Recent advances in HIV-associated cardiovascular diseases in Africa

Abstract

The last decade has witnessed major advances in our understanding of the epidemiology and pathophysiology of HIV-related cardiovascular disease in sub-Saharan Africa. In this review, we summarise these and discuss clinically relevant advances in diagnosis and treatment. In the Heart of Soweto Study, 10% of patients with newly diagnosed cardiovascular disease were HIV positive, and the most common HIV-related presentations were cardiomyopathy (38%), pericardial disease (13%) and pulmonary arterial hypertension (8%). HIV-related cardiomyopathy is more common with increased immunosuppression and HIV viraemia. With adequate antiretroviral therapy, the prevalence is low. Contributing factors such as malnutrition and genetic predisposition are under investigation. In other settings, pericardial disease is the most common presentation of HIV-related cardiovascular disease (over 40%), and over 90% of pericardial effusions are due to Mycobacterium tuberculosis (TB) pericarditis. HIV-associated TB pericarditis is associated with a greater prevalence of myopericarditis, a lower rate of progression to constriction, and markedly increased mortality. The role of steroids is currently under investigation in the form of a randomised controlled trial. HIV-associated pulmonary hypertension is significantly more common in sub-Saharan Africa than in developed countries, possibly as a result of interactions between HIV and other infectious agents, with very limited treatment options. It has recently been recognised that patients with HIV are at increased risk of sudden death. Infection with HIV is independently associated with QT prolongation, which is more marked with hepatitis C co-infection and associated with a 4.5-fold higher than expected rate of sudden death. The contribution of coronary disease to the overall burden of HIV-associated cardiovascular disease is still low in sub-Saharan Africa.

Descriptive epidemiology and short-term outcomes of heart failure hospitalisation in rural Haiti

“…Cardiomyopathies may be attributed to micronutrient deficiencies19 or viral infections 20. Genetic polymorphisms among people of African ancestry have been associated with familial cardiomyopathies 21.…”

Global health and cardiovascular disease

“…In HIV-infected patients in sub-Saharan Africa, close to 100% of pericardial effusions are due to tuberculosis; the association with myopericarditis is common and an important part of it (40%) evolves with decreased LVEF 37. A factor of major relevance is that HIV-related cardiomyopathy is more common with increased immunosuppression and viraemia, whereas adequate antiretroviral therapy lowers its prevalence,38 implying that controlling this disease may reduce its CVD consequences.…”

“…Health systems in HICs face the rising costs of technology intensive care for their aging populations and cost-effectiveness studies are essential to optimise allocation of resources 52 53. LMICs have a more difficult task, as they have to confront the double burden of diseases and the interaction between them, exemplified by the growing numbers of HIV-related CVDs 7 38. In these countries, health systems must be prepared for the rise of NCDs, but still cope with the burden of communicable and nutritional diseases, to which the social determinants are even more important, such as the housing conditions for rheumatic heart disease and Chagas heart disease 11 54.…”

Myopericarditis in tuberculous pericardial effusion: prevalence, predictors and outcome

“…There has been a dramatic resurgence in the face of the HIV pandemic, with increased extrapulmonary or disseminated involvement 2. Close to 100% of pericardial effusions in those infected with HIV in sub-Saharan Africa are due to TB, compared with 50–70% without HIV and less than 5% in the developed world 3. Our preliminary observations suggest that in patients with TB pericarditis, co-infection with HIV is associated with increased clinical features of heart failure, haemodynamic instability, electrocardiographic ST elevation and an increased mortality, as compared with HIV-uninfected patients 4 5.…”