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AIDS cardiomyopathy: first rule out other myocardial risk factors
International Elsevier
CARD10
Journal of Cardiology,
35
29 (1990) 35-31
01131
AIDS cardiomyopathy: first rule out other myocardial risk factors K.H. van Hoeven I, Brahm Segal 1 and Stephen M. Factor 122 Departments
of ’ Pathology and ’ Medicine, Albert Einstein College of Medicine, Bronx, NY, U.S.A. (Received 2 April 1990; accepted 5 April 1990)
Van Hoeven KH, Segal B, Factor SM. AIDS cardiomyopathy: Int J Cardiol 1990;29:35-37.
first rule out other myocardial risk factors.
Consecutive autopsies of 59 male AIDS patients revealed that 21 had other myocardial risk factors: 17 were alcohol abusers and 6 had hypertension or coronary artery disease. AIDS patients with these myocardial risk factors were older (mean age 45 versus 35 years, P < 0.00, and were more likely to have cardiomegaly (mean heart weight 397 grams versus 350 grams, P = 0.06) thanpatients with AIDS alone. When evaluating patients for AIDS cardiomyopathy, other myocardial risk factors must be considered. Key words: AIDS;
Cardiomyopathy;
Autopsy
Introduction Recent studies have reported structural, functional, and histopathologic abnormalities of the heart in patients with AIDS [l-3]. These reports examined consecutive series of AIDS patients, without using criteria to exclude AIDS patients with other myocardial risk factors. We tested the hypothesis that at least some of the heart disease encountered in AIDS patients may be partially attributable to other myocardial risk factors. By examining straightforward autopsy-derived parameters, we found more gross cardiac abnormalities in AIDS patients with other
Correspondence to: SM. Factor, M.D., Dept. of Pathology F-538, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, U.S.A. Supported in part by grants HL 37412 and HL 07071 from the National Institutes of Health.
0167-5273/90/$03.50
myocardial risk factors than in those patients with AIDS alone.
Methods The clinical and autopsy records were reviewed retrospectively for consecutive adult male AIDS patients who died at the Bronx Municipal Hospital Center during the years 1986 through 1988. Data were collected for the following variables: age at death, risk factor for AIDS, history of alcohol abuse and hypertension, time interval between diagnosis of AIDS and death, heart weight, left ventricular free wall thickness, presence of coronary artery disease, myocarditis, and histology evidence of viral infection other than human immunocleficiency virus at autopsy. A computerized database was constructed and analyzed. Values are reported as means plus or minus one standard deviation.
Q 1990 Elsevier Science Publishers B.V. (Biomedical Division)
36
Results
Percent
Fifty-nine male AIDS patients were identified who fit the study protocol. Of these 59, 21 were found to have myocardial risk factors other than infection with the human immunodeficiency virus; 17 were alcohol abusers, 4 had hypertension and 2 had coronary artery disease. Clinical and autopsy data are presented in Table 1. Notably, the prevalence of alcohol abuse was four times more common among intravenous drug users than in nondrug users (odds ratio 4.2). Compared to patients with AIDS alone, AIDS patients with other myocardial risk factors were significantly older, and were more likely to have cardiomegaly and abnormally increased left ventricular free wall thickness. Fig. 1 reveals the heart weight distribution between these two groups. There was no statisticial correlation be-
TABLE 1 Comparison of chnical and autopsy parameters among AIDS patients with and without other myocardial risk factors. Parameter
AIDS alone
Number(W) 38 (64%) Mean age 35*8 Mean time interval from diagnosis to death in months 7.8 Risk factors for AIDS intravenous drug 27 (71%) users (%) 0 alcohol abusers homosexuals (W) 12 (32%) 0 alcohol abusers 3 Unknown risk Heterosexual contact 0 Autopsy findings (W) with other viral infections present at death 21(55%) (S) with myocarditis 4 (11%) Mean heart weight (g) 350 f 82 Mean left ventricular free wall thickness (cm) 1.46*0.34
Of
cases
do,
AIDS with other myocardial risk factors 21(36%) 45*11
P
300-349
360-399
400-449
460-499
500*
Heart Weight (grams) m
AIDS
alone
m
AIDS
l
other
MRF
Fig. 1. Heart weight distribution among AIDS patients with and without other myocardial risk factors (MRF). The heart weight of AIDS patients with other myocardial risk factors tends to be greater than the heart weight of patients with AIDS alone.
