Cardiac diseases in AIDS medical therapy: Difference between revisions
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{{Cardiac diseases in AIDS}} | {{Cardiac diseases in AIDS}} | ||
{{CMG}}; {{AE}} {{RT}} | {{CMG}}; {{AE}} {{RT}} | ||
==Overview== | |||
If the patient is not on [[antiretroviral therapy]], medical therapy for cardiac diseases in [[HIV]] infected patients requires co-ordination of care between cardiology and infectious disease department, in order to formulate an individualized treatment plan based on risk factors. Drug therapy for cardiac diseases in HIV patients is same as that for the general population, except for consideration for interactions of these drugs with [[HAART]]. Moreover, the benefits of HAART outweighs the risk of interactions with cardiac drugs. However, cardiotoxic drugs need to be discontinued. | |||
==Medical Therapy== | ==Medical Therapy== | ||
Majority of the AIDS patients with pericarditis are asymptomatic. Small pericardial | ===Pericarditis=== | ||
Majority of the [[AIDS]] patients with [[pericarditis]] are asymptomatic. Small [[pericardial effusion]]s without [[tamponade]] can be followed up without any further testing. In symptomatic patients with large effusions with or without a tamponade, [[pericardiocentesis]] is indicated to obtain culture and cytology <ref name="pmid8017317">{{cite journal |author=Hsia J, Ross AM |title=Pericardial effusion and pericardiocentesis in human immunodeficiency virus infection |journal=[[The American Journal of Cardiology]] |volume=74 |issue=1 |pages=94–6 |year=1994 |month=July |pmid=8017317 |doi= |url=}}</ref>. If tamponade occurs, immediate drainage is necessary <ref name="pmid10047635">{{cite journal |author=Chen Y, Brennessel D, Walters J, Johnson M, Rosner F, Raza M |title=Human immunodeficiency virus-associated pericardial effusion: report of 40 cases and review of the literature |journal=[[American Heart Journal]] |volume=137 |issue=3 |pages=516–21 |year=1999 |month=March |pmid=10047635 |doi= |url=}}</ref>. | |||
It is recommended that patients with pericarditis of unknown etiology be treated emperically for ''Mycobacterium tuberculosis''. Addition of [[ | It is recommended that patients with pericarditis of unknown etiology be treated emperically for ''[[Mycobacterium tuberculosis]]'' (4-drug therapy ([[isoniazid]], [[rifampicin]], [[pyrazinamide]], and [[ethambutol]]) for 2 months followed by 2 drugs (isoniazid and rifampicin) for 4 months). Addition of [[prednisolone]] to anti-tubercular therapy is associated with rapid recovery, lower mortality rates and decreased need for surgical intervention <ref name="pmid17976506">{{cite journal |author=Syed FF, Mayosi BM |title=A modern approach to tuberculous pericarditis |journal=[[Progress in Cardiovascular Diseases]] |volume=50 |issue=3 |pages=218–36 |year=2007 |pmid=17976506 |doi=10.1016/j.pcad.2007.03.002 |url=}}</ref><ref name="pmid3723722">{{cite journal |author=Sunderam G, McDonald RJ, Maniatis T, Oleske J, Kapila R, Reichman LB |title=Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS) |journal=[[JAMA : the Journal of the American Medical Association]] |volume=256 |issue=3 |pages=362–6 |year=1986 |month=July |pmid=3723722 |doi= |url=}}</ref>. In patients with undiagnosed pericardial effusion empiric anti-tuberculous therapy should be considered. | ||
Bacterial and fungal causes of pericarditis are treated with appropriate anti-bacterials and anti-fungals. | Bacterial and fungal causes of pericarditis are treated with appropriate anti-bacterials and anti-fungals. | ||
Pericarditis secondary to lymphoma can be treated with radiation and/or chemotherapy. However, combination chemotherapy has been shown to significantly increase the risk of early death from opportunistic infections. | Pericarditis secondary to [[lymphoma]] can be treated with radiation and/or [[chemotherapy]]. However, combination chemotherapy has been shown to significantly increase the risk of early death from opportunistic infections. | ||
Treatment of [[heart failure]] in patients with AIDS is similar to that of in general population. ACE | ===Heart Failure=== | ||
Treatment of [[heart failure]] in patients with AIDS is similar to that of in general population. [[ACE inhibitor]]s, [[diuretic]]s, [[beta-blocker]]s and [[digoxin]] are indicated as usual. Also, drugs that are known to cause cardiac side effects should be discontinued. | |||
