Pathogenesis of HIV-associated heart disease

High Prevalence of AH in HIV Patients on ART, in Bahia, Brazil

INTRODUCTION

The prevalence of arterial hypertension (AH) in HIV-patients is highly variable and its association with antiretroviral therapy (ART) is controversial.

OBJECTIVE

To estimate the prevalence of AH and associated factors in HIV-patients on ART.

METHODS

This cross-sectional study was conducted in HIV-patients attended in a referral center in Salvador, Brazil. We evaluated clinical, socio-demographic and anthropometric data. Student's ttests or Mann-Whitney's and Pearson's chi-square tests were used to compare the groups. Values of p <0.05 were considered significant. The variables that presented a value of p <0.20 were included in a logistic regression model.

RESULTS

We evaluated 196 patients (60.7% male) with a mean age of 46.8 ± 11.7 years and a mean body mass index of 24.9 ± 5.3 kg / m2. The median elapsed time since HIV diagnosis and ART use was 11.8 (4.4 - 18.1) and 7.2 (2.7 - 15.3) years, respectively. The prevalence of AH was 41.8%. For individuals > 50 years old, there was a significant association between the increased abdominal circumference and AH and patients ≤ 50 years old presented significant association between AH and overweight, increased abdominal circumference and number of previous ART regimens. After multivariate analysis, age [OR:1.085; 95% CI 1,039 - 1,133], overweight [OR: 4.205; 95% CI 1,841 - 9,606], family history of AH [OR: 2.938; 95% CI 1,253 - 6.885], increased abdominal circumference [OR: 2.774; 95% CI 1.116 - 6.897] and life-time number of ART regimens used [OR: 3.842; 95% CI 1.307 - 11.299] remained associated with AH.

CONCLUSION

AH was highly prevalent and was associated not only with classical risk factors for arterial hypertension, but also with specific ART regimens.

Association Between HIV Infection and the Risk of Heart Failure With Reduced Ejection Fraction and Preserved Ejection Fraction in the Antiretroviral Therapy Era: Results From the Veterans Aging Cohort Study

Importance

With improved survival, heart failure (HF) has become a major complication for individuals with human immunodeficiency virus (HIV) infection. It is unclear if this risk extends to different types of HF in the antiretroviral therapy (ART) era. Determining whether HIV infection is associated with HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), or both is critical because HF types differ with respect to underlying mechanism, treatment, and prognosis.

Objectives

To investigate whether HIV infection increases the risk of future HFrEF and HFpEF and to assess if this risk varies by sociodemographic and HIV-specific factors.

Design, Setting, and Participants

This study evaluated 98 015 participants without baseline cardiovascular disease from the Veterans Aging Cohort Study, an observational cohort of HIV-infected veterans and uninfected veterans matched by age, sex, race/ethnicity, and clinical site, enrolled on or after April 1, 2003, and followed up through September 30, 2012. The dates of the analysis were October 2015 to November 2016.

Exposure

Human immunodeficiency virus infection.

Main Outcomes and Measures

Outcomes included HFpEF (EF≥50%), borderline HFpEF (EF 40%-49%), HFrEF (EF<40%), and HF of unknown type (EF missing).

Results

Among 98 015 participants, the mean (SD) age at enrollment in the study was 48.3 (9.8) years, 97.0% were male, and 32.2% had HIV infection. During a median follow-up of 7.1 years, there were 2636 total HF events (34.6% were HFpEF, 15.5% were borderline HFpEF, 37.1% were HFrEF, and 12.8% were HF of unknown type). Compared with uninfected veterans, HIV-infected veterans had an increased risk of HFpEF (hazard ratio [HR], 1.21; 95% CI, 1.03-1.41), borderline HFpEF (HR, 1.37; 95% CI, 1.09-1.72), and HFrEF (HR, 1.61; 95% CI, 1.40-1.86). The risk of HFrEF was pronounced in veterans younger than 40 years at baseline (HR, 3.59; 95% CI, 1.95-6.58). Among HIV-infected veterans, time-updated HIV-1 RNA viral load of at least 500 copies/mL compared with less than 500 copies/mL was associated with an increased risk of HFrEF, and time-updated CD4 cell count less than 200 cells/mm3 compared with at least 500 cells/mm3 was associated with an increased risk of HFrEF and HFpEF.

