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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.
Overview
A wide variety of cardiovascular complications are seen in advanced HIV infected patients. The most common are:
Epidemiology and demographics
Pericardial diseases in the form of pericardial effusion or cardiac tamponade[5][7][8][9] have been recognized as a complication since HIV infection was first reported in 1981.
- In a small autopsy study, 24% cases reported major cardiac pathology [10].
- The incidence of pericardial effusion in patients with asymptomatic AIDS was 11% per year before the introduction of effective highly active antiretroviral therapy (HAART). The 6 month survival rate of AIDS patients with effusion was significantly shorter (36%) than the survival rate without effusions (93%). This shortened survival rate remained statistically significant after adjustment for lead-time bias and was independent of CD4 count and albumin level[5].
- The incidence of AIDS-related cardiac disease is very high in Africa in comparison to that seen in the developed countries. In the period from 1993 to 1999 in Burkina Faso, 79% of AIDS patients exhibited cardiac involvement, whereas in an Italian study in the period from 1992 to 1995, the incidence of AIDS-related cardiac disease was 6.5%[11].
Pathophysiology
Patients with advanced HIV have pericardial involvement at some point and the most common abnormality is pericardial effusion[12].
- Asymptomatic effusions are mostly small and idiopathic.
- In advanced HIV disease, effusions are a part of generalized seroeffusive process involving pleural and peritoneal surfaces, possibly related to enhanced cytokine expression, resulting in moderate to large effusions.
- Congestive heart failure, Kaposi sarcoma, and Tuberculosis are independently associated with moderate to large effusions.
Etiology
It is often difficult to identify the etiology of pericardial effusion in HIV-infected patients. The common organisms isolated are:
Supportive trial data:
- A retrospective study [19] of 29 patients with AIDS-related pericardial effusion who underwent fluid cultures and pericardial biopsy, etiology was established only in 7% patients. The causes included:
- Mycobacterium tuberculosis (1%),
- Staphylococcus aureus (1%), and
- Neoplasms (2% adenocarcinoma and 3% lymphoma)
- Another study that evaluated pericardial effusions in 17 patients with HIV [4], revealed etiologic evidence in 5 patients of which 2 were found to have lymphoma, and 1 each had staphylococcus aureus, mycobacterium tuberculosis, and fungal infection.
Diagnosis
History and symptoms:
The frequency and severity of the above symptoms varies with the stage of the infection and the degree of involvement of the pericardium.
- Majority of the are asymptomatic and present with an increase in the cardiac silhouette on chest x-ray.
- Symptomatic patients present with the following:
- Chest pain: characteristically sharp and pleuritic in nature, exacerbated by inspiration and relieved by sitting up and leaning forward.
- breathlessness
- Malaise
- Fever
- Cough
- Ankle edema and/or ascites
- About a third of patients with symptomatic pericardial effusion can develop signs of cardiac tamponade. [9]
Echocardiogram demonstrating swinging motion of the heart in cardiac tamponade: <youtube v=U4xQ3-VRiNg/>
Physical Examination:
Vitals:
- pulsus paradoxus and
- hypotension (in cardiac tamponade),
Neck:
- Jugular venous distension with a prominent Y descent and Kussmaul's sign may be present.
<youtube v=uB1c2zvkaew/>
Chest:
- Ewart's sign: Dullness to percussion beneath the angle of left scapula from compression of the left lung by pericardial fluid may be present.
