Hypertension in the HIV-infected patient

Factors associated with prognostic or treatment outcomes in HIV/AIDS patients with and without hypertension in Eswatini

Non-communicable diseases are increasing faster in HIV/AIDS patients than in the general population. We studied the association between hypertension and other possible confounding factors on viral load and CD4-cell counts in hypertensive and non-hypertensive HIV/AIDS patients receiving antiretroviral therapy (ART) at a large hospital in Eswatini over a 4-year period. We performed a retrospective longitudinal review of the medical records of 560 ART patients divided into non-hypertension and hypertension groups (n = 325 and n = 235) from July 27 to September 8, 2018. Generalized Estimated Equation was used to analyze the longitudinal data. Hypertensive patients were more likely to have improved CD4-cell counts than non-hypertensive patients (OR = 1.83, [1.37–2.44]). ART patients with hypertension were more likely to have detectable viral loads, though not significant (OR = 1.37 [0.77–2.43]). In non-hypertensive patients, second line ART was significantly associated with viral load (OR = 8.61 [2.93–25.34]) and adverse side effects (OR = 3.50 [1.06–11.54]), while isoniazid preventive therapy was significantly associated with CD4-cell counts (OR = 1.68 [1.16–2.45]). In hypertensive patients, factors associated with viral load were WHO HIV stage (OR = 2.84 [1.03–7.85]) and adherence (OR = 8.08 [1.33–49.04]). In both groups, CD4-cell counts significantly and steadily increased over time (p-value < 0.001). Results show a significant association between hypertension and CD4 cell counts but not viral load. In ART patients with and without hypertension, the factors associated with prognostic markers were different. More attention may need to be paid to ART patients with well controlled HIV status to monitoring and controlling of hypertension status.

Viral Infection and Cardiovascular Disease: Implications for the Molecular Basis of COVID-19 Pathogenesis

The current pandemic of coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While this respiratory virus only causes mild symptoms in younger healthy individuals, elderly people and those with cardiovascular diseases such as systemic hypertension are susceptible to developing severe conditions that can be fatal. SARS-CoV-2 infection is also associated with an increased incidence of cardiovascular diseases such as myocardial injury, acute coronary syndrome, and thromboembolism. Understanding the mechanisms of the effects of this virus on the cardiovascular system should thus help develop therapeutic strategies to reduce the mortality and morbidity associated with SARS-CoV-2 infection. Since this virus causes severe and fatal conditions in older individuals with cardiovascular comorbidities, effective therapies targeting specific populations will likely contribute to ending this pandemic. In this review article, the effects of various viruses—including other coronaviruses, influenza, dengue, and human immunodeficiency virus—on the cardiovascular system are described to help provide molecular mechanisms of pathologies associated with SARS-CoV-2 infection and COVID-19. The goal is to provide mechanistic information from the biology of other viral infections in relation to cardiovascular pathologies for the purpose of developing improved vaccines and therapeutic agents effective in preventing and/or treating the acute and long-term consequences of SARS-CoV-2 and COVID-19.

Magnitude and associated factors of diabetes mellitus and hypertension among adult HIV-positive individuals receiving highly active antiretroviral therapy at Jugal Hospital, Harar, Ethiopia

BACKGROUND

People with HIV infection are at increased risk of noncommunicable diseases (NCDs). Diabetes mellitus (DM) and hypertension are recognized as the major NCDs. Except few findings in general population, there is no well-documented evidence on the magnitude of NCDs and associated factors among HIV-positive patients.

PURPOSE

The aim of this study was to determine the magnitude and associated factors of DM and hypertension among adult HIV-positive subjects receiving highly active antiretroviral therapy (HAART).

METHODS

A hospital-based cross-sectional study was conducted from February to April at Jugal Hospital, Harar, Eastern Ethiopia. Sociodemographic and anthropometric data and blood pressure (BP) were collected by senior clinical nurses. A total of 5 mL of venous blood was collected. Serum glucose and lipid profile were measured using the Autolab 18 clinical chemistry analyzer. Data were analyzed using STATA version 13.

