1
|
Gutiérrez RL, Riddle MS, Porter CK, Maciel M, Poole ST, Laird RM, Lane M, Turiansky GW, Jarell A, Savarino SJ. A First in Human Clinical Trial Assessing the Safety and Immunogenicity of Two Intradermally Delivered Enterotoxigenic Escherichia coli CFA/I Fimbrial Tip Adhesin Antigens with and without Heat-Labile Enterotoxin with Mutation LT(R192G). Microorganisms 2023; 11:2689. [PMID: 38004700 PMCID: PMC10672875 DOI: 10.3390/microorganisms11112689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/25/2023] [Accepted: 10/31/2023] [Indexed: 11/26/2023] Open
Abstract
INTRODUCTION Enterotoxigenic E. coli (ETEC) is a leading cause of diarrhea in travelers as well as for children living in low- to middle-income countries. ETEC adhere to intestinal epithelium via colonization factors (CFs). CFA/I, a common CF, is composed of a polymeric stalk and a tip-localized minor adhesive subunit, CfaE. Vaccine delivery by the transcutaneous immunization of dscCfaE was safe but was poorly immunogenic in a phase 1 trial when administered to volunteers with LTR(192G) and mLT. To potentially enhance the immunogenicity of CfaE while still delivering via a cutaneous route, we evaluated the safety and immunogenicity of two CfaE constructs administered intradermally (ID) with or without mLT. METHODS CfaE was evaluated as a donor strand-complemented construct (dscCfaE) and as a chimeric construct (Chimera) in which dscCfaE replaces the A1 domain of the cholera toxin A subunit and assembles non-covalently with the pentamer of heat-labile toxin B (LTB). Subjects received three ID vaccinations three weeks apart with either dscCfaE (1, 5, and 25 µg) or Chimera (2.6 and 12.9 µg) with and without 0.1 µg of mLT. Subjects were monitored for local and systemic adverse events. Immunogenicity was evaluated by serum and antibody-secreting cell (ASC) responses. RESULTS The vaccine was well-tolerated with predominantly mild and moderate local vaccine site reactions characterized by erythema, induration and post-inflammatory hyperpigmentation. High rates of serologic and ASC responses were seen across study groups with the most robust responses observed in subjects receiving 25 µg of dscCfaE with 0.1 mcg of LT(R192G). CONCLUSION Both ETEC adhesin vaccine prototypes were safe and immunogenic when co-administered with mLT by the ID route. The observed immune responses induced with the high dose of dscCfaE and mLT warrant further assessment in a controlled human infection model.
Collapse
Affiliation(s)
- Ramiro L. Gutiérrez
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
| | - Mark S. Riddle
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
| | - Chad K. Porter
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Milton Maciel
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Steven T. Poole
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Renee M. Laird
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Michelle Lane
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
| | - George W. Turiansky
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Abel Jarell
- Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Stephen J. Savarino
- Naval Medical Research Command, Silver Spring, MD 20910, USA; (R.L.G.); (S.T.P.)
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| |
Collapse
|
2
|
Woldu B, Temu TM, Kirui N, Christopher B, Ndege S, Post WS, Kamano J, Bloomfield GS. Diastolic dysfunction in people with HIV without known cardiovascular risk factors in Western Kenya. Open Heart 2022; 9:openhrt-2021-001814. [PMID: 35064055 PMCID: PMC8785204 DOI: 10.1136/openhrt-2021-001814] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/08/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives Diastolic dysfunction (DD) has been reported to be highly prevalent in people living with HIV (PLWH) on antiretroviral therapy (ART) leading to the hypothesis that it may be an early marker of myocardial disease. Our objective was to evaluate the prevalence of DD in people living with human immunodeficiency virus without known history of diabetes or hypertension in Western Kenya. Methods In this cross-sectional study in western Kenya, 110 PLWH on ART and without known diabetes or hypertension were matched for age ±5 years and sex to HIV-uninfected controls. Study participants underwent a comprehensive two-dimensional echocardiogram and laboratory testing. Results The mean (SD) age in the HIV-positive group was 42.9 (8.6) years compared with 42.1 (12.9) years in the HIV-uninfected group. Mean (SD) CD4 +T cell count for the HIV-positive group was 557 (220) cells/ml. Mean systolic and diastolic blood pressures were within the normal range and comparable between the two groups. Mean body mass index was 25.2 (5.4) kg/m2 and 26.3 (5.4) kg/m2 in HIV-positive and uninfected participants, respectively. There was only 1 (0.9 %) case of DD in each group. Despite low prevalence of DD, PLWH had 5.76 g/m2 higher left ventricular mass index (p=0.01) and 2.77 mL/m2 larger left atrial volume (p=0.02) compared with the HIV-negative group after adjusting for risk factors associated with DD. Conclusion Contrary to prior reports, DD in PLWH was low. Environmental and cardiovascular disease risk factors such as diabetes and hypertension may be significant modifiers for development and progression of DD in PLWH.
Collapse
Affiliation(s)
- Bethel Woldu
- Academic Model Providing Access to Healthcare, Eldoret, Kenya .,MedStar Heart & Vascular Institute, Baltimore, Maryland, USA.,Department of Medicine, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Tecla M Temu
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Nicholas Kirui
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Uasin Gishu County, Kenya.,Moi Teaching and Referral Hospital, Eldoret, Uasin Gishu, Kenya
| | | | - Samson Ndege
- Academic Model Providing Access to Healthcare, Eldoret, Kenya.,Moi Teaching and Referral Hospital, Eldoret, Uasin Gishu, Kenya
| | - Wendy S Post
- Department of Medicine, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jemima Kamano
- Academic Model Providing Access to Healthcare, Eldoret, Kenya.,Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Uasin Gishu County, Kenya
| | - Gerald S Bloomfield
- Academic Model Providing Access to Healthcare, Eldoret, Kenya.,Department of Medicine and Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| |
Collapse
|
3
|
Echocardiographic Findings Among Virally Suppressed HIV-Infected Aging Asians Compared with HIV-Negative Individuals. J Acquir Immune Defic Syndr 2021; 85:379-386. [PMID: 32701821 DOI: 10.1097/qai.0000000000002456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Prevalence of cardiovascular disease increases with age. Little is known about the prevalence and risk factors for echocardiographic abnormalities among older people living with HIV (PLHIV) from Asia. DESIGN A cross-sectional study was conducted among PLHIV aged >50 years (N = 298) on antiretroviral treatment (ART) and HIV-negative controls (N = 100) frequency matched by sex and age in Thailand. METHODS All participants underwent standard 2-dimensional transthoracic echocardiography performed by trained cardiologists who were blinded to the participant's care and HIV status. Logistic regression was used to examine the association between cardiac abnormalities and risk factors. RESULTS The median age was 54.7 years (60.8% men) with 37.2% having hypertension and 16.6% having diabetes mellitus. PLHIV was on ART for a median of 16.2 years with current CD4 cell counts of 616 cells per cubic millimeter. Echocardiogram abnormalities did not differ among PLHIV (55%) and the controls (60%). The major abnormalities in PLHIV were following: left ventricular (LV) hypertrophy: 37% men and 42.2% women, LV systolic dysfunction (0.7%), diastolic dysfunction (24.2%), and pulmonary hypertension (3.9%). From the multivariate analyses in PLHIV, being aged >60 years was independently associated with diastolic dysfunction, whereas female sex and left atrial volume index of >34 mL/m were associated with pulmonary hypertension (P < 0.05). None of the ART was significantly associated with any major echocardiographic abnormalities. CONCLUSIONS In this long-term, well-suppressed, older, Asian PLHIV cohort, the prevalence of asymptomatic LV systolic dysfunction and pulmonary hypertension were relatively low, whereas the diastolic dysfunction and LV hypertrophy were common. Echocardiographic findings did not differ between PLHIV and HIV-uninfected controls.
