Cardiomyopathy in HIV patients has been shown to progress faster than idiopathic Dilated Cardiomyopathy in the HIV negative population. It is therefore important to recognize this condition early in this population and manage it appropriately. Studies need to be done to validate the current therapy for cardiomyopathy in this population since it is still unclear that LV dysfunction in this population responds in a similar fashion as in HIV negative patients with Dilated Cardiomyopathy
1. HIV associated Dilated
Cardiomyopathy
Leonard Sowah, MBChB, MPH
Assistant Professor of Medicine
University of Maryland School of Medicine
2. Educational Objectives
Relative Magnitude of Dilated Cardiomyopathy in HIV
patients
Discuss the Pathophysiological Mechanisms involved in
this condition
Discuss clinical Manifestations
Evaluation of patients with suspected Cardiomyopathy
Therapeutic Options for HIV associated Dilated
Cardiomyopathy
Areas of Future Research
3. Disease Epidemiology
Incidence of HIV associated Dilated
Cardiomyopathy was 15.9/1,0000 person yrs in
the pre HAART era1
HAART therapy has reduced incidence by close
to 30% in developed countries2, 3
The adjusted hazard ratio of mortality
comparing HIV DCM to Idiopathic DCM is 5.861
Prevalence in Developing countries is about 32%4
1. AIDS 2003; 17: Suppl 1, S46 – S50
2. J Infect Dis 2000; 40: 282 -4
3. J. Acquir Immune DeficSyndr 2001; 27: 318 – 20
4. Postgrad Med J 2002: 78: 678 - 81
4. Epidemiology Continued
40 – 52% of patients who died of AIDS in the Pre
HAART era had evidence of Myocarditis at
autopsy1
In data from the Pre to Early HAART Era median
survival in HIV positive children with LV
dysfunction was 101 days compared with 472
days in patients with normal hearts2
In a Cohort of Perinatally infected HIV patients
the cumulative 5 yr survival was lower in patients
with baseline depressed LV fractional shortening3
1. Klatt EC. 2003; Adv Cardiol; 40: 23 - 48
2. N Engl J Med 1998, 339: 1153 – 1155
3. J Peadiatric 2002, 141: 327 - 334
5. Etiology
Likely related to infection of Cardiac
Myocytes by opportunistic organisms
DNA Hybridization of cardiac tissue from
autopsies of HIV associated DCM reveal
• Toxoplasmagondi – 12 %
• Coxsackie B3 – 32%
• EBV – 8%
• CMV – 4%
• HIV – 82%
Klatt EC. 2003; Adv Cardiol; 40: 23 - 48
6. Etiology
HIV cardiac muscle auto-immunity, HIV
positive patients are 4x more likely to
have cardiac auto-antibodies
In one study 43% of had cardiac specific
auto-antibodies
AIDS 2003, 17: S21 – S28
Heart 1998, 79: 599 - 604
7. Nutritional Factors
Malabsorption and diarrhea in HIV may
lead to micro-nutrient deficiency
Selenium replacement may restore LV
function in HIV and reverse DCM in
selenium deficient patients
HIV may be associated with vitamin B12,
carnitine, growth hormone and thyroid
hormone deficiencies all of which may
be associated with LV dysfunction
J ClinNutr 1997; 66: 660 - 4
8. Association with HIV Encephalopathy
HIV Encephalopathy is associated with
severe LV dysfunction
HIV virus persists in myocardial and
cerebral viral reservoir even after
starting HAART
These cells may cause progressive tissue
damage by the release of cytotoxic
cytokines
Fischer SD, Lipschultz SE, Ann NY AcadSci 2001; 946:13 - 22
9. Clinical Presentation
May present as acute myocarditis if seen
early
Fever with flu-like symptoms
Palpitations
Atypical chest pain
Shortness of breath
Am J Emergen Med 2001; 19: 566 - 74
10. Physical Signs
Physical exam may be normal
Signs of heart failure may be present
Bilateral basal crackles
Bi-pedal edema
Pericardial friction rub
Am J Emergen Med 2001; 19: 566 - 74
11. Lab Investigations
New changes from baseline EKG
Usually conduction abnormalities, LBBB, First
degree AV block
Chest X-ray
Cardiomegaly mainly LV Dilatation with
rounding of the apex
Elevated Cardiac Troponins
Occurs in early stages with myocarditis may be
confused with a new Myocardial Infarction
Increase in CK-MB
Am J Emergen Med 2001; 19: 566 - 74
12. CONDUCTION SYSTEM ABNORMALITIES
First degree AV Block
Bundle branch Block
In one autopsy series 5/12 patients who
died of HIV associated DCM had intracardiac
conduction abnormalities
Histopathology shows myocarditis with
fibromatous degeneration of the conduction
system
AIDS Res Human Retroviruses 1998; 14: 1071 - 77
13. ECHOCARDIOGRAPHY
Echocardiography is the mainstay
diagnosis
There is Concentric Left Ventricular
hypertrophy
There is ventricular dilatation
Left Ventricular Ejection Fraction is
reduced with global hypokinesia
Usually no regional wall motion
abnormalities
AIDS Res Human Retroviruses 1998; 14: 1071 – 77
Indian Heart J. 2010 Jul-Aug;62(4):330-4
14. Coronary Angiograms
Not required in all cases however in
patients with significant CAD risk
factors may be helpful.
Coronary blood vessels are usually
free of significant occlusive
atheroscleroctic disease
Am J Emergen Med 2001;19: 566 - 74
15. HISTOPATHOLOGY
HIV associated Cardiomyopathy is
associated with intense staining for
TNF α and iNOS (inducible Nitric Oxide
Synthase) compared with Idiopathic
DCM
Other histological features did not
differ significantly from idiopathic
DCM
1. AIDS Res Human Retroviruses 1998; 14: 1071 - 77
17. Clinical Management
In one Pediatric series patients
treated with monthly IV
Immunoglobulin infusions were shown
to revert back to normal LV wall
thickness1
Therapy for LV systolic dysfunction is
otherwise the mainstay of
management2
1. Circulation 1995,; 92: 2220 – 25
2. Am J Emergen Med 2001; 19: 566 - 74
18. Management
Patients with systolic dysfunction are
treated like standard CHF patients
Loop Diuretics
Aldosterone Receptor Blockers
Ace-Inhibotors
B-blockers can be started once patient
is euvolemic
Digoxin may be added to improve
contractility
1. Am J Emergen Med 2001; 19: 566 - 74
19. Adjunctive Management
AICD (Automatic Implantable Cardiac
Defibrillators)
Can be used in patients with severely
depressed LV dysfunction
This has not been validated to reduce
incidence of sudden cardiac death in the
HIV positive population
N Engl J Med 2005; 352:225–237
20. USE OF AICD IN HEART FAILURE
N Engl J Med 2005; 352:225–237
21. Areas of Future Research
Validation of standard CHF therapy in
HIV associated DCM ?
Data on the efficacy of AICD in HIV
associated DCM
Use of IV immunoglobulin in early
identified adult disease at the early
myocarditis stage
Editor's Notes
Adenovirus infection was found to cause LV dysfunction without any evidence of myocarditis, suggesting that Adeno virus infection may cause myocyte damage without any associated inflammatory changes