RESULTS

A total of 425 HIV-infected individuals taking HAART of age ranging from 18 to 68 years were included. The prevalence of DM and hypertension were 7.1% (95% CI: 4.9-9.9) and 12.7% (95% CI: 9.8-16.2), respectively. Increased blood triglyceride (adjusted odds ratio [AOR] =4.7, 95% CI: 1.7-13.1), high BP (AOR =3.3, 95% CI: 1.1-9.5), and high baseline body mass index (BMI) (AOR =8.7, 95% CI: 2.4-31.8) were significantly associated with DM. In contrast, raised waist-hip ratio (AOR =4.6, 95% CI: 1.6-13.3), raised blood glucose (AOR =3.5, 95% CI: 1.1-11.4), increased total cholesterol (AOR =3.9, 95% CI: 1.3-11.9), high current BMI (AOR =3.8, 95% CI: 1.5-9.6), drinking alcohol (AOR =3.4, 95% CI: 1.5-8.1), CD4 count <500 cell/mL (AOR =2.7, 95% CI: 1.3-5.6), and longer duration of HAART (AOR =2.3, 95% CI: 1.1-5.1) were significantly associated with hypertension.

CONCLUSION

DM and hypertension were frequent among HIV patients on HAART, and they were linked to the well-known risk factors. Therefore, regular screening and monitoring of DM and hypertension before and after the initiation of HAART is of paramount importance.

Prevalence and determinants of selected cardio-metabolic risk factors among people living with HIV/AIDS and receiving care in the South West Regional Hospitals of Cameroon: a cross-sectional study

Objective

Metabolic disorders and cardiovascular risk factors are not routinely assessed in the care of HIV patients in developing countries, known to have the highest disease burden. We described the prevalence and factors associated with major cardio-metabolic risk factors (obesity, diabetes and hypertension) in HIV/AIDS patients.

Results

The prevalence of diabetes, hypertension and obesity were 11.3% (95% CI 8.10–15.43), 24.8% (95% CI 20.1–30.0) and 14.5% (95% CI 11.1–19.3) respectively. Central obesity and high alcohol intake were the factors significantly associated with diabetes mellitus, while central obesity and overweight/obesity were significantly associated with having hypertension. Short duration of antiretroviral therapy was the significant predisposing factor for obesity. On multivariate analyses, the only association observed was between central obesity and diabetes (Adjusted OR 2.52, 95% CI 1.01–6.30, P = 0.048). Conclusively, DM, HTN and obesity are highly prevalent in HIV/AIDS patients in the SWR hospitals of Cameroon, with that of DM and obesity being higher than that seen in the general population while that of HTN equaling that of the general population. Awareness of these data among clinicians involved in the management of these patients should be emphasized.

Hypertension in treated and untreated patients with HIV: a study from 2011 to 2013 at the Jos University Teaching Hospital, Nigeria

Background

Individuals with HIV, especially those on antiretroviral therapy (ART), may have increased risk of hypertension. We investigated the prevalence of hypertension at enrolment and 12 months after commencing ART in a Nigerian HIV clinic.

Methods

Data from patients enrolled for ART from 2011 to 2013 were analysed, including 2310 patients at enrolment and 1524 re-evaluated after 12 months of ART. The presence of hypertension, demographic, clinical and biochemical data were retrieved from standardized databases. Bivariate and logistic regressions were used to identify baseline risk factors for hypertension.

Results

Prevalence of hypertension at enrolment was 19.3% (95% CI 17.6-20.9%), and age (p<0.001), male sex (p=0.004) and body mass index (BMI) (p<0.001) were independent risk factors for hypertension. Twelve months after initiating ART, a further 31% (95% CI 17.6-20.9%) had developed hypertension. Total prevalence at that point was 50.2%. Hypertension among those on ART was associated with age (p=0.009) and BMI (p=0.008), but not with sex. There were no independently significant associations between hypertension and CD4+ counts, viral load or type of ART.

Conclusions

Hypertension is common in HIV infected individuals attending the HIV clinic. Patients initiating ART have a high risk of developing hypertension in the first year of ART. Since BMI is modifiable, life-style advice aimed at weight reduction is strongly advisable.

Predictors of hypertension in an urban HIV-infected population at the University of Calabar Teaching Hospital, Calabar, Nigeria

Background

The introduction of highly active antiretroviral therapy (HAART) has remarkably improved the prognosis of human immunodeficiency virus (HIV)-infected patients, at the expense of the development of long-term complications such as cardiovascular and renal diseases. Hypertension (HTN) is a major risk factor for cardiovascular diseases and its associated mortality. In this study, we aimed to determine the prevalence of HTN and to identify possible predictors among HIV-infected patients attending the HIV Special Treatment Clinic at the University of Calabar Teaching Hospital, Calabar.