Lifestyle modification (smoking cessation, weight reduction) and control of hypertension, diabetes and elevated cholesterol should be paid special attention. | Lifestyle modification (smoking cessation, weight reduction) and control of [[hypertension]], [[diabetes]] and elevated cholesterol should be paid special attention. | ||
===Infective Endocarditis=== | |||
Treatment of [[infective endocarditis]] in HIV-infected patients is similar to that of in the general population. | |||
Appropriate antibiotics against methicillin resistant ''Staphylococcus aureus'' ([[MRSA]]) should be administered for those who are IV drug abusers. | |||
===Pulmonary Hypertension=== | |||
Pulmonary hypertension can be treated by [[calcium channel blocker]]s, [[diuretic]]s, anticoagulation and prostacyclin analogues ([[epoprostenol]]). | |||
===Cardiac Tumors=== | |||
Chemotherapy and radiation therapy have been shown to have a variable effect in the treatment of primary cardiac lymphoma <ref name="pmid10479855">{{cite journal |author=Montalbetti L, Della Volpe A, Airaghi ML, Landoni C, Brambilla-Pisoni G, Pozzi S |title=Primary cardiac lymphoma. A case report and review |journal=[[Minerva Cardioangiologica]] |volume=47 |issue=5 |pages=175–82 |year=1999 |month=May |pmid=10479855 |doi= |url=}}</ref>. | |||
===Nutritional Deficiencies=== | |||
[[Selenium]]<ref name="pmid1865554">{{cite journal |author=Kavanaugh-McHugh AL, Ruff A, Perlman E, Hutton N, Modlin J, Rowe S |title=Selenium deficiency and cardiomyopathy in acquired immunodeficiency syndrome |journal=[[JPEN. Journal of Parenteral and Enteral Nutrition]] |volume=15 |issue=3 |pages=347–9 |year=1991 |pmid=1865554 |doi= |url=}}</ref> and [[carnitine]] deficiencies have been related to [[dilated cardiomyopathy]] and their supplementation has shown to be associated with recovery. | |||
==Management of Coronary Risk Factors in HIV-Infected Patients== | |||
In HIV patients with cardiovascular risk factors risk assessment is done using [[Framingham risk score]] <ref name="pmid16630034">{{cite journal |author=Law MG, Friis-Møller N, El-Sadr WM, ''et al.'' |title=The use of the Framingham equation to predict myocardial infarctions in HIV-infected patients: comparison with observed events in the D:A:D Study |journal=[[HIV Medicine]] |volume=7 |issue=4 |pages=218–30 |year=2006 |month=May |pmid=16630034 |doi=10.1111/j.1468-1293.2006.00362.x |url=}}</ref>. This risk score is used to calculate the 10-year risk of [[myocardial infarction]] or cardiac death in HIV patients with two or more risk factors. | |||
===Dyslipidemia=== | |||
Guidelines for the management of [[dyslipidemia]] in HIV patients are <ref>Guidelines for the Evaluation and Management of Dyslipidemia in Human Immunodeficiency Virus (HIV)-Infected Adults Receiving Antiretroviral Therapy: Recommendations of the HIV Medicine Association of the Infectious Disease Society of America and the Adult AIDS Clinical Trials Group</ref>: | |||
* If triglyceride (TG) levels are between 200 and 500 mg/dL and non-HDL-C cholesterol levels are high a [[statin]] is recommended. | |||
* If [[TG]] levels are higher than 500 mg/dL a [[fibrate]] ([[fenofibrate]]) should be started. | |||
However, statins and fibrates must be used with caution in HIV patients who are on HAART regimens containing [[protease inhibitors]], because of potential interactions. Protease inhibitors inhibit cytochrome P3A4 that metabolizes statins, thereby elevating the blood levels of these drugs. Statin drugs that are considered safe to use along with protease inhibitors are: | |||
* [[Pravastatin]] | |||
* [[Rosuvastatin]] | |||
* [[Atorvastatin]] | |||
Exceptions and contraindications for the use of statins in HIV patients include: | |||
* Pravastatin should not be prescribed in patients taking protease inhibitors | |||
* [[Lovastatin]] and [[simvastatin]] are contraindicated in patients taking protease inhibitors | |||
Studies have shown that adding a lipid-lowering drug is more beneficial than switching the anti-retroviral regimen as this may be associated with virologic failure <ref name="pmid15958836">{{cite journal |author=Calza L, Manfredi R, Colangeli V, ''et al.'' |title=Substitution of nevirapine or efavirenz for protease inhibitor versus lipid-lowering therapy for the management of dyslipidaemia |journal=[[AIDS (London, England)]] |volume=19 |issue=10 |pages=1051–8 |year=2005 |month=July |pmid=15958836 |doi= |url=}}</ref>. | |||
