A Study on Heart Diseases in HIV Positive Patients

INTRODUCTION: Human Immunodeficiency virus (HIV) belongs to the family Retroviridae and sub-family Lentivirinae. HIV-1 causes the Acquired Immunodeficiency Syndrome (AIDS). By definition, any HIV infected individual with a CD4 T cell count of less than 200/microliter has AIDS, regardless of the presence of symptoms or opportunistic diseases. AIDS was first recognized in the Unites States in 1981, when the US Centres for Disease Control and Prevention (CDC) reported the unexplained occurrence of Pneumocystis carinii (jirovecii) pneumonia in five previously healthy homosexual men in Los Angeles and of Kaposi’s sarcoma in twenty-six previously healthy homosexual men in New York and Los Angeles. In 1983, Human Immunodeficiency virus was isolated from a patient with lymphadenopathy and in 1984 it was demonstrated clearly to be the causative agent of AIDS. Early therapeutic goals focused on prolongation of life by aggressive treatment of often fatal opportunistic infections, such as Pneumocystis carinii (jirovecii) pneumonia. Descriptions of specific HIV related myocarditis and cardiomyopathy appeared during the 1980s and overall mortality fell with improved prophylactic regimens against opportunistic infection and clinical surveillance programmes. In the mid 1990s the advent of combination highly active antiretroviral therapy (HAART) made a major impact on the morbidity and mortality of HIV patients. Combination therapy reduces viral replication, delays disease progression, and prolongs survival, while limiting development of viral resistance. Survival to 40-50 years is no loner unusual and coronary artery disease, either de novo or as an iatrogenic consequence of newer treatment regimens, is emerging as an important problem. Recent studies report increased rates of coronary events in HIV patients or in HIV patients receiving HAART.40,41Protease inhibitors, a main component of HAART, induce deleterious metabolic effects such as dyslipidemia and insulin resistance. HIV infection is characterized by an acquired, irreversible, profound immunosuppression that predisposes patients to multiple opportunistic infections, malignancies, and progressive dysfunction of multiple organ systems. HIV specifically infects and gradually depletes CD4+ lymphocytes but may also affect other cell types, including monocytes/macrophages, endothelial cells, glial cells, intestinal epithelial cells, and possible neurons. Studies have suggested that HIV may exhibit a cardiac tropism, but the heart may also be affected by other opportunistic viruses, fungi and protozoa. Cardiac disease associated with HIV may therefore be multi factorial, and can be caused by infectious or neoplastic complications or their treatments, any of the established causes of cardiac disease in other patient populations, or by HIV infection of the myocardium itself. So, the knowledge of the relative frequency of each form of heart disease in patients with HIV is constantly evolving. AIMS AND OBJECTIVES: 1. To find out the prevalence of cardiac disease in HIV positive individuals. 2. To assess the correlation between the development of cardiac disease and the CD4 lymphocyte count in HIV positive individuals. 3. To determine the correlation between clinical findings and echocardiographic cardiac involvement in HIV positive individuals. 4. To know the common cardiac manifestations in the study group. MATERIALS AND METHODS: The study was performed in the Institute of Internal Medicine, Government General Hospital in close association with the Department of Cardiology and the Department of Microbiology in the same hospital. The study is an observational type of study. Forty five patients who were detected to be HIV positive were included in the study. The patients were selected from the inpatient wards of the Institute of Internal Medicine, Government General Hospital. The HIV serology of the study population was done by double Enzyme Linked Immuno-Sorbent Assay (ELISA) using Microwell ELISA test at the Department of Microbiology, Government General Hospital. If the ELISA was positive initially, it was repeated twice to confirm the HIV seropositive state. Inclusion Criteria: HIV seropositive patients; seropositivity being confirmed by ELISA at the Department of Microbiology, Government General Hospital, Chennai. Exclusion Criteria: • Patients on treatment with Highly Active Anti-retroviral Therapy (HAART). • Patients with Hyperlipidemia, Systemic Hypertension, Diabetes Mellitus, Ischemic Heart Disease, Rheumatic Heart Disease, Congenital Heart Disease and Collagen Vascular Disorders. CONCLUSIONS: The prevalence of cardiac disease in HIV positive patients was 26.6% in this study. • All patients with symptoms suggestive of heart disease did not have cardiac lesions on echocardiogram. This may be due to the fact that symptoms of respiratory diseases and anemia in HIV disease can mimic symptoms of heart disease. • Among the various heart diseases in HIV positive patients, pericardial disease was seen in maximum number of patients (13%). • Small asymptomatic pericardial effusions in HIV disease tend to resolve spontaneously with time and do not require diagnostic evaluation. • Large pericardial effusions and severe dilated cardiomyopathy in HIV disease are usually associated with opportunistic infections due to severe immunosuppression. • The prevalence of heart disease increases with duration of the HIV illness. • Patients with heart diseases can be asymptomatic in early stages of the disease so periodic electrocardiographic and echocardiographic evaluation should be done at regular intervals from the time of diagnosis of HIV disease. • All HIV positive patients who had heart disease echocardiographically had CD4 counts of less that 250 cells/mm3. • Early diagnosis and treatment of cardiac lesions could improve the quality of life and longevity of HIV infected individual. • Smoking does not have any increased risk for cardiac disease in HIV infected individuals when compared to non HIV general population