Human immunodeficiency virus infection and pulmonary hypertension: two new cases and a review of 86 reported cases

Pulmonary arterial hypertension confirmed by right heart catheterization following COVID-19 pneumonia: A case report and review of literature

BACKGROUND

Pulmonary arterial hypertension (PAH) is a disease of the arterioles resulting in an increased resistance in pulmonary circulation with associated high pressures in the pulmonary arteries, causing irreversible remodeling of the pulmonary arterial walls. Coronavirus disease 2019 (COVID-19) has been associated with development of new onset PAH in the literature leading to symptoms of dyspnea, cough and fatigue that persist in spite of resolution of acute COVID-19 infection. However, the majority of these cases of COVID related PAH were diagnosed using echocardiographic data or via right heart catheterization in mechanically ventilated patients.

CASE SUMMARY

Our case is the first reported case of COVID related PAH diagnosed by right heart catheterization in a non-mechanically ventilated patient. Right heart catheterization has been the gold standard for diagnosis of pulmonary hypertension. Our patient had right heart catheterization four months after her initial COVID-19 infection due to persistent dyspnea.

CONCLUSION

This revealed new onset PAH that developed following her infection with COVID-19, an emerging sequela of the infection

Multimodality Imaging in HIV-Associated Cardiovascular Complications: A Comprehensive Review

Human immunodeficiency virus (HIV) infection is a leading cause of mortality and morbidity worldwide. The introduction of antiretroviral therapy (ART) has significantly reduced the risk of developing acquired immune deficiency syndrome and increased life expectancy, approaching that of the general population. However, people living with HIV have a substantially increased risk of cardiovascular diseases despite long-term viral suppression using ART. HIV-associated cardiovascular complications encompass a broad spectrum of diseases that involve the myocardium, pericardium, coronary arteries, valves, and systemic and pulmonary vasculature. Traditional risk stratification tools do not accurately predict cardiovascular risk in this population. Multimodality imaging plays an essential role in the evaluation of various HIV-related cardiovascular complications. Here, we emphasize the role of multimodality imaging in establishing the diagnosis and aetiopathogenesis of various cardiovascular manifestations related to chronic HIV disease. This review also provides a critical appraisal of contemporary data and illustrative cases.

Pulmonary Arterial Hypertension in Patients Infected with the Human Immunodeficiency Virus

It is important to recognize and treat human immunodeficiency virus-associated pulmonary arterial hypertension (HIV-PAH) because of the associated morbidity and mortality. With the introduction of antiretroviral therapies (ART), improved survival has changed the focus of treatment management from immunodeficiency-related opportunistic infections to chronic cardiovascular complications, including HIV-PAH. The 2018 6th World Symposium of Pulmonary Hypertension recommended a revised definition of PAH that might result in a greater number of patients with HIV-PAH; however, the implication of this change is not yet clear. Here, we review the current literature on the diagnosis, management, and outcomes of patients with HIV-PAH.

Prevalence and risk factors of pulmonary hypertension among adult patients with HIV infection in Ethiopia

Globally, non-communicable diseases are increasing in people living with HIV. Pulmonary hypertension is a rare non-communicable disease in people living with HIV with a reported prevalence of <1%. However, data on pulmonary hypertension in people living with HIV from Africa are scarce and are non-existent from Ethiopia. This study aimed to examine the prevalence and severity of echocardiographic pulmonary hypertension and risk factors associated with pulmonary hypertension in people living with HIV in Ethiopia. A total of 315 consecutive adult people living with HIV followed at the Tikur Anbessa Specialized Hospital HIV Referral Clinic were enrolled from June 2018 to February 2019. Those with established pulmonary hypertension of known causes were excluded. A structured questionnaire was used to collect data on demographics, respiratory symptoms, physical findings, physician-diagnosed lung disease, and possible risk factors. Pulmonary hypertension was defined by a tricuspid regurgitant velocity of ≥2.9 m/sec on transthoracic echocardiography. A tricuspid regurgitant velocity ≥3.5, which translates into a pulmonary arterial pressure/right ventricular systolic pressure of ≥50 mmHg, was considered moderate-to-severe pulmonary hypertension. The mean age of the participants was 44.5 ± 9.8 years and 229 (72.7%) were females. Pulmonary hypertension was diagnosed in 44 (14.0%) of participants, of whom 9 (20.5%) had moderate-to-severe disease. In those with pulmonary hypertension, 17 (38.6%) were symptomatic: exertional dyspnea, cough, and leg swelling were seen in 12 (27.3%), 9 (20.5%), and 4 (9.1%), respectively. There was no significant difference in those with pulmonary hypertension compared to those without the disease by gender, cigarette smoking, previous history of pulmonary tuberculosis treatment, physician-diagnosed chronic obstructive pulmonary disease or bronchial asthma, duration of anti-retroviral therapy therapy or anti-retroviral regimen type. Pulmonary hypertension looks to be a frequent complication in people living with HIV in Ethiopia and is often associated with significant cardiopulmonary symptoms. Further studies using right heart catheterization are needed to better determine the etiology and prevalence of pulmonary hypertension in people living with HIV in Ethiopia compared to other countries.

