Cardiomyopathy in HIV patients has been shown to progress faster than idiopathic Dilated Cardiomyopathy in the HIV negative population. It is therefore important to recognize this condition early in this population and manage it appropriately. Studies need to be done to validate the current therapy for cardiomyopathy in this population since it is still unclear that LV dysfunction in this population responds in a similar fashion as in HIV negative patients with Dilated Cardiomyopathy

1. HIV associated Dilated
Cardiomyopathy
Leonard Sowah, MBChB, MPH
Assistant Professor of Medicine
University of Maryland School of Medicine

2. Educational Objectives
 Relative Magnitude of Dilated Cardiomyopathy in HIV
patients
 Discuss the Pathophysiological Mechanisms involved in
this condition
 Discuss clinical Manifestations
 Evaluation of patients with suspected Cardiomyopathy
 Therapeutic Options for HIV associated Dilated
Cardiomyopathy
 Areas of Future Research

3. Disease Epidemiology
 Incidence of HIV associated Dilated
Cardiomyopathy was 15.9/1,0000 person yrs in
the pre HAART era1
 HAART therapy has reduced incidence by close
to 30% in developed countries2, 3
 The adjusted hazard ratio of mortality
comparing HIV DCM to Idiopathic DCM is 5.861
 Prevalence in Developing countries is about 32%4
1. AIDS 2003; 17: Suppl 1, S46 – S50
2. J Infect Dis 2000; 40: 282 -4
3. J. Acquir Immune DeficSyndr 2001; 27: 318 – 20
4. Postgrad Med J 2002: 78: 678 - 81

4. Epidemiology Continued
 40 – 52% of patients who died of AIDS in the Pre
HAART era had evidence of Myocarditis at
autopsy1
 In data from the Pre to Early HAART Era median
survival in HIV positive children with LV
dysfunction was 101 days compared with 472
days in patients with normal hearts2
 In a Cohort of Perinatally infected HIV patients
the cumulative 5 yr survival was lower in patients
with baseline depressed LV fractional shortening3
1. Klatt EC. 2003; Adv Cardiol; 40: 23 - 48
2. N Engl J Med 1998, 339: 1153 – 1155
3. J Peadiatric 2002, 141: 327 - 334

5. Etiology
 Likely related to infection of Cardiac
Myocytes by opportunistic organisms
 DNA Hybridization of cardiac tissue from
autopsies of HIV associated DCM reveal
• Toxoplasmagondi – 12 %
• Coxsackie B3 – 32%
• EBV – 8%
• CMV – 4%
• HIV – 82%
Klatt EC. 2003; Adv Cardiol; 40: 23 - 48

6. Etiology
 HIV cardiac muscle auto-immunity, HIV
positive patients are 4x more likely to
have cardiac auto-antibodies
 In one study 43% of had cardiac specific
auto-antibodies
AIDS 2003, 17: S21 – S28
Heart 1998, 79: 599 - 604

7. Nutritional Factors
 Malabsorption and diarrhea in HIV may
lead to micro-nutrient deficiency
 Selenium replacement may restore LV
function in HIV and reverse DCM in
selenium deficient patients
 HIV may be associated with vitamin B12,
carnitine, growth hormone and thyroid
hormone deficiencies all of which may
be associated with LV dysfunction
J ClinNutr 1997; 66: 660 - 4

8. Association with HIV Encephalopathy
 HIV Encephalopathy is associated with
severe LV dysfunction
 HIV virus persists in myocardial and
cerebral viral reservoir even after
starting HAART
 These cells may cause progressive tissue
damage by the release of cytotoxic
cytokines
Fischer SD, Lipschultz SE, Ann NY AcadSci 2001; 946:13 - 22

9. Clinical Presentation
 May present as acute myocarditis if seen
early
 Fever with flu-like symptoms
 Palpitations
 Atypical chest pain
 Shortness of breath
Am J Emergen Med 2001; 19: 566 - 74

10. Physical Signs
 Physical exam may be normal
 Signs of heart failure may be present
 Bilateral basal crackles
 Bi-pedal edema
 Pericardial friction rub
Am J Emergen Med 2001; 19: 566 - 74

11. Lab Investigations
 New changes from baseline EKG
 Usually conduction abnormalities, LBBB, First
degree AV block
 Chest X-ray
 Cardiomegaly mainly LV Dilatation with
rounding of the apex
 Elevated Cardiac Troponins
 Occurs in early stages with myocarditis may be
confused with a new Myocardial Infarction
 Increase in CK-MB
Am J Emergen Med 2001; 19: 566 - 74

12. CONDUCTION SYSTEM ABNORMALITIES
 First degree AV Block
 Bundle branch Block
 In one autopsy series 5/12 patients who
died of HIV associated DCM had intracardiac
conduction abnormalities
 Histopathology shows myocarditis with
fibromatous degeneration of the conduction
system
AIDS Res Human Retroviruses 1998; 14: 1071 - 77

13. ECHOCARDIOGRAPHY
 Echocardiography is the mainstay
diagnosis
 There is Concentric Left Ventricular
hypertrophy
 There is ventricular dilatation
 Left Ventricular Ejection Fraction is
reduced with global hypokinesia
 Usually no regional wall motion
abnormalities
AIDS Res Human Retroviruses 1998; 14: 1071 – 77
Indian Heart J. 2010 Jul-Aug;62(4):330-4

14. Coronary Angiograms
 Not required in all cases however in
patients with significant CAD risk
factors may be helpful.
 Coronary blood vessels are usually
free of significant occlusive
atheroscleroctic disease
Am J Emergen Med 2001;19: 566 - 74

15. HISTOPATHOLOGY
 HIV associated Cardiomyopathy is
associated with intense staining for
TNF α and iNOS (inducible Nitric Oxide
Synthase) compared with Idiopathic
DCM
 Other histological features did not
differ significantly from idiopathic
DCM
1. AIDS Res Human Retroviruses 1998; 14: 1071 - 77

16. NYHA CLASSIFICATION OF HEART
FAILURE
American Heart Association

17. Clinical Management
 In one Pediatric series patients
treated with monthly IV
Immunoglobulin infusions were shown
to revert back to normal LV wall
thickness1
 Therapy for LV systolic dysfunction is
otherwise the mainstay of
management2
1. Circulation 1995,; 92: 2220 – 25
2. Am J Emergen Med 2001; 19: 566 - 74

18. Management
 Patients with systolic dysfunction are
treated like standard CHF patients
 Loop Diuretics
 Aldosterone Receptor Blockers
 Ace-Inhibotors
 B-blockers can be started once patient
is euvolemic
 Digoxin may be added to improve
contractility
1. Am J Emergen Med 2001; 19: 566 - 74

19. Adjunctive Management
 AICD (Automatic Implantable Cardiac
Defibrillators)
 Can be used in patients with severely
depressed LV dysfunction
 This has not been validated to reduce
incidence of sudden cardiac death in the
HIV positive population
N Engl J Med 2005; 352:225–237

20. USE OF AICD IN HEART FAILURE
N Engl J Med 2005; 352:225–237

21. Areas of Future Research
 Validation of standard CHF therapy in
HIV associated DCM ?
 Data on the efficacy of AICD in HIV
associated DCM
 Use of IV immunoglobulin in early
identified adult disease at the early
myocarditis stage