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Myocardial and Pericardial Disease in HIV
William G. Harmon1, Gul H. Dadlani, Stacy D. Fisher
1Division of Pediatric Cardiology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 631, Rochester, NY 14642, USA. steve_lipshultz@urmc.rochester.edu
Insights
HIV-infected individuals require regular cardiac evaluations to detect early left ventricular dysfunction. Prompt treatment of underlying conditions and specific therapies can improve heart function and quality of life.
Area of Science:
- Cardiology
- Infectious Diseases
- Public Health
Background:
- Cardiovascular complications are prevalent in the human immunodeficiency virus (HIV)-infected population.
- HIV is increasingly manageable as a chronic disease, necessitating focus on long-term health outcomes.
- Subclinical cardiac dysfunction is common and requires proactive management.
Purpose of the Study:
- To outline strategies for preventive, screening, and therapeutic cardiac care in HIV-infected individuals.
- To emphasize the importance of early detection and management of left ventricular (LV) dysfunction.
- To discuss the role of various interventions, including pharmacologic and supportive therapies, in managing HIV-related cardiac conditions.
Main Methods:
- Periodic cardiac evaluation, including echocardiography, for early detection of LV dysfunction.
- Diagnosis and treatment of underlying infectious, endocrine, nutritional, and immunologic disorders contributing to cardiac dysfunction.
- Consideration of endomyocardial biopsy for etiology-specific therapy.
- Application of standard congestive heart failure management, including afterload reduction with ACE inhibitors where appropriate.
- Evaluation and management of dyslipidemia and metabolic syndrome associated with highly active antiretroviral therapy (HAART).
- Assessment of pericardial effusions, differentiating between nonspecific and those requiring further investigation.
Main Results:
- Early identification of subclinical cardiac dysfunction through echocardiography is crucial.
- Treatment of underlying disorders can lead to improvement or normalization of myocardial function.
- Intravenous immunoglobulin (IVIG) shows promise in preserving LV parameters in HIV-infected children.
- HAART may necessitate management of dyslipidemia and metabolic syndrome.
- Asymptomatic pericardial effusions are common in advanced HIV and usually nonspecific.
Conclusions:
- Comprehensive cardiac care, including regular screening and prompt treatment, is essential for improving survival and quality of life in HIV-infected patients.
- Etiology-specific treatment of cardiac dysfunction, alongside standard heart failure management, is recommended.
- Further research into immunomodulatory therapies like IVIG for pediatric HIV-related cardiomyopathy is warranted.
- Management of HAART-associated metabolic complications and careful consideration of drug interactions are vital.
Abstract:
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.