NADPH oxidase-mediated endothelial injury in HIV- and opioid-induced pulmonary arterial hypertension

We previously demonstrated that the combined exposure of human pulmonary microvascular endothelial cells (HPMECs) to morphine and viral protein(s) results in the oxidative stress-mediated induction of autophagy, leading to shift in the cells from early apoptotic to apoptosis-resistant proliferative status associated with the angioproliferative remodeling observed in pulmonary arterial hypertension (PAH). In this study, we tried to delineate the major source of HIV-1 protein Tat and morphine induced oxidative burst in HPMECs and its consequences on vascular remodeling and PAH in an in vivo model. We observed switch from the initial increased expression of NADPH oxidase (NOX) 2 in response to acute treatment of morphine and HIV-Tat to later increased expression of NOX4 on chronic treatment in the endoplasmic reticulum of HPMECs without any alterations in the mitochondria. Furthermore, NOX-dependent induction of autophagy was observed to play a pivotal role in regulating the endothelial cell survival. Our in vivo findings showed significant increase in pulmonary vascular remodeling, right ventricular systolic pressure, and Fulton index in HIV-transgenic rats on chronic administration of morphine. This was associated with increased oxidative stress in lung tissues and rat pulmonary microvascular endothelial cells. Additionally, endothelial cells from morphine-treated HIV-transgenic rats demonstrated increased expression of NOX2 and NOX4 proteins, inhibition of which ameliorated their increased survival upon serum starvation. In conclusion, this study describes NADPH oxidases as one of the main players in the oxidative stress-mediated endothelial dysfunction on the dual hit of HIV-viral protein(s) and opioids.

Drug abuse and HIV-related pulmonary hypertension: double hit injury

: Improved survival among HIV-1-infected individuals with the advent of antiretroviral therapy has clearly led to a greater prevalence of noninfectious complications. One of the most devastating sequelae in these individuals is the development of pulmonary arterial hypertension (PAH). Various epidemiological studies suggest worse survival of HIV-PAH patients when compared with other forms of PAH. Given that only a subset and not all HIV-infected individuals develop HIV-PAH, it is suggested that an additional second-hit of genetic or environmental trigger is needed for the development of PAH. In this context, it has been well documented that HIV patients who abuse illicit drugs such as stimulants, opioids, and the like, are more susceptible to develop PAH. In this review, we highlight the studies that support the significance of a double hit of HIV and drug abuse in the incidence of PAH and focus on the research that has been undertaken to unravel the pathobiology and vascular remodeling mechanisms underlying the deleterious synergy between HIV infection and drugs of abuse in orchestrating the development of PAH.

Drug-induced pulmonary arterial hypertension: a primer for clinicians and scientists

Drug-induced pulmonary arterial hypertension (D-PAH) is a form of World Health Organization Group 1 pulmonary hypertension (PH) defined by severe small vessel loss and obstructive vasculopathy, which leads to progressive right heart failure and death. To date, 16 different compounds have been associated with D-PAH, including anorexigens, recreational stimulants, and more recently, several Food and Drug Administration-approved medications. Although the clinical manifestation, pathology, and hemodynamic profile of D-PAH are indistinguishable from other forms of pulmonary arterial hypertension, its clinical course can be unpredictable and to some degree dependent on removal of the offending agent. Because only a subset of individuals develop D-PAH, it is probable that genetic susceptibilities play a role in the pathogenesis, but the characterization of the genetic factors responsible for these susceptibilities remains rudimentary. Besides aggressive treatment with PH-specific therapies, the major challenge in the management of D-PAH remains the early identification of compounds capable of injuring the pulmonary circulation in susceptible individuals. The implementation of pharmacovigilance, precision medicine strategies, and global warning systems will help facilitate the identification of high-risk drugs and incentivize regulatory strategies to prevent further outbreaks of D-PAH. The goal for this review is to inform clinicians and scientists of the prevalence of D-PAH and to highlight the growing number of common drugs that have been associated with the disease.

Venous Thrombosis Among Patients with AIDS

Thrombosis has been considered an uncommon complication in patients with AIDS. In a 42-month period, 28 adult male homosexuals with AIDS experienced 34 thrombotic events. All but three received HAART regimen, two a successful round of double nucleoside analog therapy, and one patient received no treatment. Median age of group was 38.5 years (range, 24 to 56 years). Median time from HIV infection to thrombosis was 40.5 months (range, 3 to 108 months). No patient had previous thrombosis, family history of thrombosis, or prothrombotic conditions. There were 31 deep vein thromboses, two pulmonary thromboembolisms, and one renal vein thrombosis. Six patients had two thrombotic events. The rate of thrombosis during the 42-month study period was 1.52% (cumulative incidence = 0.30%/year), while the rate of thrombosis in 600 patients before the era of protease inhibitor therapy was 0.33% (cumulative incidence approximately 0.055%/year) (p < 0.001). Due to high incidence of thrombotic recurrences and hemorrhagic complications while using oral anticoagulants, acetylsalicylic acid was initiated; no thrombotic episodes were recorded while using this drug. Protein C and protein S deficiency were found in nine and two patients, respectively. Two patients had lupus anticoagulant and two activated protein C resistance (APCR) without FV Leiden mutation (APCR test was negative after initial screening). Fifteen patients had no thrombophilic abnormalities. These data suggest that protease inhibitors could be a risk factor for venous thrombosis not due to thrombophilic abnormalities but likely related to abnormalities in platelets or endothelium.

Infectious and Non-infectious Etiologies of Cardiovascular Disease in Human Immunodeficiency Virus Infection

Background:

Increasing rates of HIV have been observed in women, African Americans, and Hispanics, particularly those residing in rural areas of the United States. Although cardiovascular (CV) complications in patients infected with human immunodeficiency virus (HIV) have significantly decreased following the introduction of antiretroviral therapy on a global scale, in many rural areas, residents face geographic, social, and cultural barriers that result in decreased access to care. Despite the advancements to combat the disease, many patients in these medically underserved areas are not linked to care, and fewer than half achieve viral suppression.

Methods:

Databases were systematically searched for peer-reviewed publications reporting infectious and non-infectious etiologies of cardiovascular disease in HIV-infected patients. Relevant articles cited in the retrieved publications were also reviewed for inclusion.

Results:

A variety of outcomes studies and literature reviews were included in the analysis. Relevant literature discussed the manifestations, diagnosis, treatment, and outcomes of infectious and non-infectious etiologies of cardiovascular disease in HIV-infected patients.

Conclusion:

In these medically underserved areas, it is vital that clinicians are knowledgeable in the manifestations, diagnosis, and treatment of CV complications in patients with untreated HIV. This review summarizes the epidemiology and causes of CV complications associated with untreated HIV and provide recommendations for management of these complications.