Materials and methods

A cross-sectional study was carried out over a 5-month period from February to July 2016. A total of 112 HIV-infected persons were consecutively recruited and their blood pressures were measured in two consecutive clinic visits. They were compared with the HIV-negative control group (n=309). Data collected were analyzed with SPSS 18, and statistical significance was set at P<0.05.

Results

There was a female preponderance in both the HIV-infected individuals and HIV-negative control group (57.5% vs. 57.4%). The mean ages were 39.3 and 33.9 years in HIV-infected and HIV-negative subjects, respectively. The risk factors that were associated with HTN in both groups were older age (>40 years), increased weight and body mass index (BMI), and presence of obesity. Male sex and duration of exposure to HAART and CD₄ count levels >200 cells/mm³ were associated with HTN in HIV-infected patients, whereas the absence of family history of HTN was significantly associated with HTN in both groups. However, in a multivariate logistic regression, the predictors of HTN in both groups are absence of family history of HTN and older age in HIV-infected patients and HIV-negative subjects, respectively.

Conclusion

Traditional risk factors such as older age, increased BMI, and obesity were linked to HTN in both HIV-infected and HIV-negative subjects, but higher CD₄ count level and cumulative HAART exposure were associated with HTN in HIV-positive individuals. In a multivariate logistic regression, the predictors of HTN in both groups are absence of family history of HTN and older age in HIV-infected patients and HIV-negative subjects, respectively.

Population-Based Assessment of Hypertension Epidemiology and Risk Factors among HIV-Positive and General Populations in Rural Uganda

BACKGROUND

Antiretroviral therapy scale-up in Sub-Saharan Africa has created a growing, aging HIV-positive population at risk for non-communicable diseases such as hypertension. However, the prevalence and risk factors for hypertension in this population remain incompletely understood.

METHODS

We measured blood pressure and collected demographic data on over 65,000 adults attending multi-disease community health campaigns in 20 rural Ugandan communities (SEARCH Study: NCT01864603). Our objectives were to determine (i) whether HIV is an independent risk factor for hypertension, and (ii) awareness and control of hypertension in HIV-positive adults and the overall population.

RESULTS

Hypertension prevalence was 14% overall, and 11% among HIV-positive individuals. 79% of patients were previously undiagnosed, 85% were not taking medication, and 50% of patients on medication had uncontrolled blood pressure. Multivariate predictors of hypertension included older age, male gender, higher BMI, lack of education, alcohol use, and residence in Eastern Uganda. HIV-negative status was independently associated with higher odds of hypertension (OR 1.2, 95% CI: 1.1-1.4). Viral suppression of HIV did not significantly predict hypertension among HIV-positives.

SIGNIFICANCE

The burden of hypertension is substantial and inadequately controlled, both in HIV-positive persons and overall. Universal HIV screening programs could provide counseling, testing, and treatment for hypertension in Sub-Saharan Africa.

Electrochemical sensing method for point-of-care cortisol detection in human immunodeficiency virus-infected patients

A novel electrochemical sensing method was devised for the first time to detect plasma cortisol, a potential psychological stress biomarker, in human immunodeficiency virus (HIV)-positive subjects. A miniaturized potentiostat (reconfigured LMP91000 chip) interfaced with a microfluidic manifold containing a cortisol immunosensor was employed to demonstrate electrochemical cortisol sensing. This fully integrated and optimized electrochemical sensing device exhibited a wide cortisol-detection range from 10 pg/mL to 500 ng/mL, a low detection limit of 10 pg/mL, and sensitivity of 5.8 μA (pg mL)⁻¹, with a regression coefficient of 0.995. This cortisol-selective sensing system was employed to estimate plasma cortisol in ten samples from HIV patients. The electrochemical cortisol-sensing performance was validated using an enzyme-linked immunosorbent assay technique. The results obtained using both methodologies were comparable within 2%–5% variation. The information related to psychological stress of HIV patients can be correlated with disease-progression parameters to optimize diagnosis, therapeutic, and personalized health monitoring.

