Starc TJ, Lipshultz SE, Easley KA, et al. J Pediatr. 2002;141:327–334
Purpose of the Study.
Human immunodeficiency virus (HIV) infection may be associated with severe cardiac complications. The objective of this study was to describe the 5-year cumulative incidence of cardiac abnormalities in HIV-infected children.
A prospective cohort was developed involving children from 10 hospitals throughout the United States. Group I included 205 HIV-infected children enrolled at a median age of 1.9 years and group II consisted of 600 HIV-exposed children enrolled prenatally or as neonates. Of this group, 93 were ultimately shown to be HIV-infected. Echocardiographic indices of left ventricular function were measured every 4 to 6 months.
In group I (retrospectively identified HIV-infected children), the 5-year incidence of left ventricular fractional shortening of ≤25% was 28%; left ventricular end-diastolic dilatation was 21.7%; and heart failure or the use of cardiac medications was 28.8%. The mortality rate 1 year after the diagnosis of heart failure was >50%. Within group II (at-risk infants), the 5-year incidence of decreased fractional shortening was 10.7% in the HIV-infected compared with 3.1% in the HIV-uninfected children. Left ventricular dilation, heart failure, or the use of cardiac medications were more common in infected children.
During the 5 years of this study, cardiac dysfunction occurred in up to 39% of HIV-infected children and was associated with an increased risk of death. The authors recommended that HIV-infected children undergo routine echocardiographic surveillance for cardiac abnormalities.
Prospective natural history studies are particularly useful as a tool to understand disease progression. The Pediatric Pulmonary and Cardiovascular Complications of Vertically Transmitted HIV Infection Study (P2C2) was initiated in 1990 and enrollment was concluded in 1994. At that time, very limited antiretroviral therapies were available and there were no potent combination therapies, currently referred to as highly active antiretroviral therapy (HAART). The remarkably high incidence of cardiac disease in this patient population largely represents the natural history of untreated or marginally treated HIV in perinatally infected children. The current incidence of heart disease in HIV-infected children is likely to be much less, and patients with previously demonstrated profound cardiac compromise have been noted to have normalized their echocardiographic measurements. It is not clear that routine echocardiographics surveillance of all HIV-infected children is indicated currently. In the HAART era, the best strategy for heart monitoring requires additional investigation.