery disease), cardiomyopathy (an enlarged heart) and valve disorders, to name just a few.

Studies have found that people living with HIV appear to be at greater risk for these conditions than their HIV-negative counterparts. This is why your doctor should monitor your heart health regularly and why any efforts you can make to promote your heart health should be part of your plan for living long and well with HIV.

Risk factors for cardiovascular disease

The many factors that can put people living with HIV at risk for cardiovascular disease include some specific to HIV as well as more traditional risk factors, such as smoking and high blood pressure.

Chronic inflammation

The chronic inflammation caused by HIV is a major contributor to blood vessel damage and the development of cardiovascular disease in people living with HIV. Antiretroviral therapy can help reduce inflammation but does not completely eliminate it or the risk of cardiovascular disease. In a 2012 study, Harvard researchers reported that the level of inflammation in the aortas (the aorta is the main artery leaving the heart) of people with HIV who did not have cardiovascular disease was similar to that of HIV-negative people with established cardiovascular disease. The inflammation did not appear to be associated with the type of antiretroviral therapy taken and it was present both in people with an undetectable viral load and in people with HIV who had no traditional risk factors for cardiovascular disease. The researchers were careful to point out that their findings do not imply that addressing traditional risk factors for cardiovascular disease is not important, but rather that inflammation should also be addressed.

Abnormal lipid levels

Many people with HIV develop abnormal lipid levels in their blood, which can increase their risk of cardiovascular disease. Untreated HIV infection, in particular, can raise triglyceride and “bad” cholesterol levels and can lower “good” cholesterol levels.

What are lipids?

Our bodies contain different kinds of fats, known as lipids. These include:

  • HDL cholesterol (high-density lipoprotein, also known as “good”cholesterol), which removes “bad” cholesterol from the blood
  • LDL cholesterol (low-density lipoprotein, also known as “bad” cholesterol), which can build up in the arteries and lead to heart disease and other health problems
  • triglycerides, which can also increase your risk for heart disease if your levels are too high, especially if you are overweight or have high blood pressure

HIV medications

Starting HIV treatment is one of the best things you can do for your heart health. But some HIV meds—in particular, some protease inhibitors and some older nukes such as d4T (stavudine, Zerit)—have been linked to an increased risk of developing cardiovascular problems. If possible, it is best to choose medications that keep that risk to a minimum. You and your doctor can work together to choose a treatment combination that can effectively suppress your HIV while causing the fewest possible side effects.

Studies have shown that when people who had elevated triglycerides and/or bad cholesterol while taking protease inhibitors (PIs) switched to taking drugs from another class—to either the non-nuke nevirapine (Viramune) or the nuke abacavir (Ziagen)—their lipid levels improved. However, some “PI-sparing” regimens may work better than others. For example, switching to the non-nuke efavirenz (Sustiva) has not been shown to consistently improve lipid levels. Luckily, if your triglyceride or bad cholesterol levels go up shortly after starting an HIV medication (suggesting that the drug might be contributing to the problem), it should be possible to find a substitute among the wide variety of antiretrovirals available today.

Although some HIV medications can have a negative impact on lipid levels (increasing cholesterol and triglyceride levels), in general, antiretrovirals can greatly decrease HIV-related inflammation and the risk for cardiovascular disease and other serious illnesses.

Drugs known to increase the risk of diabetes can also contribute to heart disease. (For more on diabetes and cardiovascular disease, see “Diabetes and Blood Sugar Problems.”)

Other risk factors

Other factors that raise the risk of cardiovascular disease for both HIV-positive and HIV-negative people include:

  • smoking
  • high blood pressure
  • diabetes
  • stress
  • a sedentary lifestyle (lack of exercise)
  • being older than 45 years if male or older than 55 if female
  • use of street drugs, such as cocaine, heroin and crystal meth
  • being overweight
  • a family history of cardiovascular disease
  • gum disease

Diagnosis

To diagnose a cardiovascular problem, your doctor will ask you about your medical history as well as any problems you have been experiencing recently.

