As the human immunodeficiency virus (HIV) pandemic enters its third decade, the resultant acquired immunodeficiency syndrome (AIDS) is a global health crisis with approximately 36 million people affected worldwide.1,2 The disease is now the principal cause of death in young adults in many parts of the USA and Europe, and morbidity and mortality have risen sixfold in sub-Saharan Africa where modern health care is unavailable to many. Furthermore, over one million children worldwide are living with HIV/AIDS and 1600 babies are born with HIV infection every day.
Early therapeutic goals focused on prolongation of life by aggressive treatment of often fatal opportunistic infections, such as Pneumocystis carinii pneumonia. Descriptions of specific HIV related myocarditis and cardiomyopathy appeared during the 1980s and overall mortality fell with improved prophylactic regimens against opportunistic infection and clinical surveillance programmes. In the mid 1990s the advent of combination highly active antiretroviral therapy (HAART) made a major impact on the morbidity and mortality of HIV patients. Combination therapy reduces viral replication, delays disease progression, and prolongs survival, while limiting development of viral resistance. Survival to 40–50 years is no longer unusual and coronary artery disease, either de novo or as an iatrogenic consequence of newer treatment regimens, is emerging as an important problem.
HIV infection is characterised by an acquired, irreversible, profound immunosuppression that predisposes patients to multiple opportunistic infections, malignancies, and progressive dysfunction of multiple organ systems. HIV specifically infects and gradually depletes CD4+ lymphocytesw1 but may also affect other cell types, including monocytes/macrophages, endothelial cells, glial cells, intestinal epithelial cells, and possibly neurons. Studies have suggested that HIV may exhibit a cardiac tropism,w2 but the heart may also be affected by other opportunistic viruses, fungi, and protozoa. Cardiac disease associated with HIV may therefore be multifactorial, and can be caused by infectious or neoplastic complications or their treatments, any of the established causes of cardiac disease in other patient populations, or by HIV infection of the myocardium itself. Knowledge of the relative frequency of each form of heart disease in patients with HIV is constantly evolving and encapsulated in a series of review articles published over the past decade.2–7 w3–8 This article presents a review of our knowledge to date.