Arterial hypertension and cardiovascular risk in HIV-infected patients

The dramatic change of the natural history of HIV-infected patients by highly active antiretroviral therapy (HAART) has exposed these patients to cardiovascular risk, including cardiovascular disease and hypertension. In HIV-infected patients, the development of arterial hypertension, at least in the medium-long term is an established feature, although recognized predictors of its development have not been clearly identified. In addition, conflicting data regarding the influence of antiretroviral therapy (ART) are reported. The presence of a proinflammatory state and oxidative stress-mediated endothelial dysfunction seem, however, to play a pathophysiologic role. In this review, we examine and provide a comprehensive, literature based, consideration of the pathophysiologic aspects of hypertension in these patients. HIV-infected patients, independently of the presence of hypertension, remain at very high cardiovascular risk due to the presence of the same cardiovascular risk factors recognized for the general population with, in addition, the indirect influence of the ART, essentially via its effect on lipid metabolism. This review based on the evidence from the literature, concludes that the management of HIV-infected patients in terms of cardiovascular prevention emerges as a priority. The consideration of cardiovascular risk in these patients should receive the same emphasis given for the general population at high cardiovascular risk, including adequate blood pressure control according to international guidelines.

Human immunodeficiency virus & cardiovascular risk

Highly active antiretroviral therapy (HAART) significantly changed the prevalence of the cardiovascular manifestations of human immunodeficiency virus (HIV)/AIDS. In developed countries, a 30 per cent reduction in the prevalence of cardiomyopathy and pericardial effusion was observed, possibly related to a reduction of opportunistic infections and myocarditis. In developing countries, however, where the availablity of HAART is limited, and the pathogenic impact of nutritional factors is significant, a 32 per cent increase was seen in the prevalence of cardiomyopathy and related high mortality rate from congestive heart failure. Also, some HAART regimens in developed countries, especially those including protease inhibitors, may cause, in a high proportion of HIV-infected patients, a lipodystrophy syndrome that is associated with an increased risk of cardiovascular events related to a process of accelerated atherosclerosis. Careful cardiac screening is warranted for patients who are being evaluated for, or who are receiving HAART regimens, particularly for those with known underlying cardiovascular risk factors, according to the most recent clinical guidelines.

Echocardiographic diagnoses in HIV-infected patients presenting with cardiac symptoms at Muhimbili National Hospital in Dar es Salaam, Tanzania

Objective

To determine the pattern of echocardiographic diagnoses in HIV-infected patients presenting with cardiac symptoms at Muhimbili National Hospital in Dar es Salaam, Tanzania.

Methods

Patients known to be HIV positive and with cardiac complaints were prospectively recruited from the Hospital’s care and treatment centre as well as from the medical wards. Clinical assessment, laboratory tests and echocardiography were performed.

Results

A total of 102 patients were recruited from September 2009 to April 2010. The patients’ mean age was 42.4 years and 68.6% were women. The most common diagnosis was pericardial effusion present in 41.2% of the patients. The effusion was large in 5.9% and small in 35.3% of the patients. Hypertensive heart disease was diagnosed in 34.3%, while pulmonary hypertension and dilated cardiomyopathy were present in 12.7 and 9.8%, respectively.

Conclusion

Cardiac abnormalities are common in HIV-infected patients, particularly when they present with symptoms.

Pathogens and atherosclerosis: update on the potential contribution of multiple infectious organisms to the pathogenesis of atherosclerosis

It is currently unclear what causes the chronic inflammation within atherosclerotic plaques. One emerging paradigm suggests that infection with bacteria and/or viruses can contribute to the pathogenesis of atherosclerosis either via direct infection of vascular cells or via the indirect effects of cytokines or acute phase proteins induced by infection at non-vascular sites. This paradigm has been supported by multiple epidemiological studies that have established positive associations between the risk of cardiovascular disease morbidity and mortality and markers of infection. It has also been supported by experimental studies showing an acceleration of the development of atherosclerosis following infection of hyperlipidaemic animal models. There are now a large number of different infectious agents that have been linked with an increased risk of cardiovascular disease. These include: Chlamydia pneumoniae, Porphyromonas gingivalis, Helicobacter pylori , influenza A virus, hepatitis C virus, cytomegalovirus, and human immunodeficiency virus. However, there are significant differences in the strength of the data supporting their association with cardiovascular disease pathogenesis. In some cases, the infectious agents are found within the plaques and viable organisms can be isolated suggesting a direct effect. In other cases, the association is entirely based on biomarkers. In the following review, we evaluate the strength of the data for individual or groups of pathogens with regard to atherosclerosis pathogenesis and their potential contribution by direct or indirect mechanisms and discuss whether the established associations are supportive of the infectious disease paradigm. We also discuss the failure of antibiotic trials and the question of persistent infection.

