Immunoglobulins and left ventricular structure and function in pediatric HIV infection

THSD7A as a Promising Biomarker for Membranous Nephrosis

Membranous nephropathy (MN) is an autoimmune disease of the kidney glomerulus and one of the leading causes of nephrotic syndrome. The disease exhibits heterogeneous outcomes with approximately 30% of cases progressing to end-stage renal disease. Traditionally, the standard approach of diagnosing MN involves performing a kidney biopsy. Nevertheless, kidney biopsy is an invasive procedure that poses risks for the patient including bleeding and pain, and bears greater costs for the health system. The clinical management of MN has steadily advanced owing to the identification of autoantibodies to the phospholipase A2 receptor (PLA2R) in 2009 and thrombospondin domain-containing 7A (THSD7A) in 2014 on the podocyte surface. At present, serum anti-PLA2R antibody detection and glomerular PLA2R antigen staining have been used for clinical diagnosis and prognosis, but the related detection of THSD7A has not been widely used in clinical practice. Here, we summarized the emerging knowledge regarding the roles THSD7A plays in MN and its clinical implications as diagnostic, prognostic, and therapeutic response as well as Methods for detecting serum THSD7A antibodies.

Correlate of Left Ventricular Systolic Function in Children with Human Immunodeficiency Virus Infection on Combined Highly Active Antiretroviral Medications in Aminu Kano Teaching Hospital, Kano State

Background

Human immunodeficiency virus (HIV) affects many organ systems in the body including the cardiovascular system, often manifesting as a subclinical left ventricular (LV) systolic dysfunction that may progress to heart failure.

Aim

This study assessed the prevalence of LV systolic dysfunction in children on highly active antiretroviral therapy (HAART) with established clinical stage 1 HIV-disease.

Materials and Methods

The study was a cross-sectional comparative study conducted in Aminu Kano Teaching Hospital from April to August 2019 on 200. It involved study participants comprising 100 WHO clinical stage 1 HIV-infected children and 100 control subjects, aged between 1 and 18 years selected using systematic sampling method. Echocardiography was carried out on the study participants who had already completed a pretested questionnaire.

Results

Out of 100 HIV-infected children studied, 49 were males and 51 females (Male: Female ratio; 0.96:1.0). The mean age at diagnosis of HIV infection was 2.6 (±2.6 years) and the median viral load was 35 copies/ml. The mean ejection and shortening fractions in HIV-infected children were 59.0% and 31.0%, respectively, compared to 64.4% and 34.0% in control subjects, respectively, and were statistically significant (P = 0.000). The prevalence of LV systolic dysfunction was 8.0% (8 out of 100) in HIV-infected children while the control groups had zero prevalence (P = 0.002). The age at diagnosis correlated negatively with LV systolic dysfunction (r = 0.23, P = 0.02).

Conclusion

This study found a subclinical LV systolic dysfunction in an HAART-established clinical stage 1 HIV-infected children. The age at diagnosis was negatively correlated with the LV systolic function. This study, therefore, support the inclusion of routine echocardiography into the evaluation of HIV-infected children.

Human Immunodeficiency Virus Infection-Associated Cardiomyopathy and Heart Failure

The landscape of human immunodeficiency virus (HIV) epidemiology and treatment is ever-changing, with the widespread and evolving use of antiretroviral therapy (ART). With timely ART, people living with HIV (PLWH) are nearing the life expectancies and the functionality of the general population; nevertheless, the effects of HIV and ART on cardiovascular health remain under investigation. The pathophysiology of HIV-related cardiomyopathy and heart failure (HF) have historically been attributed to systemic inflammation and changes in cardiometabolic function and cardiovascular architecture. Importantly, newer evidence suggests that ART also plays a role in modulating the process of HIV-related cardiomyopathy and HF. In the short term, newer highly active ART (HAART) seems to have cardioprotective effects; however, emerging data on the long-term cardiovascular outcomes of certain HAART medications, i.e., protease inhibitors, raise concerns about the potential adverse effects of these drugs in the clinical course of HIV-related HF. As such, the traditional phenotypes of dilated cardiomyopathy and left ventricular systolic failure that are associated with HIV-related heart disease are incrementally being replaced with increasing rates of diastolic dysfunction and ischemic heart disease. Moreover, recent studies have found important links between HIV-related HF and other clinical and biochemical entities, including depression, which further complicate cardiac care for PLWH. Considering these trends in the era of ART, the traditional paradigms of HIV-related cardiomyopathy and HF are being called into question, as is the therapeutic role of interventions such as ventricular assist devices and heart transplantation. In all, the mechanisms of HIV-related myocardial damage and the optimal approaches to the prevention and the treatment of cardiomyopathy and HF in PLWH remain under investigation.