===Insulin Resistance=== | |||
* Studies have shown to improve insulin sensitivity in HIV patients with use of [[rosiglitazone]] and [[meformin]] <ref name="pmid17148967">{{cite journal |author=Mulligan K, Yang Y, Wininger DA, ''et al.'' |title=Effects of metformin and rosiglitazone in HIV-infected patients with hyperinsulinemia and elevated waist/hip ratio |journal=[[AIDS (London, England)]] |volume=21 |issue=1 |pages=47–57 |year=2007 |month=January |pmid=17148967 |doi=10.1097/QAD.0b013e328011220e |url=}}</ref>. | |||
===Lifestyle Modifications=== | |||
* Smoking cessation, dietary changes and exercise should be encouraged in HIV infected patients to further reduce the risk for developing coronary artery disease. | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
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[[CME Category::Cardiology]] | |||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Disease]] | |||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]
Overview
If the patient is not on antiretroviral therapy, medical therapy for cardiac diseases in HIV infected patients requires co-ordination of care between cardiology and infectious disease department, in order to formulate an individualized treatment plan based on risk factors. Drug therapy for cardiac diseases in HIV patients is same as that for the general population, except for consideration for interactions of these drugs with HAART. Moreover, the benefits of HAART outweighs the risk of interactions with cardiac drugs. However, cardiotoxic drugs need to be discontinued.
Medical Therapy
Pericarditis
Majority of the AIDS patients with pericarditis are asymptomatic. Small pericardial effusions without tamponade can be followed up without any further testing. In symptomatic patients with large effusions with or without a tamponade, pericardiocentesis is indicated to obtain culture and cytology [1]. If tamponade occurs, immediate drainage is necessary [2].
It is recommended that patients with pericarditis of unknown etiology be treated emperically for Mycobacterium tuberculosis (4-drug therapy (isoniazid, rifampicin, pyrazinamide, and ethambutol) for 2 months followed by 2 drugs (isoniazid and rifampicin) for 4 months). Addition of prednisolone to anti-tubercular therapy is associated with rapid recovery, lower mortality rates and decreased need for surgical intervention [3][4]. In patients with undiagnosed pericardial effusion empiric anti-tuberculous therapy should be considered.
Bacterial and fungal causes of pericarditis are treated with appropriate anti-bacterials and anti-fungals.
Pericarditis secondary to lymphoma can be treated with radiation and/or chemotherapy. However, combination chemotherapy has been shown to significantly increase the risk of early death from opportunistic infections.
Heart Failure
Treatment of heart failure in patients with AIDS is similar to that of in general population. ACE inhibitors, diuretics, beta-blockers and digoxin are indicated as usual. Also, drugs that are known to cause cardiac side effects should be discontinued.
Lifestyle modification (smoking cessation, weight reduction) and control of hypertension, diabetes and elevated cholesterol should be paid special attention.
Infective Endocarditis
Treatment of infective endocarditis in HIV-infected patients is similar to that of in the general population. Appropriate antibiotics against methicillin resistant Staphylococcus aureus (MRSA) should be administered for those who are IV drug abusers.
Pulmonary Hypertension
Pulmonary hypertension can be treated by calcium channel blockers, diuretics, anticoagulation and prostacyclin analogues (epoprostenol).
Cardiac Tumors
Chemotherapy and radiation therapy have been shown to have a variable effect in the treatment of primary cardiac lymphoma [5].
Nutritional Deficiencies
Selenium[6] and carnitine deficiencies have been related to dilated cardiomyopathy and their supplementation has shown to be associated with recovery.
Management of Coronary Risk Factors in HIV-Infected Patients
In HIV patients with cardiovascular risk factors risk assessment is done using Framingham risk score [7]. This risk score is used to calculate the 10-year risk of myocardial infarction or cardiac death in HIV patients with two or more risk factors.