[Coronary artery disease in HIV-infected subjects. Results of 101 coronary angiographies]

BACKGROUND

The introduction of antiretroviral therapy has brought cardiac disease as a comorbidity in HIV-infected patients in particular into focus. The present study analyses the results of coronary angiography in this patient population.

METHODS

Over a time period of 12 years, 101 coronary angiographies were performed in HIV-infected patients. A retrospective analysis included demographic parameters, cardiac history, cardiovascular risk factors, HIV-specific parameters including antiretroviral therapy and the results of coronary angiographies.

RESULTS

Of the subjects included in the study, 89% were men. The mean age in the analysed population was 50.2 years at the time of coronary angiography. Patients had an elevated rate of cardiovascular risk factors including diabetes mellitus (15.9%), arterial hypertension (65.9%), hyperlipidemia (56.8 %) and smoking (68.2 %). Primary coronary angiography demonstrated coronary disease in 59.1%. Of all patients with coronary artery disease, 70% underwent coronary intervention. Subjects who underwent coronary intervention exhibited hyperlipidemia significantly more often (77.8% vs. 42.3%, p=0.02). Cardiovascular risk factors play a prominent role in the development of premature arteriosclerosis in HIV-infected patients. Furthermore, our data highlight the importance of invasive diagnostics in this patient group.

The human immunodeficiency virus and the cardiometabolic syndrome in the developing world: an African perspective

The advent of highly active antiretroviral therapy (HAART) has transformed human immunodeficiency virus (HIV)/AIDS into a manageable chronic disorder. Clinical care, however, needs to address the metabolic, anthropometric, and cardiovascular changes associated with HIV infection and HAART. Studies in developing countries suggest an increasing incidence of HIV-associated cardiometabolic syndrome (CMS), especially in urban settings. Predictions indicate that the greatest increase in the prevalence of diabetes will occur in Africa over the next 2 decades due to lifestyle changes. This, coupled with increased access to HAART, may exponentially increase the prevalence of CMS in developing countries, where HIV infection is prevalent. Appropriate evaluation and intervention programs need to be implemented in the developing world, especially sub-Saharan Africa, to curtail HIV-related CMS. This should include routine cardiovascular risk assessments, management of HIV infection with more "metabolically friendly" HAART, and encouragement of lifestyle modifications, particularly smoking cessation, weight management, regular exercise, and adherence to a healthy diet.

[Hypertension, HIV infection, and highly active antiretroviral therapy]

The decline in mortality resulting from the use of highly active antiretroviral therapy (HAART) has been accompanied by an increase in metabolic complications that produce accelerated atherosclerosis. Hypertension is one of the most important cardiovascular risk factors. Little is known about the impact of HAART on blood pressure, and it is uncertain whether chronic HIV infection or HAART have a role in the development of hypertension. In this study, the research on the relationships between hypertension and HIV infection published to date is reviewed. Antiretroviral therapy appears to have a modest impact on blood pressure and to be partially mediated by the metabolic changes occurring with this treatment.

Antiretroviral treatment and age-related comorbidities in a cohort of older HIV-infected patients

BACKGROUND

The availability of several therapeutic regimens has transformed HIV infection from a life-threatening disease into a chronic condition. Older patients (>50 years old) with HIV infection constitute a new treatment challenge in terms of the cumulative effects of ageing and antiretroviral therapy (ART).

METHODS

The immunovirological effects and metabolic interactions of 48 weeks of ART in older patients followed up in three Infectious Diseases Units in Milan, Italy since 1994 were compared with those in younger controls aged 25-35 years.