An Outlook on the Impact of HIV Infection and Highly Active Antiretroviral Therapy on the Cardiovascular System - A Review

HIV has been related to various cardiovascular pathologies in both adults and children. Highly active antiretroviral therapy (HAART) has been effective in subduing viral replication and improving immunity thereby reducing the effects of HIV both in AIDS and other chronic diseases related to the virus. Complications related to HAART have been reported with metabolic disorders and cardiac effects seen based on the therapy. HIV and HAART have shown to have direct effects on the cardiovascular system, and more public awareness and medical knowledge are required on this subject. This literature review tries to shed some light on the role of HIV and HAART in the cardiovascular manifestations seen in HIV-infected individuals.

Cardiomyopathy and Heart Failure in Patients With HIV Infection

With the advent and widespread use of antiretroviral therapy (ART), the epidemiology of cardiomyopathy and heart failure (HF) associated with HIV infection is changing. Near-normal life expectancy in contemporary HIV-infected populations has been associated with prolonged exposure to increased cardiometabolic burden and chronic immune activation and systemic inflammation. Therefore, the pre-ART phenotype of HIV-associated cardiomyopathy with overt left ventricular systolic dysfunction and poor prognosis has been replaced over time by cardiomyopathy with a more insidious course, more frequent ischemic background, and highly prevalent left ventricular diastolic dysfunction. Patients with HIV are more prone to development of coronary artery disease and development of HF after myocardial infarction. The role of ongoing immune activation and systemic inflammation, despite highly active ART (HAART), appears to be central in this process. The role of HAART toxicity is controversial, as HAART itself appears to be protective for the development of HF, but recent data suggest that protease inhibitors might adversely affect the course of HIV-associated HF. Because of these unique features, the optimal therapeutic approach for HIV-associated cardiomyopathy remains unknown. The current therapeutic approaches are an extrapolation from noninfected populations. Importantly, the significance of the highly prevalent diastolic abnormalities among HIV-infected patients is not known. Therefore, further research is needed to identify its prognostic implications. Considering the prevalence of structural and functional cardiac abnormalities in HIV-infected persons and the lack of evidence on how to best screen and treat these patients, systematic research on this topic is a public health priority.

A Test in Context: D-Dimer

D-dimer is a soluble fibrin degradation product that results from ordered breakdown of thrombi by the fibrinolytic system. Numerous studies have shown that D-dimer serves as a valuable marker of activation of coagulation and fibrinolysis. Consequently, D-dimer has been extensively investigated for the diagnosis of venous thromboembolism (VTE) and is used routinely for this indication. In addition, D-dimer has been evaluated for determining the optimal duration of anticoagulation in VTE patients, for diagnosing and monitoring disseminated intravascular coagulation, and as an aid in the identification of medical patients at high risk for VTE. Thus, quantification of D-dimer levels serves an important role in guiding therapy. This review: 1) describes how D-dimer is generated; 2) reviews the assays used for its detection; and 3) discusses the role of D-dimer determination in these various conditions.

HIV Infection and Risk of Cardiovascular Diseases Beyond Coronary Artery Disease

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.

The Causes of HIV-Associated Cardiomyopathy: A Tale of Two Worlds

Antiretroviral therapy (ART) has transformed the clinical profile of human immunodeficiency virus (HIV) from an acute infection with a high mortality into a treatable, chronic disease. As a result, the clinical sequelae of HIV infection are changing as patients live longer. HIV-associated cardiomyopathy (HIVAC) is a stage IV, HIV-defining illness and remains a significant cause of morbidity and mortality among HIV-infected individuals despite ART. Causes and clinical manifestations of HIVAC depend on the degree of host immunosuppression. Myocarditis from direct HIV toxicity, opportunistic infections, and nutritional deficiencies are implicated in causing HIVAC when HIV viral replication is unchecked, whereas cardiac autoimmunity, chronic inflammation, and ART cardiotoxicity contribute to HIVAC in individuals with suppressed viral loads. The initiation of ART has dramatically changed the clinical manifestation of HIVAC in high income countries from one of severe, left ventricular systolic dysfunction to a pattern of subclinical cardiac dysfunction characterized by abnormal diastolic function and strain. In low and middle income countries, however, HIVAC is the most common HIV-associated cardiovascular disease. Clear diagnostic and treatment guidelines for HIVAC are currently lacking but should be prioritized given the global burden of HIVAC.

