HIV and cardiovascular medicine

The Interplay of Malignancy and Endocarditis: A Report of a Rare Case of Marantic Endocarditis in Metastatic Lung Adenocarcinoma

Endocarditis involves inflammation of the inner layer of the heart, known as the endocardium. This condition typically presents with vegetation, with bacteria and fungi usually being the primary culprits. It is divided into two main categories based on its cause: infectious endocarditis and noninfectious endocarditis (NIE). Most cases of NIE are associated with malignancies, most of which are adenocarcinomas of the pancreas and lungs. We present the case of a 63-year-old man with recently diagnosed stage 3 non-small cell lung cancer and a previous history of thrombosis to the renal and popliteal arteries alongside an extensive cardiovascular history who presented with blurry vision secondary to multiple acute ischemic strokes, initially thought to be a consequence of septic emboli due to bacterial endocarditis; however, further workup revealed otherwise, illustrating the complex relationship between malignancy and endocarditis and its ramification.

Mortality and comorbidities in a Nationwide cohort of HIV-infected adults: comparison to a matched non-HIV adults' cohort, France, 2006-18

BACKGROUND

Human immunodeficiency virus (HIV) remains a significant cause of morbidity and mortality worldwide. The aim of this study was to describe the mortality rate and associated comorbidities in a nationwide population-based cohort of persons living with HIV (PLWHIV) and to compare it with mortality in an age and gender-matched cohort of non-HIV individuals in France.

METHODS

Using data from the French national health data system, we identified and included 173 712 PLWHIV (66.5% men) and 173 712 non-HIV participants (66.5% men) matched for age and gender. PLHIV were identified based on ICD-10 HIV diagnoses, HIV-specific laboratory tests, and/or prescriptions for antiretroviral therapy specific to HIV. Hazard ratios (HRs) of mortality were assessed using multiple Cox regression models.

RESULTS

During the 13 years of follow-up (2006-18), we observed 20 018 deaths among PLWHIV compared with 6262 deaths among non-HIV participants (11.52% vs. 3.60%, P < 0.001). The over-mortality of PLWHIV was expressed by univariable HR = 2.135 (2.072-2.199), which remained significant after adjustment for region, Complementary Universal Health Insurance and AME, with multivariable HR = 2.182 (2.118-2.248). The results remained significant after adjusting for comorbidities, including infectious diseases [HR = 1.587 (1.538-1.638)]. Notably, PLWHIV were more importantly associated with mortality in women [HR = 2.966 (2.767-3.180)], compared in men [HR = 1.961 (1.898-2.027)].

CONCLUSION

Although the life expectancy of PLWHIV has globally increased, the causes of death should be prioritized in prevention policies and care management. Gender-specific policies should be highlighted, as we observed a higher impact of HIV mortality in women.

National trend of heart failure and other cardiovascular diseases in people living with human immunodeficiency virus

BACKGROUND

As people living with human immunodeficiency virus (HIV) (PLWH) enjoy longer life expectancy with highly effective antiretroviral therapy, they are encountering challenging cardiovascular health risks.

AIM

To retrospectively examine the increasing burden of cardiovascular diseases in PLWH over the past decade.

METHODS

All hospitalizations for heart failure (HF), ischemic heart disease (IHD), and cerebrovascular disease (CeVD) in PLWH were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM codes in the National Inpatient Sample from 2008 to 2018. Outcomes included number of hospitalizations, in-hospital mortality, length of stay, and total hospital charge. Trend of the outcomes from 2008 to 2018 were analyzed using Cochran-Armitage trend test and simple linear regression.

RESULTS

The number of hospitalizations for HF in PLWH increased from 4212 in 2008 to 6700 in 2018 (P_trend < 0.01). Similar increasing trend was seen with those for IHD and CeVD over the decade (P_trend < 0.01). A decreasing trend of in-hospital mortality was observed in all hospitalizations of PLWH (P_trend < 0.01) and CeVD in PLWH (P_trend < 0.01), but not in those for HF (P_trend = 0.67) and IHD (P_trend = 0.13). The trend of length of stay was decreasing in all hospitalizations of PLWH (P_trend < 0.01), but increasing in those for HF in PLWH (P_trend < 0.01). An increasing trend of total hospital charge was observed in hospitalizations for HF, IHD, and CeVD (P_trend < 0.01).

CONCLUSION

The burden of cardiovascular diseases has significantly increased in hospitalizations of PLWH from 2008 to 2018. Continued efforts are needed to address the additional cardiovascular risks in this vulnerable population.