RESULTS

The 159 older patients and 118 controls enrolled in the study were comparable for HIV stage, baseline CD4 cell count and viral load but differed for mode of HIV transmission, comorbid conditions and related chronic treatments. Mean viral load decreased after 48 weeks of treatment by 2.6 log(10) HIV RNA copies/mL and CD4 count increased by 137.5 cells/microL in older patients, and similar values for immunovirological effects were obtained in the young controls. The relative risk (RR) of an abnormal test in older patients was 7.33 [95% confidence interval (CI) 4.36-12.36] for glucose, 1.73 (95% CI 1.45-2.07) for total cholesterol, 1.56 (95% CI 1.22-2.0) for high-density lipoprotein cholesterol, 1.26 (95% CI 1.02-1.56) for triglycerides, 6.48 (95% CI 4.36-9.66) for serum creatinine, and 0.45 (95% CI 0.35-0.58) for ALT. Moderate/severe liver and renal toxicities were recorded in the older patients but not in the controls. The tolerability of ART did not differ between the older patients and the controls. Thirty-nine new cardiovascular, endocrine-metabolic and neuralgic disorders (24.52 per 100 person-years) were diagnosed in the older patients and four (3.39 per 100 person-years) in the controls (P<0.0001).

CONCLUSIONS

Diseases induced by, or related to, the toxic effects of antiretrovirals interact with age-specific health profiles, raising new questions and challenges. Comparative epidemiological studies, research studies addressing specific questions and surveillance are needed to answer the questions that arise in clinical monitoring.

Highly Active Antiretroviral Therapy-Associated Metabolic Syndrome and Cardiovascular Risk

The introduction of highly active antiretroviral therapy (HAART) has significantly modified the course of human immunodeficiency virus (HIV) disease, with longer survival and improved quality of life of HIV-infected subjects. However, HAART regimens, especially those including protease inhibitors, have been shown to cause in a high proportion of HIV-infected patients a metabolic syndrome (lipodystrophy/lipoatrophy, dyslipidemia, type 2 diabetes mellitus, insulin resistance) that may be associated with an increased risk of cardiovascular disease (coronary artery disease and stroke). A careful stratification of the cardiovascular risk and cardiovascular monitoring of patients under HAART is needed according to the most recent clinical guidelines.

Highly Active Antiretroviral Therapy–Associated Metabolic Syndrome: Pathogenesis and Cardiovascular Risk*

The introduction of highly active antiretroviral therapy (HAART) has significantly modified the course of HIV disease, with longer survival and improved quality of life of HIV-infected subjects. However, HAART regimens, especially those including protease inhibitors (PIs) have been shown to cause in a high proportion of HIV-infected patients a metabolic syndrome that may be associated with an increased risk of cardiovascular disease (about 1.4 cardiac events per 1,000 years of therapy according to the Framingham score). Metabolic features associated with somatic changes (lipodystrophy/lipoatrophy) include dyslipidemia (about 70% of patients), insulin resistance (elevated C-peptide and insulin), type 2 diabetes mellitus (8%-10% of the patients), hypertension (up to 75% of patients), coagulation abnormalities (25% of patients), lactic acidemia, and elevated hepatic transaminases (nonalcoholic steatohepatitis). HAART-associated metabolic syndrome is an increasingly recognized clinical entity. A better understanding of the molecular mechanisms responsible for this syndrome will lead to the discovery of new drugs that will reduce the cardiovascular risk in patients under HAART. A careful stratification of the cardiovascular risk and cardiovascular monitoring of patients under HAART is needed according to the most recent clinical guidelines.

Cardiovascular complications of human immunodeficiency virus infection

The heart and great vessels are not the sites most frequently affected by opportunistic infections and neoplastic processes in patients with acquired immune deficiency syndrome (AIDS). However, cardiovascular complications occur in a significant number of such patients and are the immediate cause of death in some. The spectrum of cardiovascular complications of AIDS that may be depicted at imaging includes dilated cardiomyopathy, pericardial effusion, human immunodeficiency virus-associated pulmonary hypertension, endocarditis, thrombosis, embolism, vasculitis, coronary artery disease, aneurysm, and cardiac involvement in AIDS-related tumors. To aid accurate diagnosis and appropriate treatment planning, radiologists should be familiar with the imaging appearance of each of these complications.