Cardiovascular Complications of HIV-Associated Immune Dysfunction

Prolonged survival in HIV infection is accompanied by an increased frequency of non-HIV-related comorbidities. It is suggested that cardiovascular diseases (CVD) occur earlier among HIV-positive patients compared with HIV-negative patients, and at a higher rate. Several factors have been proposed which can be categorized into traditional and nontraditional risk factors. Immune dysfunction is a nontraditional risk factor that contributes significantly to cardiovascular pathology. Markers of inflammation are elevated in HIV-infected patients, and elevations in markers such as high-sensitivity C-reactive protein, D-dimer, and interleukin-6 (IL-6) have been associated with increased risk for cardiovascular disease. However, the data currently suggest the most practical advice is to start antiretroviral therapy early and to manage traditional risk factors for CVD aggressively. A better understanding of the mechanisms of CVD in this population and further efforts to modify chronic inflammation remain an important research area.

Cardiovascular manifestations of HIV infection in children

BACKGROUND

HIV infection in children is now considered as a chronic condition, in which various non-infectious complications may occur, including those affecting the developing cardiovascular system. As children are expected to survive well into adulthood, understanding childhood as well as potential future cardiovascular complications is of major importance.

METHODS AND RESULTS

We reviewed published literature on childhood cardiac manifestations and longer term effects of pediatric HIV infection on the cardiovascular system. Evidence gaps that should be prioritized in research are highlighted. Through poorly understood mechanisms, HIV infection may cause various cardiac complications already manifesting in childhood, such as structural and functional myocardial derangements, pulmonary hypertension, pericardial effusion and possibly endocarditis. Evidence indicates that HIV infection in children also has unfavorable effects on the vasculature and cardiovascular biomarkers, such as increased intima-media thickness and decreased flow-mediated dilation, a marker of endothelial function. However, studies are small and predominantly include antiretroviral therapy-treated children, so that it is difficult to differentiate between effects of HIV infection per se and antiretroviral therapy treatment, reported in adults to have cardiovascular side effects.

CONCLUSIONS

HIV infection in children may greatly impact the cardiovascular system, including effects on the heart, which tend to manifest early in childhood, and on the vasculature. The underlying mechanisms, essential for targeted prevention, are poorly understood. Current evidence largely stems from research in adults. However, as modes of infection, immune maturity, growth and development, and treatment are markedly different in children, specific pediatric research, accounting for the complex interplay of normal growth and development, HIV infection and treatment, is clearly warranted.

Cardiovascular involvements in HIV-infected patients

The lifespan of HIV-infected patients is increasing, and cardiovascular diseases becoming a major comorbidity and leading cause of death in this population due to high prevalence of the cardiac risk factors and possibly due to the use of antiretroviral therapy. Aggressive reduction of these risk factors and treatment of cardiovascular diseases are crucial to decrease the cardiovascular mortality in these patients.

Cardiac effects in perinatally HIV-infected and HIV-exposed but uninfected children and adolescents: a view from the United States of America

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.

Competing risks for death and cardiac transplantation in children with dilated cardiomyopathy: results from the pediatric cardiomyopathy registry

BACKGROUND

Pediatric dilated cardiomyopathy (DCM) is the leading indication for heart transplantation after 1 year of age. Risk factors by etiology at clinical presentation have not been determined separately for death and transplantation in population-based studies. Competing risks analysis may inform patient prioritization for transplantation listing.