Collapse
|
4
|
Kingery JR, Goyal P, Hosalli R, Lee MH, Desderius B, Kalokola F, Makubi A, Fadhil S, Kapiga S, Karmali D, Kaminstein D, Devereux R, McNairy M, Johnson W, Fitzgerald D, Peck R. Human Immunodeficiency Virus-Associated Myocardial Diastolic Dysfunction and Soluble ST2 Concentration in Tanzanian Adults: A Cross-Sectional Study. J Infect Dis 2021; 223:83-93. [PMID: 32526008 PMCID: PMC7781450 DOI: 10.1093/infdis/jiaa328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/09/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The aims of this study were (1) to compare the prevalence of myocardial diastolic dysfunction (DD) in antiretroviral therapy (ART)-naive people living with human immunodeficiency virus (PLWH) to human immunodeficiency virus (HIV)-uninfected adults in East Africa and (2) to determine the association between serum concentration of the cardiac biomarkers ST2 and DD. METHODS In this cross-sectional study, we enrolled PLWH and uninfected adults at a referral HIV clinic in Mwanza, Tanzania. Standardized history, echocardiography, and serum were obtained. Regression models were used to quantify associations. RESULTS We enrolled 388 ART-naive PLWH and 461 HIV-uninfected adults with an average age of 36.0 ± 10.2 years. Of PLWH in the third, fourth, and fifth decades of life, 5.0%, 12.5%, and 32.7%, respectively, had DD. PLWH had a higher prevalence of DD (adjusted odds ratio, 2.71 [95% confidence interval, 1.62-4.55]; P < .0001). PLWH also had a higher probability of dysfunction with one or fewer traditional risk factors present. Serum ST2 concentration was associated with dysfunction in PLWH but not uninfected participants (P = .04 and P = .90, respectively). CONCLUSIONS In a large population of young adults in sub-Saharan Africa, DD prevalence increased starting in the third decade of life. HIV was independently associated with dysfunction. Serum ST2 concentration was associated with DD in PLWH but not HIV-uninfected participants. This pathway may provide insight into the mechanisms of HIV-associated dysfunction.
Collapse
Affiliation(s)
- Justin R Kingery
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
- Center for Global Health, Department of Internal Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Parag Goyal
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- Division of Cardiovascular Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Rahul Hosalli
- Center for Global Health, Department of Internal Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Myung Hee Lee
- Center for Global Health, Department of Internal Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Bernard Desderius
- Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Fredrick Kalokola
- Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Abel Makubi
- Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Salama Fadhil
- Mwanza Intervention Trials Unit, London School of Hygiene and Tropical Medicine, Mwanza, Tanzania
| | - Saidi Kapiga
- Mwanza Intervention Trials Unit, London School of Hygiene and Tropical Medicine, Mwanza, Tanzania
| | - Dipan Karmali
- Division of General Internal Medicine, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Daniel Kaminstein
- Center for Ultrasound Education, Department of Emergency Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Richard Devereux
- Division of Cardiovascular Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Margaret McNairy
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- Center for Global Health, Department of Internal Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Warren Johnson
- Center for Global Health, Department of Internal Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Daniel Fitzgerald
- Center for Global Health, Department of Internal Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Robert Peck
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
- Center for Global Health, Department of Internal Medicine, Weill Cornell Medicine, New York, New York, USA
- Mwanza Intervention Trials Unit, London School of Hygiene and Tropical Medicine, Mwanza, Tanzania
| |
Collapse
|
5
|
Ozemek C, Erlandson KM, Jankowski CM. Physical activity and exercise to improve cardiovascular health for adults living with HIV. Prog Cardiovasc Dis 2020; 63:178-183. [PMID: 32014512 DOI: 10.1016/j.pcad.2020.01.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 01/29/2020] [Indexed: 12/11/2022]
Abstract
Pharmacologic advancements in the treatment of human immunodeficiency virus (HIV) has extended the life expectancy of people living with HIV (PLWH). An unfortunate side effect of HIV treatment, however, is an increased prevalence of dyslipidemia, glycemic dysregulation and abnormal distribution of body fat (lipodystrophy). Consequently, the risk of developing cardiovascular disease (CVD) is significantly increased in PLWH and ultimately a major cause of mortality. Physical activity and exercise training are interventions that have effectively protected against the development of CVD and, in the presence of CVD, has help mitigate morbidity and mortality. Early concerns over potential immunosuppressive effects of exercise in PLWH have largely been dispelled and in some cases exercise has been shown to strengthen markers of immune function. Interventions with aerobic exercise, resistance exercise, and their combination, particularly at higher intensities, are showing promising health outcomes in PLWH. This review will summarize the key cardiovascular and metabolic effects of antiretroviral therapy; the effects of the types and intensities of exercise on cardiorespiratory fitness, cardiometabolic markers, and muscle strength; and provide recommendations on strategies to apply exercise interventions in clinical settings.