Cardiovascular disease associated with human immunodeficiency virus: a review

The cardiovascular manifestations of human immunodeficiency virus (HIV) infection have changed significantly following the introduction of highly active antiretroviral therapy (HAART) regimens. On one hand, HAART has altered the course of HIV disease, with longer survival of HIV-infected patients, and cardiovascular complications of HIV infection such as myocarditis have been reduced. On the other hand, HAART is associated with an increase in the prevalence of both peripheral and coronary arterial disease. As longevity increases in HIV-infected individuals, long-term effects, such as cardiovascular disease, are emerging as leading health issues in this population. In the present review article, we discuss HIV-associated cardiovascular disease, focusing on epidemiology, etiopathogenesis, diagnosis, prognosis, management and therapy. Cardiovascular involvement in treatment-naive patients is still important in situations such as non-adherence to treatment, late initiation of treatment, and/or limited access to HAART in developing countries. We therefore describe the cardiovascular consequences in treatment-naive patients and the potential effect of antiretroviral treatment on their regression, as well as the metabolic and cardiovascular implications of HAART regimens in HIV-infected individuals.

HIV-associated pulmonary arterial hypertension: from bedside to the future

Pulmonary arterial hypertension (PAH) is a life-threatening complication of HIV infection. The prevalence of HIV-associated PAH (HIV-PAH) seems not to be changed over time, regardless of the introduction of highly active antiretroviral therapy (HAART). In comparison with the incidence of idiopathic PAH in the general population (1-2 per million), HIV-infected patients have a 2500-fold increased risk of developing PAH. HIV-PAH treatment is similar to that for all PAH conditions and includes lifestyle changes, general treatments and specific treatments.

Pulmonary Arterial Hypertension among HIV-Infected Children: Results of a National Survey and Review of the Literature

Since the advent of highly active anti-retroviral therapy, HIV-related mortality has decreased dramatically. As a consequence, patients are living longer, and HIV infection is becoming a chronic disease. Patients and caretakers have to deal with chronic complications of infection and treatment, such as cardiovascular diseases, which now represent an important health issue, even in the pediatric population. Prevalence of pulmonary arterial hypertension (PAH) in the adult HIV population is around 0.4-0.6%, which is around 1000- to 2500-fold more prevalent than in the general population. In recent adult PAH registries, HIV has been identified as the fourth cause of PAH, accounting for approximately 6-7% of cases. Therefore, regular screening is recommended in HIV-infected adults by many experts. If HIV-associated PAH is mainly reported in HIV-infected adults, pediatric cases have also been, albeit rarely, described. This scarcity may be due to a very low PAH prevalence, or due to the lack of systematic cardiovascular screening in pediatric patients. As PAH may manifest only years or decades after infection, a systematic screening should perhaps also be recommended to HIV-infected children. In this context, we retrospectively looked for PAH screening in children included in our national Swiss Mother and Child HIV cohort study. A questionnaire was sent to all pediatric infectious disease specialists taking care of HIV-infected children in the cohort. The questions tried to identify symptoms suggestive of cardiovascular risk factors and asked which screening test was performed. In the 71 HIV-infected children for which we obtained an answer, no child was known for PAH. However, only two had been screened for PAH, and the diagnosis was not confirmed. In conclusion, PAH in HIV-infected children is possibly underestimated due to lack of screening. Systematic echocardiographic evaluation should be performed in HIV-infected children.

Pulmonary arterial hypertension related to human immunodeficiency virus infection: A case series

AIM: To present 18 new cases of human immunodeficiency virus (HIV)-related pulmonary arterial hypertension (PAH) with presenting features, treatment options and follow-up data.

METHODS: This is a single-centre, retrospective, observational study that used prospectively collected data, conducted during a 14-year period on HIV-related PAH patients who were referred to a pulmonary hypertension unit. All patients infected with HIV were consecutively admitted for an initial evaluation of PAH during the study period and included in our study. Right heart catheterisation was used for the diagnosis of PAH. Specific PAH treatment was started according to the physician’s judgment and the recommendations for idiopathic PAH. The data collected included demographic characteristics, parameters related to both HIV infection and PAH and disease follow-up.

RESULTS: Eighteen patients were included. Intravenous drug use was the major risk factor for HIV infection. Risk factors for PAH, other than HIV infection, were present in 55.5% patients. The elapsed time between HIV infection and PAH diagnoses was 12.2 ± 6.9 years. At PAH diagnosis, 94.1% patients had a CD4 cell count > 200 cells/μL. Highly active antiretroviral therapy (present in 47.1% patients) was associated with an accelerated onset of PAH. Survival rates were 93.8%, 92.9% and 85.7% at one, two and three years, respectively. Concerning specific therapy, 33.3% of the patients were started on a prostacyclin analogue, and the rest were on oral drugs, mainly phosphodiesterase-5 inhibitors. During the follow-up period, specific therapy was de-escalated to oral drugs in all of the living patients.

CONCLUSION: The survival rates of HIV-related PAH patients were higher, most likely due to new aggressive specific therapy. The majority of patients were on oral specific therapy and clinically stable. Moreover, sildenafil appears to be a safe therapy for less severe HIV-related PAH.

Contributions of pulmonary hypertension to HIV-related cardiac dysfunction

BACKGROUND/AIM

To evaluate the prevalence of pulmonary hypertension among patients living with HIV/AIDS and to determine its contribution to cardiac dysfunction.

METHOD

A hospital based cross sectional study was carried out over a 6-month period at the Jos University Teaching Hospital. The subjects were 200 confirmed HIV positive patients, ≥18 years of age who consented to the study. Physical examination, laboratory investigations, 2 dimensional and Doppler echocardiography were conducted on the subjects.