METHODS AND RESULTS

The Pediatric Cardiomyopathy Registry enrolled 1731 children diagnosed with DCM from 1990 to 2007. Etiologic, demographic, and echocardiographic data collected at diagnosis were analyzed with competing risks methods stratified by DCM etiology to identify predictors of death and transplantation. For idiopathic DCM (n=1192), diagnosis after 6 years of age, congestive heart failure, and lower left ventricular (LV) fractional shortening z score were independently associated with both death and transplantation equally. In contrast, increased LV end-diastolic dimension z score was associated only with transplantation, whereas lower height-for-age z score was associated only with death. For neuromuscular disease (n=139), lower LV fractional shortening was associated equally with both end points, but increased LV end-diastolic dimension was associated only with transplantation. The risks of death and transplantation were increased equally for older age at diagnosis, congestive heart failure, and increased LV end-diastolic dimension among those with myocarditis (n=272) and for congestive heart failure and decreased LV fractional shortening among those with familial DCM (n=79).

CONCLUSIONS

Risk factors for death and transplantation in children varied by DCM etiology. For idiopathic DCM, increased LV end-diastolic dimension was associated with increased transplantation risk but not mortality. Conversely, short stature was significantly related to death but not transplantation. These findings may present an opportunity to improve the transplantation selection algorithm.

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.

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.

Cytokines in HIV-associated cardiomyopathy

Among the multiple cardiac manifestations occurring in HIV-infected patients, cardiomyopathy is one of the most challenging. Its incidence has only slightly decreased since the introduction of highly active antiretroviral therapy (HAART). Also, its pathogenesis remains relatively unclear. Although several studies demonstrated the presence of HIV genome in the heart of patients, more recent developments found that viral infection plays an indirect role only, as well as they recognized the contribution of proinflammatory cytokines in the progression of the disease. Experimental studies on animals and cultured myocytes have established the signalling pathway triggered by proinflammatory cytokines in heart failure and cardiomyopathy. Tumor necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1) and IL-6 promote expression of inducible nitric oxide synthase (iNOS) in cardiomyocytes through activation of p38 mitogen-activated protein kinase (p38 MAPK) and nuclear factor kappaB (NFkappaB). TNF-alpha and high concentrations of NO also induce cardiomyocyte apoptosis by TNF type 1 receptor activation. This biological framework, which is also involved in progression of cardiomyopathy in humans, is more pronounced in HIV-infected patients, in whom proinflammatory cytokines TNF-alpha, IL-1 and IL-6 are increased, resulting in an enhanced expression of cardiac iNOS, especially in patients with a low CD4 T cell count. This may account for the worse outcome of heart failure in HIV-infected patients. However, there are only few data today to support future therapeutic implications of cytokines antagonism in treatment of HIV-infected patients with cardiomyopathy. Whether modulation of TNF production or selective inhibition of p38 MAPK pathway could be useful approaches remains uncertain.

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.

Frequency of clinically unsuspected myocardial injury at a children's hospital

BACKGROUND

Ill children are at risk but rarely screened for myocardial injury. The frequency of such injury in ill children is unknown. Elevated levels of plasma cardiac troponin I (cTnI) can detect subclinical myocardial injury.

METHODS

We measured cTnI levels from 283 Children's Hospital, Boston patients (median age 2.10 years, range 0.13-22.4 years) seen in an outpatient or emergency clinic without clinically apparent cardiac disease. We took > or = 0.5 ng/mL as an indication of myocardial injury. We also measured plasma creatine kinase-MB, total creatine kinase, and myoglobin, and performed a chart review.

RESULTS

Fifteen (7.8%) of the 193 acutely ill children and 4 (4.4%) of the 90 well children had an elevated cTnI level (P = .44). Within the acutely ill group, the children with elevated cTnI were younger and had lower mean hemoglobin and hematocrit levels. Cardiac troponin I levels correlated with creatine kinase-MB (r = 0.22; P < .001) but not with creatine kinase or myoglobin. The 4 children with cTnI > 0.89 ng/mL, who also had plasma cardiac troponin T measured, showed cardiac troponin T elevations that were consistent with unstable angina levels in adults. Four children had high-level cTnI elevations (> 2 ng/mL) consistent with acute myocardial infarction levels in adults.

CONCLUSIONS

Elevated cTnI levels occur in children without clinically apparent cardiac disease and can be at adult unstable angina or acute myocardial infarction levels. Prospective studies to determine the clinical significance of these findings and their relationship to the development of cardiomyopathy are warranted.