Collapse
Affiliation(s)
- Cemal Ozemek
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA.
| | - Kristine M Erlandson
- School of Medicine, Division of Infectious Diseases, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | | |
Collapse
|
6
|
Oursler KK, O'Boyle HM, Briggs BC, Sorkin JD, Jarmukli N, Katzel LI, Freiberg MS, Ryan AS. Association of Diastolic Dysfunction with Reduced Cardiorespiratory Fitness in Adults Living with HIV. AIDS Patient Care STDS 2019; 33:493-499. [PMID: 31821043 DOI: 10.1089/apc.2019.0149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Despite the high prevalence of diastolic dysfunction in adults living with HIV, the impact on cardiorespiratory fitness (CRF) is understudied. The objective of this cross-sectional study was to investigate the relationship between cardiac function and CRF in adults with HIV. Adults receiving antiretroviral therapy with no history of coronary artery disease (CAD) or heart failure were eligible to participate. Cardiac function was assessed by resting Doppler echocardiography. CRF was measured by oxygen utilization at peak exercise (VO2peak). The majority of participants were African American (86%) and male (97%) with a mean [standard deviation (SD)] age of 56.6 (7.1) years and median CD4 lymphocyte count of 492 cells/mL. The mean (SD) VO2peak was 26.1 (5.5) mL/(kg·min). Age, diabetes, hypertension, and hemoglobin were associated with VO2peak. Overall, diastolic dysfunction was present in 38% and was associated with lower VO2peak (p < 0.05). VO2peak was lower among those with impaired myocardial relaxation (e' <8 cm/s) compared with normal relaxation [mean ± SE mL/(kg·min), 25.2 ± 0.6 vs. 27.7 ± 0.9, p < 0.05]. Adjusted for age and clinical factors, each unit increase in left ventricular relaxation (E/A) was associated with an average 4.4 mL/(kg·min) higher VO2peak, representing more than one metabolic equivalent. We conclude that diastolic dysfunction is independently associated with clinically significant low CRF in adults with HIV and no history of CAD or heart failure. These results highlight the importance of recognizing diastolic dysfunction in individuals living with HIV regardless of their cardiovascular disease history.
Collapse
Affiliation(s)
- Krisann K. Oursler
- Department of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
- Geriatrics Extended Care, Salem Veterans Affairs Medical Center, Salem, Virginia
| | - Hillary M. O'Boyle
- Department of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Brandon C. Briggs
- Geriatrics Extended Care, Salem Veterans Affairs Medical Center, Salem, Virginia
| | - John D. Sorkin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Baltimore Veterans Affairs Medical Center Geriatric Research, Education, and Clinical Center at the Veterans Affairs Maryland Health Care System, Baltimore, Maryland
| | - Nabil Jarmukli
- Geriatrics Extended Care, Salem Veterans Affairs Medical Center, Salem, Virginia
| | - Leslie I. Katzel
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Baltimore Veterans Affairs Medical Center Geriatric Research, Education, and Clinical Center at the Veterans Affairs Maryland Health Care System, Baltimore, Maryland
| | - Matthew S. Freiberg
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Alice S. Ryan
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Baltimore Veterans Affairs Medical Center Geriatric Research, Education, and Clinical Center at the Veterans Affairs Maryland Health Care System, Baltimore, Maryland
| |
Collapse
|
7
|
Mishra TK, Mishra SK, Singh S. Cardiovascular manifestations of people living with HIV/AIDS: Report from a hot spot in eastern India. Indian Heart J 2019; 71:338-343. [PMID: 31779863 PMCID: PMC6890952 DOI: 10.1016/j.ihj.2019.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/04/2019] [Accepted: 09/01/2019] [Indexed: 11/17/2022] Open
Abstract
Objective To study the profile and characteristics of cardiovascular abnormalities among patients living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) at a tertiary care hospital in India. The association of cardiovascular abnormalities with the CD4 count and disease stages, according to the World Health Organization (WHO) classification, was also analyzed. Methods A total of 200 patients with HIV/AIDS were compared with 50 healthy controls. All patients underwent blood investigations, chest X-ray, electrocardiography, and echocardiography. Results The mean age of the patients was 38.66 ± 9.22 years, with a male-to-female ratio of 3.25:1. Echocardiographic abnormalities were found in 52% of the patients and 12% of the controls, with the most common abnormality being left ventricular diastolic dysfunction. Echocardiographic abnormalities were markedly more common in patients with a CD4 count of <200/μL. The advanced stage of the disease, according to the WHO classification, was also associated with an increased incidence of echocardiographic abnormalities. Conclusions Cardiovascular abnormalities in the form of electrocardiogram and ECHO findings were present in 54.5% and 52% of patients, respectively. Echocardiographic findings showed significant correlation with CD4 count and WHO disease stage.
Collapse
|
8
|
Barnes RP, Lacson JCA, Bahrami H. HIV Infection and Risk of Cardiovascular Diseases Beyond Coronary Artery Disease. Curr Atheroscler Rep 2017; 19:20. [PMID: 28315199 DOI: 10.1007/s11883-017-0652-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) increasingly afflicts people living with HIV (PLWH) in the contemporary era of antiretroviral therapy (ART). Coronary artery disease (CAD) is the most widely studied cardiovascular problem in PLWH; however, less is known about other clinically relevant subtypes of CVD such as heart failure (HF), cerebrovascular disease, sudden cardiac death, pericardial diseases, and pulmonary hypertension. This paper reviews evidence of other subtypes of CVD as emerging issues in the post-ART era. RECENT FINDINGS Recent studies have shown that PLWH have higher risk of HF as well as subclinical impairment of left ventricular (LV) mechanics (systolic and diastolic dysfunction) and myocardial abnormalities (fibrosis and steatosis). The underlying mechanisms, however, are not well-understood. A few studies have also shown higher rates of atrial fibrillation and sudden cardiac death in PLWH. Ischemic stroke is the most common stroke type in the post-ART era, with underlying mechanisms like those identified in CAD: chronic inflammation and associated vasculopathy. Studies of great vessels (carotid artery and aorta) and peripheral arterial disease show heterogeneous results. Small subclinical pericardial effusions are common in PLWH in post-ART era. Pulmonary hypertension continues to be an underdiagnosed and potentially fatal complication of HIV infection. PLWH remain at higher risk for all types of CVD including heart failure, stroke, and arrhythmias in the post-ART era. Chronic inflammation may play an important role in this increased risk. More studies are needed to further elucidate the extent of non-coronary CVD in PLWH and the underlying mechanisms for them.
Collapse
Affiliation(s)
- Revery P Barnes
- Department of Family Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - John Charles A Lacson
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Hossein Bahrami
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. .,Division of Cardiovascular Medicine, Department of Medicine, University of Southern California, Los Angeles, CA, USA. .,Department of Radiology, Keck School of Medicine, University of Southern California, 2020 Zonal Ave, Los Angeles, CA, 90033, USA.