HIV Tat Protein Induces Myocardial Fibrosis Through TGF-β1-CTGF Signaling Cascade: A Potential Mechanism of HIV Infection-Related Cardiac Manifestations

Human immunodeficiency virus (HIV) infection is a risk factor of cardiovascular diseases (CVDs). HIV-infected patients exhibit cardiac dysfunction coupled with cardiac fibrosis. However, the reason why HIV could induce cardiac fibrosis remains largely unexplored. HIV-1 trans-activator of transcription (Tat) protein is a regulatory protein, which plays a critical role in the pathogenesis of various HIV-related complications. In the present study, recombinant Tat was administered to mouse myocardium or neonatal mouse cardiac fibroblasts in different doses. Hematoxylin-eosin and Masson's trichrome staining were performed to observe the histological changes of mice myocardial tissues. EdU staining and MTS assay were used to evaluate the proliferation and viability of neonatal mouse cardiac fibroblasts, respectively. Real-time PCR and western blot analysis were used to detect CTGF, TGF-β1, and collagen I mRNA and protein expression levels, respectively. The results showed that Tat promoted the occurrence of myocardial fibrosis in mice. Also, we found that Tat increased the proliferative ability and the viability of neonatal mouse cardiac fibroblasts. The protein and mRNA expression levels of TGF-β1 and CTGF were significantly upregulated both in Tat-treated mouse myocardium and neonatal mouse cardiac fibroblasts. However, co-administration of TGF-β inhibitor abrogated the enhanced expression of collagen I induced by Tat in neonatal mouse cardiac fibroblasts. In conclusion, Tat contributes to HIV-related cardiac fibrosis through enhanced TGF-β1-CTGF signaling cascade.

An Unusual Case of Hashimoto's Thyroiditis Presenting as Impending Cardiac Tamponade in a Patient with Acquired Immune Deficiency Syndrome (AIDS)

Patient: Male, 52-year-old

Final Diagnosis: Hashimoto’s thyroiditis

Symptoms: Acute epigastric pain • confusion • diarrhea • episodic gastrointestinal discomfort • fatigue • nausea • vomiting

Medication: —

Clinical Procedure: Radiographic-assisted pericardiocentesis

Specialty: Hematology

Assessment of Pulmonary Arterial Hemodynamic and Vascular Changes by Pulmonary Pulse Transit Time in Patients with Human Immunodeficiency Virus Infection

Introduction

Pulmonary arterial hypertension and human immunodeficiency virus (HIV) infection is a well-known association. Pulmonary pulse transit time (pPTT) is a recent echocardiographic marker that might be used for evaluation of pulmonary arterial stiffness (PAS) in patients with HIV infection. We aimed to investigate whether pPTT elevated in patients with HIV infection compared to healthy controls and its association with echocardiographic indices of right ventricular functions.

Materials and Methods

Fifty HIV (+) patients from infectious disease outpatient clinics and fifty age- and sex-matched HIV (-) healthy volunteers were enrolled in this study. pPTT was measured from pulmonary vein flow velocity as the time interval between the R-wave in the electrocardiography and corresponding peak late systolic was then calculated as the mean from two separate pw-Doppler measurements.

Results

pPTT, tricuspid annular peak systolic excursion (TAPSE) and right ventricle fractional area change (FAC) were significantly lower in patients with HIV than control patients (177.1 ± 34.9 vs. 215.7 ± 35.7 msn, P < 0.001; 2.33 ± 0.28 vs. 2.19 ± 0.22, P = 0.039; 45 [4.25] vs. 41.1 [4.0], P = 0.032, respectively). pPTT was positively correlated with FAC, TAPSE and cluster of differentiation 4 count (r = 0.210; P = 0.036, r = 0.256; P = 0.041, r = 0.304; P = 0.044, respectively).

Conclusion

Our study showed that pPTT, TAPSE, and right ventricle FAC levels were lower in patients with HIV infection. pPTT is an important predictor in patients with HIV expected to develop pulmonary vascular pathology.

Fetal cardiac evaluation in HIV-positive women under HAART therapy in a Romanian hospital

Human immunodeficiency virus (HIV) is an RNA (ribonucleic acid) virus that causes acquired immunodeficiency syndrome (AIDS). This disease has a major socioeconomical impact. The aim of the present study was to assess the fetal heart structure and function in HIV-positive pregnant women on highly active antiretroviral therapy (HAART). This is a prospective study conducted between January, 2018 and December, 2019. The hearts of fetuses from 14 HIV-positive pregnant women on HAART were assessed. Statistically significant sex-related cardiac changes in HIV-exposed uninfected fetuses of pregnant women on HAART were found. A narrow aorta was detected in female fetuses and a smaller left ventricular transverse diameter in male fetuses. Overall, the myocardial performance index remained unaltered. The impact of antiretroviral therapy on fetal heart seems to be sex-related. Accurate and complete information about the risks and benefits of antiretroviral treatment and management strategies to improve fetal outcomes may also ensure better compliance of the mothers to this treatment.