Conclusions and Relevance

Individuals who are infected with HIV have an increased risk of HFpEF, borderline HFpEF, and HFrEF compared with uninfected individuals. The increased risk of HFrEF can manifest decades earlier than would be expected in a typical uninfected population. Future research should focus on prevention, risk stratification, and identification of the mechanisms for HFrEF and HFpEF in the HIV-infected population.

Human Immunodeficiency Virus and Heart Failure in Low- and Middle-Income Countries

Successful combination therapy for human immunodeficiency virus (HIV) has transformed this disease from a short-lived infection with high mortality to a chronic disease associated with increasing life expectancy. This is true for high- as well as low- and middle-income countries. As a result of this increased life expectancy, people living with HIV are now at risk of developing other chronic diseases associated with aging. Heart failure has been common among people living with HIV in the eras of pre- and post- availability of antiretroviral therapy; however, our current understanding of the pathogenesis and approaches to management have not been systematically addressed. HIV may cause heart failure through direct (e.g., viral replication, mitochondrial dysfunction, cardiac autoimmunity, autonomic dysfunction) and indirect (e.g., opportunistic infections, antiretroviral therapy, alcohol abuse, micronutrient deficiency, tobacco use) pathways. In low- and middle-income countries, 2 large observational studies have recently reported clinical characteristics and outcomes in these patients. HIV-associated heart failure remains a common cardiac diagnosis in people living with heart failure, yet a unifying set of diagnostic criteria is lacking. Treatment patterns for heart failure fall short of society guidelines. Although there may be promise in cardiac glycosides for treating heart failure in people living with HIV, clinical studies are needed to validate in vitro findings. Owing to the burden of HIV in low- and middle-income countries and the concurrent rise of traditional cardiovascular risk factors, strategic and concerted efforts in this area are likely to impact the care of people living with HIV around the globe.

HIV-1–Related Cardiovascular Disease Is Associated With Chronic Inflammation, Frequent Pericardial Effusions, and Probable Myocardial Edema

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.

Heart failure in sub-Saharan Africa

The heart failure syndrome has been recognized as a significant contributor to cardiovascular disease burden in sub-Saharan African for many decades. Seminal knowledge regarding heart failure in the region came from case reports and case series of the early 20th century which identified infectious, nutritional and idiopathic causes as the most common. With increasing urbanization, changes in lifestyle habits, and ageing of the population, the spectrum of causes of HF has also expanded resulting in a significant burden of both communicable and non-communicable etiologies. Heart failure in sub-Saharan Africa is notable for the range of etiologies that concurrently exist as well as the healthcare environment marked by limited resources, weak national healthcare systems and a paucity of national level data on disease trends. With the recent publication of the first and largest multinational prospective registry of acute heart failure in sub-Saharan Africa, it is timely to review the state of knowledge to date and describe the myriad forms of heart failure in the region. This review discusses several forms of heart failure that are common in sub-Saharan Africa (e.g., rheumatic heart disease, hypertensive heart disease, pericardial disease, various dilated cardiomyopathies, HIV cardiomyopathy, hypertrophic cardiomyopathy, endomyocardial fibrosis, ischemic heart disease, cor pulmonale) and presents each form with regard to epidemiology, natural history, clinical characteristics, diagnostic considerations and therapies. Areas and approaches to fill the remaining gaps in knowledge are also offered herein highlighting the need for research that is driven by regional disease burden and needs.

Impact of Highly Active Antiretroviral Therapy on paediatric Human Immunodeficiency Virus-associated left ventricular dysfunction within the Johannesburg teaching hospital complex

OBJECTIVE

To analyse the outcome of children with left ventricular dysfunction placed on Highly Active Antiretroviral Therapy.

METHOD

This study is a retrospective review of records of Human Immunodeficiency Virus-positive children with left ventricular dysfunction. Demographic data were collected. Left ventricular fractional shortening, CD4 percentage, viral load, and nutritional status were compared before and during antiretroviral therapy.