RESULTS

The mean age of the patients was 38 ± 9 years, and there were 142 females (71%). Females were younger, mean age 36 ± 8 years versus 41 ± 10 years for males (p-value <0.01). The median CD4 cell count was 312 cells/μl, there were no homosexual or intravenous drug user among the subjects. Eight of the subjects had pulmonary hypertension, with a case prevalence of 4%, and this had no relationship to CD4 cell count. Both systolic and diastolic functions were worse in subjects with pulmonary hypertension, with a negative correlation between mean pulmonary arterial systolic pressure (mPASP) and parameters like ejection fraction (r = -0.28, p-value 0.0003), fractional shortening (r = -0.21, p-value 0.003), deceleration time (r = -0.13. p-value 0.09).

CONCLUSION

Immune-suppression affects the cardiac function adversely and coexisting pulmonary hypertension contributes to poor systolic and diastolic function in affected patients. The subtle nature of presentation of pulmonary hypertension and other cardiac dysfunctions in HIV/AIDS patients demand a high-index of suspicion and early intervention if detected, to ensure better care for these emerging threats to our patients.

A novel expression of exercise induced pulmonary hypertension in human immunodeficiency virus patients: a pilot study

Background:

Patients with the human immunodeficiency virus (HIV) are at risk for multiple pulmonary complications including pulmonary hypertension. Exercise induced pulmonary hypertension (EIPH) has been previously described in patients with scleroderma, sickle cell disease and chronic obstructive pulmonary disease, yet has not been associated with the HIV population.

Methods:

A prospective case-control study design was implemented. Four HIV patients with unexplained dyspnea and four healthy controls underwent symptom-limited stationary bicycle exercise. Transthoracic Doppler Echocardiography was used to measure tricuspid regurgitation velocity which was used to calculate the right ventricular to right atrial pressure (RV-RA) gradient at rest and at peak exercise using the simplified Bernoulli’s equation. Change in RV-RA gradient between rest and peak exercise was calculated and considered to represent change in pulmonary arterial systolic pressure.

Results:

The mean age was 41.25 years (±8.7) for patients and 33.5 years (±6.0) for controls. The mean CD4 count of patients was 191.5 cells/μL (±136.2). Patients had a significantly higher increase in RV-RA gradient as compared to controls (180.2% vs. 27.5%, p = 0.03).

Discussion:

This pilot study suggests that it is feasible to use recumbent bicycle and transthoracic Doppler echocardiography for the evaluation of EIPH among HIV patients with dyspnea of unknown etiology. The study is too small to draw any broad conclusion. Further evaluation of this concept with a larger study is warranted.

Echocardiographic diagnoses in HIV-infected patients presenting with cardiac symptoms at Muhimbili National Hospital in Dar es Salaam, Tanzania

Objective

To determine the pattern of echocardiographic diagnoses in HIV-infected patients presenting with cardiac symptoms at Muhimbili National Hospital in Dar es Salaam, Tanzania.

Methods

Patients known to be HIV positive and with cardiac complaints were prospectively recruited from the Hospital’s care and treatment centre as well as from the medical wards. Clinical assessment, laboratory tests and echocardiography were performed.

Results

A total of 102 patients were recruited from September 2009 to April 2010. The patients’ mean age was 42.4 years and 68.6% were women. The most common diagnosis was pericardial effusion present in 41.2% of the patients. The effusion was large in 5.9% and small in 35.3% of the patients. Hypertensive heart disease was diagnosed in 34.3%, while pulmonary hypertension and dilated cardiomyopathy were present in 12.7 and 9.8%, respectively.

Conclusion

Cardiac abnormalities are common in HIV-infected patients, particularly when they present with symptoms.

Pulmonary arterial hypertension in human immunodeficiency virus infection

Because of the improvement in survival rates of human immunodeficiency virus (HIV)-infected patients after the introduction of combined antiretroviral therapy, pulmonary arterial hypertension (PAH) has become an important cause of morbidity. As the awareness of PAH has increased, it is more likely that this condition will be diagnosed more frequently and earlier in the course of the disease and HIV infection. The etiopathogenesis is not clear; no evidence of direct infection of the pulmonary vascular tree has been found and the current evidence seems to favor a role of dysregulated cytokine response to HIV infection. The pathological changes of plexiform arteriopathy are indistinguishable from the pathological changes of idiopathic pulmonary arterial hypertension (IPAH). Dyspnea is the most common presenting symptom. Echocardiography, though always not accurate in diagnosing PAH and estimating its severity, remains the main screening tool. Right heart catheterization is the gold standard investigation for diagnosis. New therapies like prostanoids, endothelin receptor antagonists, and phosphodiesterase inhibitors have improved the outcome of patients with HIV-associated PAH. However, the overall prognosis of HIV-infected patients who develop PAH still remains poor.

Successful switch to sitaxsentan in a patient with HIV-related pulmonary arterial hypertension and late intolerance to nonselective endothelin receptor blockade

Pulmonary arterial hypertension [PAH] is a rare but well-known cardiovascular condition potentially associated with human immunodeficiency virus [HIV] infection and is currently recognized to be one of the most ominous noninfectious HIV complications. Although there is no clear evidence supporting the use of any medication for the treatment of HIV-related PAH, many of the currently available agents have been shown to exert some clinical benefits HIV-PAH patients. To date, no data are available regarding the potential effects of sitaxsentan, a selective endothelin type-A receptor antagonist, in this peculiar patient population. We report the case of a successful switch to sitaxsentan in a HIV-infected patient with PAH initially receiving bosentan who developed a late treatment-related side-effect.