Myocardial Inflammatory Changes Before and After Antiretroviral Therapy Initiation in People With Advanced Human Immunodeficiency Virus Disease

Because of the high frequency of late presentation of human immunodeficiency virus (HIV) disease in our population, we decided to explore the presence of myocarditis among people with HIV infection and advanced immunosuppression (less than 200 CD4⁺ cells/μL) and to describe the inflammatory changes observed after combined antiretroviral therapy initiation in an observational, longitudinal, prospective cohort. We performed both cardiovascular magnetic resonance imaging and doppler transthoracic echocardiogram.

The Use of Two-Dimensional Strain Measured by Speckle Tracking in the Identification of Incipient Ventricular Dysfunction in HIV-Infected Patients on Antiretroviral Therapy, Untreated HIV Patients and Healthy Controls

BACKGROUND

Most cardiovascular abnormalities in patients infected with the human immunodeficiency virus (HIV) have been associated with myocardial damage directly caused by the virus. Some cases, however, may be associated with adverse effects from antiretroviral therapy (ART). New ventricular function assessment techniques are capable of detecting early changes in the cardiac function of HIV-infected patients using or not using ART. The usefulness of these techniques has been little employed in these patients.

OBJECTIVES

To investigate the potential influence of antiretroviral therapy (ART) on the occurrence of subclinical left ventricular systolic dysfunction evaluated by myocardial strain rate analysis using two-dimensional speckle tracking echocardiography (2-D Echo) in treated HIV patients compared to untreated patients and healthy individuals.

METHODS

Sixty-eight HIV-infected patients with no cardiovascular symptoms, normal left ventricular (LV) ejection fraction (> 0.55 on 2-D Echo) were divided into three groups: 11 patients not using antiretroviral therapy (NT), 24 using protease inhibitor (PI) and 33 using non-nucleoside reverse transcriptase inhibitor (NNRTI). We also studied 30 normal non-HIV infected individuals (Ctrl). Demographic, clinical, biochemical and anthropometric data were collected. Preliminary transthoracic echocardiography included study of myocardial strain using two-dimensional speckle tracking. We studied strain and strain rate in the seventeen left ventricular (LV) myocardial segments in the longitudinal, circumferential and radial axes. Statistical analysis of the data was done with IBM SPSS - version 20 for Windows. Upon analysis of the data, namely the normality of independent variables in the different groups and the homogeneity of the variances between the groups, Kruskal-Wallis' non-parametric test was done, followed by Dunn's multiple comparison tests to test the significance of the differences between the values measured in the study groups. A significance level of 5% was adopted for decision-making on statistical tests.

RESULTS

The mean age of HIV patients was 40 ± 8.65 years and the mean age of controls was 50 ± 11.6 years (p < 0.001). Median LV global longitudinal strain (GLS) of NT patients (-17.70%), PI patients (-18.27%) and NNRTIs (-18.47%) were significantly lower than that of the Ctrl group (-20.77%; p = 0.001). There was no significant difference in mean SLG between treated patients (PI, NNRTI) and untreated (NT) patients. No significant differences were observed in mean circumferential and radial strain, nor on circumferential and radial strain rates between the NT, PI, NNRTI and Ctrl groups.

CONCLUSION

The data suggest that HIV patients present, on myocardial strain measured by speckle tracking, signs of early LV systolic dysfunction that seem to be unrelated to the presence of ART. The prognostic significance of this condition in these patients deserves further studies.

The role of HIV Tat protein in HIV-related cardiovascular diseases

The human immunodeficiency virus (HIV) is a major global public health issue. HIV-related cardiovascular disease remains a leading cause of morbidity and mortality in HIV positive patients. HIV Tat is a regulatory protein encoded by tat gene of HIV-1, which not only promotes the transcription of HIV, but it is also involved in the pathogenesis of HIV-related complications. This review is aimed at summarizing the current understanding of Tat in HIV-related cardiovascular diseases.

A classical case of non-bacterial thrombotic endocarditis from pancreatic adenocarcinoma presenting as multiple strokes, myocardial infarction and acute limb ischaemia

Non-bacterial thrombotic endocarditis (NBTE) classically presents in the context of pancreatic adenocarcinomas. Echocardiography is useful to investigate for valvular vegetations, and institution of early treatment is crucial as this can be complicated by multiple systemic emboli, leading to significant morbidity or mortality in serious cases. Treatment options involve anticoagulation with unfractionated heparin, and the role of surgical intervention is unclear. In this report, we describe a classical case of a middle-aged lady with unresectable pancreatic adenocarcinoma who developed NBTE complicated by multiple systemic emboli. She eventually succumbed from poor neurological status from multiple cerebral emboli. Awareness of this condition is required by clinicians for early diagnosis and prompt treatment.