Dyslipidemia
Guidelines for the management of dyslipidemia in HIV patients are [8]:
- If triglyceride (TG) levels are between 200 and 500 mg/dL and non-HDL-C cholesterol levels are high a statin is recommended.
- If TG levels are higher than 500 mg/dL a fibrate (fenofibrate) should be started.
However, statins and fibrates must be used with caution in HIV patients who are on HAART regimens containing protease inhibitors, because of potential interactions. Protease inhibitors inhibit cytochrome P3A4 that metabolizes statins, thereby elevating the blood levels of these drugs. Statin drugs that are considered safe to use along with protease inhibitors are:
Exceptions and contraindications for the use of statins in HIV patients include:
- Pravastatin should not be prescribed in patients taking protease inhibitors
- Lovastatin and simvastatin are contraindicated in patients taking protease inhibitors
Studies have shown that adding a lipid-lowering drug is more beneficial than switching the anti-retroviral regimen as this may be associated with virologic failure [9].
Insulin Resistance
- Studies have shown to improve insulin sensitivity in HIV patients with use of rosiglitazone and meformin [10].
Lifestyle Modifications
- Smoking cessation, dietary changes and exercise should be encouraged in HIV infected patients to further reduce the risk for developing coronary artery disease.
References
- ↑ Hsia J, Ross AM (1994). "Pericardial effusion and pericardiocentesis in human immunodeficiency virus infection". The American Journal of Cardiology. 74 (1): 94–6. PMID 8017317. Unknown parameter
|month=ignored (help) - ↑ Chen Y, Brennessel D, Walters J, Johnson M, Rosner F, Raza M (1999). "Human immunodeficiency virus-associated pericardial effusion: report of 40 cases and review of the literature". American Heart Journal. 137 (3): 516–21. PMID 10047635. Unknown parameter
|month=ignored (help) - ↑ Syed FF, Mayosi BM (2007). "A modern approach to tuberculous pericarditis". Progress in Cardiovascular Diseases. 50 (3): 218–36. doi:10.1016/j.pcad.2007.03.002. PMID 17976506.
- ↑ Sunderam G, McDonald RJ, Maniatis T, Oleske J, Kapila R, Reichman LB (1986). "Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS)". JAMA : the Journal of the American Medical Association. 256 (3): 362–6. PMID 3723722. Unknown parameter
|month=ignored (help) - ↑ Montalbetti L, Della Volpe A, Airaghi ML, Landoni C, Brambilla-Pisoni G, Pozzi S (1999). "Primary cardiac lymphoma. A case report and review". Minerva Cardioangiologica. 47 (5): 175–82. PMID 10479855. Unknown parameter
|month=ignored (help) - ↑ Kavanaugh-McHugh AL, Ruff A, Perlman E, Hutton N, Modlin J, Rowe S (1991). "Selenium deficiency and cardiomyopathy in acquired immunodeficiency syndrome". JPEN. Journal of Parenteral and Enteral Nutrition. 15 (3): 347–9. PMID 1865554.
- ↑ Law MG, Friis-Møller N, El-Sadr WM; et al. (2006). "The use of the Framingham equation to predict myocardial infarctions in HIV-infected patients: comparison with observed events in the D:A:D Study". HIV Medicine. 7 (4): 218–30. doi:10.1111/j.1468-1293.2006.00362.x. PMID 16630034. Unknown parameter
|month=ignored (help) - ↑ Guidelines for the Evaluation and Management of Dyslipidemia in Human Immunodeficiency Virus (HIV)-Infected Adults Receiving Antiretroviral Therapy: Recommendations of the HIV Medicine Association of the Infectious Disease Society of America and the Adult AIDS Clinical Trials Group
- ↑ Calza L, Manfredi R, Colangeli V; et al. (2005). "Substitution of nevirapine or efavirenz for protease inhibitor versus lipid-lowering therapy for the management of dyslipidaemia". AIDS (London, England). 19 (10): 1051–8. PMID 15958836. Unknown parameter
|month=ignored (help) - ↑ Mulligan K, Yang Y, Wininger DA; et al. (2007). "Effects of metformin and rosiglitazone in HIV-infected patients with hyperinsulinemia and elevated waist/hip ratio". AIDS (London, England). 21 (1): 47–57. doi:10.1097/QAD.0b013e328011220e. PMID 17148967. Unknown parameter
|month=ignored (help)