tween heart weight and age (correlation coefficient = 0.17). The incidence at autopsy of concurrent viral infections, myocarditis, and the time interval from diagnosis of AIDS to death did not differ between these two groups. Thus, these parameters did not explain the differences in gross heart abnormalities which were found between AIDS patients with and without other myocardial risk factors. Discussion
15 (71%) 15 2 (10%) 1 2 2
1.59 kO.26
250-299
< 0.01
6.5
12 (57%) 3 (14%) 397*92
ZOO-249
0.06
0.16
Previous clinical and pathological studies of the heart in AIDS patients have found that between 50 and 60% have cardiac abnormalities [1,2]; however, no criteria were used to exclude patients who may have had other myocardial risk factors. The data we have shown demonstrate that it is important to take into account other myocardial risk factors when reporting cardiac lesions in AIDS. Furthermore, the data suggest that previous estimates of the prevalence of cardiac abnormalities in AIDS patients may be exaggerated. It is important to emphasize that these data do not refute the existence of a true AIDS cardiomyopathy. Some of our patients with cardiomegaly and AIDS alone demonstrated a dilated cardiomyopathy at autopsy with no histologic evidence of viral inclusions. Furthermore, cardiac tissues of selected AIDS patients from this
series have demonstrated the presence of HIV-l DNA sequences by Southern blot and the finding of multilamellated membrane bodies in myocytes by electron microscopy [4]. By utilizing more careful and prudent patient selection criteria, further studies are needed to characterize and define the pathogenesis of AIDS cardiomyopathy. References 1 Levy WS, Simon GL, Rios JC, Ross AM. Prevalence of cardiac abnormalities in human immunodeficiency virus infection. Am J Cardiol 1989:63:86-89.
2 Roldan EO, Moskowitz L, Hensley GT. Pathology of the heart in acquired immunodeficiency syndrome. Arch Path01 Lab Med 1987;111:943-946. 3 Monsuez JJ, Kinney EL, Vittecoq D, et al. Comparison among acquired immune deficiency syndrome patients with and without clinical evidence of cardiac disease. Am J Cardiol 1988;62:1311-1313. 4 FIomenbaum M, Soeiro R, Udem SA, Kress Y, Factor SM. Proliferative membranopathy and human immunodeficiency virus in AIDS hearts. J Acquir Immune Defic Syndr 1989;2:129-135.
CARD10
Journal of Cardiology,
35
29 (1990) 35-31
01131
AIDS cardiomyopathy: first rule out other myocardial risk factors K.H. van Hoeven I, Brahm Segal 1 and Stephen M. Factor 122 Departments
of ’ Pathology and ’ Medicine, Albert Einstein College of Medicine, Bronx, NY, U.S.A. (Received 2 April 1990; accepted 5 April 1990)
Van Hoeven KH, Segal B, Factor SM. AIDS cardiomyopathy: Int J Cardiol 1990;29:35-37.
first rule out other myocardial risk factors.
Consecutive autopsies of 59 male AIDS patients revealed that 21 had other myocardial risk factors: 17 were alcohol abusers and 6 had hypertension or coronary artery disease. AIDS patients with these myocardial risk factors were older (mean age 45 versus 35 years, P < 0.00, and were more likely to have cardiomegaly (mean heart weight 397 grams versus 350 grams, P = 0.06) thanpatients with AIDS alone. When evaluating patients for AIDS cardiomyopathy, other myocardial risk factors must be considered. Key words: AIDS;
Cardiomyopathy;
Autopsy
Introduction Recent studies have reported structural, functional, and histopathologic abnormalities of the heart in patients with AIDS [l-3]. These reports examined consecutive series of AIDS patients, without using criteria to exclude AIDS patients with other myocardial risk factors. We tested the hypothesis that at least some of the heart disease encountered in AIDS patients may be partially attributable to other myocardial risk factors. By examining straightforward autopsy-derived parameters, we found more gross cardiac abnormalities in AIDS patients with other
Correspondence to: SM. Factor, M.D., Dept. of Pathology F-538, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, U.S.A. Supported in part by grants HL 37412 and HL 07071 from the National Institutes of Health.
0167-5273/90/$03.50
myocardial risk factors than in those patients with AIDS alone.
Methods The clinical and autopsy records were reviewed retrospectively for consecutive adult male AIDS patients who died at the Bronx Municipal Hospital Center during the years 1986 through 1988. Data were collected for the following variables: age at death, risk factor for AIDS, history of alcohol abuse and hypertension, time interval between diagnosis of AIDS and death, heart weight, left ventricular free wall thickness, presence of coronary artery disease, myocarditis, and histology evidence of viral infection other than human immunocleficiency virus at autopsy. A computerized database was constructed and analyzed. Values are reported as means plus or minus one standard deviation.