Infectious and Non-infectious Etiologies of Cardiovascular Disease in Human Immunodeficiency Virus Infection

Background:

Increasing rates of HIV have been observed in women, African Americans, and Hispanics, particularly those residing in rural areas of the United States. Although cardiovascular (CV) complications in patients infected with human immunodeficiency virus (HIV) have significantly decreased following the introduction of antiretroviral therapy on a global scale, in many rural areas, residents face geographic, social, and cultural barriers that result in decreased access to care. Despite the advancements to combat the disease, many patients in these medically underserved areas are not linked to care, and fewer than half achieve viral suppression.

Methods:

Databases were systematically searched for peer-reviewed publications reporting infectious and non-infectious etiologies of cardiovascular disease in HIV-infected patients. Relevant articles cited in the retrieved publications were also reviewed for inclusion.

Results:

A variety of outcomes studies and literature reviews were included in the analysis. Relevant literature discussed the manifestations, diagnosis, treatment, and outcomes of infectious and non-infectious etiologies of cardiovascular disease in HIV-infected patients.

Conclusion:

In these medically underserved areas, it is vital that clinicians are knowledgeable in the manifestations, diagnosis, and treatment of CV complications in patients with untreated HIV. This review summarizes the epidemiology and causes of CV complications associated with untreated HIV and provide recommendations for management of these complications.

Transforming growth factor-β1-mediated cardiac fibrosis: potential role in HIV and HIV/antiretroviral therapy-linked cardiovascular disease

HIV infection elevates the incidence of cardiovascular disease (CVD) independent of traditional risk factors. Autopsy series document cardiac inflammation and endomyocardial fibrosis in the HIV+ treatment naïve, and gadolinium enhancement magnetic resonance imaging has identified prominent myocardial fibrosis in the majority of HIV+ individuals despite use of suppressive antiretroviral therapies (ART). The extent of such disease may correlate with specific ART regimens. For example, HIV-infected patients receiving ritonavir (RTV)-boosted protease inhibitors have the highest prevalence of CVD, and RTV-exposed rodents exhibit cardiac dysfunction coupled with cardiac and vascular fibrosis, independent of RTV-mediated lipid alterations. We recently showed that platelet transforming growth factor (TGF)-β1 is a key contributor to cardiac fibrosis in murine models. We hypothesize that in the HIV+/ART naïve, cardiac fibrosis is a consequence of proinflammatory cytokine and/or ART-linked platelet activation with release of TGF-β1. Resultant TGF-β1/Smad signaling would promote collagen synthesis and organ fibrosis. We document these changes in a pilot immunohistochemical evaluation of cardiac tissue from two ART-naive pediatric AIDS patients. In terms of ART, we showed that RTV inhibits immunoproteasome degradation of TRAF6, a nuclear adapter signaling molecule critical to the regulation of proinflammatory cytokine signaling pathways involved in osteoclast differentiation and accelerated osteoporosis. We now present a model illustrating how RTV could similarly amplify TGF-β1 signaling in the promotion of cardiac fibrosis and accelerated CVD. Supportive clinical data correlate RTV use with elevation of NT-proBNP, a biomarker for CVD. We discuss potential interventions involving intrinsic modulators of inflammation and collagen degradation, including carbon monoxide-based therapeutics.

Anolunula in Fingernails among Patients Infected with HIV

Lunula is the white, half-moon shaped area seen in proximal ends of some nails. Though a few studies have described the nail changes that can occur in association with HIV infection, none of these paid much attention to lunula. Aims and Objectives. To study the lunula in fingernails among HIV infected patients. Materials and Methods. An observational, cross-sectional study to record presence of lunula in 168 HIV-positive patients and compare it with age and sex matched 168 healthy HIV-negative control. Anolunula (absence of lunula) in HIV-positive patients was correlated with CD4 counts, stages of HIV infection, time since patient was diagnosed as HIV-positive, and status of antiretroviral therapy. Results. Anolunula was present in significantly more fingernails in HIV-positive patients compared to HIV-negative controls. There was a highly significant difference for total anolunula (anolunula in all fingernails) in study and control group. Incidence of total anolunula was directly proportional to the stage of HIV infection, increasing progressively as the HIV infection advances from stage 1 to stage 4. Conclusion. Absence of lunula is related to not only HIV infection per se but also the stages of HIV infection.

