AIDS and the Heart

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 ...