Cardiovascular Manifestations of HIV

Aka: Cardiovascular Manifestations of HIV, HIV related Cardiovascular Complications, HIV Cardiomyopathy

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II. Causes: Infection

  1. Mycobacterium
  2. Nocardia
  3. Cryptococcus neoformans
  4. Histoplasma capsulatum
  5. Aspergillus
  6. Cytomegalovirus (CMV)
  7. Epstein-Barr Virus (EBV)
  8. Toxoplasmosis

III. Causes: Medication adverse effects

  1. Direct cardiotoxicity
    1. Abacavir (Ziagen)
    2. Lopinavir/Ritonavir (Kaletra)
  2. Dyslipidemia or Lipodystrophy
    1. Protease Inhibitors (especially boosted Protease Inhibitors)
    2. Abacavir
    3. Efavirenz
    4. Elvitegravir/Cobicistat

IV. Findings

  1. Common
    1. Coronary Artery Disease
      1. Longstanding HIV carries a coronary disease equivalent risk similar to Diabetes Mellitus
      2. HIV-Related Contributing Factors to accelerated atherogenesis
        1. Chronic inflammatory changes
        2. Virus infected Macrophages
        3. Endothelial dysfunction
        4. CD4 Count <500 is associated with an increased risk of coronary events (even if it rebounds)
        5. Patients with HIV also have higher rates of Tobacco Abuse and Hypertension
        6. Protease Inhibitors also increase dyslipidemia and Insulin Resistance
      3. References
        1. Frieberg (2013) JAMA Intern Med 173(8):614-22 [PubMed]
    2. Cerebrovascular Disease
      1. Secondary to direct HIV neurotoxicity, opportunistic infections, Coagulopathy, chronic inflammation
      2. Patients with HIV also have higher rates of Tobacco Abuse, IVDA, CAD, Hypertension, CKD
      3. Strokes occur at younger ages in HIV patients (esp. with lower CD4 Counts, higher viral loads)
      4. D'Ascenzo (2015) J Cardiovasc Med 16(12):839-43 [PubMed]
    3. Dyslipidemia
      1. Obtain lipid panel and Serum Glucose at time of HIV diagnosis
      2. Repeat lipid panel and Glucose screening at perioidic intervals
      3. Protease Inhibitors provoke Hypertriglyceridemia and Low HDL
      4. Consider Statins if indicated (based on non-HIV Infection guidelines)
        1. Risk of Statin-related Drug Interactions with Protease Inhibitors, NNRTI agents
    4. Cardiomyopathy
      1. Dilated Cardiomyopathy (25% advanced HIV)
      2. Left Ventricular Dysfunction (21% advanced HIV)
      3. Myocardial fibrosis
        1. Present in up to 82% of HIV patients and often asymptomatic
      4. HIV-Related Contributing Factors
        1. Older Antiretroviral therapy (AZT)
        2. Kaposi Sarcoma
        3. Opportunistic Infections (Cryptococcus, Toxoplasmosis)
        4. Malignant infiltration (e.g. Kaposi Sarcoma, Non-Hodgkin Lymphoma, Leiomyosarcoma)
  2. Less common
    1. Myocarditis
    2. Pericardial Effusion
      1. May develop from HIV Infection or Immunocompromised state
      2. Opportunistic infections (e.g. Mycobacterium, HSV, CMC, Toxoplasmosis, Histoplasmosis, Cryptococcus)
      3. Malignancy (Kaposi Sarcoma, Lymphoma)
    3. Pericarditis
    4. Arrhythmias
    5. Autonomic Dysfunction
  3. Rare Conditions
    1. Endocarditis
      1. In addition to Bacteria (staph, strep, HACEK), fungal organisms (e.g. Candidiasis, Cryptococcus)
    2. Primary Pulmonary Hypertension (plexogenic pulmonary arteriopathy)

V. Symptoms

  1. Most are asymptomatic

VI. Signs

  1. Usually clinically silent
  2. Pericardial Effusions (usually sterile) in 25%

VII. Management

  1. See Cardiomyopathy
  2. In those with Cardiac Risk Factors, avoid agents with cardiotoxicity risk (see above)
  3. Tobacco Cessation
  4. Hyperlipidemia Management wth Statin indicated for 10 year Cardiac Risk >5 to 7.5%
    1. Risk of Statin-Induced Myopathy
    2. Start with low dose Atorvastatin (Lipitor) 10 mg or Rosuvastatin (Crestor)

VIII. Reference

  1. Baloor (2018) Exam Preparatory Manual for Undergraduates Medicine, Jaypee Brothers, India, p. 242
  2. (2019) Presc Lett 26(8): 46
  3. Mathieu (April, 2000) Federal Practitioner, p. 18-20
  4. Swaminathan and Bafuma in Herbert (2017) EM:Rap 17(3): 2
  5. Chu (2017) Am Fam Physician 96(3): 161-9 [PubMed]

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