Etiology of valvular heart disease

The etiology of valvular heart diseases (VHD) has changed in the last 50 years in the industrialized countries. A significant reduction in the incidence of rheumatic fever and its sequelae, increase in life expectancy, recognition of new causes of VHD and advancement in technology are responsible for the metamorphosis of the etiology of VHD. Heritable disorders of connective tissue (marfan syndrome, Ehlers-Danlos syndrome, adult polycystic kidney disease, floppy mitral valve/mitral valve prolapse); congenital heart disease (bicuspid aortic valve); inflammatory/immunologic disorders (rheumatic fever, AIDS, Kawasaki disease, syphilis, seronegative spondyloarthropathies, systemic lupus erythematosus, antiphospholipid syndrome); endocardial disorders (nonbacteremic thrombotic endocarditis, infective endocarditis, endomyocardial fibroelastosis); myocardial dysfunction (ischemic heart disease, dilated cardiomyopathy, hypertrophic cardiomyopathy); diseases and disorders of other organs (chronic renal failure, carcinoid heart disease); aging (calcific aortic stenosis, mitral annular calcification); postinterventional valvular disease; drugs and physical agents are all clinical entities associated with VHD. It should be emphasized that VHDs still constitute a major health problem which will increase with the aging population.

Marantic endocarditis presenting with multifocal neurological symptoms

Non-bacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, has been reported to occur in 0.3-9.3% of the adult population at autopsy. NBTE associated with malignancy is an underrecognised cause of thromboembolic disorders. The clinical spectrum encountered and investigation results can be non-specific, often mimicking other acute conditions such as infective endocarditis. We describe the case of a 34-year-old woman with non-localising and multifocal neurological symptoms, who was subsequently diagnosed with NBTE secondary to a resectable primary lung adenocarcinoma.

Recent advances in HIV-associated cardiovascular diseases in Africa

The last decade has witnessed major advances in our understanding of the epidemiology and pathophysiology of HIV-related cardiovascular disease in sub-Saharan Africa. In this review, we summarise these and discuss clinically relevant advances in diagnosis and treatment. In the Heart of Soweto Study, 10% of patients with newly diagnosed cardiovascular disease were HIV positive, and the most common HIV-related presentations were cardiomyopathy (38%), pericardial disease (13%) and pulmonary arterial hypertension (8%). HIV-related cardiomyopathy is more common with increased immunosuppression and HIV viraemia. With adequate antiretroviral therapy, the prevalence is low. Contributing factors such as malnutrition and genetic predisposition are under investigation. In other settings, pericardial disease is the most common presentation of HIV-related cardiovascular disease (over 40%), and over 90% of pericardial effusions are due to Mycobacterium tuberculosis (TB) pericarditis. HIV-associated TB pericarditis is associated with a greater prevalence of myopericarditis, a lower rate of progression to constriction, and markedly increased mortality. The role of steroids is currently under investigation in the form of a randomised controlled trial. HIV-associated pulmonary hypertension is significantly more common in sub-Saharan Africa than in developed countries, possibly as a result of interactions between HIV and other infectious agents, with very limited treatment options. It has recently been recognised that patients with HIV are at increased risk of sudden death. Infection with HIV is independently associated with QT prolongation, which is more marked with hepatitis C co-infection and associated with a 4.5-fold higher than expected rate of sudden death. The contribution of coronary disease to the overall burden of HIV-associated cardiovascular disease is still low in sub-Saharan Africa.

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.

Echocardiographic patterns in treatment-naïve HIV-positive patients in Lagos, south-west Nigeria

Introduction

Cardiovascular abnormalities are common in HIV-infected patients, although often clinically quiescent. This study sought to identify by echocardiography early abnormalities in treatment-naïve patients.

Methods

One hundred patients and 50 controls with no known traditional risk factors for cardiovascular disease were recruited for the study. The cases and controls were matched for age, gender and body mass index. Both groups had clinical and echocardiographic evaluation for cardiac abnormalities, and CD₄ count was measured in all patients.

Results

The cases comprised 57 females (57.0%) and 43 males (43.0%), while the controls were 28 females (56.0%) and 22 males (44.0%) (χ² = 0.01; p = 0.913). The mean age of the cases was 33.2 ± 7.7, while that of the controls was 31.7 ± 9.7 (t = 1.02; p = 0.31). Echocardiographic abnormalities were significantly more common in the cases than the controls (78 vs 16%; p = 0.000), including systolic dysfunction (30 vs 8%; p = 0.024) and diastolic dysfunction (32 vs 8%; p = 0.002). Other abnormalities noted in the cases were pericardial effusion in 47% (χ² = 32.10; p = 0.000) and dilated cardiomyopathy in 5% (five); none of the controls had either complication. One patient each had aortic root dilatation, mitral valve prolapse and isolated right heart dilatation and dysfunction.

Conclusion

Cardiac abnormalities are more common in HIV-infected people than in normal controls. A careful initial and periodic cardiac evaluation to detect early involvement of the heart in the HIV disease is recommended.