Heart Disease in Patients with HIV/AIDS-An Emerging Clinical Problem

HIV/AIDS (Human immunodeficiency virus/ Acquired immuno deficiency syndrome) is a growing global problem, in terms of its incidence and mortality. Patients with HIV/AIDS are living much longer with HAART (Highly active antiretroviral therapy) therapy so much so that HIV/AIDS has now become a part of the chronic disease burden, like hypertension and diabetes. Patients with HIV/AIDS and symptoms suggestive of cardiac disease represent a diagnostic and therapeutic challenge in clinical practice; Cardiologists are more frequently encountering this problem. An algorithmic, anatomic approach to diagnosis, localizing disease to the endocardium, myocardium and pericardium can be useful. An intimate knowledge of opportunistic infections affecting the heart, effects of HAART therapy and therapy for opportunistic infections on the heart is needed to be able to formulate a differential diagnosis. Effects of HAART therapy, especially protease inhibitors on lipid and glucose metabolism, and their influence on progression to premature vascular disease require consideration. Treatment of cardiac disease, in HIV/AIDS patients can vary from non-HIV patients, based on drug interactions, differences in responsiveness, and other factors; and this area requires further research.

Cardiovascular manifestations in human immunodeficiency virus-infected patients

Human immunodeficiency virus (HIV) is now a pandemic. It afflicts multiple organs, including the cardiovascular system. This occurs by direct invasion as well as opportunistic infections complicating acquired immunodeficiency syndrome. The presence of newer highly active antiretroviral therapy has led to longer survival of patients infected with HIV, but the cardiac abnormalities related to HIV have remained less well characterized. It is now evident that cardiac involvement in patients with acquired immunodeficiency syndrome is relatively common. This includes coronary artery disease, dilated cardiomyopathy, pericardial effusion, pulmonary hypertension, and ill effects of highly active antiretroviral therapy in the form of lipodystrophy, lipoatrophy, and dyslipidemia. In fact, HIV can now be viewed as a potential risk factor for coronary artery disease, and the dilemma facing clinicians is how to quantify this risk. Awareness of accelerated coronary artery disease and dilated cardiomyopathy is critical to implement preventive measures early in the course of HIV. However, better guidelines are still needed on the basis of prospective randomized controlled studies involving large populations. In conclusion, this review describes cardiac abnormalities associated with HIV, including possible molecular mechanisms. The co-morbid sequelae, their presentation, and pharmacologic management are also discussed.

Pulmonary arterial hypertension and its association with HIV infection: an overview

There has been substantial progress in our understanding of the pathogenesis and clinical consequences of infection with HIV since the virus was first identified more than 20 years ago. The details of the viral replication cycle are increasingly better understood as are the identification of host elements that both regulate viral replication and are necessary for it. Greater understanding of these events has resulted in the development of therapies for HIV infection and as a consequence there has been a dramatic improvement in overall survival in the era of HAART. With this improvement in survival has come an increasing recognition of the importance of many long-term sequelae of subclinical immune deficiency and the attendant immune activation that characterize HIV infection. One complication of chronic HIV infection for which the pathogenesis is obscure is pulmonary arterial hypertension (PAH). Cases of HIV-related PAH (PAH-HIV) have been recognized with increasing frequency in recent years. Although it is likely that PAH-HIV has an underlying etiology specifically related to HIV infection, it shares several key clinical and pathological similarities with other forms of PAH. This article outlines the features, classification and treatment of PAH, and recent theories about the underlying etiology of the disease. We will also discuss the occurrence of PAH in HIV infection and propose some hypotheses regarding pathogenesis that will be covered in more detail in the accompanying articles in this supplement.

Myocardial disease in human immunodeficiency virus (HIV) infection: a review

Heart muscle disease is the most important cardiovascular manifestation of HIV infection and is likely to become even more prevalent as HIV infected patients live longer. This may present as myocarditis, dilated cardiomyopathy or isolated left or right ventricular dysfunction. Myocardial involvement in HIV infection is multifactorial and may arise as a result of myocardial invasion with HIV itself, opportunistic infections, viral infections, autoimmune response to viral infection, drug-related cardiac toxicity, nutritional deficiencies, and prolonged immunosuppression. Both adults and children are affected with severity ranging from incidental microscopic inflammatory findings at autopsy to clinically significant cardiac disease with chronic cardiac dysfunction. It is associated with a poor prognosis, and results in symptomatic heart failure in up to 5% of HIV patients. Clinical pathological studies from the pre-HAART era show a 30% prevalence of cardiomyopathy in patients with AIDS. The introduction of highly active antiretroviral therapy (HAART) regimens has substantially modified the course of HIV disease by lengthening survival and improving quality of life of HIV-infected patients. There is also good evidence that HAART significantly reduces the incidence of cardiovascular manifestations of HIV infection. By preventing opportunistic infections and reducing the incidence of myocarditis, HAART regimens have reduced the prevalence of HIV-associated cardiomyopathy by almost 7-fold from the pre-HAART era. HAART is however only available to a minority of HIV infected individuals in most areas of the world and studies from the pre-HAART period still apply. In this review, the aetiopathogenesis and presentation of HIV related myocardial disease were reviewed and measures taken to improve survival discussed.

Resolution of human immunodeficiency virus type 1 infection-related severe pulmonary hypertension in a very low-birth-weight infant

Pulmonary arterial hypertension (PAH) affects approximately 0.5% of human immunodeficiency virus (HIV)-infected adults with poor prognosis. The effectiveness of highly active antiretroviral therapy for treatment of HIV-related PAH (HIV-PAH) remains controversial. Little is known about the incidence, clinical course, and therapy options for PAH in HIV-1-infected pediatric patients. Here, we report the case of a preterm infant with HIV-related life-threatening PAH, which resolved after initiation of highly active antiretroviral therapy.

Role of HIV and human herpesvirus-8 infection in pulmonary arterial hypertension

BACKGROUND

Previous work has found a high prevalence of pulmonary arterial hypertension in HIV-infected persons, but establishment of a causal relationship has been limited by the lack of well characterized contemporaneous HIV-uninfected comparator groups. Among HIV-uninfected persons, human herpesvirus-8 (HHV-8) has also been linked to pulmonary arterial hypertension (PAH), but whether this relationship occurs among HIV-infected persons - who have among the highest prevalence of HHV-8 infection - has not been examined.