RESULTS

We reviewed the records of 34 Human Immunodeficiency Virus-positive children with left ventricular dysfunction. In all, 18 patients received antiretroviral therapy (group one) and 16 were antiretroviral therapy naive (group two). The median age of group one at initial visit was 94 months, with a male-to-female ratio of 1:1. Of those, 17 children showed improved left ventricular function on treatment, with an increase in fractional shortening (median: 17-33.5%; p less than 0.0001). There was no significant statistical difference between the groups regarding initial fractional shortening. In group one, the CD4 percentage improved (median: 12% to 30.5%; p less than 0.0001), with viral load suppression (median: 24,900 copies per millilitre to less than 25 copies per millilitre; p less than 0.0001). There was weight gain in group one (median z-score: -1.70 to -1.32; p equal to 0.0083). Proper statistical analysis in group two was not possible because of poor follow-up of patients.

CONCLUSION

The findings are in keeping with other reports that have shown improvement in left ventricular function in patients with Human Immunodeficiency Virus-associated cardiomyopathy treated with Highly Active Antiretroviral Therapy. Recovery of myocardial function is associated with improvement in immunological and nutritional statuses.

Benefícios do treinamento aeróbio e/ou resistido em indivíduos HIV+: uma revisão sistemática

A aids é uma doença crônica, caracterizada pela depleção dos linfócitos T, sendo o vírus HIV o seu agente causador. A sua infecção e tratamento farmacológico estão ligados às alterações físicas e fisiológicas, que podem diminuir a qualidade de vida. Sendo assim, o objetivo do estudo foi elaborar uma revisão sistemática sobre os estudos publicados no PubMed e Capes entre 1998 e 2008, com humanos soropositivos e que investigaram os impactos do treinamento aeróbio e/ou resistido nos aspectos fisiológicos, metabólicos, psicológicos, imunológicos e físicos. Foram discutidos protocolos que utilizaram apenas treinamento de força ou aeróbio e os que utilizaram ambos e a grande maioria encontrou resultados favoráveis às variáveis pesquisadas. Quanto ao modelo de prescrição para essa população, este deve ser composto por exercícios de força, de oito a 15 repetições máximas (trabalho de hipertrofia) e por exercícios aeróbios (contínuo ou intervalado), com duração de 20 a 60 minutos e intensidade variando de 50 a 85% da frequência cardíaca máxima ou 45-85% do consumo máximo de oxigênio, ambos três a cinco vezes por semana. Dessa forma, ao elaborar um programa de atividade física, é importante conhecer a atual condição física e fisiológica do indivíduo HIV+, para que a sua condição de esforço não seja superestimada ou subestimada.

Cardiovascular manifestations in human immunodeficiency virus-infected patients

Human immunodeficiency virus (HIV) is now a pandemic. It afflicts multiple organs, including the cardiovascular system. This occurs by direct invasion as well as opportunistic infections complicating acquired immunodeficiency syndrome. The presence of newer highly active antiretroviral therapy has led to longer survival of patients infected with HIV, but the cardiac abnormalities related to HIV have remained less well characterized. It is now evident that cardiac involvement in patients with acquired immunodeficiency syndrome is relatively common. This includes coronary artery disease, dilated cardiomyopathy, pericardial effusion, pulmonary hypertension, and ill effects of highly active antiretroviral therapy in the form of lipodystrophy, lipoatrophy, and dyslipidemia. In fact, HIV can now be viewed as a potential risk factor for coronary artery disease, and the dilemma facing clinicians is how to quantify this risk. Awareness of accelerated coronary artery disease and dilated cardiomyopathy is critical to implement preventive measures early in the course of HIV. However, better guidelines are still needed on the basis of prospective randomized controlled studies involving large populations. In conclusion, this review describes cardiac abnormalities associated with HIV, including possible molecular mechanisms. The co-morbid sequelae, their presentation, and pharmacologic management are also discussed.

Effect of HIV-1-related protein expression on cardiac and skeletal muscles from transgenic rats

Background

Human immunodeficiency virus type 1 (HIV-1) infection and the consequent acquired immunodeficiency syndrome (AIDS) has protean manifestations, including muscle wasting and cardiomyopathy, which contribute to its high morbidity. The pathogenesis of these myopathies remains partially understood, and may include nutritional deficiencies, biochemical abnormalities, inflammation, and other mechanisms due to viral infection and replication. Growing evidence has suggested that HIV-1-related proteins expressed by the host in response to viral infection, including Tat and gp120, may also be involved in the pathophysiology of AIDS, particularly in cells or tissues that are not directly infected with HIV-1. To explore the potentially independent effects of HIV-1-related proteins on heart and skeletal muscles, we used a transgenic rat model that expresses several HIV-1-related proteins (e.g., Tat, gp120, and Nef). Outcome measures included basic heart and skeletal muscle morphology, glutathione metabolism and oxidative stress, and gene expressions of atrogin-1, muscle ring finger protein-1 (MuRF-1) and Transforming Growth Factor-β₁ (TGFβ₁), three factors associated with muscle catabolism.

