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Cardiac effects in perinatally HIV-infected and HIV-exposed but uninfected children and adolescents: a view from the United States of America.

Lipshultz SE, Miller TL, Wilkinson JD, Scott GB, Somarriba G, Cochran TR, Fisher SD - J Int AIDS Soc (2013)

Bottom Line: Although lymphomas have been found in HIV-infected children, the incidence is low and cardiac malignancy is rare.In non-HIV-infected infants born to HIV-infected mothers, foetal exposure to ART is associated with reduced LV dimension, LV mass, and septal wall thickness and with higher LV fractional shortening and contractility during the first two years of life.Laboratory tests should include a lipid profile, fasting glucose, and HIV viral load.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatrics, Jackson Memorial Medical Center and the Sylvester Comprehensive Cancer Center, Holtz Children's Hospital, University of Miami Miller School of Medicine, Miami, FL, USA. slipshultz@med.miami.edu

ABSTRACT

Introduction: Human immunodeficiency virus (HIV) infection is a primary cause of acquired heart disease, particularly of accelerated atherosclerosis, symptomatic heart failure, and pulmonary arterial hypertension. Cardiac complications often occur in late-stage HIV infections as prolonged viral infection is becoming more relevant as longevity improves. Thus, multi-agent HIV therapies that help sustain life may also increase the risk of cardiovascular events and accelerated atherosclerosis.

Discussion: Before highly active antiretroviral therapy (HAART), the two-to-five-year incidence of symptomatic heart failure ranged from 4 to 28% in HIV patients. Patients both before and after HAART also frequently have asymptomatic abnormalities in cardiovascular structure. Echocardiographic measurements indicate left ventricular (LV) systolic dysfunction in 18%, LV hypertrophy in 6.5%, and left atrial dilation in 40% of patients followed on HAART therapy. Diastolic dysfunction is also common in long-term survivors of HIV infection. Accelerated atherosclerosis has been found in HIV-infected young adults and children without traditional coronary risk factors. Infective endocarditis, although rare in children, has high mortality in late-stage AIDS patients with poor nutritional status and severely compromised immune systems. Although lymphomas have been found in HIV-infected children, the incidence is low and cardiac malignancy is rare. Rates of congenital cardiovascular malformations range from 5.6 to 8.9% in cohorts of HIV-uninfected and HIV-infected children with HIV-infected mothers. In non-HIV-infected infants born to HIV-infected mothers, foetal exposure to ART is associated with reduced LV dimension, LV mass, and septal wall thickness and with higher LV fractional shortening and contractility during the first two years of life.

Conclusions: Routine, systematic, and comprehensive cardiac evaluation, including a thorough history and directed laboratory assays, is essential for the care of HIV-infected adults and children as cardiovascular illness has become a part of care for long-term survivors of HIV infection. The history should include traditional risk factors for atherosclerosis, prior opportunistic infections, environmental exposures, and therapeutic and illicit drug use. Laboratory tests should include a lipid profile, fasting glucose, and HIV viral load. Asymptomatic cardiac disease related to HIV can be fatal, and secondary effects of HIV infection often disguise cardiac symptoms, so systematic echocardiographic monitoring is warranted.

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Cardiac dysfunction in HIV-infected patients. HAART=highly active antiretroviral therapy; LV=left ventricular; PPD=purified protein derivative; TSH=thyroid-stimulating hormone. Reproduced with permission from “Fisher SD, Lipshultz SE. Chapter 72: Cardiovascular abnormalities in HIV-infected individuals. In: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Ninth Edition. Editors: Bonow RO, Mann DL, Zipes DP, Libby P. Philadelphia: Elsevier Saunders. 1618–27. 2011 ISBN: 978-1-4377-0398-6.”
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Figure 0003: Cardiac dysfunction in HIV-infected patients. HAART=highly active antiretroviral therapy; LV=left ventricular; PPD=purified protein derivative; TSH=thyroid-stimulating hormone. Reproduced with permission from “Fisher SD, Lipshultz SE. Chapter 72: Cardiovascular abnormalities in HIV-infected individuals. In: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Ninth Edition. Editors: Bonow RO, Mann DL, Zipes DP, Libby P. Philadelphia: Elsevier Saunders. 1618–27. 2011 ISBN: 978-1-4377-0398-6.”

Mentions: Serial echocardiographic measurements should be performed at clinically relevant intervals, such as four months, after medical therapy is begun. Monitoring recommendations for testing and timing of follow-up are based on studies relating impaired LV fractional shortening to a worse prognosis. A biopsy should be considered if cardiac function continues to deteriorate or if the clinical course worsens. Patients with heart failure who have not responded to two weeks of medical therapy may benefit from cardiac catheterization and endomyocardial biopsy, which may reveal lymphocytic infiltrates suggesting myocarditis or treatable opportunistic infections (by special stains), permitting aggressive therapy of an underlying pathogen [5,52,62,68,71,74]. Angiography should be performed selectively if there are risk factors for atherosclerotic disease or suggestive clinical symptoms (Figure 3) [33,44].