Q 1990 Elsevier Science Publishers B.V. (Biomedical Division)
36
Results
Percent
Fifty-nine male AIDS patients were identified who fit the study protocol. Of these 59, 21 were found to have myocardial risk factors other than infection with the human immunodeficiency virus; 17 were alcohol abusers, 4 had hypertension and 2 had coronary artery disease. Clinical and autopsy data are presented in Table 1. Notably, the prevalence of alcohol abuse was four times more common among intravenous drug users than in nondrug users (odds ratio 4.2). Compared to patients with AIDS alone, AIDS patients with other myocardial risk factors were significantly older, and were more likely to have cardiomegaly and abnormally increased left ventricular free wall thickness. Fig. 1 reveals the heart weight distribution between these two groups. There was no statisticial correlation be-
TABLE 1 Comparison of chnical and autopsy parameters among AIDS patients with and without other myocardial risk factors. Parameter
AIDS alone
Number(W) 38 (64%) Mean age 35*8 Mean time interval from diagnosis to death in months 7.8 Risk factors for AIDS intravenous drug 27 (71%) users (%) 0 alcohol abusers homosexuals (W) 12 (32%) 0 alcohol abusers 3 Unknown risk Heterosexual contact 0 Autopsy findings (W) with other viral infections present at death 21(55%) (S) with myocarditis 4 (11%) Mean heart weight (g) 350 f 82 Mean left ventricular free wall thickness (cm) 1.46*0.34
Of
cases
do,
AIDS with other myocardial risk factors 21(36%) 45*11
P
300-349
360-399
400-449
460-499
500*
Heart Weight (grams) m
AIDS
alone
m
AIDS
l
other
MRF
Fig. 1. Heart weight distribution among AIDS patients with and without other myocardial risk factors (MRF). The heart weight of AIDS patients with other myocardial risk factors tends to be greater than the heart weight of patients with AIDS alone.
tween heart weight and age (correlation coefficient = 0.17). The incidence at autopsy of concurrent viral infections, myocarditis, and the time interval from diagnosis of AIDS to death did not differ between these two groups. Thus, these parameters did not explain the differences in gross heart abnormalities which were found between AIDS patients with and without other myocardial risk factors. Discussion
15 (71%) 15 2 (10%) 1 2 2
1.59 kO.26
250-299
< 0.01
6.5
12 (57%) 3 (14%) 397*92
ZOO-249
0.06
0.16
Previous clinical and pathological studies of the heart in AIDS patients have found that between 50 and 60% have cardiac abnormalities [1,2]; however, no criteria were used to exclude patients who may have had other myocardial risk factors. The data we have shown demonstrate that it is important to take into account other myocardial risk factors when reporting cardiac lesions in AIDS. Furthermore, the data suggest that previous estimates of the prevalence of cardiac abnormalities in AIDS patients may be exaggerated. It is important to emphasize that these data do not refute the existence of a true AIDS cardiomyopathy. Some of our patients with cardiomegaly and AIDS alone demonstrated a dilated cardiomyopathy at autopsy with no histologic evidence of viral inclusions. Furthermore, cardiac tissues of selected AIDS patients from this
series have demonstrated the presence of HIV-l DNA sequences by Southern blot and the finding of multilamellated membrane bodies in myocytes by electron microscopy [4]. By utilizing more careful and prudent patient selection criteria, further studies are needed to characterize and define the pathogenesis of AIDS cardiomyopathy. References 1 Levy WS, Simon GL, Rios JC, Ross AM. Prevalence of cardiac abnormalities in human immunodeficiency virus infection. Am J Cardiol 1989:63:86-89.
2 Roldan EO, Moskowitz L, Hensley GT. Pathology of the heart in acquired immunodeficiency syndrome. Arch Path01 Lab Med 1987;111:943-946. 3 Monsuez JJ, Kinney EL, Vittecoq D, et al. Comparison among acquired immune deficiency syndrome patients with and without clinical evidence of cardiac disease. Am J Cardiol 1988;62:1311-1313. 4 FIomenbaum M, Soeiro R, Udem SA, Kress Y, Factor SM. Proliferative membranopathy and human immunodeficiency virus in AIDS hearts. J Acquir Immune Defic Syndr 1989;2:129-135.