Results

Consistent with HIV-1 associated myopathies in humans, HIV-1 transgenic rats had increased relative heart masses, decreased relative masses of soleus, plantaris and gastrocnemius muscles, and decreased total and myosin heavy chain type-specific plantaris muscle fiber areas. In both tissues, the levels of cystine (Cyss), the oxidized form of the anti-oxidant cysteine (Cys), and Cyss:Cys ratios were significantly elevated, and cardiac tissue from HIV-1 transgenic rats had altered glutathione metabolism, all reflective of significant oxidative stress. In HIV-1 transgenic rat hearts, MuRF-1 gene expression was increased. Further, HIV-1-related protein expression also increased atrogin-1 (~14- and ~3-fold) and TGFβ₁ (~5-fold and ~3-fold) in heart and plantaris muscle tissues, respectively.

Conclusion

We provide compelling experimental evidence that HIV-1-related proteins can lead to significant cardiac and skeletal muscle complications independently of viral infection or replication. Our data support the concept that HIV-1-related proteins are not merely disease markers, but rather have significant biological activity that may lead to increased oxidative stress, the stimulation of redox-sensitive pathways, and altered muscle morphologies. If correct, this pathophysiological scheme suggests that the use of dietary thiol supplements could reduce skeletal and cardiac muscle dysfunction in HIV-1-infected individuals.

Diffuse-regressive alterations and apoptosis of myocytes: possible causes of myocardial dysfunction in HIV-related cardiomyopathy

OBJECTIVE

To determine the frequency of cardiac alterations in necropsies of AIDS patients in pre-HAART era and better understand the pathogenesis of HIV-related cardiomyopathy.

DESIGN

Retrospective study of 94 complete necropsies.

METHOD

Macroscopic, histopathologic (histochemical, immunohistochemical and in situ hybridization techniques) and ultra structural myocardial evaluation (23 cases).

RESULTS

Cardiac alterations were observed in 94.4%; 74% showed variable degrees of cardiac dilation not related to known cardiovascular diseases. Eighty-two percent (81.8%) of patients with biventricular dilation showed diffuse-regressive alterations (thinning and waving cardiomyocytes with increase of lipofuscin pigment granules). Myocarditis was diagnosed in 27 cases (28.7%), 16 (59.3%) of known etiology. The ultra structural study has revealed cardiomyocytes alterations (mitochondriosis, loss of myofibrils, increase in the amount of perinuclear-lipofuscin pigment granules) associated to activation signals of capillary-endothelial cells (enhancement of pseudopodia and transcellular channels). Cardiomyocytes' apoptosis was demonstrated at structural level in 10 (43.5%) patients; tumor necrosis factor alpha (TNF alpha) was detected in 17/18 cases.

CONCLUSIONS

This pioneer study described the association of histopathological and ultra structural findings (thinning and waving cardiomyocytes with increase of lipofuscin pigment granules, mitochondriosis and loss of myofibrils) with different degrees of cardiac-chamber dilation probably representing a spectrum of alterations that would lead to myocardial dysfunction and development of HIV-related cardiomyopathy. Cardiomyocytes' apoptosis observed at ultra structural level and demonstration of TNF alpha associated to described alterations suggest that this cytokine plays an important role in both negative-inotropic effect and capacity to induce apoptosis through death receptor-controlled pathway.

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.

Renal complications in HIV

Highly Active Antiretroviral Therapy has revolutionised the care of individuals living with HIV-1. As the prognosis for this population has improved, there is an increased risk of other major causes of morbidity and mortality, including renal disease. This review discusses the frequency and causes of renal pathology, how to make the diagnosis and monitor for renal disease in HIV-infected individuals. The review was conducted having examined the key evidence focussing upon HIV and renal complications obtained from peer-reviewed journals (level of evidence I-IV). As the population of individuals living with HIV increases, so too does the prevalence of renal disease. Physicians should be vigilant and recognise individuals at risk of renal complications, and be aware of how to monitor, investigate and treat those affected.

