Cardiac diseases in AIDS
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-525-6884, Cafer Zorkun, M.D.
Introduction
Cardiac involvement in human immunodeficiency virus (HIV) infection has been evaluated and described by several autopsy and echocardiography based studies. Obviously, it is much more prevalent than is clinically apparent.
Additionally, as HIV-infected patients live longer as a result of highly active antiretroviral therapy (HAART), cardiovascular problems are becoming more prominent. This is due to the direct effects of HIV infection and indirectly due to its treatment (drug side effects) as well as the contribution of other established causes of cardiac disease in other populations.
Pericarditis
Pericarditis, often associated with pericardial effusion, is the most common finding in patients with HIV infection. Autopsy series have reported up to 37% prevalence of pericardial disease in HIV infected patients. The prevalence observed in echocardiographic series is as high as 59%.
Approximately two-thirds of AIDS patients with symptomatic pericarditis have an identifiable and potentially treatable etiology.
Mycobacterial infections are a common infectious cause of tamponade in AIDS patients
Surgical pericardial biopsy is the diagnostic test of choice if pericardial fluid microscopy is negative in patients with suspected tuberculous pericarditis.
Myocarditis and Cardiomyopathy
The spectrum of myocardial involvement in HIV infection is wide and includes inflammatory myocarditis, dilated cardiomyopathy, and infiltrative neoplastic disease.
The prevalence of myocarditis in HIV infection is variable depending on the population selected and the methods used. Autopsy studies of HIV infected adults have reported myocarditis in up to 52% of patients. Echocardiographic series have identified cardiomyopathy in 30 - 40% of HIV infected patients.
The underlying etiology of myocarditis in HIV infected individuals is broad. HIV has been detected in cardiac tissue by culture, molecular techniques and immunohistochemistry.
Diagnostic modalities and findings are in general similar to those reported for non HIV-infected patients.
- Chest radiographs may show cardiomegaly
- ECG findings are nonspecific.
- Echocardiography is the main diagnostic tool in documenting cardiac dysfunction.
- Myocardial biopsy may be useful but may be insensitive. A specific etiology is found on biopsy only in a small minority (20%) of cases. Histology generally shows only small focal collections of mononuclear cells, usually without evidence of myonecrosis.
Several infectious agents have been implicated in HIV associated myocardial disease. These include:
- Toxoplasmosis
- Tuberculosis
- Atypical mycobacterial infections
- Cryptococcosis
- Histoplasmosis
- Cytomegalovirus
- Coxsackie virus
- Chagas disease
Selenium deficiciency, L-carnitine deficiency, and vitamin B deficiency have been associated with myocardial dysfunction and cardiomyopathy.
Several drugs, used either for the treatment of HIV infection itself or its complications, have been associated with cardiac related toxicities. Recreational use of cocaine, methamphetamine, and alcohol can cause cardiac toxicity as they can in the non HIV infected population.
Endocardial Diseases
A common incidental finding at autopsy in patients dying of AIDS is thrombotic nonbacterial marantic endocarditis, a condition in which sterile valvular vegetations occur without an infectious cause. Systemic embolization is an uncommon clinical presentation of marantic endocarditis: valve destruction or clinical valve dysfunction is rare.
Infective endocarditis in HIV-infected patients is uncommon and occurs almost exclusively in intravenous drug users.
Cardiac Tumors
Kaposi's sarcoma as seen in patients with AIDS, can involve the myocardium and pericardium and classically presents with pericardial effusion or less commonly cardiac tamponade. Primary cardiac lymphoma is a rare malignancy associated with AIDS that presents with heart failure or ventricular arrhythmias secondary to these tumors.
Coronary Artery Disease
Congestive Heart Failure
Things to remember about drug therapy in patients with AIDS or HIV infected Individuals
Vitamin B12
Treatment of anemia related to zidovudine therapy in HIV-infected patients: To elevate or maintain the red blood cell level (as manifested by the hematocrit or hemoglobin determinations) and to decrease the need for transfusions in these patients when the endogenous erythropoietin level is less than or equal to 500 milliunits/mL and the dose of zidovudine is less than or equal to 4200 mg/week.
