Patients infected with the human immunodeficiency virus (HIV) have an increased risk of developing heart disease. Among the most common heart problems associated with HIV are pericarditis (inflamed sac surrounding the heart), endocarditis (infection of the lining inside the heart), cancer that affects the heart, pulmonary high blood pressure, and coronary artery disease (CAD).
There are many reasons why HIV patients may have an increased risk of developing heart disease. Since HIV attacks the body's immune system, patients are vulnerable to infections that may spread to the heart and cause disease. Also, some HIV medications may cause conditions such as dyslipidemia (high levels of fat in the blood), diabetes, or metabolic syndrome, which are risk factors for heart disease.
In addition, conditions unrelated to HIV, such as obesity, smoking, and family history of heart disease, may predispose patients to heart problems.
Treatment for heart disease varies depending on the type and severity of the specific condition. Because most cases of heart disease in HIV patients are associated with infections, antimicrobials are a common treatment. Antibiotics are used to treat bacterial infections, antifungals are used to treat fungal infections, and antivirals are used to treat viral infections.
Patients can reduce their risks of heart disease by exercising, eating healthfully, and not smoking. HIV patients should also receive a combination of antiretrovirals called highly active antiretroviral therapy (HAART). This therapy suppresses HIV and boosts the immune system, making the patient less vulnerable to infections.
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Since HIV patients have weakened immune systems, they have an increased risk of developing cancers that may spread to the heart. This is because they have fewer immune cells, which are the body's first line of defense against cancerous cells. There have been reports of HIV/AIDS patients who developed Kaposi's sarcoma and non-Hodgkin's lymphoma that involved the heart.
Kaposi's sarcoma is a cancer that develops in connective tissues, such as bone, cartilage, fat, blood vessels, muscle, or tissues related to tendons or ligaments. A herpes virus called human herpes virus 8 (HHV-8) has been shown to cause AIDS-related Kaposi's sarcoma.
In rare cases, Kaposi's sarcoma may spread to the heart. If this happens, most patients do not experience functional problems with the heart. In fact, Kaposi's sarcoma that has spread to the heart is rarely diagnosed because patients do not usually experience symptoms that suggest the heart has cancer. Most of these cases are identified during an autopsy, after a patient has died.
Lymphoma describes a group of cancers that affect the lymphatic system, which is part of the body's immune defense system. Non-Hodgkin's lymphoma affects about 20% of HIV/AIDS patients and it has been associated with the Epstein-Barr virus or hepatitis. In rare cases, this type of cancer may spread to the heart.
AIDS-related cancer that spreads to the heart has become uncommon since the introduction of highly active antiretroviral therapy (HAART). This therapy is a combination of anti-HIV drugs (antiretrovirals) that suppress HIV and boost the body's immune system. Patients receiving HAART are less likely to develop infections associated with these cancers.
coronary artery disease
HIV patients have an increased risk of developing coronary artery disease (CAD), also called coronary heart disease (CHD). CAD occurs when the blood vessels that supply oxygenated blood to the heart muscle (coronary arteries) gradually become narrowed or blocked by plaque deposits. Plaque is combination of fatty material, calcium, scar tissue, and proteins.
Plaque build up in the arteries is associated with several risk factors, including high cholesterol and low-density lipoprotein (LDL) levels in the blood, low levels of high-density lipoprotein (HDL), high blood pressure, smoking, diabetes mellitus, obesity, age, family history of heart disease, sedentary or inactive lifestyle, stress, and male gender.
The plaque deposits decrease the space through which blood can flow. As platelets (disc-shaped particles in the blood that aid clotting) come to the area, blood clots form around the plaque, causing the artery to narrow even more.
Sometimes the blood clot breaks apart, and blood supply is restored. In other cases, the blood clot may completely block the blood supply to the heart muscle. This lack of blood flow (called ischemia) can "starve" some of the heart muscle of oxygen and lead to chest pain (angina). A heart attack, also known as a myocardial infarction, results when blood flow is completely blocked. Heart attacks usually happen when a blood clot forms over a plaque that has ruptured.
It remains unknown exactly why HIV patients are more likely to develop CAD than HIV-negative patients. Researchers are investigating whether HIV treatment or HIV itself plays a role. Some studies suggest that patients who take antiretrovirals called protease inhibitors have an increased risk of heart attacks.
Common symptoms of CAD include chest pain, shortness of breath, irregular or fast heartbeat, weakness or dizziness, nausea, and increased sweating.
The standard diagnostic procedure for CAD is a carotid ultrasonography. This procedure evaluates blood flow using a wand-like device, called a transducer. The transducer sends high-frequency sound waves into the neck to determine if there is any narrowing or clotting in the arteries.
Drugs used to treat CAD include platelet inhibitors such as aspirin or clogidogrel (Plavix®); beta blockers such as metoprolol (Lopressor® or Toprol®); calcium channel blockers such as amlodipine (Norvasc®) or diltiazem (Cardizem®); angiotensin inhibiting drugs or ACE inhibitors such as lisinopril (Prinivil® or Zestril®) or ramipril (Altace®); statins; or HMG-CoA reductase inhibitors such as atorvastatin (Lipitor®) or lovastatin (Mevacor®).
Arteries that are severely blocked may need to be expanded using angioplasty and stent placement. This procedure involves using a wire mesh that expands in the blood vessel, allowing more blood to flow normally. A specialized doctor called a cardiologist performs these procedures at a hospital. A tube or catheter is inserted into a blood vessel. Several types of balloons, stents, and/or catheters are available to treat the plaque inside the vessel. Some of these surgical tools contain anti-clotting medications. The physician chooses the type of procedure based on individual patient needs.