Rapid progression of atherosclerotic coronary artery disease in patients with human immunodeficiency virus infection

We describe the case of a 39-year-old human immunodeficiency virus (HIV)-infected man with angiographically documented rapid progression of coronary artery disease. Over a time course of only 2 months, he developed high-grade stenosis of the left anterior descending coronary artery. The risk of myocardial infarction is increased in patients with HIV infection receiving antiretroviral therapy. However, the absolute risk is small and the marked overall benefits of antiretroviral therapy are evident. Patients receiving HIV protease inhibitors should be screened for hyperlipidemia, hyperglycemia, and hypertension. They may be candidates for lipid-lowering therapies depending on their long-term prognosis and individual risk of cardiovascular disease. Care is need because of possible drug interactions between lipid-lowering drugs and antiretroviral therapy. Invasive treatment of acute myocardial infarction does not differ from that in patients not infected with HIV. The rate of progression of coronary artery disease and the restenosis rate, however, are often unexpectedly high in these patients.

Pigmentation: a potential cutaneous marker for AIDS?

Pigmentation of skin, nails and mucosae has frequently been described in HIV positive patients. Various causes for this phenomenon have been ascribed, which include intake of various drugs like zidovudine, opportunistic infections like toxoplasmosis and adrenocortical suppression. However, there has been no uniform explanation. We describe three AIDS patients with different personal and disease profiles but essentially the same pattern of pigmentation. This pattern of pigmentation is thereby discussed. We also propose that this pigmentation could be a result of late stage HIV disease per se and thus could serve as a useful cutaneous marker for the same.

Traitement antirétroviral et risque cardio-vasculaire

Current antiretroviral therapy protocols enable long-term survival of HIV-infected patients, decreasing the risk of infectious complications. Three classes of anti-HIV treatments are available. With longer survival, unusual cardiovascular complications related to iatrogenic biological anomalies (dyslipidemia and impaired glucose tolerance) have appeared among this young population which is exposed to usual risk factors of atherosclerosis. Antiretroviral therapies are suspected to cause these complications, inducing maturity-onset diabetes in 4 to 20% of patients, impaired glucose tolerance in 15 to 60%, hypertriglyceridemia in 15 to 74% depending on the survey, and hypercholesterolemia in 20 to 60%, especially in case of associated lipodystrophia. A lipid battery including total cholesterol, HDL, and triglycerides, and 12-h fasting blood glucose should be obtained before initiating antiretroviral therapy. Any anomalous finding should be followed carefully with regular surveillance every 3 to 6 months and search for other causes of secondary dyslipidemia. In the event of casual and persisting elevation of LDL-cholesterol levels, a statin treatment can be introduced. For secondary prevention, irrespective of the context, recommendations currently merge with the consensus applying to the general population. These patients require careful surveillance of cardiovascular risk factors and a specific care in addition to treatment of their immunodeficiency.

Prevalence of hypertension in HIV-positive patients on highly active retroviral therapy (HAART) compared with HAART-naïve and HIV-negative controls: results from a Norwegian study of 721 patients

Highly active antiretroviral therapy (HAART) may induce dyslipidemia, insulin resistance and body fat distribution similar to that seen in the metabolic syndrome. Hypertension is often a part of the classic metabolic syndrome, but few studies are published about hypertension in HIV-positive patients on HAART. The aim of this study was to compare the prevalence of hypertension in HIV-positive patients on HAART with that in HIV-positive/HAART-naïve patients and HIV-negative controls. The cross-sectional study included 283 unselected HIV-positive ambulatory patients, 219 who were on HAART and 64 who were HAART-naïve. Age- and gender-matched controls (n=438) were randomly selected from a simultaneous health survey of the general population. The prevalence of hypertension was 21% in patients on HAART, 13% in HAART-naïve patients (P=0.20), and 24% in HIV-negative controls (P=0.28). Among several possible risk factors for hypertension, only body mass index (BMI) was found to be a confounder. BMI was similar in HAART-treated and HAART-naïve patients but elevated in controls compared to HAART-treated patients. After adjustment for BMI, the prevalence of hypertension in HIV-negative controls was slightly lower than that in patients on HAART (P=0.29). The results demonstrated a prevalence of hypertension in patients on HAART similar to that in HIV-negative controls. The prevalence of hypertension was somewhat higher in patients on HAART compared to HAART-naïve patients, but the difference was not statistically significant. Considering the marked drop in mortality following antiretroviral therapy, we conclude that the possible influence of HAART on the prevalence of hypertension appears to be a minor problem.