| |
Collapse
|
9
|
Manner IW, Waldum-Grevbo B, Witczak BN, Bækken M, Øktedalen O, Os I, Schwartz T, Sjaastad I. Immune markers, diurnal blood pressure profile and cardiac function in virologically suppressed HIV-infected patients. Blood Press 2017; 26:332-340. [PMID: 28675304 DOI: 10.1080/08037051.2017.1346459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE Non-dipping nocturnal blood pressure (BP) pattern has been reported prevalent among HIV-infected patients and is associated with adverse cardiovascular outcomes. The aims of this observational study were to identify predictors of nocturnal BP decline, and to explore whether diurnal BP profile is associated with alterations in cardiac structure and function. MATERIALS AND METHODS A total of 108 treated HIV-infected patients with suppressed viremia underwent ambulatory BP measurement, 51 of these patients also underwent echocardiography. RESULTS Non-dipping nocturnal BP pattern was present in 51% of the patients. Decreased nocturnal decline in systolic BP (SBP) correlated with lower CD4 count (rsp = 0.21, p = 0.032) and lower CD4/CD8 ratio (rsp = 0.26, p = 0.008). In multivariate linear regression analyses, lower BMI (p = 0.015) and CD4/CD8 ratio <0.4 (p = 0.010) remained independent predictors of nocturnal decline in SBP. Nocturnal decline in SBP correlated with impaired diastolic function, e' (r = 0.28, p = 0.049) as did nadir CD4 count (rsp = 0.38, p = 0.006). In multivariate linear regression analyses, nadir CD4 count <100 cells/μL (p = 0.037) and age (p < 0.001) remained independent predictors of e'. CONCLUSIONS Compromised immune status may contribute to attenuated diurnal BP profile as well as impaired diastolic function in well-treated HIV infection.
Collapse
Affiliation(s)
- Ingjerd W Manner
- a Department of Nephrology , Oslo University Hospital , Oslo , Norway
| | | | - Birgit Nomeland Witczak
- b Institute for Experimental Medical Research , Oslo University Hospital and University of Oslo , Oslo , Norway
| | - Morten Bækken
- a Department of Nephrology , Oslo University Hospital , Oslo , Norway
| | - Olav Øktedalen
- c Department of Infectious Diseases , Oslo University Hospital , Oslo , Norway
| | - Ingrid Os
- a Department of Nephrology , Oslo University Hospital , Oslo , Norway.,d Institute of Clinical Medicine, Faculty of Medicine , University of Oslo , Oslo , Norway
| | - Thomas Schwartz
- b Institute for Experimental Medical Research , Oslo University Hospital and University of Oslo , Oslo , Norway.,c Department of Infectious Diseases , Oslo University Hospital , Oslo , Norway
| | - Ivar Sjaastad
- b Institute for Experimental Medical Research , Oslo University Hospital and University of Oslo , Oslo , Norway.,e Department of Cardiology , Oslo University Hospital , Oslo , Norway
| |
Collapse
|
10
|
Affiliation(s)
- Monica R Shah
- Program in Adult and Pediatric Cardiac Research, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA.
| | - Renee P Wong
- Program in Adult and Pediatric Cardiac Research, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| |
Collapse
|
11
|
Ntusi NAB, Ntsekhe M. Human immunodeficiency virus-associated heart failure in sub-Saharan Africa: evolution in the epidemiology, pathophysiology, and clinical manifestations in the antiretroviral era. ESC Heart Fail 2016; 3:158-167. [PMID: 28834662 PMCID: PMC5657330 DOI: 10.1002/ehf2.12087] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 01/24/2016] [Accepted: 01/26/2016] [Indexed: 01/12/2023] Open
Abstract
The survival of patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) who have access to highly active antiretroviral therapy (ART) has dramatically increased in recent times. This review focuses on HIV‐associated heart failure in sub‐Saharan Africa (SSA). In HIV infected persons, heart failure may be related to pathology of the pericardium, the myocardium, the valves, the conduction system, or the coronary and pulmonary vasculature. HIV‐associated heart failure can be because of direct consequences of HIV infection, autoimmune reactions, pro‐inflammatory cytokines, opportunistic infections (OIs) or neoplasms, use of ART or therapy for OIs and presence of traditional cardiovascular risk factors. Myocardial involvement includes diastolic dysfunction, asymptomatic left ventricular dysfunction, cardiomyopathy, myocarditis, fibrosis, and steatosis. Pericardial diseases include pericarditis, pericardial effusions (rarely causing tamponade), pericardial constriction, and effusive‐constrictive syndromes. Coronary artery disease is commonly reported in industrial nations, although its prevalence is thought to be low in HIV‐infected persons from SSA.
Collapse
Affiliation(s)
- Ntobeko A B Ntusi
- Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Mpiko Ntsekhe
- Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| |
Collapse
|
12
|
Ntusi N, O’Dwyer E, Dorrell L, Wainwright E, Piechnik S, Clutton G, Hancock G, Ferreira V, Cox P, Badri M, Karamitsos T, Emmanuel S, Clarke K, Neubauer S, Holloway C. HIV-1–Related Cardiovascular Disease Is Associated With Chronic Inflammation, Frequent Pericardial Effusions, and Probable Myocardial Edema. Circ Cardiovasc Imaging 2016; 9:e004430. [DOI: 10.1161/circimaging.115.004430] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background—
Patients with treated HIV infection have clear survival benefits although with increased cardiac morbidity and mortality. Mechanisms of heart disease may be partly related to untreated chronic inflammation. Cardiovascular magnetic resonance imaging allows a comprehensive assessment of myocardial structure, function, and tissue characterization. We investigated, using cardiovascular magnetic resonance, subclinical inflammation and myocardial disease in asymptomatic HIV-infected individuals.
Methods and Results—
Myocardial structure and function were assessed using cardiovascular magnetic resonance at 1.5-T in treated HIV-infected individuals without known cardiovascular disease (n=103; mean age, 45±10 years) compared with healthy controls (n=92; mean age, 44±10 years). Assessments included left ventricular volumes, ejection fraction, strain, regional systolic, diastolic function, native T1 mapping, edema, and gadolinium enhancement. Compared with controls, subjects with HIV infection had 6% lower left ventricular ejection fraction (
P
<0.001), 7% higher myocardial mass (
P
=0.02), 29% lower peak diastolic strain rate (
P
<0.001), 4% higher short-tau inversion recovery values (
P
=0.02), and higher native T1 values (969 versus 956 ms in controls;
P
=0.01). Pericardial effusions and myocardial fibrosis were 3 and 4× more common, respectively, in subjects with HIV infection (both
P
<0.001).
Conclusions—
Treated HIV infection is associated with changes in myocardial structure and function in addition to higher rates of subclinical myocardial edema and fibrosis and frequent pericardial effusions. Chronic systemic inflammation in HIV, which involves the myocardium and pericardium, may explain the high rate of myocardial fibrosis and increased cardiac dysfunction in people living with HIV.