Immunodeficient patients: Vitamin B12 malabsorption may occur in patients with AIDS or HIV infection. Consider monitoring levels.
Epoetin Alfa (Erythropoietin; EPO)
Zidovudine-treated, HIV-infected patients: Available evidence suggests that patients receiving zidovudine with endogenous serum erythropoietin levels greater than 500 milliunits/mL are unlikely to respond to therapy.
Not indicated for treatment of anemia in HIV-infected patients or cancer patients due to other factors such as iron or folate deficiencies, hemolysis, or gastrointestinal system bleeding, which should be managed appropriately.
Zidovudine-treated, HIV-infected and cancer patients – Measure hemoglobin once a week until it is stabilized; measure periodically thereafter.
Zidovudine-treated HIV-infected patients – Adverse experiences greater than 3% were consistent with the progression of HIV infection: pyrexia, fatigue, headache, cough, diarrhea, rash, nausea, respiratory congestion, shortness of breath, asthenia, skin reaction, and dizziness.
Progestins
HIV-infected women: Although megestrol has been used extensively in women for endometrial and breast cancers, its use in HIV-infected women has been limited. All the women in the clinical trials reported breakthrough bleeding.
Amphotericin B
Cryptococcal meningitis in HIV: Treatment of cryptococcal meningitis in HIV-infected patients (AmBisome only. AmBisome Treatment– Administer 6 mg/kg/day using a controlled infusion device over approximately 120 minutes; infusion time may be reduced to 60 minutes if well tolerated or increased if patient experiences discomfort).
Itraconazole
HIV infection: Because hypochlorhydria has been reported in HIV-infected patients, the absorption of itraconazole may be decreased in these patients. Administration with a cola beverage has been shown to increase itraconazole absorption in these patients.
Caspofungin Acetate
Esophageal candidiasis: 50 mg/day. Because of the risk of relapse of oropharyngeal candidiasis in patients with HIV infections, consider suppressive oral therapy.
Antituberculosis Drugs in HIV infected Individuals
The initial phase of a 6-month tuberculosis regimen consists of isoniazid, rifabutin, pyrazinamide, and ethambutol for patients receiving therapy with protease inhibitors or non nucleoside reverse transcriptase inhibitors. These drugs are administered;
- Daily for at least the first 2 weeks, followed by twice weekly dosing for 6 weeks or
- Daily for 8 weeks to complete the 2 month induction phase.
The second phase of treatment consists of rifabutin and isoniazid administered twice weekly or daily for 4 months.
Do not use tuberculosis regimens consisting of isoniazid, ethambutol, and pyrazinamide (i.e., 3 drug regimens that do not contain a rifampicin, an aminoglycoside [e.g., streptomycin, amikacin, kanamycin], or capreomycin) for the treatment of patients with HIV related tuberculosis. The minimum duration of therapy is 18 months (or 12 months after documented culture conversion) if these regimens are used for the treatment of tuberculosis.
Administer pyridoxine (vitamin B6) 25 to 50 mg daily or 50 to 100 mg twice weekly to all HIV-infected patients who are undergoing tuberculosis treatment with isoniazid to reduce the occurrence of isoniazid induced side effects in the central and peripheral nervous system.
Because the MMWR's most recent recommendations for the use of antiretroviral therapy strongly advise against interruptions of therapy, and because alternative tuberculosis treatments that do not contain rifampicin are available, previous anti tuberculosis therapy options that involved stopping protease inhibitor therapy to allow the use of rifampicin are no longer recommended.
The 2 month regimen: According to the MMWR, the 2-month daily regimen of rifampin and pyrazinamide is recommended in HIV-infected people. However, the drug toxicities may be increased. Continuation of anti tuberculosis treatment is recommended for >6 months if the patient is still sputum or culture positive, if resistant organisms are present or if the patient is HIV positive.
Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
