Cardiovascular manifestations of HIV have been altered by the
introduction of highly active antiretroviral therapy (HAART) regimens.
On one hand, HAART has significantly modified the course of HIV disease,
lengthened survival, and improved the quality of life of HIV-infected
patients. On the other hand, the early data have raised concerns that
HAART is associated with an increase in both peripheral and coronary
arterial diseases.1 The HAART-associated
changes are relevant only to the minority of HIV-infected individuals
worldwide who have access to HAART. Thus, studies conducted before HAART
became available remain globally applicable.
Most studies that have described cardiac complications in AIDS
patients were postmortem, although some clinical series have been
reported. It is now clear that cardiac involvement in AIDS patients is
relatively common. Although most such conditions are clinically
quiescent, some may have devastating and fatal outcomes. Pericardial
effusion and myocarditis are among the most commonly reported
abnormalities. Cardiomyopathy, endocarditis, and coronary vasculopathy
have also been reported. Symptomatic cardiac disease was described
first in children but is also seen in HIV-infected adults 2,3.
Patients with AIDS can have cardiac pathology related to
opportunistic infections and tumors.
TYPES OF CARDIAC DISEASE
Patients with advanced HIV infection can have a variety of
cardiovascular manifestations. The most common are:
- Pulmonary vascular disease and pulmonary
- An increased incidence of vascular disease
including coronary artery disease
The prevalence of pericardial effusion in asymptomatic AIDS patients
has been estimated at 11% before the introduction of HAART4 .
HIV infection should be included in the differential diagnosis of
unexplained pericardial effusion or tamponade. Pericardial effusion in
HIV disease may be related to opportunistic infections or to malignancy,
but most often a clear pathology is not found.1
Significant pericardial effusion has been identified in up to 40% of
AIDS patients with echocardiography or autopsy 5, making this
one of the most common cardiac abnormalities in AIDS patients. Most of
those reported cases were, however, asymptomatic.
HIV disease is recognized as an important cause of dilated
cardiomyopathy, with an estimated annual incidence of 15.9 in 1000
before the introduction of HAART6
The prevalence of infective endocarditis in HIV-infected patients is
similar to that in patients of other risk groups, such as intravenous
drug users.7Estimates of endocarditis prevalence vary from
6.3% to 34% of HIV-infected patients who use intravenous drugs
independently of HAART regimens.7 Right-sided valves are
predominantly affected, and the most frequent agents are
Staphylococcus aureus (>75% of cases), Streptococcus pneumoniae,
Haemophilus influenzae, Candida albicans,
Aspergillus fumigatus, and Cryptococcus neoformans.7
HIV-Associated Pulmonary Hypertension
The pathogenesis of primary pulmonary hypertension in HIV infection
is multifactorial and poorly understood.1
Clinical symptoms and outcomes of patients with right ventricular
dysfunction are related to the degree of pulmonary hypertension, varying
from a mild asymptomatic condition to severe cardiac impairment with cor
pulmonale and death.8
HIV Therapy and the Heart
cardiovascular actions/interactions of common HIV therapies are reported
in Table 1.
Cardiovascular Actions/Interactions of Common HIV Therapies
Cardiac Side Effects
(RTI) Transcriptase Inhibitors Nucleoside
Abacavir (Ziagen), zidovudine (AZT,
Lactic acidosis (rare), hypotension,
skeletal muscle myopathy, (mitochondrial dysfunction
hypothesized, but not seen clinically)
Delavirdine (Rescriptor), efavirenz (Sustiva),
Delavirdine can cause serious toxic effects
if given with antiarrhythmic drugs and myocardial ischemia if
given with vasoconstrictors
Amprenavir (Agenerase), indinavir (Crixivan),
nelfinavir (Viracept), ritonavir (Norvir), saquinavir (Invirase,
Implicated in premature atherosclerosis,
dyslipidemia, insulin resistance, and lipodystrophy/lipoatrophy
It is clear from this article that cardiac abnormalities in AIDS
patients are relatively common. The endocardium, myocardium,
pericardium, and even the coronary vessels can be affected. It may be
more common in more advanced HIV disease . When clinically significant
cardiac complication does develop, the signs and symptoms may be
misinterpreted for noncardiac causes such as pulmonary infections that
can mimic heart symptoms. Therefore, it is critical that the
differential diagnosis be prudently done to avoid missing treatable
It is hoped that HAART regimens, by improving the clinical course of
HIV disease, will reduce the incidence of pericardial effusions and
myocardial involvement of HIV-associated malignancies and co-infections.
A careful cardiological screening, however, is warranted for patients
who are being evaluated for or who are receiving HAART regimens,
especially those with other known underlying cardiovascular risk
factors, as the atherogenic effects of protease inhibitors may
synergistically promote the acceleration of coronary heart and
cerebrovascular disease and enhance the risk of death due to myocardial
infarction and stroke.
G, Fisher SD, Lipshultz SE. Pathogenesis of HIV-associated
cardiovascular complications. Lancet
Infect Dis. 2001;
Lipshultz SE, Chanock S, Sanders SP, et al. Cardiovascular
manifestations of human immunodeficiency virus infection in infants and
children. Am J Cardiol 1989; 63:1489.
Luginbuhl LM, Orav EJ, McIntosh K, Lipshultz SE. Cardiac morbidity and
related mortality in children with HIV infection. JAMA 1993; 269:2869.
4. Heidenreich PA, Eisenberg MJ, Kee LL, et
al. Pericardial effusion in AIDS: incidence and survival.
5. Fink L, Reicheck N, St. John Sutton M. Cardiac
abnormalities in acquired immune deficiency syndrome. Am J Cardiol
6.Barbaro G, Klatt EC, HIV infection and the
cardiovascular system. AIOS Rev.
7.Barbaro G, Di Lorenzo G, Grisorio B, et al.
Cardiac involvement in the acquired immunodeficiency syndrome: a
multicenter clinical-pathological study.
AIDS Res Hum Retroviruses.
8.Pellicelli AM, Palmieri F, D’Ambrosio C, et
al. Role of human immunodeficiency virus in primary pulmonary
hypertension: case reports. Angiology.