Prevalence of Cardiac Manifestations in HIV-Infected Patients in Iran

Abstract

To the Editors: HIV infection has affected more than 33 million persons and led to more than 2 million annual mortality globally.1 According to the latest HIV statistics in Iran, there were 17,815 HIV-infected and 1459 patients with confirmed AIDS in 2008.2 Considering 3 important issues-heart affliction by HIV,3 increasing age-related problems including cardiac complications in patients receiving antiretroviral therapy,4,5 and increasing prevalence of HIV infection and ischemic heart disease in Iran.6 Besides the importance of the timely diagnosis of cardiovascular diseases-this study estimates the prevalence of heart diseases in HIV-infected patients for decreasing those complications through early diagnosis. This survey was conducted on 134 HIV-infected patients in the Iranian Research Center of HIV/AIDS in Imam Khomeini Hospital (Tehran University of Medical Sciences, Tehran, Iran) from 2007 to 2008. Participants' age, sex, weight, height, smoking and drug abuse, history of heart disease, and antiretroviral therapy were recorded. A fasting blood sample was achieved for blood sugar, triglyceride, cholesterol, high-density lipoprotein, and low-density lipoprotein. Participants underwent electrocardiography and echocardiography for left ventricular ejection fraction; pulmonary artery pressure; and myocardial, pericardial, and valvular heart disease. We used the independent 2-sample t test and χ2 test to compare the mean differences of the variables. The results are shown as mean (±SD) or number (%). Within the study population, 84 participants (62.68%) showed heart problems and 51 subjects (38.05%) were affected by AIDS. The participants' characteristics are shown in Table 1. Pericardial effusion and pulmonary hypertension are significantly more frequent among patients with CD4 count ≤200 per milliliter, and low left ventricular ejection fraction (≤50%) was significantly more frequent in patients with CD4 count ≤200 per milliliter than those with CD4 count >200 per milliliter (P = 0.02). Pulmonary hypertension was significantly similar in low and high CD4 count (P = 0.10). Electrocardiographic changes were observed in 129 patients (96.26%), of which all of them had various abnormal rhythms. There were 27 (20.14%) and 5 (3.73%) subjects with right and left cardiac axis deviation, respectively. Long and short PR interval existed in 11 (8.20%) and 1 (0.7%) participants, respectively. There were also ST-T segment deviation (n = 13, 9.70%) and right (n = 11, 8.20%) and left (n = 5, 3.73%) bundle branch block. Antiretroviral therapy significantly correlated with ST-T segment deviation (P = 0.021). The most common valvular lesion was mitral valve prolapse (42.53%). Two addict patients suffered from tricuspid valve vegetations with fever, cough, and dyspnea. The presence of Staphylococcus aureus and infective endocarditis was confirmed in blood culture. There were 10 patients (7.46%) with (mainly systolic) myocardial dysfunction.TABLE 1: Demographic, Clinical, and Paraclinical Characteristics of HIV-Infected Patients Referred to the Iranian Research Center for HIV/AIDS (IRCHA) from 2007 to 2008Cardiac diseases are among the most prevalent conditions in HIV-infected patients7; they were likewise in the present study as 62.68% of patients suffered from cardiac abnormalities. Nearly half of our HIV-infected patients were intravenous drug abusers, which is remarkably lower than other surveys.8 We did not find the reported lipid disorders.5 We realized that mitral valve prolapse was the most frequent complicated valve vs. tricuspid valve in another study.9 The prevalence of infective endocarditis (almost 1.5%) was similar to another survey in Africa.10 Corresponding to other investigations,11,12 all infective endocarditis cases were right sided with a history of intravenous drug abuse. The lower prevalence of infective endocarditis in our study is probably due to the selection of outpatient subjects who are symptom free. The prevalence of pericardial effusion in our study (5.22%) was close to that of a 5-year survey (7%).13 Our result supports this finding that pericardial effusion was more common in patients with the mean CD4 count <300 per milliliter.14 Pulmonary hypertension is 1000 times more frequent in HIV-infected subjects.11,15 Its reported prevalence for Zimbabwe and India was 0.6%-5% and 20%, respectively,9,16 vs. 12.68% in our investigation. We support the concept that occurrence of pulmonary hypertension does not correlate with CD4 count.17 The prevalence of myocardial dysfunction in our study (7.46%) is close to the range of the reported complication (8%-15%).18,19 It is proposed that left bundle branch block, atrioventricular block, and ST-T segment deviation are among the most frequent abnormalities.20-22 In our study irrespective of insignificant dysrhythmias, right axis deviation, ST-T segment deviation, right bundle branch block, and short PR interval are the most common significant electrocardiographic features. In our study, higher frequency of pulmonary hypertension probably leads to higher frequency of right axis deviation. Albeit cardiac complications are expected to appear in the elderly, we observed them in younger and mostly asymptomatic subjects. This proposes a scrutiny for cardiac complications in HIV-infected patients, even if they are young or symptom free. Azar Hadadi, MD* Sina Moradband Badie, MD† Maryam Rohamm, MD‡ Mehrnaz Rasoolinejad, MD§ Nahid Mirzaee, MD‡ Reza Hamidian, MD* *Sina Hospital †Amir Alam Hospital ‡Imam Khomeini Hospital Tehran University of Medical Sciences, Tehran, Iran §Imam Khomeini Hospital, Iranian Research Center of HIV/AIDS, Tehran University of Medical Sciences, Tehran, Iran