Cardiovascular abnormalities are common in 25-75% of AIDS patients, caused by either direct infection from HIV or indirect effects of antiretroviral therapy. Cardiovascular diseases are among the top 4 leading causes of death in AIDS patients. HIV attacks the immune system and can cause conditions like dilated cardiomyopathy, endocarditis, myocarditis, pericarditis, pulmonary hypertension, coronary artery disease, and atherosclerosis. Risk factors for cardiovascular problems in AIDS patients include malnutrition, opportunistic infections, autoimmunity, malignancy, lifestyle factors, and certain antiretroviral drugs which can cause metabolic abnormalities. Lifestyle modifications, lipid management, immunoglobulin therapy, surgery, and addressing nutritional deficiencies

1. By pharmacist Ala’a F. Alwazni

2. Cardiovascular abnormalities have been reported
in acquired immunodeficiency syndrome pt.
(25-75%) either due to HIV infection itself or
because of antiretroviral therapy mediated
metabolic changes & adverse effects.
Studies suggest that:
CV EVENTS ARE THE UNDERLYING CAUSE IN
MORE THAN 10% OF DEATHS IN PT. WITH HIV,
& RANKS IN THE TOP 4 LEADING CAUSES OF
MORTALITY (USUALLY AFTER AIDS-RELATED
EVENTS, END-STAGE LIVER DIS. &
MALIGNANCY).

3. HIV attacks the body’s immune sys. resulting in
profound suppression of T-cell macrophage-
mediated immunity & abnormal B-cell
lymphocyte function, affected humoral
immunity causing frequently life threatening
superinfections.
HIV medications may cause conditions as
dyslipidemia, diabetes or metabolic synd. Which
are risk factors for heart diseases.
Conditions unrelated to HIV such as obesity,
smoking, family history of heart dis., I.V. drugs
& alcohol abuse may predispose pt. to heart
problems.

5. DilatedCardiomyopathy
Annual incidence of 15.9 in 1000 cases.
Mortality was higher in children with
baseline depressed left ventricular
fractional shortening /increased left
ventricular dimension, thickness, mass
wall stress, heart rate or blood pressure.

6. Endocarditis
Bacterial infection of inner lining of the
heart, starts in blood stream & spreads to the
heart; fungal & viral endocarditis reported.
Nonbacterial thrombotic endocarditis
(marantic) occurs in 3-5% of AIDS pt. (with
HIV wasting syndrome).
Presentation: fever, chills, weakness, aching
muscles & joints, persistent cough,
hematuria, weight loss, tenderness in spleen
and swelling in the legs or abdomen.

7. Myocarditis
The most frequent cause of DCM in HIV
pt.
HIV-1 virions infect myocardial cells in
patchy distributions without clear direct
association, dendritic cell possibly play
a pathogenic role in the interaction
between HIV-1 & the myocyte and in the
activation of multifunctional cytokines
(CK) that contribute to tissue damage.

8. Pericarditis&PericardialEffusion
Inflammation of the sac-like membrane that
surrounds the heart, caused by infection
(Staphylococcus, Tuberculosis or Herpes
simplex) that spreads to the heart.
Presentation: chest pain, shortness of breath,
fever, fatigue, dry cough & swollen legs or
abdomen.
Patients may have pleural effusions (occur
when membrane surrounds the heart fills with
fluid);due to opportunistic inf. or malignancy.

9. Autoimmunity&Malignancy
Cardiac-specific auto-antibodies (anti- α
myosin auto Ab.) reported in ~30% of pt.
& play a role in the pathogenesis of HIV-
related heart dis.
HIV patients have weakened immunity,
so they have an increased risk of
developing cancers that may spread to
heart (rare cases) ex., Kaposi sarcoma &
Lymphoma.

10. PulmonaryHighBloodPressure
Common among pt. with advanced HIV dis.
(occur when the arteries in lung become
narrowed or blocked).
Pathogenesis: HIV-infection of alveolar
macrophages release of (TNF-α, oxide anion &
proteolytic enzymes)as well as activation of
genetic factors.
Presentation: varying from mild asymptomatic to
sever cardiac impairment with corpulmonale and
death. Symptoms include SOB, fatigue, dizziness,
chest pain, bluish colored lips, increased heart
beat & swelling of the ankles, legs & abdomen.

11. Coronary Artery Diseases
Inflammatory vascular dis. Including
polyarteritis nodosa, Henoch-Schönlein
purpura, drug-induced hypersensitivity
vasculitis, Kawasaki-like syndrome &
Takayasu’s arteritis have been described.
The risk of developing CAD linked to
cytomegalovirus or HIV itself,(even though
association between viral inf. & CA lesion is
not clear) as well as to ART.
Presentation: chest pain, SOB, irregular heart
beat, dizziness, nausea & increased sweating.

12. Atherosclerosis&Card.Abnormalities
HIV inf. Contribute to the development of
atherosclerosis by causing gaps to open up
in the endothelium of bl. vessels as well as
inducing apoptosis of endothelial cells
[inflamm. Markers correlated with internal
intima media thickness (sVCAM-1,
myeloperoxidase, and TNF-α) were reported
in HIV pts].
Common risk factor reported with cardiac
abnormality in HIV pt. was malnourishment.

13. Common in HIV pts.(late stage dis.),
contribute in induction of ventricular
dysfunction independently of HAART
regimens.
Examples include:
 Trace elements--»associated with
cardiomyopathy
 Selenium--»reverse cardiomyopathy and
restore left ventricular function
 Vitamin B12, carnitine, and growth/ thyroid
hormone ----»ass. with left vent. dysfunction

14.  Life style modification
 Lipid monitoring & tx.(pravastatin
preferred for HIV pt. as well as new drugs
like PPARs & Fibric acid derivatives).
 MI & PHT tx. With usual anticoagulants,
vasodilators & aspirin.
 Immunoglobulin therapy indicated for
children with cardiomyopathy
 Surgical intervention reported for highly
risk pt. with endocarditis/ pericardial
effusion.

15. Prolonged, high dose therapy with
interferon-α, doxorubicin & foscarnet
found to be associated with dilated
cardiomyopathy.
Amphotericin B, ganciclovir,
trimethoprim-sulfamethoxazole &
pentamidine were associated with
cardiac arrhythmias.

16. CV risk increased by 1.3-4 folds due to
metabolic changes associated with
HAART; (HAART itself is recommended
for prevention of CVD & increase their
risk in the same time).
CV risk in ART categories are attributed to:
i. NRTIs----lactic acidosis & lipodystrophy.
ii. NNRTIs----changes of lipid profile.
iii. PIs----metabolic alterations, dyslipidemic
atherogenic effect & hyper-
homocysteinemia in children.