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 Table of Contents  
EDITORIAL COMMENTRY
Year : 2014  |  Volume : 11  |  Issue : 1  |  Page : 1-2

Cardiovascular abnormality in children with human immunodeficiency virus: Is there a need for cardiac screening?


Department of Child Health, Paediatric Cardiology Unit, University of Benin/University of Benin Teaching Hospital, Benin City, Nigeria

Date of Web Publication7-Apr-2014

Correspondence Address:
Wilson E Sadoh
Department of Child Health, Paediatric Cardiology Unit, University of Benin/University of Benin Teaching Hospital, Benin City
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-7969.130037

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How to cite this article:
Sadoh WE. Cardiovascular abnormality in children with human immunodeficiency virus: Is there a need for cardiac screening?. Nig J Cardiol 2014;11:1-2

How to cite this URL:
Sadoh WE. Cardiovascular abnormality in children with human immunodeficiency virus: Is there a need for cardiac screening?. Nig J Cardiol [serial online] 2014 [cited 2020 Sep 29];11:1-2. Available from: http://www.nigjcardiol.org/text.asp?2014/11/1/1/130037

Human immunodeficiency virus (HIV) infection is a pandemic with more than 34 million people living with the virus globally. Sub-Saharan Africa is home to 23.5 million persons living with the infection of which over 3 million are children. [1],[2] Nigeria's HIV prevalence is 4.1%, [3] while the annual HIV positive birth is 56,681. [4]

The HIV infection is a multisystemic disease with affectation of organ systems such as the respiratory, neurologic, hematologic, and gastroenteritis been described in both adults and children. The cardiovascular involvement is less well-reported on in children especially those of African descent in whom the burden of the infection is high.

Cardiovascular abnormalities in HIV

Cardiovascular complications from HIV infection result from a complex interplay of events ranging from direct myocardial invasion by HIV, chronic inflammatory immune response, endothelial dysfunction, autoimmunity to the HIV virus, pulmonary hypertension from recurrent parenchymal lung disease, and drug-related cardiotoxicity. [5]

Okoromah et al., [3] in a study on cardiovascular dysfunction in HIV-infected Nigerian children found a prevalence of 75.9% of cardiovascular abnormalities and recommended routine echocardiographic screening of HIV-infected children. The types of cardiovascular abnormalities that have been described in children include; pericarditis, myocarditis, dilated cardiomyopathy, valvular/vascular heart diseases, pulmonary vascular disease, pulmonary hypertension, cardiac failure, left ventricular systolic dysfunction, and increased left ventricular mass. The study by Ige et al., [6] an article in this issue, on left ventricular mass and diastolic dysfunction in children with HIV, uniquely found that there is a significantly higher prevalence of left ventricular diastolic dysfunction than in controls. They noted that diastolic dysfunction occurred in asymptomatic subjects. The study also found that increased left ventricular mass was more prevalent in children with HIV than in controls. Importantly, the subjects with increased left ventricular mass were younger and had more severe disease. The fact that the major route of transmission of HIV in children is vertical coupled with the poor health-seeking behavior of people especially from low socioeconomic background, may lead to a good number of young HIV-infected children with severe disease presenting to our clinics with various cardiovascular abnormalities.

The earlier studies [3],[6] are echocardiography-based works. There are typical electrocardiographic findings in studies on HIV-infected adults. Sani et al., in 2005 reported on the prevalent prolonged QTc in a population of HIV-infected Nigerian adults. There is a paucity of electrocardiographic studies on Nigerian HIV-infected children. However, other electrocardiographic studies in HIV-infected children in Africa [7] and Thailand [8] showed that besides prolonged QTc, other electrocardiographic abnormalities seen include low-voltage QRS complexes, ST-segment and T-wave changes, ventricular or supraventricular tachycardia, right bundle branch block, and enlargement of various heart chambers. HIV-infected individuals with prolonged QTc are at increased risk of having arrhythmias some of which may be fatal.