Left ventricular systolic function in Nigerian children with human immunodeficiency virus infection

OBJECTIVE

The objective of this article was to compare the left ventricular (LV) systolic function of human immunodeficiency virus (HIV)-infected children with that of healthy controls, determine the prevalence of LV systolic dysfunction in HIV-infected children, and its association with age, stage of disease, and use of zidovudine.

STUDY DESIGN

This was a comparative cross-sectional descriptive study.

SETTING

A University Teaching Hospital in North-Central Nigeria in 2008.

PATIENTS

One hundred fifty HIV-infected children aged 6 weeks-14 years, and an equal number of age- and sex-matched apparently healthy controls.

OUTCOME MEASURES

Left ventricular internal dimensions in diastole and systole, LV fractional shortening (FS) and ejection fraction (EF). Left ventricular systolic dysfunction was considered present when FS was <28% or EF was <50%.

RESULTS

Mean LV internal dimensions in diastole was similar in subjects and controls (P= .26). Left ventricular internal dimensions in systole was significantly larger in subjects (2.7 cm, 95% confidence interval [CI] 2.6-2.8 cm) than controls (2.4 cm, 95% CI 2.3-2.5 cm) (P < .001). Mean FS of 27.8% (26.8-28.8%) in subjects was significantly reduced compared with 33.7% (33.1-34.3%) in controls (P < .001), as was EF 61.5% (60.7-62.3%) in subjects and 70.5% (69.7-71.3%) in controls (P < .001). Left ventricular systolic dysfunction was detected in 75 (50.0%, 95% CI 41.7-58.3%) subjects and 5 (3.3%, 95% CI 2.2-6.7) controls (P < .001). Subjects with left ventricular systolic dysfunction were significantly older than those without (P < .001) but did not differ significantly from them with respect to zidovudine therapy or stage of disease.

CONCLUSIONS

Left ventricular systolic dysfunction is significantly more frequent in HIV-infected children compared with controls. Left ventricular systolic function in HIV-infected children deteriorates with increasing age and should be serially evaluated in them.

O uso da L-carnitina como adjuvante no tratamento da miocardiopatia dilatada em criança com Aids

OBJETIVO: Apresentar a resposta cardiovascular à L-carnitina de um paciente com insuficiência cardíaca congestiva decorrente de miocardiopatia dilatada pelo vírus da imunodeficiência humana. DESCRIÇÃO DO CASO: Criança com quadro clínico de insuficiência cardíaca congestiva grave devido à miocardiopatia dilatada pela síndrome de imunodeficiência adquirida. O tratamento para as manifestações clínicas foi instituído, com pouca resposta clínica. Com objetivo de melhorar o desempenho energético/metabólico dos cardiomiócitos, foi instituída terapia com L-carnitina. Observou-se significativa melhora clínica do paciente, em relação ao desempenho cardíaco, mesmo antes do início do tratamento com os fármacos antirretrovirais. COMENTÁRIOS: A L-carnitina é um composto que facilita o transporte dos ácidos graxos de cadeia longa para dentro da mitocôndria. Nesse caso, o uso da L-carnitina parece ser clinica e bioquimicamente justificado.

Immune reconstitution inflammatory syndrome and human immunodeficiency virus-associated myocarditis

Myocarditis is a well-recognized cardiac manifestation of human immunodeficiency virus (HIV) infection, and alterations in the immune system likely play an important role in the pathogenesis of heart muscle disease in HIV-infected patients. Highly active antiretroviral therapy (HAART) has greatly improved survival in HIV patients but not without uncovering new and unique manifestations of disease. Immune reconstitution inflammatory syndrome is a collection of inflammatory disorders in which a pathologic inflammatory response and clinical deterioration occur during recovery of the immune system after HAART. To our knowledge, a correlation between immune reconstitution inflammatory syndrome and HIV-associated myocarditis has not been described previously. We report a case of acute myocarditis presenting with refractory ventricular arrhythmias in a patient with AIDS who experienced rapid immune recovery with the initiation of HAART. The case underscores the importance of recognizing this potential complication of AIDS treatment and calls for renewed vigilance concerning cardiac manifestations of HIV, especially during the immune reconstitution phase.

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.