METHODS AND RESULTS

We echocardiographically calculated pulmonary artery systolic pressure and measured HHV-8 antibodies in HIV-infected and HIV-uninfected adults. Among the 196 HIV-infected participants, the median pulmonary artery systolic pressure (PASP) was 27.5 mmHg and 35.2% had PASP greater than 30 mmHg. This compared to a median of 22 mmHg among 52 HIV-uninfected participants in whom 7.7% had a PASP greater than 30 mmHg (P < 0.001). After adjustment for injecting drug and stimulant use, smoking, age, and gender, HIV-infected participants had 5.1 mmHg higher mean PASP and seven fold greater odds of having a PASP greater than 30 mmHg (P < 0.001). Although we found no association between HHV-8 and PAH among all HIV-infected participants, a borderline relationship was present when restricting to those without risk factors for PAH.

CONCLUSION

HIV-infected persons have a high prevalence of elevated PASP, which is independent of other risk factors for PAH. This suggests a causal role of HIV in PAH and emphasizes the need to understand the natural history of PAH in this setting. A role for HHV-8 infection in PAH remains much less definitive.

Pulmonary arterial hypertension

It is important for the general internist to maintain a high degree of suspicion for pulmonary hypertension in appropriate cases. This article reviews the definition and classification of pulmonary hypertension, epidemiology and risk factors, signs and symptoms, diagnostic approach, and treatment strategies. Multiple effective therapies now exist for pulmonary arterial hypertension, and thus early diagnosis and referral will translate into meaningful survival and better lives for our patients.

Pulmonary Vascular Disease

The pulmonary vasculature is an anatomic compartment that is frequently overlooked in the histologic review of lung biopsy samples, other than those obtained specifically to assess pulmonary vascular disease.1 Though often of a nonspecific nature, the histologic pattern of vascular remodeling may at times suggest its underlying pathogenesis and provide clues to the cause of pulmonary hypertension.2 Disproportionately severe vascular pathology may further indicate alternate disease processes, such as congestive heart failure or thromboemboli, contributing to the patient’s overall respiratory condition.

Pulmonary hypertension can be a sequela of prior Pneumocystis pneumonia

Improved treatment regimens have reduced fatalities from opportunistic diseases, such as Pneumocystis pneumonia, in AIDS patients. However, serious chronic conditions, including pulmonary hypertension (PH), are increasing in this group. We report here that when CD4 T cells in Pneumocystis-infected mice are temporally depleted and then allowed to return, the extended inflammation results in PH that persists after Pneumocystis is eliminated. Using this model of PH, we have found that i) the onset of PH is correlated with the return of CD4 T cells, but PH persists after CD4 levels diminish; ii) vascular remodeling accompanies PH, but whereas temporary medial hypertrophy is evident with transient PH in immunocompetent mice, persistent PH is associated with perivascular fibrosis; iii) elevated levels of the fibrotic mediator FIZZ1 are found in bronchoalveolar lavage fluid of mice with persistent PH; and iv) although Th2-related mechanisms may be involved in PH etiology, PH still occurs in interleukin-4 receptor-deficient mice under these conditions. Overall, the data presented here demonstrate that the immune response to an infectious disease pathogen, such as Pneumocystis, can, when perturbed and prolonged, lead to later development of a serious chronic condition such as PH.

Current Update on HIV-associated Vascular Disease and Endothelial Dysfunction

Highly active antiretroviral therapy (HAART) has greatly reduced the risk of early death from opportunistic infections and extended the lifespan of people infected with the human immunodeficiency virus (HIV). Thus, many complications and organic damage in the HIV-infected population emerge. Cardiovascular disease as coronary artery disease has become a matter of particular concern. Its incidence is greatly increased in the HIV-infected population over that of people of the same age in the absence of general cardiovascular risk factors. Despite several clinical and laboratory studies in the association between HIV infection and cardiovascular disease, the pathogenic mechanisms of this significant clinical problem are largely unknown and are now under active investigation. Endothelial dysfunction is possibly the most plausible link between HIV infection and atherosclerosis. Increased expression of adhesion molecules such as intercellular adhesion molecule (ICAM)-1 and endothelial adhesion molecule (E-selectin) and inflammatory cytokines such as tumor necrosis factor (TNF)-alpha and interleukin (IL-6 has been reported in HIV-positive patients. The effect of HAART on endothelial function in HIV-positive patients is also demonstrated. In this review, we focus on the recent research update of HIV-associated vascular disease and vascular injury. We analyze and discuss the recent clinical and laboratory investigations on the effect of HIV, viral protein, and HAART therapy on endothelial injury and vascular disease; identify the areas of controversy and clinical relevance; and suggest some directions for future research.

Imaging of Cerebrovascular and Cardiovascular Disease in AIDS Patients

OBJECTIVE

The purpose of this article is to show the imaging findings in patients who have cerebrovascular and cardiovascular complications caused by AIDS.

CONCLUSION

Detection of multifocal aneurysms, unexplained cardiomyopathy, and venous thrombosis in high-risk patients should suggest the possibility of AIDS.

