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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Pericardial effusion

  • Lymphocytic myocarditis

  • Dilated cardiomyopathy and left ventricular systolic dysfunction

  • Myocardial Kaposi’s sarcoma and non-Hodgkin’s lymphoma

  • Pulmonary hypertension secondary to multiple pulmonary infarctions, or primary pulmonary hypertension

  • Accelerated atherosclerosis as a consequence of longer survival and the use of antiretroviral agents

GENERAL CONSIDERATIONS

  • Most HIV-infected patients with cardiac abnormalities have acquired immunodeficiency syndrome (AIDS)

  • Pericardial effusion is less common today but is associated with a poor prognosis

  • The cause of idiopathic myocarditis is uncertain but may be due to direct myocardial infection by the HIV virus, autoimmune mechanisms, other viruses, or opportunistic infection

  • Clinically important dilated cardiomyopathy is the most common finding in low socioeconomic populations

  • Cardiac tumors such as Kaposi’s sarcoma, intracavity growth, and obstruction should be considered

  • Pulmonary hypertension is unusual in HIV-infected patients and is associated with poor survival

  • Protease inhibitors, which are part of most HAART (highly active antiretroviral treatment) regimens, are associated with metabolic abnormalities that lead to accelerated atherosclerosis and increased cardiovascular risk

  • Coronary artery disease is the most common finding in higher socioeconomic populations

  • Prolonged QT interval and torsades de pointes have been described in hospitalized patients with HIV infection, even without drug therapy

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Worsened fatigue

  • Breathlessness/dyspnea

  • Edema

  • Chest pain

PHYSICAL EXAM FINDINGS

  • Patients with significant pericardial disease

    • – Elevated jugular venous pressure

    • – A pericardial friction rub

  • Patients with a dilated cardiomyopathy

    • – Elevated jugular venous pressure

    • – Pulmonary rales

    • – Displaced sustained apical impulse

    • – Gallop rhythms

  • Patients with pulmonary hypertension

    • – Increased P2

    • – Right ventricular lift

    • – Murmur of tricuspid regurgitation

DIFFERENTIAL DIAGNOSIS

  • Idiopathic dilated cardiomyopathy from other causes

  • Other causes of myocardial ischemia

  • Dilated cardiomyopathy secondary to interferon-alfa used to treat Kaposi’s sarcoma

  • Other causes of pericardial effusion

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • HIV serology

  • CD4 count

  • Other tests based on the clinical situation

ELECTROCARDIOGRAPHY

  • Low-voltage QRS and/or electrical alternans may suggest a pericardial effusion

  • Rare patients may have PR depression and/or diffuse ST elevation with acute pericarditis

  • Q waves in patients with prior myocardial infarction

  • Prolonged QT interval

IMAGING STUDIES

  • Chest x-ray:

    • – Enlarged cardiac silhouette due to a pericardial effusion or cardiomegaly

  • Echocardiogram (routine echo not indicated to screen for cardiovascular involvement):

    • – Pericardial effusion

    • – Cardiac chamber enlargement

    • – Reduced ventricular function

  • Stress testing:

    • – May be indicated in patients with symptoms of myocardial ischemia or ventricular dysfunction

DIAGNOSTIC PROCEDURES

  • Cardiac catheterization:

    • – Coronary angiography may be indicated in patients presenting with signs or symptoms of myocardial ischemia or infarction

TREATMENT

CARDIOLOGY ...

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