Cardiovascular disease and toxicities related to HIV infection and its therapies

Cardiovascular manifestations of HIV vary according to disease stage, treatment regimen and geographical location. Common cardiac complications of HIV disease in patients off highly active antiretroviral therapy (HAART) include dilated cardiomyopathy, myocarditis, pericardial effusion, endocarditis, pulmonary hypertension and non-antiretroviral drug-related cardiotoxicity. However, with the introduction of HAART that has substantially modified the course of HIV disease by lengthening survival, additional cardiovascular consequences are a result of the metabolic syndrome with a propensity toward hyperlipidaemia and atherosclerotic heart disease. Because most of the world's HIV-infected patients have not been treated with HAART, the principal HIV-associated cardiovascular manifestations of patients off HAART are reviewed and new knowledge about the prevalence, pathogenesis and treatment in the HAART era are emphasised in this review. Exercise, a nonpharmacological approach to treating HAART-associated metabolic syndrome, is also discussed.

HIV-related cardiovascular disease and drug interactions

HIV infection is a global public health issue that is frequently associated with cardiovascular involvement. These HIV-associated cardiovascular manifestations are often clinically occult or attributed incorrectly to other non-cardiac disease processes. A heightened awareness and routine screening for cardiovascular involvement in HIV-infected patients leads to earlier detection and the hope for a reduction in associated morbidity and mortality. Left ventricular dysfunction, an independent predictor of mortality in HIV-infected patients, is the result of many causes in this population and may result in dilated cardiomyopathy and congestive heart failure in about 10% of patients. Other HIV-associated cardiovascular problems include infective endocarditis, cardiovascular malignancy, pulmonary arterial hypertension, vasculitis, pericardial effusion, premature atherosclerosis, and arrhythmias. HIV-associated cardiovascular emergencies include congestive heart failure, pulmonary edema, supraventricular and ventricular arrhythmias, endocarditis, and tamponade. Anti-infective and immunomodulatory therapies may be particularly helpful in this population to reduce associated cardiovascular disease. Highly active antiretroviral therapy may result in lipodystrophy, hyperlipidemia, truncal adiposity, and insulin resistance that can be improved by physical activity and training programs. Cardiovascular complications of therapeutic drugs in HIV-infected patients include torsade de pointes, congestive heart failure, dyslipidemia, accelerated atherosclerosis, and myocardial infarction. In summary, cardiovascular complications are important contributors to morbidity and mortality in HIV-infected patients that can be detected early in many cases and treated effectively.

Cardiovascular complications in patients with HIV infection

As advances in early diagnosis and aggressive therapy, as well as better supportive care, become available to a larger number of patients with HIV infection, survival is being prolonged, and more patients are experiencing cardiac abnormalities. The most common cardiac manifestations of HIV disease are dilated cardiomyopathy, myocarditis, pericardial effusion, endocarditis, pulmonary hypertension, HIV-associated malignant neoplasms, and drug-related cardiotoxicity. 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. However, early data have raised concerns about HAART being associated with an increase in peripheral and coronary arterial disease. This review discusses the principal HIV-associated cardiovascular manifestations and emphasizes new knowledge about their prevalence, pathogenesis, and treatment.

Predictors of cardiac morbidity and related mortality in children with acquired immunodeficiency syndrome

OBJECTIVES

The aim of this study was to determine the prevalence of cardiovascular dysfunction and its predictors in children with acquired immunodeficiency syndrome (AIDS).

BACKGROUND

Cardiovascular manifestations are common among children with AIDS but may be clinically occult.

METHODS

We reviewed the medical records, echocardiograms, electrocardiograms, and Holter monitor studies of 68 children with AIDS. We tested clinical and demographic characteristics at the time of AIDS diagnosis for their ability to predict serious cardiac events, death, and cardiac death.

RESULTS

The median time from AIDS diagnosis to death or end of follow-up was 1.0 year (range, 1 week to 7.9 years). Nineteen patients (28%) experienced serious cardiac events after AIDS diagnosis. Of 43 patients who died, 15 (35%) had cardiac dysfunction. Multivariable analyses revealed that recurrent bacterial infections, wasting, encephalopathy, male gender, and an earlier year of AIDS diagnosis were predictors of serious cardiac events (relative risk [RR] = 9.3, 6.9, 4.7, 4.1, and 0.76, respectively, p < 0.05). Wasting, encephalopathy, a low age-adjusted CD4 count, a low age-adjusted immunoglobulin G (IgG) level, and an earlier year of AIDS diagnosis increased the risk of all-cause mortality (RR = 8.9, 5.1, 2.7, 0.82, and 0.8, respectively, p <or= 0.02). Male gender, a low age-adjusted CD4 count, and a low age-adjusted IgG level increased the risk for cardiac death (RR = 16.9, 4.2, and 0.68, respectively, p <or= 0.05).

