HIV 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 arterial hypertension due to activation of endothelial cells, or secondary to multiple pulmonary infarctions

• Accelerated atherosclerosis as a result of increased vascular inflammation

• Valvular heart disease and infective endocarditis

GENERAL CONSIDERATIONS

• HIV-related heart disease can affect the pericardium, myocardium, coronary arteries, pulmonary vasculature, and the systemic vasculature

• Pericardial effusion is the most common cardiac pathology (10–40% of patients) and is associated with a poor prognosis

• The etiology and pathogenesis of HIV-associated cardiomyopathy are uncertain but may be due to direct myocardial infection by the HIV virus, abnormal inflammatory response, autoimmune mechanisms, antiretroviral therapy, or opportunistic infection

• Clinically important dilated cardiomyopathy is present in 1–3%

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

• Pulmonary arterial hypertension is present in 0.5% of HIV-infected patients and is associated with poor survival

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

• Prolonged QT interval and isolated ST-T–wave abnormalities are electrocardiographic abnormalities described in HIV patients

• Valvular heart disease is common in HIV-positive patients, and the rates of infective endocarditis are similar to those in other high-risk groups

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

• Worsened fatigue

• Breathlessness/dyspnea

• Edema

• Chest pain

PHYSICAL EXAM FINDINGS

• Patients with significant pericardial disease:

  • – Elevated jugular venous pressure

  • – Muffled heart sounds or a pericardial friction rub

• Patients with a dilated cardiomyopathy:

  • – Elevated jugular venous pressure

  • – Pulmonary rales

  • – Displaced sustained apical impulse

  • – Gallop rhythms

• Patients with pulmonary arterial hypertension:

  • – Increased P₂

  • – Right ventricular lift

  • – Murmur of tricuspid regurgitation

DIFFERENTIAL DIAGNOSIS

• Coronary artery disease due to traditional atherosclerotic risk factors

• Idiopathic dilated cardiomyopathy

• 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-segment 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

  • – New regurgitant valvular lesion

• Stress testing:

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