Need for cardiovascular screening

The high prevalence and range of cardiovascular abnormalities seen in children with HIV raises the need for screening for cardiovascular abnormality at baseline and perhaps at follow-up, to identify early those with cardiovascular abnormalities and institute measure where possible to ameliorate or halt the progression of such abnormality. Although it is echocardiographic screening that is being suggested, screening may also include chest radiograph and electrocardiography. The fact that some of the children with cardiovascular abnormalities are asymptomatic, may lend credence to the need to screen every HIV-infected child for possible cardiac abnormality. For instance, asymptomatic children with significant pericardial effusion may be picked up on echocardiography were echocardiographic test routine for HIV-infected children, and thus, provide an opportunity to prevent its progression to massive effusion and cardiac tamponade. The possibility of the above scenario playing out is supported by the association of HIV with dilated cardiomyopathy, a condition commonly complicated by pericardial effusion. The detection of pericardial effusion is best with echocardiography, being sometimes missed by Clinical evaluation and other investigating modalities. This has been shown in an earlier report. [9]

However, going by the large number of HIV-infected children, a policy of routine screening for cardiac abnormality may constitute a large burden on the health system and economic burden to the affected families most of whom are poor and may not afford the extra cost of cardiac investigations. The issue of economic burden is important against the background of the current program that ensures provision of free antiretroviral therapy and tests to HIV-infected patients in the country. Were the cardiac investigations to be free, who picks the bill, as the programs are run by donor agencies?

Where screening of every HIV infected child for cardiovascular abnormalities is not possible, then selected cases with increased risk of having cardiac complications should be investigated and managed as such. Infected children presenting with cardiac symptoms will be a clear indication for cardiac investigation, while a case may be made for children with severe HIV disease, but without cardiovascular symptoms as may be supported by findings from the Ige et al., study in which asymptomatic HIV-infected children also had cardiac abnormality. In addition, cardiovascular abnormalities seem to progress with worsening HIV disease. In the case of asymptomatic children, without severe disease, further studies are needed to develop evidence-based guideline to identify those who will require cardiovascular evaluation. Using clear indications for cardiac evaluation may reduce the burden on the small but growing number of facilities with pediatric cardiovascular care in the country and still improve cardiovascular care for HIV-infected children.


  Conclusion Top


HIV may be complicated by cardiovascular abnormality in children. There is need to identify those who will need cardiac evaluation and treatment. Clearly those with cardiovascular symptoms will be evaluated. There is, however, need for further studies in this subject to produce evidence-based guidelines for cardiovascular evaluation in HIV-infected children and also to study other areas such as electrocardiographic findings in children with HIV in which there is currently paucity of studies.

 
  References Top

1.Joint United Nations Programme on HIV/AIDS (UNAIDS) sub-Saharan Africa Regional Fact Sheet: UNAIDS Report on sub-Saharan Regional AIDS Epidermics; 2012. Found at: http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2012/gr2012/2012_FS_regional_ssa_en.pdf [Accessed 10 March 2014].  Back to cited text no. 1
    
2.Joint United Nations Programme on HIV/AIDS (UNAIDS) Global Facts Sheet: UNAIDS Global Fact Sheet World AIDS Day 2012 Report. Found at: http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2012/gr2012/JC2434_WorldAIDSday_results_en.pdf [Accessed 10 March 2014].  Back to cited text no. 2
    
3.Okoromah CA, Ojo OO, Ogunkunle OO. Cardiovascular dysfunction in HIV-infected children in a sub-Saharan African country: Comparative cross-sectional observational study. J Trop Pediatr 2012;58:3-11.  Back to cited text no. 3
    
4.National Agency for the Control of AIDS (NACA) National Factsheet: NACA national Factsheet Update on the HIV/AIDS Epidemic and Response in Nigeria; 2011. Found at: http://www.nigeriahivinfo.com/fact_sheets/hiv_fact_sheet_2011.pdf [Accessed 11 March 2014].  Back to cited text no. 4
    
5.Yunis NA, Stone VE. Cardiac manifestation of HIV/AIDS: A review of disease spectrum and clinical management. J Acquir Immune Defic Syndr Hum Retrovirol 1998;18:145-54.  Back to cited text no. 5
    
6.Ige OO, Oguche S, Yilgwan CS, Bode-Thomas F. Left ventricular mass and diastolic dysfunction in children infected with the human immunodeficiency virus. Nig J Cardiol 2014;11:8-12.  Back to cited text no. 6
  Medknow Journal  
7.Lubega S, Zirembuz GW, Lwabi IP, Heart disease among children with HIV/AIDS attending the paediatric infectious disease clinic at Mulago Hospital. Afr Health Sci 2005;5:219-26.  Back to cited text no. 7
    
8.Pongprot Y, Sittiwangkul R, Silvilairat S, Sirisanthana V. Cardiac manifestations in HIV-infected Thai children. Ann Trop Paediatr 2004;24:153-9.  Back to cited text no. 8
    
9.Sadoh WE, Okugbo SU, Isah AI. The clinical, radiographic and electrocardiographic correlates of childhood pericardial effusion diagnosed with echocardiography. Nig J Cardiol 2013;10:51-6.  Back to cited text no. 9
  Medknow Journal  




 

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