Collapse
Affiliation(s)
- Ntobeko Ntusi
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| | - Eoin O’Dwyer
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| | - Lucy Dorrell
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| | - Emma Wainwright
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| | - Stefan Piechnik
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| | - Genevieve Clutton
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| | - Gemma Hancock
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| | - Vanessa Ferreira
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| | - Pete Cox
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| | - Motasim Badri
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| | - Theodoros Karamitsos
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| | - Sam Emmanuel
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| | - Kieran Clarke
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| | - Stefan Neubauer
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| | - Cameron Holloway
- From the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom (N.N., S.P., V.F., T.K., S.N., C.H.); Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa (N.N., M.B.); Department of Cardiology, St.Vincent’s Hospital, Darlinghurst, New South Wales, Australia (E.O., S.E., C.H.); Department of
| |
Collapse
|
13
|
Fontes-Carvalho R, Mancio J, Marcos A, Sampaio F, Mota M, Rocha Gonçalves F, Gama V, Azevedo A, Leite-Moreira A. HIV patients have impaired diastolic function that is not aggravated by anti-retroviral treatment. Cardiovasc Drugs Ther 2015; 29:31-9. [PMID: 25749869 DOI: 10.1007/s10557-015-6573-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE Recent studies have shown that HIV infection is independently associated with heart failure. Diastolic dysfunction (DD) is frequent in HIV patients, but it is unclear whether this is an effect of the HIV infection itself or of the anti-retroviral therapy (ART). Our aim was to compare diastolic function in HIV treatment-naïve, HIV-ART patients and controls. METHODS We prospectively enrolled 206 consecutive patients with HIV-1 infection and 30 controls, selected by frequency matching for age and sex. HIV patients were divided in two subgroups: ART-naïve (n = 88) and ART (n = 118). Diastolic function was assessed and graded by echocardiography, according to modern consensus criteria and using tissue Doppler analysis. RESULTS Compared to controls, ART-naïve patients had lower E' velocities (E' septal: 10.2 ± 2.4 vs 11.9 ± 2.6 cm/s, p = 0.02), higher E/E' ratio (7.8 ± 1.9 vs 6.9 ± 1.6,p = 0.02) and higher prevalence of DD (19 % vs 3.3 %,p = 0.05). HIV patients under ART also had worse diastolic function compared to controls (E' septal: 10.3 ± 2.5 cm/s;p < 0.01; E/E'ratio: 8.0 ± 2.0,p < 0.01; DD prevalence: 23 %;p = 0.01), but no significant differences were found between ART-naïve and ART HIV subgroups. In multivariable logistic regression analysis, age and body mass index were the only independent predictors of reduced diastolic reserve in HIV patients. Regarding systolic function, there were no significant differences in ejection fraction or S' velocities between controls and HIV subgroups. CONCLUSIONS HIV treatment-naïve patients have reduced diastolic reserve that is not worsened by ART. These data reinforce the association of diastolic dysfunction with the HIV infection itself and not with the anti-retroviral therapy.
Collapse
Affiliation(s)
- Ricardo Fontes-Carvalho
- Cardiology Department, Gaia Hospital Center, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal,
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Mendes L, Silva D, Miranda C, Sá J, Duque L, Duarte N, Brito P, Bernardino L, Poças J. Impact of HIV infection on cardiac deformation. Rev Port Cardiol 2014; 33:501-9. [PMID: 25242674 DOI: 10.1016/j.repc.2013.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 09/16/2013] [Accepted: 12/20/2013] [Indexed: 10/24/2022] Open
Abstract
AIM The aim of this study was to detect abnormalities in left ventricular myocardial function due to HIV (human immunodeficiency virus) infection without established cardiovascular disease. METHODS An echocardiogram was performed in 50 asymptomatic HIV-infected patients (age 41 ± 6 years, 64% male) and in 20 healthy individuals. Conventional echocardiography and pulsed tissue Doppler imaging (TDI) were performed according to the guidelines. The strain rate of the basal segments was obtained with color tissue Doppler and used to evaluate systolic strain rate (SRS), early diastolic strain rate (SRE) and late diastolic strain rate (SRA). Longitudinal, radial and circumferential strain were assessed by 2D speckle tracking. RESULTS The mean duration of HIV infection was 10 ± 5 years, CD4 count was 579 ± 286 cells/mm³, 32% had detectable viral load, and 86% were under treatment. Of the HIV-infected patients, one had grade 1 diastolic dysfunction. The groups were not different except for E wave (HIV 0.72 ± 0.17 m/s vs. control 0.84 ± 0.16 m/s, p=0.01), longitudinal strain (-19.5 ± 1.9% vs. -21 ± 2%, p=0.005), SRS (-1.1 ± 0.28 s⁻¹ vs. -1.3 ± 0.28 s⁻¹, p=0.02) and SRE (1.8 ± 0.4 s⁻¹ vs. 2.2 ± 0.4 s⁻¹, p<0.001), but only SRS (p=0.03, 95% CI 0.036; 0.67) and SRE (p=0.001, 95% CI -0.599; -0.168) had independent value. CONCLUSION In an HIV-infected population without established cardiovascular disease, myocardial deformation abnormalities can be detected with strain and strain rate, revealing markers of myocardial injury.
Collapse
Affiliation(s)
- Lígia Mendes
- Cardiology Department, Hospital de São Bernardo, Setúbal, Portugal.
| | - Daniela Silva
- Cardiology Department, Hospital Militar, Lisboa, Portugal
| | - Carla Miranda
- Cardiology Department, Hospital de São Bernardo, Setúbal, Portugal
| | - Joana Sá
- Infectious Disease Department, Hospital de São Bernardo, Setúbal, Portugal
| | - Luís Duque
- Infectious Disease Department, Hospital de São Bernardo, Setúbal, Portugal
| | - Nelson Duarte
- Infectious Disease Department, Hospital de São Bernardo, Setúbal, Portugal
| | - Paula Brito
- Infectious Disease Department, Hospital de São Bernardo, Setúbal, Portugal
| | | | - José Poças
- Infectious Disease Department, Hospital de São Bernardo, Setúbal, Portugal
| |
Collapse
|
15
|
Impact of HIV infection on cardiac deformation. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.repce.2013.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
16
|
Abstract
Presently, patients with human immunodeficiency virus infection are living longer and are frequently encountered in medical practice. HIV infection is a systemic disease, which affects a wide spectrum of organs. Cardiac involvement is frequent, and the consequent clinical manifestations are a common reason to seek medical advice. In this review, we discuss the different cardiac sequelae of HIV infection.
Collapse
|
17
|
Silva ML, Nassar SM, Silva AP, Ponce LL, Pires MMDS. Biventricular diastolic function assessed by Doppler echocardiogram in children vertically infected with human immunodeficiency virus. J Pediatr (Rio J) 2014; 90:403-7. [PMID: 24631170 DOI: 10.1016/j.jped.2014.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/26/2013] [Accepted: 11/28/2013] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE to determine, by Doppler-echocardiography, the frequency of cardiac diastolic dysfunction in asymptomatic and clinically stable pediatric patients with vertical infection by the human immunodeficiency virus (HIV), from the cardiovascular viewpoint. METHODS this was an observational, prospective, and cross-sectional study, performed at a regional referral clinic for patients with HIV, in a convenience sample of 94 individuals, assessing biventricular diastolic function by Doppler-echocardiography, and weight, blood hemoglobin, and percentage of lymphocytes T-CD4(+). RESULTS fifty patients had diastolic dysfunction. Left ventricular dysfunction occurred in 38.7%, and the predominant type of dysfunction was decreased myocardial compliance. Right ventricular dysfunction was observed in 29.4% of the sample, and abnormal relaxation was the most prevalent type. Simultaneous biventricular dysfunction occurred in 14.1% of the individuals. There was no association between dysfunction and the immune status. CONCLUSIONS diastolic dysfunction occurred, individually or simultaneously, with no association with immune status; decreased myocardial compliance was predominant in the left ventricle, and abnormal relaxation in the right ventricle.