Molecular mechanisms of HIV protease inhibitor-induced endothelial dysfunction

Highly active antiretroviral therapy incorporating protease inhibitors (PIs) is successful in controlling HIV infection and has dramatically improved the prognosis of HIV-infected patients. The therapeutic benefit of long-term use of HIV PIs is compromised by an increased risk of cardiovascular disease, however, including metabolic syndrome and endothelial dysfunction. Although clinical evidence strongly suggests an association of the use of HIV PIs with endothelial dysfunction, the underlying molecular mechanisms have not been fully elucidated yet. In this review, we describe recent advances in the molecular mechanisms of PI-induced endothelial dysfunction. The available evidence demonstrates that certain HIV PIs could induce endothelial dysfunction, including a decrease of endothelium-dependent vasorelaxation, inhibition of the nitric oxide synthase system, increase of oxidative stress, and activation of mitogen-activated protein kinases. HIV infection itself may also induce endothelial dysfunction and injury. These new discoveries provide a better understanding of the molecular mechanisms of the interaction between HIV PIs and vascular cells and may suggest potential approaches to control HIV PI-associated cardiovascular complications.

Cardiac transplantation in HIV-positive patients: are we there yet?

The epidemiology and clinical picture in human immunodeficiency virus (HIV) infection has evolved tremendously over the years, leaving health-care professionals having to cope with continuously transforming challenges in the management of HIV-infected patients.

HAART to heart: HIV-related cardiomyopathy and other cardiovascular complications

More than one million Americans have been diagnosed with human immunodeficiency virus (HIV). Advances in prevention and treatment of HIV have led to an increased life expectancy for patients with HIV infection. Due to their increased life span, HIV+ patients are now presenting to hospitals with an increased number of diverse late-stage complications, such as cardiomyopathy and other cardiovascular conditions. These complications are as a direct or indirect result of HIV disease, HIV treatment modalities, comorbid conditions, dietary and lifestyle factors, and unknown etiologies. Cardiac complications, particularly HIV-related dilated cardiomyopathy, are potentially life-threatening diagnoses, with symptoms that may be minimized with appropriate cardiac-specific assessments and treatments, patient teaching, and collaboration among nurses caring for the HIV-positive client with cardiac disease.

Power spectral analysis of heart rate variability in HIV-infected and AIDS patients

BACKGROUND

In HIV-infected patients the risks for cardiovascular disease are multifactorial. Autonomic dysfunction has been detected in the early phase of HIV infection as well as in AIDS patients with advanced cardiomyopathy.

METHODS

Forty AIDS patients receiving highly active antiretroviral therapy (HAART), 40 HIV+ naïve of HAART, and 40 control subjects were studied. Computerized analysis of heart rate variability was performed using an analog to digital converter. R-R intervals were obtained from a standard ECG, recorded in DII lead in supine rest and after the cold-face and tilt tests. The series of R-R intervals were assessed in time and frequency domains using an autoregressive algorithm.

RESULTS

There was no difference regarding to mean values of R-R intervals and variance in baseline. The normalized power of the low-frequency (LF) component and the low-frequency/high-frequency (HF) ratio (LF/HF) was significantly decreased in the HIV group. Responses of normalized HF and LF/HF ratio during the cold-face test were significantly decreased in the HIV group, as compared to the control. During the tilt test, a higher augmentation of normalized LF and the LF/HF ratio was observed in the HIV group compared with the control. The AIDS group was similar to the control in baseline and after cold-face and tilt tests.

CONCLUSION

The HIV group presented in baseline conditions, a shift of cardiac sympathovagal balance, an exacerbated response of the LF component during the tilt test, and an ineffective cardiac vagal response to the cold-face test suggesting sympathetic and parasympathetic dysfunction. AIDS patients receiving HAART did not present these autonomic alterations.

Impact of Human Immunodeficiency Virus Infection on Cardiovascular Disease in Africa

Background— Human immunodeficiency virus (HIV) infection is the single greatest health challenge facing Africa today. However, the impact of the HIV epidemic on the cardiovascular system in Africans has received scant attention in the world literature.

Methods and Results— We searched MEDLINE (January 1, 1980, to December 31, 2004) and reference lists of literature on HIV and the heart in Africa and contacted experts in the field. The search for this review yielded 22 articles involving HIV and the cardiovascular system from 8 countries in Africa.

