In a large US study of more than 30,000 veterans, 2.6% developed atrial fibrillation (AF) over a median time of 6.8 years. This was significantly more common (and independent of other risk factors) in those with lower CD4+ T cell counts and higher HIV viral loads (17). As in all cases of AF, treatment is usually required. This may be rhythm or rate control.  Rate control is most usually with a beta blocker. Digoxin is not frequently used in the management of AF but may be necessary since calcium channel blockers have the potential to interact with some antiretroviral drugs.  Usual agents for rhythm control are flecainide (only in the absence of cardiac disease), sotalol or amiodarone.  Pulmonary vein isolation (PVI) can be considered if the symptoms are hard to control, though recent evidence has not shown any superiority of PVI in terms of clinical outcomes (18). The need for anticoagulation in the general population with AF is determined by their stroke risk score (eg ATRIA or CHADVasc score). However, only a weak correlation between CHAD2Vasc score and thromboembolic events was shown in an HIV-infected population and warfarin use was not effective (19).  Nevertheless, given the weight of other evidence it is not appropriate to withhold anticoagulation on the basis of this one study, although it may be reasonable not to anticoagulate those patients with only borderline risk. Outcome trials with direct oral anticoagulant drugs, such as apixaban, have not included patients with HIV infection.

There have been mixed reports of HIV protease inhibitors (PIs) having a detrimental effect on electrical conduction in the heart; some studies found QT prolongation (20) while others did not (21). While it is not necessary to perform an ECG on everyone commencing PIs, it would be advisable to do so in patients with CVD risk factors, both before commencing treatment and a few months afterwards, to see if there is a discernable effect. Care should be taken when prescribing other drugs that may also exacerbate QT prolongation and arrhythmias, including macrolides, fluoroquinolones, triazole and imidazole antifungal agents, pentamidine and methadone (22).