Sep. 28, 2000 DALLAS, Sept. 26 - For the first time researchers have linked heart failure to increased risk of death in children with HIV, according to a study in today's Circulation: Journal of the American Heart Association. The study shows that heart problems were associated with dying from AIDS regardless of a child's CD4 cell count, which is a measure of immune system function.
Researchers also found that, compared to children without heart problems, those who had heart abnormalities - such as reduced pumping ability, an enlarged left ventricle, or abnormal thickening of the heart muscle - were more likely to die within three years of being diagnosed with a heart condition.
"Because the significance of heart failure in children with HIV infection has been unclear, the condition has been overlooked," says the study's lead author Steven E. Lipshultz, M.D., professor of pediatrics and oncology at the University of Rochester School of Medicine.
"Unfortunately," he says, "the shortness of breath that characterizes heart failure is often misdiagnosed as a lung infection and treated with antibiotics when the children really need cardiac drugs and specialized nutritional support." Heart failure is a condition in which the heart can't squeeze with enough force to meet the body's need for blood supply. Lipshultz says heart problems are also prevalent in adults with HIV.
Researchers followed 193 children treated at 10 medical centers for about five years. They looked at the childrens' hearts using echocardiograms, which are simple, painless tests that create an ultrasound picture of the heart.
The five-year survival rate for children with enlarged left ventricles and increased heart wall thickness was 22.5 percent. In contrast, the five-year survival rate among children with normal heart dimensions was 76.2 percent. Five-year survival was 64.2 percent among children with only increased wall thickness, and 51.7 percent among children with only enlarged left ventricles. "This suggests that monitoring heart status should become a part of the care of children with HIV," says Lipshultz, who is also chief of pediatric cardiology at Children's Hospital at Strong and the University of Rochester Medical Center. HIV causes AIDS, the severe suppression of the body's immune system. "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 says that when the AIDS epidemic began, children like those in this study - all of whom got HIV from their mothers before birth - usually died by age two. However, he says new treatments have increased survival for children in the developed world, and HIV-positive U.S. children now live an average of nine years.
"The percentage of HIV-positive children with congestive heart failure increases the longer the children live," Lipshultz says. An earlier study by Lipshultz and his colleagues found that 10 percent of HIV-positive children develop chronic congestive heart failure and another 10 percent develop transient heart failure that requires treatment for less than a month, usually when another illness strains their hearts. Heart 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, such as pneumonia, the medical teams that treat children with HIV usually include pediatricians and lung specialists but seldom cardiologists, he says.
"Heart problems in children with HIV are very common and the death and suffering they cause is oftentimes under appreciated," he says. "Aggressive treatment could reduce the suffering and give these children back some of their childhood."
Claude Lenfant, M.D., Director of the National Heart, Lung and Blood Institute, which funded the study, says, "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."
Co-authors include Kirk A. Easley, M.S.; E. John Orav, Ph.D.; Samuel Kaplan, M.D.; Thomas J. Starc, M.D., M.P.H.; J. Timothy Bricker, M.D.; Wyman W. Lai, M.D., M.P.H.; Douglas S. Moodie, M.D.; George Sopko, M.D., M.P.H.; Steven D. Colan, M.D. All are members of the P2C2 HIV study, a natural history study of heart and lung complications of HIV infection transmitted by maternal exposure.
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