CONCLUSIONS

Serious cardiac events and cardiac death are common among children with AIDS. Factors such as recurrent bacterial infections, wasting, encephalopathy, male gender, low CD4 and IgG levels, and an earlier year at AIDS diagnosis may identify high-risk patients.

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

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

Mediators in HIV-associated cardiovascular disease: a focus on cytokines and genes

As longevity increases in HIV-infected individuals, late effects such as cardiovascular disease and, more specifically, symptomatic heart failure are emerging as leading health issues. In the present review, we discuss possible cytokine and gene-mediated effects on HIV-associated cardiovascular illness that may play a role in diagnosis, management, and therapy of HIV-associated heart failure.

Cardiomyocyte injury to transplant: pediatric management

Cardiomyocyte injury in pediatric patients has a vast number of causes, which are often distinct from the causes of adult heart failure. However, the management of pediatric heart failure and heart transplantation has generally been inferred from adult studies. New therapies show great promise for the neurohormonal regulation of heart failure and the ability to control immunosuppression after heart transplantation. Large, randomized, multicenter, controlled clinical trials are needed to determine the efficacy of these therapies in this population. This article reviews the current recommendations and evidence-based medicine, where available, for the medical management of myopathic dysfunction and transplantation in pediatric patients.

Myocardial and Pericardial Disease in HIV

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

The post-mortem pathology of HIV-1-infected African children

A retrospective review of autopsy findings and medical records in 33 HIV-infected children living in a Kenyan orphanage is described. Their ages ranged from 1 month to 18 years and median age at death was 71 months (range 7-156). Respiratory disorders were probably the primary cause of death in 21 (64%), in 19 (90%) of whom pyogenic parenchymal lung disease was detected. A presumptive clinical diagnosis of pulmonary tuberculosis had been made in 14 (67%); these children also had a history of recurrent acute lower respiratory tract infections (more than four infections/year). At autopsy, however, only one case of tuberculosis was identified (disseminated disease). Pneumocystis carinii pneumonia was not identified. Primary bacterial meningitis was detected in 33%. The associated findings included disseminated Kaposi sarcoma in two children and cryptococcal meningitis in one child. It is concluded that pyogenic infections are common causes of morbidity and mortality in HIV-1-infected African children. Management should include prompt treatment and, if indicated, prophylaxis for recurrent bacterial infections, and early evaluation and treatment of pulmonary tuberculosis.

Cardiovascular monitoring and therapy for HIV-infected patients

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

HIV-associated cardiovascular complications: a new challenge for emergency physicians

Cardiac complications associated with the AIDS may present to emergency physicians and are often secondary to opportunistic infections or malignancy, but may also be associated with other aspects of the human immunodeficiency virus (HIV) or its treatment. In this review article, we will discuss HIV-associated cardiac disease which may be encountered in the ED, emphasizing the prevalence, pathogenesis, and treatment of related disorders.

Ventricular dysfunction clinical research in infants, children and adolescents

These two issues of Progress in Pediatric Cardiology comprehensively illustrate the wealth of currently available information on the pathophysiology of heart failure, age-related myocardial responsiveness, energy metabolism, cardiopulmonary interactions, the pressure-volume relationship, the systemic inflammatory response, the management of heart failure, pediatric pharmacology, the use of heart failure therapies including digoxin, ACE inhibitors, beta-adrenergic blockers, inotropic agents, diuretics, vasodilators, calcium sensitizers, angiotensin and aldosterone receptor blockers, growth hormone, and future gene therapy. The etiology and course of ventricular dysfunction in children is poorly characterized. Furthermore, many changing developmental properties of the pediatric myocardium and differences in the etiologies of ventricular dysfunction in children compared with adults are illustrated in these articles, invalidating the concept that children can safely be considered small adults for the purpose of understanding heart failure pathophysiology and treatment. However, these articles reveal that strikingly little research in children with ventricular dysfunction exists in terms of well-designed large-scale studies of the epidemiology or multicenter controlled clinical therapeutic trials. A future research agenda is proposed to improve understanding etiologies, course and treatment of ventricular dysfunction in children that is based on organized and funded cooperative groups since no one pediatric cardiac center treats enough children with a particular etiology of ventricular dysfunction. In conclusion, significant understanding of basic mechanisms of pediatric ventricular dysfunction and effective therapies for adults with ventricular dysfunction exist. A multicenter pediatric cardiac ventricular dysfunction network would allow improved understanding of diseases and treatments, and result in evidence-based medicine for pediatric patients with ventricular dysfunction.