Cardiovascular complications and atherosclerotic manifestations in the HIV-infected population: type, incidence and associated risk factors

Before the introduction of successful antiretroviral therapy (ART), cardiovascular complications in HIV-infected patients were largely those resulting from immunosuppression (e.g. myocarditis, pericarditis, tamponade). With the advent of ART, there has been a spectacular decrease in morbidity and mortality in HIV-infected individuals. However, alongside metabolic complications caused by ART such as insulin resistance, dyslipidemia and lipodystrophy syndrome have been observed, which potentially increase the risk of cardiovascular complications, in particular coronary artery disease. Whether HIV infection and ART are independent and individual coronary risk factors is still controversial. More and more data are available demonstrating that increasing the duration of exposure to ART, and in particular protease inhibitors, increases the risk of myocardial infarction. At the same time, chronic infection, inflammation and the disruption of immune balance as a result of HIV infection itself may have the potential to alter vascular structure and function. In this article, we will review cardiovascular complications in HIV-infected patients before and after the advent of ART, focusing on coronary artery disease, its diagnosis, prognosis and therapy.

Myocardial disease in human immunodeficiency virus (HIV) infection: a review

Heart muscle disease is the most important cardiovascular manifestation of HIV infection and is likely to become even more prevalent as HIV infected patients live longer. This may present as myocarditis, dilated cardiomyopathy or isolated left or right ventricular dysfunction. Myocardial involvement in HIV infection is multifactorial and may arise as a result of myocardial invasion with HIV itself, opportunistic infections, viral infections, autoimmune response to viral infection, drug-related cardiac toxicity, nutritional deficiencies, and prolonged immunosuppression. Both adults and children are affected with severity ranging from incidental microscopic inflammatory findings at autopsy to clinically significant cardiac disease with chronic cardiac dysfunction. It is associated with a poor prognosis, and results in symptomatic heart failure in up to 5% of HIV patients. Clinical pathological studies from the pre-HAART era show a 30% prevalence of cardiomyopathy in patients with AIDS. The introduction of highly active antiretroviral therapy (HAART) regimens has substantially modified the course of HIV disease by lengthening survival and improving quality of life of HIV-infected patients. There is also good evidence that HAART significantly reduces the incidence of cardiovascular manifestations of HIV infection. By preventing opportunistic infections and reducing the incidence of myocarditis, HAART regimens have reduced the prevalence of HIV-associated cardiomyopathy by almost 7-fold from the pre-HAART era. HAART is however only available to a minority of HIV infected individuals in most areas of the world and studies from the pre-HAART period still apply. In this review, the aetiopathogenesis and presentation of HIV related myocardial disease were reviewed and measures taken to improve survival discussed.

Assistência de enfermagem a um paciente infartado portador de HIV, baseada na teoria do autocuidado: estudo de caso

OBJETIVO: Aplicar a Sistematização da Assistência de Enfermagem (SAE) a um paciente portador de HIV e infartado. MÉTODOS: Trata-se de um estudo de caso realizado em um hospital escola localizado na região metropolitana de São Paulo, em novembro de 2003, utilizando a Sistematização da Assistência de Enfermagem e propondo diagnósticos de enfermagem com base na taxonomia II NANDA bem como as intervenções de enfermagem relacionadas. RESULTADOS: Os principais diagnósticos de enfermagem identificados foram: Risco para controle ineficaz do regime terapêutico, ansiedade, perfusão tissular cardíaca alterada, mobilidade física prejudicada, proteção alterada, risco para infecção, entre outros. CONCLUSÃO: O estudo mostrou a importância da Sistematização da Assistência de Enfermagem e da decisão do paciente em engajar-se no autocuidado a fim de proporcionar uma melhora no padrão de resposta do doente à doença.

Non-bacterial thrombotic endocarditis

Non-bacterial thrombotic endocarditis (NBTE) is a disease characterised by the presence of vegetations on cardiac valves, which consist of fibrin and platelet aggregates and devoid of inflammation or bacteria. NBTE has increasingly been recognised as a condition associated with numerous diseases and a potentially life-threatening source of thromboembolism. NBTE is not a common entity; however it is frequently underestimated, probably due to underlying diseases (cancer, autoimmune disorders, HIV). NBTE is difficult to diagnose and relies on strong clinical suspicion. NBTE is also difficult to manage and each case should be individually managed by identifying and treating the underlying pathology. Surgical intervention is not recommended unless the patient is in acute congestive failure.

Antiretroviral Drug Levels and Interactions Affect Lipid, Lipoprotein, and Glucose Metabolism in HIV-1 Seronegative Subjects: A Pharmacokinetic-Pharmacodynamic Analysis

BACKGROUND

HIV-infected patients treated with antiretroviral medications (ARVs) develop undesirable changes in lipid and glucose metabolism that mimic the metabolic syndrome and may be proatherogenic. Antiretroviral drug levels and their interactions may contribute to these metabolic alterations.

