Elsevier

American Heart Journal

Volume 151, Issue 6, June 2006, Pages 1147-1155
American Heart Journal

Curriculum in Cardiology
Cardiovascular disease in HIV infection

https://doi.org/10.1016/j.ahj.2005.07.030Get rights and content

The survival of patients with HIV infection who have access to highly active antiretroviral therapy has dramatically increased. In HIV-infected persons, cardiovascular disease can be associated with HIV infection, opportunistic infections or neoplasias, use of antiretroviral drugs or treatment of opportunistic complications, mode of HIV acquisition (such as intravenous drug use), or with the classic non–HIV-related cardiovascular risk factors (such as smoking or age). Diseases of the heart associated with HIV infection or its opportunistic complications include pericarditis and myocarditis. Pericarditis may lead to pericardial effusion rarely causing tamponade. Cardiomyopathy is often clinically silent with asymptomatic left ventricular systolic dysfunction. Endocarditis is mainly the consequence of intravenous drug abuse, possibly leading to life-threatening valvular insufficiency with the need for cardiac surgery. A further serious condition associated with HIV infection is pulmonary hypertension potentially leading to right heart failure. The cardiovascular complications of HIV infection such as cardiomyopathy and pericarditis have been reduced by highly active antiretroviral therapy, but premature coronary atherosclerosis is now a growing problem because antiretroviral drugs can lead to serious metabolic disturbances resembling those in the metabolic syndrome. Lipodystrophy, a clinical syndrome of peripheral fat wasting, central adiposity, dyslipidemia, and insulin resistance, is most prevalent among patients treated with protease inhibitors. These patients should thus be screened for hyperlipidemia, hyperglycemia, and hypertension, and they may be candidates for lipid-lowering therapies. When initiating lipid-lowering therapy, interactions between statins and HIV protease inhibitors affecting cytochrome P450 function must be considered. Restenosis rate after percutaneous coronary intervention may be unexpectedly high.

Section snippets

Pericarditis

Pericardial effusion is frequently seen in asymptomatic HIV-infected patients. Large effusion causing tamponade is rare. HAART has considerably decreased the incidence of pericarditis and pericardial effusion (Table I),5 which are often caused by tuberculosis in patients with HIV infection. Associated myocarditis is present in up to a third of cases.6 Mortality is high, particularly in the presence of pericardial effusion. Pericardiocentesis is essential for the diagnosis and specific therapy,

HIV and pulmonary hypertension

Primary pulmonary hypertension, first described in hemophilic HIV-infected patients, occurs with a frequency of approximately 0.5% in patients with HIV infection, whereas the general yearly incidence is only approximately 1 to 2 per 1 million people.18 There is no relation to the disease stage as reflected by CD4 counts. Although repetitive opportunistic pulmonary infections can cause right ventricular dysfunction, that is, cor pulmonale, there is no association with the incidence of pulmonary

Aneurysmatic vascular disease

Cerebral artery aneurysms are frequent in children vertically infected with HIV. In adults, a number of case reports describe aneurysms of the aorta and peripheral and cerebrovascular arteries sometimes necessitating surgical repair.27 These aneurysms may be as a result of vasculitic changes induced by the virus,28 or by other infectious causes such as cytomegalovirus and tuberculosis. However, an infective agent is not always identified.28

Epidemiology

Sporadic case reports raising concerns about premature coronary artery disease in patients treated with HAART led to retrospective analysis of large cohort studies.

Previous studies have reached conflicting conclusions whether the incidence of myocardial infarction (MI) is indeed increased in this patient population. Although some investigators found an association,29 others did not.30

In 700 HIV-infected patients treated with HAART, 9 patients (1.3%) had acute coronary events after an average

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