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HIV and the Heart
HIV and AIDS affect >36 million people worldwide. Increased survival among HIV-infected persons who have access to effective combination antiretroviral therapy (ART) and rising rates of new diagnoses among older adults have resulted in growing numbers of older people living with HIV.
Some cardiac manifestations more commonly seen before availability of effective ART, such as dilated cardiomyopathy (DCM), myocarditis, and pericarditis, are now relatively rare in individuals treated for HIV. Instead, traditionally age-related illnesses, like atherosclerotic cardiovascular disease (ASCVD), have become increasingly important in HIV care. This chapter explores common cardiac diseases in HIV-infected individuals and the ways in which etiologies differ compared with the general population ( Fig. 70.1 ). Optimal care of cardiac disease in the HIV-infected patient should be integrated among the cardiologist, the HIV care provider, and the primary care provider.
Cardiac Manifestations of AIDS.
Etiology and Pathogenesis
The etiology underlying cardiac diseases in HIV infection is multifactorial and may include one or more of the following categories: (1) direct viral effect of HIV and associated chronic inflammation; (2) HIV-associated infections and/or opportunistic diseases; (3) antiretroviral medications; and (4) risk factors common to the general population that are highly prevalent in populations affected by HIV (e.g., hyperlipidemia, smoking, and hypertension). Treatment of cardiac disease in HIV-infected patients should address pathways underlying the disease process and modifiable risk factors.
Clinical Presentation
Dilated Cardiomyopathy
In the pre-ART era, DCM was found in 20% to 40% of patients with long-standing HIV infection, even in the absence of an AIDS-defining diagnosis. Currently, HIV-associated DCM is rare and may be related to impaired immune function, direct cardiotoxic effects of HIV or HIV proteins, drug-related toxicity, and/or nutritional deficiencies.
Specific opportunistic infections implicated include viral (cytomegalovirus, herpes simplex), protozoal (Toxoplasma gondii) , bacterial (Mycobacterium tuberculosis, Mycobacterium avium-intracellulare) , and fungal ( Cryptococcus neoformans, Aspergillus fumigatus, Histoplasma capsulatum, Coccidioides immitis , and Candida spp.) infections and should be considered in evaluation of the HIV-infected patient with DCM. Ability to identify the causative agent of DCM is often limited, and clinical management focuses on treatment of heart failure and supportive measures. In patients who have uncontrolled HIV, effective ART is also indicated, and virological control can lead to a significant improvement in cardiac function.
Pulmonary Hypertension
Although uncommon, pulmonary arterial hypertension (PAH) independently predicts mortality among people living with HIV. The prevalence of PAH is estimated to be 1 in 200 in HIV-infected individuals compared with 1 in 200,000 in the general population, and rates remain essentially unchanged despite use of effective ART. The pathogenesis underlying PAH in HIV infection remains unclear but may be related to duration of infection, effects of HIV on endothelial function, or sequelae of opportunistic pulmonary infections. Early recognition and treatment of PAH is recommended because clinical management of more advanced disease and cardiopulmonary complications is challenging. Treatment of PAH in HIV-infected patients is the same as for other nonidiopathic PAH. Initiation of ART, although important for control of HIV, has not been shown to improve PAH.
Pericardial Effusions and Pericarditis
Pericardial effusions are commonly seen in HIV-infected individuals. Clinical manifestations include asymptomatic effusions detected on echocardiography, pericarditis with and/or without constriction, and tamponade. The clinical presentation of pericarditis alone is not different in HIV-infected and uninfected individuals, and etiology is most often not determined. Specific considerations in this population include infections (viral, fungal, and mycobacterial, with tuberculosis as a particular concern in patients at high risk for this coinfection), malignancies (e.g., Kaposi sarcoma [KS] and non-Hodgkin lymphoma [NHL]), and other HIV-associated diseases (e.g., nephropathy).
Infective Endocarditis
Infective endocarditis in HIV-infected individuals has similar prevalence to that in individuals with the same risk behaviors and similar clinical presentation. Staphylococcus aureus and Streptococcus viridans are the major responsible organisms. As in all cases of endocarditis, exposure history can help guide assessment of likely pathogens (e.g., intravenous drug use increases risk for S. aureus ). However, certain organisms are seen more frequently in HIV-infected individuals who are at higher risk of Salmonella bacteremia, which results in endocarditis, than are seen in immunocompetent patients. Other than Candida species, fungal endocarditis ( Aspergillus fumigatus, Histoplasma capsulatum, and Cryptococcus neoformans ) is also more common in HIV-infected individuals; however, this remains relatively rare. Individuals with late-stage HIV infection and advanced immunosuppression have a worse prognosis and higher mortality than those who are earlier in the disease course.
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