Cardiac dysfunction and mortality in HIV-infected children: The Prospective P2C2 HIV Multicenter Study. Pediatric Pulmonary and Cardiac Complications of Vertically Transmitted HIV Infection (P2C2 HIV) Study Group

BACKGROUND

Left ventricular (LV) dysfunction is common in children infected with the human immunodeficiency virus (HIV), but its clinical importance is unclear. Our objective was to determine whether abnormalities of LV structure and function independently predict all-cause mortality in HIV-infected children.

METHODS AND RESULTS

Baseline echocardiograms were obtained on 193 children with vertically transmitted HIV infection (median age, 2.1 years). Children were followed up for a median of 5 years. Cox regression was used to identify measures of LV structure and function predictive of mortality after adjustment for other important demographic and baseline clinical risk factors. The time course of cardiac variables before mortality was also examined. The 5-year cumulative survival was 64%. Mortality was higher in children who, at baseline, had depressed LV fractional shortening (FS) or contractility; increased LV dimension, thickness, mass, or wall stress; or increased heart rate or blood pressure (P0.02 for each). Decreased LV FS (P<0.001) and increased wall thickness (P=0.004) were also predictive of increased mortality after adjustment for CD4 count (P<0.001), clinical center (P<0.001), and encephalopathy (P<0.001). FS showed abnormalities for up to 3 years before death, whereas wall thickness identified a population at risk only 18 to 24 months before death.

CONCLUSIONS

Depressed LV FS and increased wall thickness are risk factors for mortality in HIV-infected children independent of depressed CD4 cell count and neurological disease. FS may be useful as a long-term predictor and wall thickness as a short-term predictor of mortality.

Organ-specific manifestations of HIV disease in children

The clinical manifestations of HIV disease in children affect multiple organ systems. The severity of each manifestation varies by organ system and can be related in many cases to multifactorial causes, namely HIV replication in affected tissue, concomitant opportunistic infection of the organ, effect of concurrent immunodeficiency or autoimmune mechanisms on the organ, or adverse end-organ drug effect (primary HIV therapy or prophylaxis regimens). More information is needed to understand the pathogenesis of the systemic effect of HIV on different organ systems, especially the CNS. Most clinicians hope that advances in therapeutic interventions for primary HIV will halt the progression of the organ-specific manifestations that have been outlined in this article, but such potent therapies will probably have their own unique and new effects on HIV-infected organ systems. Vigilance for organ-specific manifestations in the era of HAART is imperative to provide the best clinical outcome for HIV-infected children.

Medical management of HIV disease in children

Significant advances have been made in the understanding of the pathophysiology of HIV infection since the beginning of the epidemic. This knowledge has translated into the development of new therapies for HIV and opportunistic infections, laboratory advances in monitoring viral and immune status, and a better understanding of factors affecting patient outcome. Concomitantly, significant progress has been made in the medical management of children with HIV infection in the past 5 years. The number of children reported with AIDS in the United States is decreasing, and efforts are shifting from caring for children with advanced immunosuppression and severe opportunistic infections to early HAART, maintenance of the immune system, and prevention of opportunistic infections. Primary care physicians are now more involved and informed in the care of HIV-infected patients. Although published data are limited, physicians who have been working with this population have observed a dramatic improvement in the quality of life and length of survival of these patients. Unfortunately, this progress is not shared by developing countries where resources are minimal and antiretroviral agents are commonly unavailable. Although efforts to develop a vaccine to prevent HIV infection are ongoing, progress has been slow. Education and awareness continue to be the most powerful weapons against HIV.