Diastolic Dysfunction is Common in Asymptomatic HIV Patients

1
Diastolic Dysfunction is Common in Asymptomatic
HIV Patients
Priscilla Y. Hsue1,2, Husam H. Farah1,2, Ann F.
Bolger1,2, Swapna Palav2, Samira Ahmed2, Amanda
Schnell1,2, Steven G. Deeks1,2, Jeffrey N.
Martin1, and David D. Waters1,2 1University of
California, San Francisco, 2San Francisco General
Hospital
Background
Table 2 Characteristics of HIV-Infected
Individuals
Results cont.
With the advent of antiretroviral therapy,
HIV-infected individuals are living longer and
developing chronic cardiovascular conditions.
Among the less well characterized conditions are
systolic and diastolic dysfunction. Prior
echocardiographic studies in HIV patients were
performed before the era of antiretroviral
medications.1,2 Studies in HIV-infected children
show that mild LV dysfunction and increased LV
mass are common and are associated with increased
mortality.3 A study of adult cocaine users with
HIV found that protease inhibitors were
associated with increased interventricular septal
thickness and decreased E/A ratios (which are
suggestive of LVH and diastolic dysfunction).4
Current use of antiretroviral medication, 81
Duration of HIV infection in years, median (IQR) 15 (11-18)
Use of antiretroviral medication Current Ever, but not current Never 81 11 8
PI duration yrs, median (IQR) 5.3 (0.96 to 7.7)
NRTI duration yrs, median (IQR) 7.9 (3.9 to 10.0)
NNRTI duration yrs, median (IQR) 0.29 (0 to 3.4)
CD4 T cell count/mm3, median (IQR) 420 (231-634)
Plasma HIV RNA copies/ml, lt75 76-1000 1001-10,000 gt10,000 63 15 9 13
Hepatitis C, 29.8
Methods cont Left ventricular hypertrophy (LVH)
Reference limits for LV mass/ BSA used
Women 43-95 g/m2 Men
49-115g/m2 Ejection Fraction
2D method 50
Predictors of LV mass index In HIV patients and
controls After adjusting for DM, CAD, age,
lipids, and cigarettes, HIV infection (Plt0.001),
male gender (P0.001), and hypertension (P0.022)
were associated with higher LV mass index. In
HIV patients only After adjustment for age, DM,
CD4 count, HIV viral load, duration of HIV
infection, and duration of PI use, male gender
(P0.012) and hypertension (P0.022) were
associated with higher LV mass index. Predictors
of diastolic dysfunction In HIV patients and
controls After adjustment for IVDU, DM, and
prior CAD, HIV infection (P0.027), LV ejection
fraction (P0.035), older age (Plt0.001), and
hypertension (P0.023) were associated with
diastolic dysfunction. In HIV patients only
After adjustment for DM, ART, duration of HIV
infection, and HIV viral load, age (P0.001), LV
ejection fraction (P0.036), and hypertension
(P0.023) were associated with diastolic
dysfunction. Predictors of Pulmonary Artery
Systolic Pressure After adjusting for age,
gender, smoking, IVDU, and hypertension,
HIV-infected subjects had a 4.0 fold greater odds
(95 CI 1.3 to 12) of having PASP gt 30mm Hg,
P0.016.
Purpose

• To determine the prevalence of systolic and
  diastolic dysfunction in a contemporary group of
  asymptomatic HIV patients
• To determine predictors of systolic and diastolic
  dysfunction in HIV-infected individuals

Figure 1A Figure 1B 1A Tricuspid
regurgitation in HIV patient 1B - Measurement of
TR jet velocity using continuous wave Doppler in
HIV patient
Results
Table 3 Echo findings
The characteristics of the patients are shown in
Tables 1 and 2. As shown in Table 3, the HIV
patients had a higher LV mass index compared to
controls. More than half of the HIV patients had
diastolic dysfunction the majority of which was
Stage 1 diastolic dysfunction.
Methods
HIV Patients n196 Controls n52 P value
LV mass index 78.5g/m2 17 69.1g/m2 14 lt0.001
LVEF 62 62 0.95
LV systolic dysfxn () 4.6 0 0.14
LVH () 11 4 0.13
Diastolic dysfunction Any () 100 (51) 15 (29) 0.004
Stage 1 () 98 (50) 15 (29) 0.006
Stage ( 2) 2 (1) 0 (0) 0.46
Patient selection - We studied HIV-infected adult
enrolled in the Study of the Consequences of the
Protease Inhibitor Era (SCOPE) cohort at San
Francisco General Hospital. This cohort consists
of 1) untreated patients, defined as no
antiretroviral therapy in the preceeding 6
months, 2) treated patients with detectable
viremia, defined as gt24 weeks HAART with the most
recent two HIV RNA levels gt50 copies/mL, and 3)
treated patients who achieved full viral
suppression defined as gt24 weeks HAART with two
most recent HIV RNA levels lt50 copies/mL. Echocard
iographic Studies - Echocardiography was
performed on 196 HIV-infected adults and 52
uninfected controls. Left ventricular ejection
fraction was assessed using the modified
Simpsons rule. Left ventricular mass was indexed
to body surface area. Diastolic dysfunction was
assessed using mitral and pulmonary vein inflow
patterns and doppler tissue imaging.5 Tricuspid
regurgitation was assessed in the parasternal
right ventricular inflow, parasternal short-axis,
and apical four-chamber views (Fig 1A). Three
sequential complexes were recorded and measured.
Continuous-wave Doppler of the peak regurgitant
jet velocity was used to estimate the pressure
gradient between the right ventricle and right
atrium using the modified Bernoulli equation
(Figure 1B). The right atrial pressure was
assessed according to degree of collapse of the
IVC.
Figure 1 . Serologic Testing for HHV-8
Results
Results
Table 1Characteristics of HIV-Infected and
Uninfected Subjects
HIV-Infected (n196) HIV-Uninfected (n52)
Age in years, median (IQR) 47 (42-52) 46 (40-56)
Male, 85 88
Race, African American Caucasian Hispanic 27 49 7 8 67 10
Injection drug use, Current Ever but not current Never 6 32 62 0.0 0.0 100
Cigarette smoking, Current Ever but not current Never Prior CAD HTN DM Hyperlipidemia 35 31 34 9 (4.6) 50 (25) 9 (4.6) 64 (33) 35 40 35 0 (0) 3 (6) 4 (7.7) 13 (25)
Conclusions
Asymptomatic HIV patients had a higher prevalence
of cardiac abnormalities, namely increased LV
mass, diastolic dysfunction, and mildly elevated
PASP, compared to uninfected controls. HIV
infection was independently associated with all
of these findings. Future studies are needed to
determine the etiology and natural history of
these abnormalities in HIV-infected individuals.
Figure 2. PAP in HIV-infected and uninfected
patients HIV-infected patients had a median PASP
of 26mm Hg (IQR 18-31) compared to controls,
22.5mm Hg (IQR 17-26), P0.001.
References

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• Meng Q et al. Use of HIV protease inhibitors is
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