Conclusions— The available information suggests that there are unique features in the etiology, presentation, and spectrum of HIV-associated cardiovascular disorders in people living in Africa. First, pericardial disease may be the initial manifestation of HIV infection in the early stages of the illness. Second, the etiology of cardiac disease tends to reflect the prevalent infectious diseases, such as tuberculosis. Third, unique cardiovascular disorders such as aneurysm of large vessels have been reported in association with HIV infection in several parts of Africa. Finally, the HIV/AIDS pandemic has put pressure on the meager healthcare resources and fragile infrastructure in many African countries, making the diagnosis and treatment of heart disease unrelated to HIV even more difficult.

HIV and cerebral aneurysms

Patients infected with the human immunodeficiency virus (HIV) or suffering from acquired immunodeficiency syndrome (AIDS) are now surviving for longer periods of time secondary to improvements in medical management. As the classical causes of morbidity and mortality in this patient population have come under better control, new complications are becoming more prevalent. In our clinical practice, there appears to have been a rise in the number of patients with HIV infection and AIDS who have experienced aneurysmal subarachnoid hemorrhage (SAH). In this paper, we review the available literature regarding cerebral aneurysms in patients infected with HIV and/or suffering from AIDS.

Abdominal aortic surgery in patients with human immunodeficiency virus infection

PURPOSE

Human immunodeficiency virus (HIV) infection is known to cause acquired immune deficiency syndrome, which has been associated with a wide array of cardiovascular pathologies. This report examined the clinical outcome of patients infected with HIV who underwent abdominal aortic reconstruction for aneurysm or occlusive disease.

METHODS

Hospital and clinic records of all patients with HIV infection who underwent an abdominal aortic operation were reviewed during an 11-year period. Relevant risk factors and clinical variables were assessed for surgical outcome.

RESULTS

Forty-eight HIV patients (mean age 54 +/- 13 years) were identified who underwent abdominal aortic bypass grafting during the study period. Indications for aortic operation included aneurysm (n = 20) and aortoiliac occlusive disease (n = 28). All patients underwent successful aortic reconstructions without intraoperative mortality. Postoperative complications and in-hospital mortality occurred in 16 patients (33%) and 7 patients (15%), respectively. The mean follow-up period was 41 months. Life-table survival rates in aneurysm and occlusive patients at 60 months were 43.2% +/- 5.3% and 46.3% +/- 7.4% (not significant), respectively. Multivariate analysis showed that low CD4 lymphocyte counts (< 200/microL, P <0.05) and hypoalbuminemia (<3.5 g/dL, P <0.05) were risk factors for postoperative complications.

CONCLUSION

Perioperative morbidity and mortality rates are high in HIV patients undergoing an abdominal aortic operation. Low CD4 lymphocyte counts and hypoalbuminemia are associated with poor clinical outcomes in HIV patients undergoing abdominal aortic reconstruction.

HIV infection, HAART, and endothelial adhesion molecules: current perspectives

In this review we summarise the data on the effects of HIV infection and its therapy with antiretroviral drugs on adhesion molecules, considered to be potential biomarkers of endothelial cell function. This is a recent area of interest, given the unexpected associations between antiretroviral therapy, metabolic alterations of lipid profile, and the risk of cardiovascular disease in the absence of clear pathogenetic links. Although convincing prospective data are still scarce, it seems timely to elucidate the potential value of non-invasive, inexpensive tests for predicting cardiovascular risk in HIV-infected patients undergoing highly active antiretroviral therapy (HAART). Endothelial function, the most plausible link between infection, inflammation, and atherosclerosis, has been investigated since the beginning of the HIV epidemic. Increased concentrations of soluble adhesion molecules, such as those from the selectin and immunoglobulin families, have consistently been reported in HIV-positive patients. The introduction of HAART has renewed interest in the study of endothelial function in HIV-positive patients, in view of some HAART-related metabolic abnormalities (hyperlipidaemia, hyperglycaemia, fat redistribution) and several large reports of premature coronary artery disease. Whether HAART reduces endothelial injury associated with HIV infection or contributes to further endothelial cell activation is still a matter of controversy. Also unclear is whether HAART acts directly or indirectly, and if protease inhibitors and other classes of antiretroviral drugs differ in their proatherosclerotic effects. This article attempts to define the state of these emerging issues, identifies areas of controversy and of potential clinical relevance, and suggests some directions for future research.