Management of cardiovascular conditions in a cohort of patients with HIV: experience from a joint HIV/cardiology clinic

Coronary artery disease

CAD was the most frequent diagnosis in this cohort. In total, 41 (34%) patients were either diagnosed or referred with suspected CAD. Details of CAD presentation, risk-factor profile and treatments carried out are shown in Table 2. Almost 70% (n = 24) of the patients presented with myocardial infarction (MI) as the initial diagnosis of CAD. These patients presented with MI at a relatively young age (mean age 48.3 years ± SD 7.5) and were treated with ART for a long period (mean duration 105.7 ± SD 69.7 months). Nearly 80% (n = 33) of the patients were dyslipidaemic and 60% (n = 25) were smokers. Only 2 patients were ART naïve prior to presentation. Nucleoside reverse transcriptase inhibitors (NRTI), either alone or in combination, were the frequently used group of drugs (Table 2). However, only 2/24 patients on NRTI or NRTI combination were on abacavir. The majority of patients were treated with percutaneous coronary intervention, with drug eluting stent being the preferred choice.

Cardiomyopathy

15 (12.5%) patients were diagnosed with cardiomyopathy following referral with heart failure symptoms and abnormal two-dimensional (2D) echocardiography. Dilated cardiomyopathy (DCM) was diagnosed in 9 cases; 7 were based on echocardiography and 2 on the basis of cardiac MRI (CMR). There were 2 cases of ischaemic cardiomyopathy. One case of ischaemic cardiomyopathy was also found to have left ventricular mural thrombus picked up on CMR and appropriately managed with warfarin. In 2 cases, hypertrophic cardiomyopathy was suspected on 2D echocardiography, confirmed on CMR, and appropriately risk stratified. There was one case each of post-partum and chemotherapy-induced cardiomyopathy. All the patients with left ventricular (LV) dysfunction were appropriately managed in line with current guidelines, including angiotensin-converting-enzyme inhibitors, beta-blockers and aldosterone antagonists. In addition, 2 patients with DCM underwent cardiac resynchronisation therapy; one with defibrillator and one with just pacing.

Hypertension

Hypertension was the primary diagnosis in 15 (12.5%) patients. This number is much higher if the patients with CAD with concomitant hypertension as a risk factor are included. In the majority of the cases no reversible cause was found and thus labelled as essential hypertension. In 1 case, hypertension was secondary to renal artery stenosis. Ambulatory blood pressure monitoring was used in 7 patients to aid in the management.

Arrhythmia

Cardiac arrhythmia was an important diagnosis seen in this cohort. Almost all were secondary to supraventricular tachyarrhythmia. Details of all 8 cases and treatment are outlined in Table 3. There were no cases of malignant arrhythmia or sudden arrhythmic cardiac death.

Others

A variety of both common and rare cardiovascular diagnoses totalling 41 (34%) patients were clustered in this group. These are outlined in Table 4

All patients with non-cardiac chest pain were discharged after appropriate investigations with myocardial perfusion scintigraphy, stress echocardiography or computerised tomography coronary angiography, in line with the hospital protocol. 14 patients were referred with palpitations as the main complaint; however history was not suggestive of any arrhythmia. These were reassured and discharged after negative yield on 24-hour Holter monitoring. 1 case of large pericardial cyst of non-specific aetiology required surgical removal in view of pain. 1 case of severe staphylococcal endocarditis required mitral valve replacement. 2 cases of massive pulmonary embolism were jointly managed with cardiologists monitoring for signs of right heart failure. 1 case of amyloid was referred to the national amyloid centre for further management. 2 cases of stroke/transient ischaemic attack with no specific aetiology underwent bubble echocardiography and trans-oesophageal echo to ensure no cause for paradoxical embolus. 2 cases of ventricular septal defect were monitored, as they were haemodynamically not significant. One case of what was thought to be abnormal electrocardiogram (ECG) was discharged as it turned out to be partial right bundle branch block on cardiology review.

Outcomes

7 cases of CAD represented with worsening angina or non-ST segment elevation myocardial infarction (NSTEMI). 2 cases of NSTEMI underwent further percutaneous coronary intervention (PCI). 2 cases of worsening angina had their medical therapy optimised as the stenosis on angiography was functionally non-significant on pressure wire testing. 1 case had aggressive atherosclerosis and was referred for coronary artery bypass surgery (CABG). A further 2 cases had medical therapy optimised, as there was no progression of disease.

Causes of death were ascertained from the HIV CoDe database. In total there were 5 deaths across the group, of which 3 were cardiovascular. This equates to 2.5% in this group and 4.3% of all HIV deaths over the last 4 years. 2 deaths were out-of-hospital: found collapsed at home. The in-hospital death was related to worsening heart failure. Both the out-of-hospital sudden deaths were discussed with the coroner. In 1 case, cause was ascertained due to MI following autopsy and the other case was labelled as death due to hypertensive heart disease with no autopsy.

In the same period, the total number of deaths in the entire HIV cohort under follow up at the Royal Free Hospital was 82. Of the 82 deaths, 25 were secondary to malignancy, 19 were related to infections, 6 were noted to be due to underlying metabolic problems, and 7 deaths were due to cardiovascular and neurological diseases. Further, 10 were attributed to suicide; 2 cases were secondary to road traffic accidents; and cause was not ascertained to 6 cases.