Collapse
Affiliation(s)
- Mauricio L Silva
- Hospital Infantil Joana de Gusmão, Secretaria de Estado da Saúde de Santa Catarina, Florianópolis, SC, Brazil; Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
| | - Silvia M Nassar
- Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil; Department of Informatics and Statistics, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - André P Silva
- Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Leandro L Ponce
- Hospital Infantil Joana de Gusmão, Secretaria de Estado da Saúde de Santa Catarina, Florianópolis, SC, Brazil
| | - Maria M de S Pires
- Hospital Infantil Joana de Gusmão, Secretaria de Estado da Saúde de Santa Catarina, Florianópolis, SC, Brazil; Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| |
Collapse
|
18
|
Silva ML, Nassar SM, Silva AP, Ponce LL, Pires MMDS. Biventricular diastolic function assessed by Doppler echocardiogram in children vertically infected with human immunodeficiency virus. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2014. [DOI: 10.1016/j.jpedp.2013.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
|
19
|
Cade WT, Overton ET, Mondy K, Fuentes LDL, Davila-Roman VG, Waggoner AD, Reeds DN, Lassa-Claxton S, Krauss MJ, Peterson LR, Yarasheski KE. Relationships among HIV infection, metabolic risk factors, and left ventricular structure and function. AIDS Res Hum Retroviruses 2013; 29:1151-60. [PMID: 23574474 DOI: 10.1089/aid.2012.0254] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Our objective was to determine if the presence of metabolic complications (MC) conveyed an additional risk for left ventricular (LV) dysfunction in people with HIV. HIV⁺ and HIV⁻ men and women were categorized into four groups: (1) HIV⁺ with MC (43±7 years, n=64), (2) HIV⁺ without MC (42±7 years, n=59), (3) HIV⁻ with MC (44±8 years, n=37), or (4) HIV⁻ controls without MC (42±8 years, n=41). All participants underwent two-dimensional (2-D), Doppler, and tissue Doppler echocardiography. Overall, the prevalence of systolic dysfunction (15 vs. 4%, p=0.02) and LV hypertrophy (9 vs. 1%, p=0.03) was greater in HIV⁺ than in HIV⁻ participants. Participants with MC had a greater prevalence of LV hypertrophy (10% vs. 1%). Early mitral annular velocity during diastole was significantly (p<0.005) lower in groups with MC (HIV⁺/MC⁺: 11.6±2.3, HIV⁻/MC⁺: 12.0±2.3 vs. HIV⁺/MC⁻: 12.4±2.3, HIV⁻/MC⁻: 13.1±2.4 cm/s) and tended to be lower in groups with HIV (p=0.10). However, there was no interaction effect of HIV and MC for any systolic or diastolic variable. Regardless of HIV status, participants with MC had reduced LV diastolic function. Although both the presence of MC and HIV infection were associated with lower diastolic function, there was no additive negative effect of HIV on diastolic function beyond the effect of MC. Also, HIV was independently associated with lower systolic function. Clinical monitoring of LV function in individuals with metabolic risk factors, regardless of HIV status, is warranted.
Collapse
Affiliation(s)
- William Todd Cade
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri
- Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
| | - Edgar Turner Overton
- Division of Infectious Disease, Washington University School of Medicine, St. Louis, Missouri
| | - Kristin Mondy
- Division of Infectious Disease, Washington University School of Medicine, St. Louis, Missouri
| | - Lisa de las Fuentes
- Cardiovascular Imaging and Clinical Research Core Laboratory, Washington University School of Medicine, St. Louis, Missouri
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | - Victor G. Davila-Roman
- Cardiovascular Imaging and Clinical Research Core Laboratory, Washington University School of Medicine, St. Louis, Missouri
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | - Alan D. Waggoner
- Cardiovascular Imaging and Clinical Research Core Laboratory, Washington University School of Medicine, St. Louis, Missouri
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | - Dominic N. Reeds
- Division of Geriatrics and Nutritional Science, Washington University School of Medicine, St. Louis, Missouri
| | - Sherry Lassa-Claxton
- Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
| | - Melissa J. Krauss
- Division of Biostatistics, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Linda R. Peterson
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | - Kevin E. Yarasheski
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri
- Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
20
|
Cardiac effects in perinatally HIV-infected and HIV-exposed but uninfected children and adolescents: a view from the United States of America. J Int AIDS Soc 2013; 16:18597. [PMID: 23782480 PMCID: PMC3687072 DOI: 10.7448/ias.16.1.18597] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 04/16/2013] [Indexed: 12/14/2022] Open
Abstract
Introduction Human immunodeficiency virus (HIV) infection is a primary cause of acquired heart disease, particularly of accelerated atherosclerosis, symptomatic heart failure, and pulmonary arterial hypertension. Cardiac complications often occur in late-stage HIV infections as prolonged viral infection is becoming more relevant as longevity improves. Thus, multi-agent HIV therapies that help sustain life may also increase the risk of cardiovascular events and accelerated atherosclerosis. Discussion Before highly active antiretroviral therapy (HAART), the two-to-five-year incidence of symptomatic heart failure ranged from 4 to 28% in HIV patients. Patients both before and after HAART also frequently have asymptomatic abnormalities in cardiovascular structure. Echocardiographic measurements indicate left ventricular (LV) systolic dysfunction in 18%, LV hypertrophy in 6.5%, and left atrial dilation in 40% of patients followed on HAART therapy. Diastolic dysfunction is also common in long-term survivors of HIV infection. Accelerated atherosclerosis has been found in HIV-infected young adults and children without traditional coronary risk factors. Infective endocarditis, although rare in children, has high mortality in late-stage AIDS patients with poor nutritional status and severely compromised immune systems. Although lymphomas have been found in HIV-infected children, the incidence is low and cardiac malignancy is rare. Rates of congenital cardiovascular malformations range from 5.6 to 8.9% in cohorts of HIV-uninfected and HIV-infected children with HIV-infected mothers. In non-HIV-infected infants born to HIV-infected mothers, foetal exposure to ART is associated with reduced LV dimension, LV mass, and septal wall thickness and with higher LV fractional shortening and contractility during the first two years of life. Conclusions Routine, systematic, and comprehensive cardiac evaluation, including a thorough history and directed laboratory assays, is essential for the care of HIV-infected adults and children as cardiovascular illness has become a part of care for long-term survivors of HIV infection. The history should include traditional risk factors for atherosclerosis, prior opportunistic infections, environmental exposures, and therapeutic and illicit drug use. Laboratory tests should include a lipid profile, fasting glucose, and HIV viral load. Asymptomatic cardiac disease related to HIV can be fatal, and secondary effects of HIV infection often disguise cardiac symptoms, so systematic echocardiographic monitoring is warranted.
