ROCHESTER, N.Y. - Heart failure (HF) has been linked to increased risk of death in children with HIV.
Researchers reported in Circulation that depressed left ventricular fractional shortening (LV FS) and increased wall thickness are risk factors for mortality in children with HIV, independent of depressed CD4 cell count and neurological disease. FS may be a long-term predictor of mortality, and wall thickness appears to be a short-term predictor.
"Because the significance of [HF] in children with HIV infection has been unclear, the condition has been overlooked," said lead researcher Steven E. Lipshultz, MD, professor of pediatrics and cardiology at the University of Rochester School of Medicine here. "Unfortunately the shortness of breath that characterizes [HF] is often misdiagnosed as a lung infection and treated with antibiotics when the children really need cardiac drugs and specialized nutritional support."
Researchers conducted baseline echocardiograms in 193 children with vertically transmitted HIV infection. Children, median age of 2.1 years, were followed for a median of five years. Measures of LV structure and function of predictive mortality, after adjustment for demographic and baseline clinical factors, were identified.
Cumulative survival after five years was 64%. The survival rate for children with enlarged left ventricles and increased heart wall thickness was 22.5% vs. 76.2% in patients with normal heart dimensions. Five-year survival was 51.7% for children with enlarged left ventricles only. Decreased LV FS (P<.001) and increased wall thickness were also predictive of increased mortality after adjustment for CD4 count, clinical center and encephalopathy.
FS showed abnormalities for up to three years prior to death, Lipshultz and colleagues reported. Wall thickness identified children at risk 18 to 24 months before death.
"This suggests that monitoring heart status should become a part of the care of children with HIV," said Lipshultz, who is also chief of pediatric cardiology at Children's Hospital at Strong and the University of Rochester Medical Center. "With monitoring, heart problems would be identified sooner and doctors could start aggressive treatment that may reduce the children's suffering and maybe prolong their lives."
Lipshultz said that when the AIDS epidemic began, children with vertically acquired HIV usually died by age 2. New treatments have increased survival for children in the developed world, and now HIV-positive children live an average of nine years.
The incidence of HF in HIV-positive children increases the longer the children live, Lipshultz said.
An earlier study by Lipshultz's group found that 10% of HIV-positive children develop chronic HF and another 10% develop transient HF that requires treatment for less than a month, usually when another illness affects their heart. Cardiac problems play a role in about one-third of all deaths in HIV-infected children.
Because HIV-positive individuals are at increased risk for respiratory infections, the medical teams that treat HIV-infected children usually include lung specialists but seldom cardiologists, he said.
"Heart problems in children with HIV are very common and the death and suffering they cause is oftentimes under appreciated," Lipshultz said.
"Aggressive treatment could reduce the suffering and give these children back some of their childhood," said Claude Lenfant, MD, director of the National Heart, Lung and Blood Institute, which funded the study. "The regular use of echocardiograms with HIV-infected children will help us identify those who may benefit from more careful examination and treatment to alter the course of the HIV-related heart disease."
For your information:
- Lipshultz SE, Easley KA, Orav EJ, et al. Cardiac dysfunction and mortality in HIV-infected children: The Prospective P2C2 HIV Multicenter Study. Circulation. 2000;102:1542-8.
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