Ana Olga Mocumbi, MD PhD FESC Physical Activity and Sports for Health and Development in Africa,...

HIV & Heart Disease in Africa

Ana Olga Mocumbi, MD PhD FESC

Physical Activity and Sports for Health and Development in Africa, Março 2014

HIV/SIDA


4

Source: U.S. Census Bureau, International Programs Center, unpublished tables.

0

10

20

30

40HIV Seroprevalence (Percent)

Botswana

Mozambique

Uganda

Zambia

Namibia

South Africa

Cardiovascular events have variable prevalence depending on

the method of screening; the most frequent manifestations are

cardiomyopathy, increase in left ventricular mass, miocarditis,

pericardial effusion, malignancies and endicarditis

Twagirumukiza M. Curr HIV Res. 2007


Any infectious agent causing systemic infection may affect the

cardiac muscle in the context of HIV but cardiac disease is usually

hidden by respiratory or cerebral manifestations; prevalence in

autopsies was between 28 and 73% in the pre-ART era

In Europe and USA morbidity and mortality are 6–10% e 1–9%,

respectively;


Cardiovascular global risk in HIV infected compared to HIV-negative

De Gaetano Donati, K., et al 2010.Physical Activity and Sports for Health and Development in Africa,

Março 2014

ART

HAART

Entry InhibitorsReverse

Transcriptase Inhibitors (RTIs)Nucleoside/

Nucleotide

RTIs (NRTIs)

Non-Nucleo

sideRTIs

(NNRTIs)

Protease Inhibitors


ART

Transformed HIV infection in a chronic condition with which

patients live for several years or decades;

Acute myocardial infarction and premature atherosclerosis occur

in young adults receiving ART, particularly protease inhibitors

Maggi P, et al. AIDS 2002; Passalaris JD, et al. Clin Infect Dis 2000.

DAD Study Group. N Engl J Med 2007; Stein JH, et al. J Acquir Immune Defic Syndr

2005


Cardiovascular Manifestations of HIV


Doenças cardíacas em pessoas infectadas pelo HIV

Doenças pericárdicas· Derrame pericárdico· Pericardite (viral, bacteriana, micótica)· Neoplasias (Sarcoma de Kaposi’s, limfoma)

Doenças miocárdicas· Cardiomiopatia dilatada associada ao HIV· Miocardite (aguda ou crónica) · Neoplasias (Sarcoma de Kaposi’s, linfoma)· Efeitos secundários de fármacos (em especial os anti-retrovirais)

Doenças do endocárdio· Endocardite infecciosa (bacteriana, micótica)· Endocardite não bacteriana trombótica

Doenças vasculares· Atherosclerose· Vasculite, perivasculite· Hipertensão arterial sistemica e pulmonar


Cardiovascular risk in HIV can be attributed to genetic factors, traditional risk factors, adverse effects of ART, and the inflammatory state related to the virus

De Gaetano Donati, K., et al 2010.

• Endotelial damage• Inflamation

• Comorbidies• Genetics

• Metabolic adverse effects

• Age• Smoking• Gender• Diabetes• Hypertension• Others

HIV Host

HAARTTraditional CV risk factors


HipertensionResist. insulinDislipidemia

20 40 60 80 years

Clinical FeaturesSubclinical Disease

AtherosclerosisHipertensive DiseaseHeart FailureDiab Mellitus type2Metabolic Syndrome

Angina/InfarctionStrokeHerat Failure Renal FailureVasculopathy

Cardiac failure & Left Ventricular Dysfunction

Ventricular dilatation in VIH+ may be due to infections, cardiotoxic agents, malnutrition,

antiretroviral therapy. Only 30 % of the HIV+ patients with ventricular dysfunction are

symptomatic, hence the need or more powerful screening using imagery.

Nosanchuk 2002, Lewis 2000, Frerichs 2002; Roy

1999 Physical Activity and Sports for Health and Development in Africa, Março 2014

Pericardial Effusion

In Africa pericardial effusion is much more frequent than in Europe or USA; 96% of the abundant effusions result from tuberculosis.

Heidenreich 1995, Stotka 1989, Reuter 2005, Neumann 2002


Arrhythmias

Tachycardia and fibrillation are the most frequent causes, usually in the context of heart failure and pericardial effusion

Cardiac arrhythmias can result from medication such as Efavirenze, foscarnet ou pentamidina.

Castillo 2002Physical Activity and Sports for Health and Development in Africa, Março 2014

Other Diseases

Thromboembolism (heart, arteries and veins) due to vasculitis or perivasculitis which also causes Aneurisms

Systemic Hypertension & Pulmonar Hypertension Ischaemic vascular disease


Metabolic Syndrome

Metabolic changes are frequently the result of ART. Thus, its incidence is expected

to increase with the increase in life expectancy associated with universal ART

Fisher 2001, Neumann 2002


Situation in Mozambique


316 (98,8%) patients were black

Race

NegraAsiaticaCaucasiana


Predominance of females 222 (69.4%)

Sexo

FemMasc


Excess of children (15.4%)

49

271

Idade

<15 anos>=15 anos

Sessao do CTC, Novembro 2013

Implications for Physical Activity

Take Home Messages


http://www.google.co.mz/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=NHLj8JAQogDkkM&tbnid=9BxUPlLV-BYL4M:&ved=0CAUQjRw&url=http://www.exercise-physiology.com.au/common-conditions.html&ei=y1EzU6f_Hc7J0AWXhID4Cg&psig=AFQjCNEJWTvkc-zzBCpuCOEIKgMlsB3flQ&ust=1395958415305596

Data from a Cardiology Clinic in Maputo, 2011

Concomitant HIV was diagnosed in 118 (11.8%) patients, of which 36 were older than 65 years

Most important conditions linked to HIV wereDilated Cardiomyopathy (45; 38.1%) Tuberculous Pericardite (23; 19.5%)

Pulmonary Embolism & Stroke


Cardiac Tamponade & Death


New Picture Age & Infection


Recommended for most cases …

Systemic HypertensionHypercholesterolemiaMetabolic SyndromeAsymptomatic…

There is need for research!


Transition & Acumulation


0-4 anos 5-15 anos

>15 anos

>65 anos

0

200

400

600

800

85 101

811

232

Distribuição por idade

997 patients observed in 12 months in a tertiary hospital

Thank you!


Ana Olga Mocumbi, MD PhD FESC Physical Activity and Sports for Health and Development in Africa,...

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