Coronary artery bypass graft (CABG) surgery is when one or more blocked blood vessels is bypassed by a graft (transplant of healthy arteries or veins) to restore normal blood flow to the heart. These grafts usually come from the patient's own arteries and veins located in the chest, leg, or arm. The graft goes around the clogged artery to create new pathways for oxygen-rich blood to flow to the heart. Some problems associated with CABG include a heart attack, stroke, blood clots, death, and sternal wound infection. Infection is most often associated with obesity, diabetes, or having had a previous CABG. Some patients may develop post-pericardiotomy syndrome a few days to six months after surgery. Symptoms typically include fever and chest pain. The incision in the chest or the graft site may be itchy, sore, numb, or bruised after surgery. Some patients report memory loss or loss of mental clarity after a CABG.
Some HIV patients may develop endocarditis, which occurs when the inner lining of the heart is infected. The infection starts in the bloodstream and spreads to the heart. Since HIV patients have weakened immune systems, they are more susceptible to developing infections that cause endocarditis.
Bacteria cause most cases of endocarditis, but viruses, fungi, and other microorganisms can also lead to the condition. There have been reports of a fungus called Candida albicans causing endocarditis. Candida albicans is present in the mouth and gut. Healthy individuals are able to prevent the fungus from multiplying and causing an infection called candidiasis. Since HIV patients have weakened immune systems, the fungus may grow uncontrollably and can potentially spread to the heart, causing endocarditis.
Common symptoms include fever, chills, fatigue, weakness, aching muscles and joints, shortness of breath, night sweats, pale complexion, persistent cough, blood in urine, unexplained weight loss, tenderness in the spleen, new heart murmur (abnormal sound of the heart that can be heard with a stethoscope), and swelling in the legs or abdomen. Some patients may develop tender, red spots under the skin of the fingers (called Osler's nodes). Some may also experience tiny purple or red spots on the skin called petechiae. Similar spots may be present in the whites of the eyes or under the fingernails.
Several tests, including blood tests, echocardiograms, and a chest X-ray, may be necessary to confirm a diagnosis. Blood tests may reveal low levels of iron in the blood, called anemia. This condition is characteristic of endocarditis. Because endocarditis can make it harder for the heart to pump blood, an X-ray may reveal blood and fluid backed up in the lungs. An echocardiogram uses sound waves to produce images of the heart. Patients with endocarditis may have abnormal thickening or leakage of heart valves or abnormal growths that contain collections of bacteria.
Left untreated, endocarditis can damage the heart valves and permanently damage the lining of the heart. If the heart suffers from permanent damage, it may lead to heart failure, which is fatal. However, most patients who are diagnosed and treated promptly experience a full recovery. Patients receive intravenous (IV) antibiotics to treat the infection. The type of antibiotic and duration of treatment depends on the type and severity of the infection, as well as the patient's overall health.
Pericarditis is a possible complication of HIV/AIDS. Pericarditis occurs when the sac-like membrane that surrounds the heart becomes inflamed. Symptoms may include chest pain, shortness of breath, fever, fatigue, dry cough, and swollen legs and/or abdomen.
Pericarditis is usually caused by an infection such as staphylococcus, tuberculosis, or herpes simplex that spreads to the heart.
Patients with pericarditis may also have pleural effusions, which occur when the membrane that surrounds the heart fills with fluid. Research suggests that the six-month survival rate of AIDS patients who have pericarditis with pleural effusions is 36%, compared to 93% of AIDS patients who have pericarditis without pleural effusions.
During a physical examination, a healthcare provider listens to the patient's heart. When the sac around the heart is inflamed, it will make a distinct noise when it rubs against the outer layer of the heart. If abnormal sounds are present, a chest X-ray is warranted. Pericarditis is diagnosed after a chest X-ray reveals inflammation around the heart.
Treatment of pericarditis depends on the underlying cause. If an infection is causing the inflammation, patients will receive antibiotics. The specific medication and duration of treatment depends on the type and severity of the infection, as well as the patient's overall health. If the patient also has pleural effusions, the fluid will need to be drained at a hospital. During the procedure, called pericardiocentesis, a healthcare provider will administer a local anesthetic to numb the patient's chest. Then, a thin needle is inserted into the heart and fluid is removed. This treatment may last several days during the course of the patient's hospitalization.
pulmonary high blood pressure
Pulmonary high blood pressure is common among patients who have advanced HIV disease. This condition occurs when the arteries in the lungs become narrowed or blocked. As a result, there is an increased pressure of blood moving into the lungs and the heart has to work harder to pump blood to the lungs.
It remains unknown exactly why HIV patients have an increased risk of developing pulmonary high blood pressure. However, many HIV patients with the condition have other known risk factors, such as intravenous drug abuse or chronic liver disease (such as hepatitis).
Common symptoms of pulmonary high blood pressure include shortness of breath, fatigue, dizziness, chest pressure or pain, bluish colored lips and skin, increased heartbeat, and swelling of the ankles, legs, and abdomen.
According to one Swiss cohort study, pulmonary artery pressure increased in HIV patients who were not receiving antiretrovirals and it decreased in patients who were receiving antiretrovirals. Therefore, HIV patients with pulmonary high blood pressure should begin antiretroviral therapy if they are not already receiving it.
In addition to antiretrovirals, patients may receive diuretics, blood vessel dilators such as prostacyclin, endothelin receptor antagonists, such as bosentan (Tracleer®), high-dose calcium channel blockers such as amlodipine (Norvasc®), and anticoagulants such as warfarin (Coumadin®). Some patients may also receive supplemental oxygen. Patients who have severe pulmonary high blood pressure and do not respond to other treatments may need a heart or lung transplant.