Cardiovascular disease in HIV infection

The survival of patients with HIV infection who have access to highly active antiretroviral therapy has dramatically increased. In HIV-infected persons, cardiovascular disease can be associated with HIV infection, opportunistic infections or neoplasias, use of antiretroviral drugs or treatment of opportunistic complications, mode of HIV acquisition (such as intravenous drug use), or with the classic non-HIV-related cardiovascular risk factors (such as smoking or age). Diseases of the heart associated with HIV infection or its opportunistic complications include pericarditis and myocarditis. Pericarditis may lead to pericardial effusion rarely causing tamponade. Cardiomyopathy is often clinically silent with asymptomatic left ventricular systolic dysfunction. Endocarditis is mainly the consequence of intravenous drug abuse, possibly leading to life-threatening valvular insufficiency with the need for cardiac surgery. A further serious condition associated with HIV infection is pulmonary hypertension potentially leading to right heart failure. The cardiovascular complications of HIV infection such as cardiomyopathy and pericarditis have been reduced by highly active antiretroviral therapy, but premature coronary atherosclerosis is now a growing problem because antiretroviral drugs can lead to serious metabolic disturbances resembling those in the metabolic syndrome. Lipodystrophy, a clinical syndrome of peripheral fat wasting, central adiposity, dyslipidemia, and insulin resistance, is most prevalent among patients treated with protease inhibitors. These patients should thus be screened for hyperlipidemia, hyperglycemia, and hypertension, and they may be candidates for lipid-lowering therapies. When initiating lipid-lowering therapy, interactions between statins and HIV protease inhibitors affecting cytochrome P450 function must be considered. Restenosis rate after percutaneous coronary intervention may be unexpectedly high.

Cardiovascular complications of human immunodeficiency virus infection

The heart and great vessels are not the sites most frequently affected by opportunistic infections and neoplastic processes in patients with acquired immune deficiency syndrome (AIDS). However, cardiovascular complications occur in a significant number of such patients and are the immediate cause of death in some. The spectrum of cardiovascular complications of AIDS that may be depicted at imaging includes dilated cardiomyopathy, pericardial effusion, human immunodeficiency virus-associated pulmonary hypertension, endocarditis, thrombosis, embolism, vasculitis, coronary artery disease, aneurysm, and cardiac involvement in AIDS-related tumors. To aid accurate diagnosis and appropriate treatment planning, radiologists should be familiar with the imaging appearance of each of these complications.

Cardiovascular disease and toxicities related to HIV infection and its therapies

Cardiovascular manifestations of HIV vary according to disease stage, treatment regimen and geographical location. Common cardiac complications of HIV disease in patients off highly active antiretroviral therapy (HAART) include dilated cardiomyopathy, myocarditis, pericardial effusion, endocarditis, pulmonary hypertension and non-antiretroviral drug-related cardiotoxicity. However, with the introduction of HAART that has substantially modified the course of HIV disease by lengthening survival, additional cardiovascular consequences are a result of the metabolic syndrome with a propensity toward hyperlipidaemia and atherosclerotic heart disease. Because most of the world's HIV-infected patients have not been treated with HAART, the principal HIV-associated cardiovascular manifestations of patients off HAART are reviewed and new knowledge about the prevalence, pathogenesis and treatment in the HAART era are emphasised in this review. Exercise, a nonpharmacological approach to treating HAART-associated metabolic syndrome, is also discussed.

Induction of apoptosis and endothelin-1 secretion in primary human lung endothelial cells by HIV-1 gp120 proteins

Pulmonary hypertension associated with human immunodeficiency virus (HIV) infection also involves injury to the lung endothelium. However, the pathogenesis of HIV-induced pulmonary hypertension is not known; we hypothesized that HIV or secreted viral proteins could play a role in vascular injury and the increased frequency of pulmonary hypertension observed in HIV-infected patients. Here, we report that exposure of HIV-1 gp120 proteins to primary human lung microvascular endothelial cells causes apoptosis, as assessed by TUNEL assay, Annexin-V staining, and DNA laddering. Using ribonuclease protection assay and Western blotting we find that gp120-induced apoptosis of lung endothelial cells involves a down-regulation in Bcl-xl mRNA and proteins. In addition, gp120 significantly increases secretion of the potent vasoconstrictor endothelin-1 by human lung endothelial cells. These data suggest that secreted HIV gp120 proteins induce lung endothelial cell injury and could contribute to the development of HIV-associated pulmonary hypertension.

Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines

Pulmonary arterial hypertension (PAH) occurs as an idiopathic process or as a component of a variety of disease processes, including chronic thromboembolic disease, connective tissue diseases, congenital heart disease, and exposure to exogenous factors including appetite suppressants or infectious agents such as HIV. This article reviews evidence for screening in susceptible patient groups and the approach to diagnosing PAH when it is suspected, and provides specific recommendations for applying this evidence to clinical practice.

Bone morphogenetic protein receptor-II mutation Arg491Trp causes malignant phenotype of familial primary pulmonary hypertension

A four-generation pedigree of familial primary pulmonary hypertension (FPPH) with 14 alive members was collected. In the family, three of the 14 alive familial members were diagnosed as FPPH. Mutations in bone morphogenetic protein receptor-II (BMPR-II) gene were screened by using sequencing analysis. A C-to-T transition at position 1471 in exon 11 of the BMPR-II gene was identified, resulting in an Arg491Trp mutation. We confirmed segregation of the mutation within the family and excluded the presence of the mutations in a panel of 240 chromosomes from normal individuals. No mutations were found in BMPR-II gene in other 10 patients with sporadic primary pulmonary hypertension. The Arg491Trp mutation is located in the kinase domain and predicted to disturb the kinase activity of BMPR-II. Total 7 familial members died at age 8-45 years with various symptoms, indicating other genetic or environmental modifiers involved in the modification of the clinical phenotype.

Pulmonary arterial hypertension related to HIV infection: improved hemodynamics and survival associated with antiretroviral therapy

This study aimed to assess the long-term course of pulmonary arterial hypertension related to infection with human immunodeficiency virus (PAHRH) and the influence of antiretroviral therapy (ART) on its characteristics. We retrospectively analyzed all 47 patients in the Swiss HIV Cohort Study in whom PAHRH was diagnosed. Among 35 patients who underwent follow-up Doppler echocardiography, the right ventricular systolic pressure over right atrial pressure gradient increased by a median of 25 mm Hg in 9 patients who had not received ART, decreased by a median of 3 mm Hg in 12 patients who had received nucleoside analogs, and decreased by a median of 21 mm Hg in 14 patients who had received highly active ART (HAART) (P<.005). Among all 47 patients, median duration of survival after PAHRH diagnosis was 2.7 years. HAART significantly decreased mortality due to PAHRH as well as other causes. This study suggests a beneficial effect of combination ART in patients with PAHRH.