Your doctor will also regularly check your blood pressure or advise you to check it with a home monitor or at the pharmacy. He or she may also recommend one or more of the following tests:

  • blood tests to assess whether you have problematic lipid levels
  • an electrocardiogram (ECG)
  • an echocardiogram
  • Holter monitoring
  • a chest X-ray
  • a CT scan
  • an MRI scan
  • a stress test
  • cardiac catheterization
  • an ultrasound of the arteries in your neck

Signs and symptoms that can indicate cardiovascular disease include:

  • high blood pressure
  • erectile dysfunction in men
  • pain in the lower legs and feet when you are active, which goes away quickly with rest (this can indicate peripheral artery disease in the blood vessels of the legs)
  • angina (pain in the chest area that can occur with or without physical activity)
  • shortness of breath
  • sudden numbness, weakness or coldness in the legs or arms (this could indicate that the blood vessels in those parts of your body are narrowed)
  • sudden loss of vision or visual disturbances
  • dizziness, lightheadedness, weakness and moments of altered consciousness (this can indicate insufficient blood supply to the brain, or stroke)

Some people may have a heart attack or stroke even if they are not experiencing any of these symptoms. Even if you have no obvious symptoms, it’s never too soon to improve your heart health.

Heart attack warning signs:

  • Uncomfortable pressure, fullness, squeezing or pain in the centre of the chest that lasts more than a few minutes (this pressure can be mild or severe)
  • Pain or numbness that spreads to the shoulders, neck, jaw or arms
  • Light-headedness, fainting, sweating, nausea or shortness of breath

Women of all ages and older men, especially those with diabetes, may experience no pain or only mild pain during a heart attack.

Stroke warning signs:

  • Sudden weakness or numbness of the face, arm or leg on one side of the body
  • Sudden vision problems (dimness or loss of vision), particularly in one eye
  • Trouble talking or understanding speech
  • Sudden, severe headaches with no apparent cause
  • Sudden dizziness or loss of balance, especially if combined with any of the above

If you experience any of these symptoms, call 9-1-1 immediately.

Preventing cardiovascular disease

There’s not much we can do about our age or the health history of our family members, but we can do a lot to keep our risk of cardiovascular disease low and maintain a healthy heart.

  • Quit smoking. Smoking is the #1 cause of cardiovascular disease among people with HIV. Smoking causes chronic inflammation of the blood vessels and heart and worsens the inflammation caused by HIV. (For more on inflammation, see Appendix A, page 56.) Smoking damages the blood vessels, negatively affects cholesterol levels, and increases blood pressure and the risk for developing diabetes. If you smoke, quitting will dramatically reduce your risk for heart disease. Many tools out there can help you quit, including Health Canada’s On the Road to Quitting and the Canadian Cancer Society’s Break It Off.
  • Keep your blood pressure under control. High blood pressure is a major risk factor for both heart attacks and strokes. A nutritious diet and regular exercise will help you maintain a healthy blood pressure. If lifestyle changes aren’t enough, your doctor can suggest medication to help keep your blood pressure in the healthy range.
  • Whenever possible, keep your stress level to a minimum. Of course, that’s easier said than done. Living with HIV and other chronic conditions can add stress to our lives on top of all the other events, pressures and responsibilities we have to deal with. Regular use of various mind/body techniques, acupuncture, massage, meditation, yoga or other relaxation techniques can help you release and manage your stress.
  • If you’re feeling depressed, find support. Studies have linked ongoing depression (a reality for many people living with HIV) to an increased risk for heart disease. If you’re feeling sad or down, especially for long periods, seek the emotional support of nonjudgmental friends and family members, access the counselling services and peer support offered by many HIV and community health organizations, and/or seek the help of a knowledgeable healthcare provider.
  • Exercise regularly. Regular exercise strengthens the heart, reduces blood pressure, improves cholesterol levels, relieves stress, helps with weight management and can decrease insulin resistance and help improve blood sugar levels. If you’ve already had cardiovascular problems, check in with your doctor about what is appropriate for you before starting an exercise program.
  • Eat a heart-healthy diet. A balanced and nutritious diet is good for your overall health and sense of well-being—and for your heart health. It is particularly important to reduce your total fat intake and eliminate from your diet all partially hydrogenated fats, also known as trans fats. Trans fats are chemically modified fats found in most margarines, vegetable shortening, many baked goods and snack foods. Stick with the fats Mother Nature made, especially monounsaturated fats like olive oil. Also, make sure you include plenty of vegetables, fruit, legumes and whole grains in your diet.