- Pericardial knock
<youtube v=Jtk2vVgQuU0/>
<youtube v=Yb-JDZGGVK4/>
Abdomen:
- Hepatojugular reflux may be present
<youtube v=4LIaUCJP2Hc/>>
Extremities: Ankle edema
References
- ↑ Corallo S, Mutinelli MR, Moroni M, Lazzarin A, Celano V, Repossini A et al. (1988) Echocardiography detects myocardial damage in AIDS: prospective study in 102 patients. Eur Heart J 9 (8):887-92. PMID: 3181175
- ↑ Himelman RB, Chung WS, Chernoff DN, Schiller NB, Hollander H (1989) Cardiac manifestations of human immunodeficiency virus infection: a two-dimensional echocardiographic study. J Am Coll Cardiol 13 (5):1030-6. PMID: 2926051
- ↑ De Castro S, Migliau G, Silvestri A, D'Amati G, Giannantoni P, Cartoni D et al. (1992) Heart involvement in AIDS: a prospective study during various stages of the disease. Eur Heart J 13 (11):1452-9. PMID: 1464334
- ↑ 4.0 4.1 Hsia J, Ross AM (1994) Pericardial effusion and pericardiocentesis in human immunodeficiency virus infection. Am J Cardiol 74 (1):94-6. PMID: 8017317
- ↑ 5.0 5.1 5.2 Heidenreich PA, Eisenberg MJ, Kee LL, Somelofski CA, Hollander H, Schiller NB et al. (1995) Pericardial effusion in AIDS. Incidence and survival. Circulation 92 (11):3229-34. PMID: 7586308
- ↑ Estok L, Wallach F (1998) Cardiac tamponade in a patient with AIDS: a review of pericardial disease in patients with HIV infection. Mt Sinai J Med 65 (1):33-9. PMID: 9458682
- ↑ Stotka JL, Good CB, Downer WR, Kapoor WN (1989). "Pericardial effusion and tamponade due to Kaposi's sarcoma in acquired immunodeficiency syndrome". Chest. 95 (6): 1359–61. PMID 2721281.
- ↑ Karve MM, Murali MR, Shah HM, Phelps KR (1992). "Rapid evolution of cardiac tamponade due to bacterial pericarditis in two patients with HIV-1 infection". Chest. 101 (5): 1461–3. PMID 1582323.
- ↑ 9.0 9.1 Chen Y, Brennessel D, Walters J, Johnson M, Rosner F, Raza M (1999) Human immunodeficiency virus-associated pericardial effusion: report of 40 cases and review of the literature. Am Heart J 137 (3):516-21. PMID: 10047635
- ↑ Cammarosano C, Lewis W (1985). "Cardiac lesions in acquired immune deficiency syndrome (AIDS)". J Am Coll Cardiol. 5 (3): 703–6. PMID 3973269.
- ↑ Pugliese A, Gennero L, Vidotto V, Beltramo T, Petrini S, Torre D (2004). "A review of cardiovascular complications accompanying AIDS". Cell Biochem Funct. 22 (3): 137–41. doi:10.1002/cbf.1095. PMID 15124176.
- ↑ Barbaro G (2003). "Pathogenesis of HIV-associated cardiovascular disease". Adv Cardiol. 40: 49–70. PMID 14533546.
- ↑ Mayosi BM, Burgess LJ, Doubell AF (2005). "Tuberculous pericarditis". Circulation. 112 (23): 3608–16. doi:10.1161/CIRCULATIONAHA.105.543066. PMID 16330703.
- ↑ Sudano I, Spieker LE, Noll G, Corti R, Weber R, Lüscher TF (2006). "Cardiovascular disease in HIV infection". Am Heart J. 151 (6): 1147–55. doi:10.1016/j.ahj.2005.07.030. PMID 16781213.
- ↑ Stechel RP, Cooper DJ, Greenspan J, Pizzarello RA, Tenenbaum MJ (1986) Staphylococcal pericarditis in a homosexual patient with AIDS-related complex. N Y State J Med 86 (11):592-3. PMID: 3467225
- ↑ Decker CF, Tuazon CU (1994) Staphylococcus aureus pericarditis in HIV-infected patients. Chest 105 (2):615-6. PMID: 8306779
- ↑ Schuster M, Valentine F, Holzman R (1985) Cryptococcal pericarditis in an intravenous drug abuser. J Infect Dis 152 (4):842. PMID: 4045235
- ↑ Freedberg RS, Gindea AJ, Dieterich DT, Greene JB (1987) Herpes simplex pericarditis in AIDS. N Y State J Med 87 (5):304-6. PMID: 3035442
- ↑ Flum DR, McGinn JT, Tyras DH (1995) The role of the 'pericardial window' in AIDS. Chest 107 (6):1522-5. PMID: 7781340