Right and left ventricular cardiac function in a developed world population with human immunodeficiency virus studied with radionuclide ventriculography

BACKGROUND

Cardiac dysfunction has been reported in a substantial part of patients infected with the human immunodeficiency virus (HIV). However, most studies are from a time before the introduction of highly active antiretroviral treatment (HAART), which has significantly reduced HIV-associated morbidity and mortality rates. Accordingly, the prevalence of HIV-associated cardiac dysfunction may also have changed. The aim of the study was to establish the prevalence of right- and left-sided cardiac dysfunction in a Danish HIV population, most of whom were undergoing HAART, with radionuclide ventriculography.

METHODS

Ninety-five consecutive patients with HIV infection were included. Mean HIV duration was 104 months, and 84% of the patients received HAART. All patients underwent radionuclide ventriculography, and plasma levels of atrial natriuetic peptide (ANP), brain natriuetic peptide (BNP), and endothelin-1 (ET-1) were measured. Thirty age- and sex-matched healthy volunteer subjects were included to establish reference values of radionuclide measurements of left and right ventricular ejection fraction and of left ventricular volume.

RESULTS

Of 95 patients with HIV, 1 (1%) had a reduced left ventricular ejection fraction and 6 (7%) had a reduced right ventricle ejection fraction (0.35-0.42) compared with reference values from the age- and sex-matched reference population. Patients with HIV and reduced cardiac function did not differ in the duration of HIV, CD4 count, CD4 nadir, or HIV RNA load. No correlations were found between reduced cardiac function and levels of the 3 peptides measured.

CONCLUSIONS

No major dysfunction of the left ventricle is present in a developed world HIV population. However, a small but significant part of this population has modestly reduced right-sided systolic function.

Human Immunodeficiency Virus: Anesthetic and Obstetric Considerations

The pandemic of acquired immune deficiency syndrome (AIDS) is on the threshold of its third decade of existence. The World Health Organization-United Nations statistics show that human immunodeficiency virus (HIV)/AIDS pandemia is set to get much worse. Women of reproductive age are the fastest growing population with HIV. Common signs and symptoms have become more moderate or subclinical, and new clinical presentations have emerged. It is quite apparent that HIV-disease affects multiple organ systems. Advances have been made in elucidating the pathogenesis of HIV. In addition, the molecular technique of viral load determination and the CD + 4 T-lymphocyte count enable evaluation of the disease, its prognosis, and its response to therapy. There is limited specific information concerning the overall risk of anesthesia and surgery of HIV/AIDS patients. However, as far as can be determined, surgical interventions do not increase the postoperative risk for complications or death and should therefore not be withheld. There is also little evidence to suggest that HIV or antiretroviral drugs increase the rate of pregnancy complications or that pregnancy may alter the course of HIV infection. General anesthesia is considered safe, but drug interactions and their impact on various organ systems should be considered preoperatively. Regional anesthesia is often the technique of choice. Yet, one must take into consideration the presence of neuropathies, local infection, or blood clotting abnormalities. It should be emphasized that all practicing anesthesiologists should be familiar with the disease and should use prenatal anesthesia consultations and a team approach to assure optimal treatment for HIV patients.

AIDS Associated With Severe Cor Pulmonale and Large Pericardial Effusion With Cardiac Tamponade

Cardiac involvement in patients with advanced HIV/AIDS is common, including pericardial effusion and pulmonary hypertension. Although there is an increased incidence of pericardial effusion in patients with AIDS, most are small and asymptomatic. The presence of a pericardial effusion and/or pulmonary hypertension is associated with shortened survival. We present a case of a 43-year-old man with AIDS and advanced cardiovascular involvement who developed severe cor pulmonale and a large pericardial effusion with cardiac tamponade.

Cardiovascular complications in patients with HIV infection

As advances in early diagnosis and aggressive therapy, as well as better supportive care, become available to a larger number of patients with HIV infection, survival is being prolonged, and more patients are experiencing cardiac abnormalities. The most common cardiac manifestations of HIV disease are dilated cardiomyopathy, myocarditis, pericardial effusion, endocarditis, pulmonary hypertension, HIV-associated malignant neoplasms, and drug-related cardiotoxicity. The introduction of highly active antiretroviral therapy (HAART) regimens has substantially modified the course of HIV disease by lengthening survival and improving quality of life of HIV-infected patients. However, early data have raised concerns about HAART being associated with an increase in peripheral and coronary arterial disease. This review discusses the principal HIV-associated cardiovascular manifestations and emphasizes new knowledge about their prevalence, pathogenesis, and treatment.

Prognostic factors for survival in human immunodeficiency virus-associated pulmonary arterial hypertension

We report a large monocentric case series of 82 patients with human immunodeficiency virus-associated pulmonary arterial hypertension (PAH). No germline mutations of the PPH1 gene (bone morphogenetic protein receptor-II) were found in any of the 19 patients tested. PAH was the direct cause of death in 72% of cases. Survival rates of the overall population at 1, 2, and 3 years were 73, 60, and 47%, respectively. Survival was significantly poorer in patients in New York Heart Association functional class III-IV at the time of diagnosis, as compared with those in functional class I-II with respective rates of 60, 45, and 28% versus 100, 90, 84% at 1, 2, and 3 years (p < 0.0001). Subsequently, we analyzed prognostic factors in patients in functional class III-IV. Univariate analysis indicated that CD4 lymphocyte count of more than 212 cells mm(-3), the use of combination antiretroviral therapy (CART), and epoprostenol infusion were related with a better survival. On multivariate analysis only CD4 lymphocyte count was an independent predictor of survival, presumably because CART and epoprostenol infusion were strongly linked in our patient population. These results suggest that patients with severe human immunodeficiency virus-associated PAH should be considered for long-term epoprostenol infusion in association with CART.