Some HIV and community organizations have a dietitian onsite. If you are looking for someone who can advise you on your diet or support you as you change your eating habits, ask your local HIV or community health organization if you can make an appointment with a registered dietitian or nutritionist.

  • Manage your lipid levels. The standard medical advice for people with high triglyceride and bad cholesterol levels is to consume less fat. But changing what you eat is unlikely to be of substantial benefit if your HIV meds are the main cause of the problem. On the other hand, if your diet is heavy on trans fats (spring rolls, French fries and doughnuts, for example), then diet could certainly be contributing to your unhealthy lipid levels. In such cases, it could help to consume less fat and sugar and cut out trans fats altogether, while eating more fruit, vegetables and whole grains (sources of soluble fibre that can block cholesterol absorption). Consuming additional soluble fibre in the form of psyllium seed (Metamucil) may also be useful. While your triglyceride and bad cholesterol levels are elevated, consider taking nutritional supplements to help protect against cardiovascular damage (see “Cholesterol-lowering agents”).
  • Maintain a healthy weight. Excess belly fat, in particular, is tied to an increased risk of heart disease.
  • Avoid street drugs that can harm your heart. Cocaine, amphetamines (speed), crystal meth and ecstasy can all raise your blood pressure and body temperature, make your heart beat faster and narrow the blood vessels that feed the heart in a way that greatly increases your risk of heart attack. Heroin can cause arrythmias and pulmonary edema (fluid in the lungs that can make it difficult to breathe). Also, injecting drugs can sometimes result in serious heart infections. If using such drugs is an issue for you, seek assistance in quitting or cutting down from an addictions counsellor or ask your doctor to refer you to someone who can help you make the changes you want.
  • Steer clear of infections. Nobody goes out looking for the flu, gum disease or any other infection, but it’s worth taking precautions to protect against them when you can because infections trigger inflammation in the body and can increase your risk for heart attack. That includes sexually transmitted infections (STIs). If you think you could be at risk for an STI, be sure to talk to your doctor about getting tested so that, if necessary, you can get treatment. Get the flu shot every year and talk to your doctor about getting a pneumococcal vaccine.

Taking these steps can greatly reduce your cardiovascular risk and improve your heart health. Not only that, but chances are you’ll look and feel better too.

Cholesterol-lowering agents

If you have “high cholesterol”—or, more accurately, high levels of triglycerides and/or “bad” cholesterol—and lifestyle changes aren’t doing the trick, your doctor may recommend that you take medication to manage your lipid levels and decrease your risk of cardiovascular disease.

Statins are the class of drugs most commonly recommended to improve lipid levels. Statins lower bad cholesterol and triglyceride levels and can raise “good” cholesterol levels. Some statins interact with certain protease inhibitors. The statins commonly prescribed by doctors for people living with HIV include pravastatin (Pravachol), atorvastatin (Lipitor) and rosuvastatin (Crestor). Statins such as lovastatin (Mevacor) and simvastatin (Zocor) should not be taken with protease inhibitors.

The heavily promoted cholesterol-lowering herbal compound Cholestin works similarly to statins and may also interact with some HIV meds. Statins can also interact with herbal supplements. Always let your doctor and pharmacist know about all of the medications and herbal supplements you’re taking.

All statins reduce the body’s ability to produce the antioxidant coenzyme Q10. This antioxidant is important for the health of the heart, nerves and muscles and particularly for the functioning parts of a cell that produces energy (called mitochondria). For this reason, some natural health practitioners and pharmacists advise people who use statins to take 200 to 400 mg of coenzyme Q10 per day.