Collapse
|
21
|
Cerrato E, D'Ascenzo F, Biondi-Zoccai G, Calcagno A, Frea S, Grosso Marra W, Castagno D, Omedè P, Quadri G, Sciuto F, Presutti D, Frati G, Bonora S, Moretti C, Gaita F. Cardiac dysfunction in pauci symptomatic human immunodeficiency virus patients: a meta-analysis in the highly active antiretroviral therapy era. Eur Heart J 2013; 34:1432-6. [PMID: 23335603 DOI: 10.1093/eurheartj/ehs471] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AIMS Human immunodeficiency virus infection (HIV) has been associated with cardiac dysfunction that, if present, can negatively affect morbidity and mortality of HIV-infected patients. Unfortunately, many of the studies on this topic were performed before the highly active antiretroviral therapy (HAART) was established. Thus, we performed a comprehensive meta-analysis to critically appraise the incidence of cardiac dysfunction in HIV-infected pauci symptomatic patients. METHODS AND RESULTS Medline, Cochrane Library, and Biomed Central were systematically screened for studies reporting on systolic and/or diastolic dysfunctions in HIV pauci-symptomatic patients. Baseline treatment and cardiac imaging data were appraised and pooled with random effect methods computing summary. At pooled analysis, including a total of 2242 patients from 11 studies, an overall average incidence of traditional cardiovascular risk factors was observed, while a low rate of previous coronary artery disease was reported. Incidence of systolic and diastolic left ventricular dysfunction was 8.33% (95% CI: 2.20-14.25) and 43.38% (95% CI: 31.73-55.03), respectively. Diastolic dysfunction was graded as first [31.85% (95% CI: 24.85-43.73)], second [8.53% (95% CI: 2.12-14.93)], and third degree [3.02% (95% CI: 1.78-4.27)]. At multivariate analysis, a high sensitivity C-reactive protein level >5 mg/L, active tobacco smoking and previous history of myocardial infarction were predictors of left ventricular systolic dysfunction [odd ratio 1.70 (95% CI: 1.03-2.77); 1.57 (95% CI: 1.03-2.34); and 15.90 (95% CI: 1.94-329.00), respectively]. Hypertension (OR = 2.30; 95% CI: 1.20-4.50) and older age (OR = 2.50 per 10 years increase; 95% CI: 1.70-3.60) were predictors of left ventricular diastolic dysfunction (Figure 3). CONCLUSIONS Systolic and diastolic dysfunction represent a common finding in pauci symptomatic HIV-infected patients, regardless to HAART.
Collapse
Affiliation(s)
- Enrico Cerrato
- Division of Cardiology, Azienda Ospedaliera Cittá della Salute e della Scienza, Corso Bramante 88-90, 10126 Turin, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Isasti G, Pérez I, Moreno T, Cabrera F, Palacios R, Santos J. Echocardiographic abnormalities and associated factors in a cohort of asymptomatic HIV-infected patients. AIDS Res Hum Retroviruses 2013; 29:20-4. [PMID: 22891715 DOI: 10.1089/aid.2012.0096] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
HIV patients have been reported to have a greater prevalence of echocardiographic abnormalities. We aimed to determine the prevalence of these abnormalities and their associated factors. This was an observational study of a cohort of asymptomatic HIV patients. Data were recorded on factors of cardiovascular interest and those related to HIV infection. All the subjects underwent a transthoracic echocardiogram. The study included 196 patients, 85.2% men, mean age 46.4 years, with a mean duration of HIV infection of 123.8 months and 27.6% with AIDS. Of the patients, 94.4% were on antiretroviral therapy and 92.5% of these had an undetectable viral load. The mean CD4 cell count was 544/mm(3). The following echocardiographic abnormalities were found: left ventricular (LV) hypertrophy 28.6%, LV diastolic dysfunction 19.9%, left atrial (LA) dilatation 7.7%, right ventricular (RV) systolic dysfunction 6.1%, pulmonary hypertension 2.6%, RV dilatation 2%, and (LV) systolic dysfunction 1%. LV hypertrophy was associated with diabetes mellitus (OR 5.3, 95% CI 1.8-15.3; p=0.001), LV diastolic dysfunction with age (OR for each extra 5 years 4.4, 95% CI 4.2-4.6; p=0.0001), obesity (OR 4.07, 95% CI 1.6-10.0; p=0.02), alcohol consumption (OR 2.5, 95% CI 1.07-6.2; p=0.03) and lower CD4 cell count (OR for each 10 CD4 cells less 10.02, 95% CI 10.00-10.04; p=0.008), and RV systolic dysfunction with hypertension (OR 5.4, 95% CI 1.6-18.2; p=0.005). Echocardiographic abnormalities in HIV patients were common, especially LV hypertrophy and diastolic dysfunction. Prospective comparative studies involving the general population are needed to determine the prevalence of HIV infection and its treatment in these abnormalities.
Collapse
Affiliation(s)
- Guillermo Isasti
- UGC del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Isabel Pérez
- UGC de Enfermedades Infecciosas, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Tamara Moreno
- UGC de Enfermedades Infecciosas, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Fernando Cabrera
- UGC del Corazón, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Rosario Palacios
- UGC de Enfermedades Infecciosas, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Jesús Santos
- UGC de Enfermedades Infecciosas, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| |
Collapse
|
23
|
Blaylock JM, Byers DK, Gibbs BT, Nayak G, Ferguson M, Tribble DR, Porter C, Decker CF. Longitudinal assessment of cardiac diastolic function in HIV-infected patients. Int J STD AIDS 2012; 23:105-10. [PMID: 22422684 DOI: 10.1258/ijsa.2011.011099] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Asymptomatic isolated diastolic dysfunction (DD), with normal left ventricular systolic function, may be the first indication of underlying cardiac disease in HIV-negative populations. We previously reported a high prevalence (37%) of DD among asymptomatic HIV-infected patients at low risk for AIDS and cardiovascular disease (CVD). We performed a longitudinal assessment of interval echocardiographic changes in this cohort over a four-year period. Repeat transthoracic echocardiograms (TTEs) utilized standard techniques. Sixty (of the original 91) HIV-infected patients, predominately men, underwent repeat TTE (median follow-up 3.7 years, interquartile range [IQR] 3.5, 4.0). Cohort characteristics (median; IQR) include age 42.0 (36.5, 46.0) years, HIV duration 16.4 years (8.1, 18.9), current CD4 count 572.0 cells/mm(3) (436.5, 839.0), antiretroviral therapy (ART) duration 8.1 years (4.8, 13.4) and Framingham risk score 1.0 (0.0, 2.0). DD was observed in 28/60 patients on re-evaluation (47%, 95% confidence interval [CI] 34%, 60%); 31% (11/36) of patients had new onset DD for an overall incidence of 8.2/100 person-years. On follow-up, subjects with DD were older, had a trend towards higher body mass index, hypertension and longer duration of HIV infection compared with subjects without DD. We confirmed a high prevalence of DD (47%) in asymptomatic HIV-infected patients at low risk for AIDS and CVD.