METHODS

Fifty six HIV-seronegative adults were enrolled in an open-label, randomized, pharmacokinetic interaction study, and received a nonnucleoside reverse transcriptase inhibitor (efavirenz on days 1-21) plus a protease inhibitor (PI; amprenavir on days 11-21), with a second PI on days 15-21 (saquinavir, nelfinavir, indinavir, or ritonavir). Fasting triglycerides, total LDL-and HDL-cholesterol, glucose, insulin, and C-peptide levels were measured on days 0, 14, 21, and 2-3 weeks after discontinuing drugs. Regression models were used to estimate changes in these parameters and associations between these changes and circulating levels of study drugs.

RESULTS

Short-term efavirenz and amprenavir administration significantly increased cholesterol, triglycerides, and glucose levels. Addition of a second protease inhibitor further increased triglycerides, total and LDL-cholesterol levels. Higher amprenavir levels predicted larger increases in triglycerides, total, and LDL-cholesterol. Two weeks after all study drugs were stopped, total, LDL-, and HDL-cholesterol remained elevated above baseline.

CONCLUSIONS

ARV regimens that include a nonnucleoside reverse transcriptase inhibitor plus single or boosted PIs are becoming more common, but the pharmacodynamic interactions associated with these regimens can result in persistent, undesirable alterations in serum lipid/lipoprotein levels. Additional pharmacodynamic studies are needed to examine the metabolic effects of ritonavir-boosted regimens, with and without efavirenz.

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.

Interventional approach to recurrent myocardial infarction in HIV-1 infection

We report a case of recurrent myocardial infarction occurring in two different coronary territories in a man with HIV-1 infection. On each occasion, clinical and angiographic success was obtained by intracoronary stent placement.

Reversible right ventricular dysfunction in patients with HIV infection

Human immunodeficiency virus-related cardiomyopathy is characterized by global left ventricular (LV) dysfunction commonly associated with biventricular dilation. Human immunodeficiency virus (HIV) cardiomyopathy carries a poor prognosis, and the role of antiretroviral therapy in the reversal of heart failure is not very clear. We report two patients with HIV infection who presented with severe right ventricular (RV) dysfunction in the absence of pulmonary parenchymal, pulmonary arterial and left ventricular myocardial involvement. During the period of intensive antiretroviral therapy, the symptoms of right heart failure progressively and remarkably improved. This was accompanied by normalization of right ventricular size and RV function documented by repeat echocardiograms. Given that the serologic tests for opportunistic infections were negative, and the RV function improvement correlated with a decrement in the viral load, it is likely that the cardiomyopathy was due to direct infection by HIV. These cases illustrate that there can be isolated involvement of the right heart in the absence of lung, significant pulmonary vascular and left ventricular disease, and also that the antiretroviral therapy might reverse the cardiomyopathy.

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.

Infection-related vasculitis

Infection-related vasculitis constitutes the most common cause of secondary vasculitis. A great variety of microorganisms can induce directly or indirectly inflammatory vascular damage resulting in vascular occlusion, tissue ischemia, and necrosis. In the developed world hepatitis B and C-related vasculitis remain the most common clinical syndromes, while HIV-associated vasculitis remains a concern in developing countries.

Modulation of host immunity by HIV may be partly achieved through usurping host autonomic functions

Modulation of host immunity has been observed in human immunodeficiency virus (HIV) infections. HIV is believed to influence host immunity through a variety of mechanisms including direct effects on host T cell survival, indirect effects on cytokine profile through modulation of immune cells, and modulation of endocrine functions that affect immunity such as steroids. We hypothesize that HIV infection may also alter host immunity through modulation of host sympatho-vagal balance. Specifically, we propose that HIV drives autonomic balance towards sympathetic bias, which can contribute to a T helper (Th)2 type immunity. A variety of paraviral syndromes associated with HIV infection such as QT prolongation, cachexia, cardiomyopathy, and lipodystrophy are consistent with evidence of autonomic dysfunction. Immunomodulatory effects of autonomic dysfunction toward Th2 bias are presented. A plausible mechanism by which HIV can influence autonomic balance through hypothalamic manipulation is offered. Shift to Th2 dominance is associated with HIV disease progression and can be viewed as a viral adaptation to promote its own survival. Autonomic remodeling by HIV may exemplify this phenomenon. Our hypothesis has implications for treatment of HIV and its associated syndromes.

HIV and anesthesia

Human immunodeficiency virus [HIV disease or acquired immunodeficiency syndrome (AIDS)] is the greatest health crisis of the twentieth and early twenty-first century. In sub-Saharan Africa, the epidemic rivals the "Black Death" of fourteenth-century Europe. AIDS is a multiorgan disease that has broad implications for anesthesiologists. New drug therapies are highly effective in most cases and have significant potential for drug interactions. The purpose of this article is to help anesthesiologists better manage persons who have HIV/AIDS in the operating room, labor and delivery suite, and other areas in which this patient population will require an increasing amount of care.