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HIV associated Dilated       CardiomyopathyLeonard Sowah, MBChB, MPHAssistant Professor of MedicineUniversity of Maryland ...
Educational Objectives Relative Magnitude of Dilated Cardiomyopathy in HIV  patients Discuss the Pathophysiological Mech...
Disease Epidemiology Incidence of HIV associated Dilated  Cardiomyopathy was 15.9/1,0000 person yrs in  the pre HAART era...
Epidemiology Continued 40 – 52% of patients who died of AIDS in the Pre  HAART era had evidence of Myocarditis at  autops...
Etiology Likely related to infection of Cardiac  Myocytes by opportunistic organisms      DNA Hybridization of cardiac t...
Etiology HIV cardiac muscle auto-immunity, HIV  positive patients are 4x more likely to  have cardiac auto-antibodies In...
Nutritional Factors Malabsorption and diarrhea in HIV may  lead to micro-nutrient deficiency    Selenium replacement may...
Association with HIV Encephalopathy HIV Encephalopathy is associated with severe LV dysfunction     HIV virus persists i...
Clinical Presentation May present as acute myocarditis if seen  early      Fever with flu-like symptoms      Palpitatio...
Physical Signs Physical exam may be normal Signs of heart failure may be present Bilateral basal crackles Bi-pedal ede...
Lab Investigations New changes from baseline EKG    Usually conduction abnormalities, LBBB, First     degree AV block C...
CONDUCTION SYSTEM ABNORMALITIES  First degree AV Block  Bundle branch Block  In one autopsy series 5/12 patients who   ...
ECHOCARDIOGRAPHY Echocardiography is the mainstay  diagnosis    There is Concentric Left Ventricular     hypertrophy   ...
Coronary Angiograms Not required in all cases however in patients with significant CAD risk factors may be helpful. Coro...
HISTOPATHOLOGY HIV associated Cardiomyopathy is  associated with intense staining for  TNF α and iNOS (inducible Nitric O...
NYHA CLASSIFICATION OF HEART          FAILURE        American Heart Association
Clinical Management In one Pediatric series patients  treated with monthly IV  Immunoglobulin infusions were shown  to re...
Management Patients with systolic dysfunction are  treated like standard CHF patients    Loop Diuretics    Aldosterone ...
Adjunctive Management AICD (Automatic Implantable Cardiac Defibrillators)   Can be used in patients with severely    dep...
USE OF AICD IN HEART FAILURE        N Engl J Med 2005; 352:225–237
Areas of Future Research Validation of standard CHF therapy in  HIV associated DCM ? Data on the efficacy of AICD in HIV...
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HIV associated cardiomyopathy

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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

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HIV associated cardiomyopathy

  1. 1. HIV associated Dilated CardiomyopathyLeonard Sowah, MBChB, MPHAssistant Professor of MedicineUniversity of Maryland School of Medicine
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
  16. 16. NYHA CLASSIFICATION OF HEART FAILURE American Heart Association
  17. 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. 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. 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. 20. USE OF AICD IN HEART FAILURE N Engl J Med 2005; 352:225–237
  21. 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

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