Cardiac effects in perinatally HIV-infected and HIV-exposed but uninfected children and adolescents: a view from the United States of America.

Lipshultz SE, Miller TL, Wilkinson JD, Scott GB, Somarriba G, Cochran TR, Fisher SD - J Int AIDS Soc (2013)

Cardiac dysfunction in HIV-infected patients. HAART=highly active antiretroviral therapy; LV=left ventricular; PPD=purified protein derivative; TSH=thyroid-stimulating hormone. Reproduced with permission from “Fisher SD, Lipshultz SE. Chapter 72: Cardiovascular abnormalities in HIV-infected individuals. In: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Ninth Edition. Editors: Bonow RO, Mann DL, Zipes DP, Libby P. Philadelphia: Elsevier Saunders. 1618–27. 2011 ISBN: 978-1-4377-0398-6.”
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3687072&req=5

Figure 0003: Cardiac dysfunction in HIV-infected patients. HAART=highly active antiretroviral therapy; LV=left ventricular; PPD=purified protein derivative; TSH=thyroid-stimulating hormone. Reproduced with permission from “Fisher SD, Lipshultz SE. Chapter 72: Cardiovascular abnormalities in HIV-infected individuals. In: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Ninth Edition. Editors: Bonow RO, Mann DL, Zipes DP, Libby P. Philadelphia: Elsevier Saunders. 1618–27. 2011 ISBN: 978-1-4377-0398-6.”
Mentions: Serial echocardiographic measurements should be performed at clinically relevant intervals, such as four months, after medical therapy is begun. Monitoring recommendations for testing and timing of follow-up are based on studies relating impaired LV fractional shortening to a worse prognosis. A biopsy should be considered if cardiac function continues to deteriorate or if the clinical course worsens. Patients with heart failure who have not responded to two weeks of medical therapy may benefit from cardiac catheterization and endomyocardial biopsy, which may reveal lymphocytic infiltrates suggesting myocarditis or treatable opportunistic infections (by special stains), permitting aggressive therapy of an underlying pathogen [5,52,62,68,71,74]. Angiography should be performed selectively if there are risk factors for atherosclerotic disease or suggestive clinical symptoms (Figure 3) [33,44].

Bottom Line: Although lymphomas have been found in HIV-infected children, the incidence is low and cardiac malignancy is rare.In non-HIV-infected infants born to HIV-infected mothers, foetal exposure to ART is associated with reduced LV dimension, LV mass, and septal wall thickness and with higher LV fractional shortening and contractility during the first two years of life.Laboratory tests should include a lipid profile, fasting glucose, and HIV viral load.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatrics, Jackson Memorial Medical Center and the Sylvester Comprehensive Cancer Center, Holtz Children's Hospital, University of Miami Miller School of Medicine, Miami, FL, USA. slipshultz@med.miami.edu

ABSTRACT

Introduction: Human immunodeficiency virus (HIV) infection is a primary cause of acquired heart disease, particularly of accelerated atherosclerosis, symptomatic heart failure, and pulmonary arterial hypertension. Cardiac complications often occur in late-stage HIV infections as prolonged viral infection is becoming more relevant as longevity improves. Thus, multi-agent HIV therapies that help sustain life may also increase the risk of cardiovascular events and accelerated atherosclerosis.

Discussion: Before highly active antiretroviral therapy (HAART), the two-to-five-year incidence of symptomatic heart failure ranged from 4 to 28% in HIV patients. Patients both before and after HAART also frequently have asymptomatic abnormalities in cardiovascular structure. Echocardiographic measurements indicate left ventricular (LV) systolic dysfunction in 18%, LV hypertrophy in 6.5%, and left atrial dilation in 40% of patients followed on HAART therapy. Diastolic dysfunction is also common in long-term survivors of HIV infection. Accelerated atherosclerosis has been found in HIV-infected young adults and children without traditional coronary risk factors. Infective endocarditis, although rare in children, has high mortality in late-stage AIDS patients with poor nutritional status and severely compromised immune systems. Although lymphomas have been found in HIV-infected children, the incidence is low and cardiac malignancy is rare. Rates of congenital cardiovascular malformations range from 5.6 to 8.9% in cohorts of HIV-uninfected and HIV-infected children with HIV-infected mothers. In non-HIV-infected infants born to HIV-infected mothers, foetal exposure to ART is associated with reduced LV dimension, LV mass, and septal wall thickness and with higher LV fractional shortening and contractility during the first two years of life.

Conclusions: Routine, systematic, and comprehensive cardiac evaluation, including a thorough history and directed laboratory assays, is essential for the care of HIV-infected adults and children as cardiovascular illness has become a part of care for long-term survivors of HIV infection. The history should include traditional risk factors for atherosclerosis, prior opportunistic infections, environmental exposures, and therapeutic and illicit drug use. Laboratory tests should include a lipid profile, fasting glucose, and HIV viral load. Asymptomatic cardiac disease related to HIV can be fatal, and secondary effects of HIV infection often disguise cardiac symptoms, so systematic echocardiographic monitoring is warranted.

Show MeSH
Related in: MedlinePlus