Collapse
Affiliation(s)
- J M Blaylock
- Walter Reed Army Medical Center, Washington, DC, USA
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Jain N, Reddy DH, Verma SP, Khanna R, Vaish AK, Usman K, Tripathi AK, Singh A, Mehrotra S, Gupta A. Cardiac abnormalities in HIV-positive patients: results from an observational study in India. J Int Assoc Provid AIDS Care 2012; 13:40-6. [PMID: 22968352 DOI: 10.1177/1545109712456740] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The clinical presentation of cardiac abnormalities in HIV-infected patients may be atypical or masked by concurrent illnesses that lead to misdiagnosis or they remain undiagnosed; therefore, this study was aimed to determine the frequency of cardiac abnormalities in HIV-infected patients. MATERIAL AND METHODS Consecutive HIV-infected patients of age >13 years were studied for 3 months, after obtaining their consent. After clinical assessment, chest x-ray, electrocardiogram, 2-dimensional echocardiography and serum Troponin T levels were done. RESULTS A total of 100 patients were studied, cardiomegaly was observed in the x-ray of 15% of them, abnormal electrocardiogram was seen in 18%, 2-dimensional echocardiography was abnormal in 67%; and diastolic dysfunction (42.8%) was the commonest abnormality followed by dilated cardiomyopathy (17.6%). Serum troponin T was elevated in 8%. The variables, opportunistic infections (OIs), antiretroviral therapy (ART), stage of HIV disease, and CD4 counts, did not affect the frequency of diastolic dysfunction. CONCLUSION The diastolic dysfunction is the most common cardiac abnormality observed in HIV-infected patients.
Collapse
Affiliation(s)
- Nirdesh Jain
- Department of Internal Medicine, Chhatrapati Shahuji Maharaj Medical University, Lucknow, India
| | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Lipshultz SE, Mas CM, Henkel JM, Franco VI, Fisher SD, Miller TL. HAART to heart: highly active antiretroviral therapy and the risk of cardiovascular disease in HIV-infected or exposed children and adults. Expert Rev Anti Infect Ther 2012; 10:661-674. [DOI: 10.1586/eri.12.53] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
26
|
|
27
|
Luo L, Ye Y, Liu Z, Zuo L, Li Y, Han Y, Qiu Z, Li L, Zeng Y, Li TS. Assessment of cardiac diastolic dysfunction in HIV-infected people without cardiovascular symptoms in China. Int J STD AIDS 2011; 21:814-8. [PMID: 21297089 DOI: 10.1258/ijsa.2010.010168] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study assessed cardiac diastolic dysfunction (DD) in HIV-infected subjects without cardiovascular symptoms in China. Eighty-four HIV-infected patients without cardiovascular symptoms were recruited and compared with 30 HIV-negative control subjects. Cardiac DD was evaluated using echocardiography including tissue Doppler imaging. DD was detected in 47.6% of AIDS patients and 42.8% of HIV-positive patients, which was significantly higher than in HIV-negative controls. After logistic regression analysis, HIV infection was independently correlated with cardiac DD (P < 0.05). Among HIV-positive subjects, logistic regression analysis showed that zidovudine exposure was associated with higher prevalence of DD (P < 0.05). Asymptomatic cardiac DD was observed frequently in HIV-infected subjects. HIV infection itself and zidovudine exposure were correlated with a higher prevalence of cardiac DD.
Collapse
Affiliation(s)
- L Luo
- Department of Infectious Diseases, Peking Union Medical College Hospital, Beijing, China
| | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Reinsch N, Neuhaus K, Esser S, Potthoff A, Hower M, Brockmeyer NH, Erbel R, Neumann T. Prevalence of cardiac diastolic dysfunction in HIV-infected patients: results of the HIV-HEART study. HIV CLINICAL TRIALS 2010; 11:156-62. [PMID: 20739268 DOI: 10.1310/hct1103-156] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE Antiretroviral therapy has improved the prognosis for many individuals with HIV infection. Consequently, HIV infection has become a chronic and manageable disease with increased risk of cardiovascular disease. Isolated diastolic dysfunction (DD) may be the first indication of underlying cardiac disease and an early marker of coronary artery disease. Our aim was to assess the prevalence of DD in HIV-infected patients. METHODS In this cross-sectional cohort study, 698 unselected patients were included. All subjects underwent two-dimensional transthoracic echocardiography with tissue Doppler imaging. RESULTS The prevalence of DD among the HIV-infected patients was 48%. Patients with DD were characterized by older age, higher body mass index, higher total cholesterol, arterial hypertension, and diabetes mellitus. Diabetes mellitus and arterial hypertension were associated with approximately four times the risk for DD (odds ratio [OR] 3.9, 95% CI 1.65-9.17; OR 3.8, 95% CI 2.49-5.71, respectively). Persons with hyperlipidemia were approximately one and a half times more likely to have DD than those without hyperlipidemia (OR 1.5, 95% CI 1.12-2.07). CONCLUSIONS In our study, an impressive high prevalence of DD in HIV-infected patients was demonstrated. Traditional cardiovascular risk factors substantially contributed to the development of DD in the HIV-infected cohort.
Collapse
Affiliation(s)
- Nico Reinsch
- Department of Cardiology, West-German Heart Center, University of Essen, Essen, Germany.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
McDonald CL, Kaltman JR. Cardiovascular disease in adult and pediatric HIV/AIDS. J Am Coll Cardiol 2009; 54:1185-8. [PMID: 19761941 DOI: 10.1016/j.jacc.2009.05.055] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2009] [Accepted: 05/06/2009] [Indexed: 11/26/2022]
|
30
|
Lozano F. Espectro de enfermedad cardiovascular en pacientes infectados por el VIH. Enferm Infecc Microbiol Clin 2009; 27 Suppl 1:3-9. [DOI: 10.1016/s0213-005x(09)73439-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|