Pericardial effusion and cardiomyopathy

Early in the HIV epidemic, high rates (11%) of pericardial effusion were noted in patients with HIV infection (8).  With the advent of ART, the condition became much less common and in one study of 802 patients (of whom 85% were taking ART), only two (0.25%) were found to have echocardiographic evidence of a pericardial effusion and in neither case was cardiac function compromised (9). However, in Africa pericardial effusions are likely to be the first manifestation of HIV/AIDS related cardiac disease, often significantly large enough to cause tamponade, of which 70% can be due to Mycobacterium tuberculosis infection (10).

Cardiomyopathy in HIV-infected patients is thought to be multi-factorial, possibly resulting from  a) direct infection of the myocardium with HIV (with or without myocarditis), b)  the release of pro-inflammatory cytokines, c) opportunistic infections including cardiotropic viruses, d) nutritional disorders, and e) drug toxicity (11). Data from early in the epidemic suggested cardiomyopathy (measured as systolic dysfunction, usually as the ejection fraction) was much more common than in current times. A meta-analysis of more than 2200 asymptomatic HIV patients well-controlled on ART put the rate of systolic dysfunction at 8.3%, but diastolic dysfunction was present in 43.4%. Systolic dysfunction was associated with high serum CRP levels, smoking and previous myocardial infarction, while diastolic dysfunction was more common in older patients and those with hypertension (12).

Despite reductions in the incidence of both pericardial effusions and systolic dysfunction, these conditions should still be considered in the setting of HIV infection when someone presents with dyspnea, cardiomegaly and a raised jugular venous pressure, especially when CD4+ T cell counts are low.

Treatment entails optimising control of HIV replication, where necessary, with the addition of standard measures for the management of pericardial effusion and cardiomyopathy as appropriate. When end-stage cardiac failure results from any cause, consideration for cardiac transplantation should be entertained, as HIV infection is not a contraindication (13).