Cardiovascular risk factors, monitoring, and therapy for HIV-infected patients

Cardiovascular complications are important contributors to morbidity and mortality in HIV-infected patients. These complications can usually be detected at subclinical levels with monitoring, which can help guide targeted interventions. This article reviews available data on types and frequency of cardiovascular manifestations in HIV-infected patients and proposes monitoring strategies aimed at early subclinical detection. In particular, we recommend routine echocardiography for HIV-infected patients, even those with no evidence of cardiovascular disease. We also review preventive and therapeutic cardiovascular interventions. For procedures that have not been studied in HIV-infected patients, we extrapolate from evidence-based guidelines for the general population.

Pathogenesis of HIV-associated heart disease

As longevity increases in HIV-infected individuals after the introduction of highly active antiretroviral therapy regimens, long-term effects such as cardiovascular disease and, more specifically, symptomatic heart failure are emerging as leading health issues. In the present review article, we discuss HIV-associated cardiovascular disease, focusing on etiopathogenetic mechanisms that may play a role in diagnosis, management, and therapy of HIV-associated heart failure in the highly active antiretroviral therapy era.

Myocardial and Pericardial Disease in HIV

Cardiovascular complications are frequently encountered in the HIV-infected population. Cardiac care providers should implement appropriate preventive, screening, and therapeutic strategies to maximize survival and quality of life in this increasingly treatable, chronic disease. All HIV-infected individuals should undergo periodic cardiac evaluation, including echocardiography, in order to identify subclinical cardiac dysfunction. Left ventricular (LV) dysfunction can result from, or be exacerbated by, a variety of treatable infectious, endocrine, nutritional, and immunologic disorders. Aggressive diagnosis and treatment of these conditions may lead to improvement or even normalization of myocardial function. Endomyocardial biopsy should be considered to direct etiology-specific therapy. Standard measures for the prevention and treatment of congestive heart failure are recommended for HIV-infected patients. Afterload reduction with angiotensin-converting enzyme inhibitors may be indicated for patients with elevated afterload and preclinical LV dysfunction diagnosed by echocardiogram. However, judicious drug selection and titration are necessary in this cohort of patients with frequent autonomic dysfunction, at risk for a number of potentially lethal drug interactions. Carnitine, selenium, and multivitamin supplementation should be considered, especially in those with wasting or diarrhea syndromes. Monthly intravenous immunoglobulin (IVIG) infusions have been demonstrated to preserve LV parameters in HIV-infected children; ventricular recovery has been documented in some children with recalcitrant HIV-related cardiomyopathy following IVIG infusion. We support the use of immunomodulatory therapy in the pediatric population, and look forward to further study into the efficacy and broader application of this approach. Highly active antiretroviral therapy (HAART) may be associated with dyslipidemia and the metabolic syndrome. This should be treated with dietary and possibly with pharmacologic interventions. Drug interactions need to be considered when instituting pharmacologic therapies. Pericardial effusions are often seen in patients with advanced HIV infection. Asymptomatic effusions are most often nonspecific in nature, related to the proinflammatory milieu found in advanced AIDS. Nonspecific effusions are a marker of advanced disease and do not require exhaustive etiologic evaluation. In contrast, large or symptomatic effusions are often associated with infection or malignancy, and warrant thorough investigation and etiology-specific treatment.

Cardiovascular monitoring and therapy for HIV-infected patients

Cardiovascular complications are important contributors to morbidity and mortality in HIV-infected patients. These complications can usually be detected at subclinical levels with monitoring, which can help guide targeted interventions. This article reviews available data on types and frequency of cardiovascular manifestations in HIV+ patients and proposes monitoring strategies aimed at early subclinical detection. In particular, we recommend routine echocardiography for HIV+ patients, even those with no evidence of cardiovascular disease. We also review preventive and therapeutic cardiovascular interventions. For procedures that have not been studied in HIV+ patients, we extrapolate from evidence-based guidelines for the general population.

Pathogenesis of HIV-associated cardiovascular complications

Reviews and studies published before the introduction of highly active antiretroviral therapy (HAART) have tracked the incidence and course of HIV infection in relation to cardiac illness in both children and adults. The introduction of HAART regimens has significantly modified the course of HIV disease, with longer survival rates and improvement of life quality in HIV-infected people expected. However, early data raised concerns about HAART being associated with an increase in both peripheral and coronary arterial diseases. In this review we discuss HIV-associated cardiovascular complications focusing on pathogenetic mechanisms that could have a role in diagnosis, management, and therapy of these complications in the HAART era.