Statins are safe for many people but they can cause side effects. Some side effects are relatively minor whereas others are potentially serious—for example, muscle problems, liver injury, and raised blood sugar levels that could lead to type 2 diabetes and a decreased ability of your body to create the active form of vitamin D. Statins can also cause birth defects and should not be used during pregnancy or by people who are considering becoming pregnant. Experts advise that you stop using statin drugs at the first sign of muscle pain, muscle tenderness, muscle weakness or tiredness and that a doctor evaluate the cause promptly. Your doctor may do a blood test for creatine phosphokinase (a measure of muscle breakdown) to see if you should continue taking a statin.

Fibrates are another class of drugs that can help with lipid abnormalities. They are considered the best choice for people who have only elevated triglycerides. Sometimes statins and fibrates are used together, but this increases the risk of muscle toxicity, a side effect of statins. Some fibrates, such as gemfibrozil, deplete both vitamin E and coenzyme Q10. Supplementing with vitamin E (400 to 800 IU daily) and coenzyme Q10 (100 to 400 mg daily) should be considered with these drugs.

Because of drug interactions with these medications, some doctors prefer the B vitamin niacin (1,000 mg daily), which can lower triglycerides significantly and bad cholesterol to a lesser degree. Niacin also works better than the statin drugs to raise good cholesterol. However, it does have several potential problems. First, many people experience flushing, redness and warmth and some people experience painful stinging and itching for a half-hour or more after taking it. A sustained-release form of niacin is much less likely to cause these problems, especially if a baby Aspirin is taken 30 minutes before the niacin. Taking niacin in the middle of a meal can also help. If you find that taking the full dose all at once causes problems, the tablet can be cut in half and be taken with breakfast and dinner. If the dose is tolerable but not high enough to normalize lipid levels, it can be increased until results are seen, but this increases the risk of liver toxicity.

While you take niacin, your doctor should do liver enzyme tests to make sure you can tolerate it. Your blood glucose (sugar) levels should also be monitored because niacin can affect blood sugar levels. Because of its potential to cause insulin-resistance problems, some experts advise against niacin for people taking antiretrovirals, especially if they are already showing signs of blood sugar problems. In the last few years, niacin use has declined, as there are no studies that show it has a major impact on heart disease and death due to heart disease.

Some people find the supplement pantethine (a form of the B-vitamin pantothenic acid) useful in raising their levels of good cholesterol.

The amino acid L-carnitine has been shown to be effective in normalizing triglyceride levels that are elevated due to HIV infection. Because it releases more free carnitine into the bloodstream, the form called acetyl-L-carnitine is more effective than plain L-carnitine. Some doctors have found that taking acetyl-L-carnitine (1,500 mg daily) along with one of the lipid-lowering drugs can normalize triglyceride levels when drugs alone do not do the job.

Omega-3 fatty acids, found in fish oil and krill oil, can decrease inflammation, may help prevent heart rhythm problems and can lower triglyceride levels. Eating fatty fish, such as wild salmon (canned salmon is often wild), anchovies, mackerel, sardines, herring and halibut, is a tasty way to get those fatty acids. Studies of the general population have shown reduced incidence of heart disease in those who consume several servings of such fish weekly. Regular use of fish oil supplements (one or two capsules, twice daily) can also help.

It’s worth remembering that even if your lipid levels can’t be completely normalized, you can lower your overall risk for heart disease by combining regular exercise, a healthy diet, meditation or other stress reduction therapies and nutrient supplementation.

The following nutrients may also help prevent arterial damage and protect the heart:

  • Magnesium (500 to 600 mg daily), which has been found to be deficient in some people with HIV, can help prevent arterial damage and protect the heart. Too much magnesium can cause diarrhea; aim for the dose that gives you soft, well-formed stools.
  • Antioxidants (including vitamin E, vitamin C, bioflavonoids, selenium, coenzyme Q10, N-acetyl-cysteine [NAC] and alpha-lipoic acid) and B vitamins help prevent the chemical changes in the blood vessels and blood fats that are required for fat to be deposited into the lining of the blood vessels, thus helping to prevent damage to the arteries. So even if you can’t fully normalize your cholesterol readings, you can help keep cholesterol from being deposited in the blood vessels by having a good supply of all of these nutrients in the body.