CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 2, March 2012
AFRICA
93
sures and lower CD
4
cell counts (82 vs 322 cells/
µ
l,
p
=
0.003).
They also presented with multiple cardiac symptoms (Table 2).
Patients with MVP differed from the rest in that they had
lower mean BMI (18 vs 25 kg/m
2
,
p
=
0.002) while the patients
with normal echocardiographic findings had significantly higher
mean CD
4
counts (449 vs 266 cells/
µ
l,
p
=
0.003) and were
less likely to present with orthopnoea (0 vs 39%,
p
=
0.001) or
oedema of the lower limbs (11 vs 48%,
p
=
0.004) (Table 2).
Echocardiographic indices differed significantly in the differ-
ent diagnoses (Table 3). Of note, patients with dilated cardio-
myopathy had the lowest ejection fraction while those with large
pericardial effusions had the lowest stroke index. As expected,
patients with hypertensive heart disease had significantly higher
values of LVMI and RWT compared to patients with normal
echocardiographic findings (Table 3). Among patients diag-
nosed with pulmonary hypertension, the mean (
±
SD) estimated
systolic pulmonary pressure was 53 (21) mmHg.
Predictors of echocardiographic diagnoses
Pericardial effusion:
in a model of age, gender, HIV duration,
CD
4
cell count, pulse rate, haemoglobin level and WBC count,
younger age was independently associated with a diagnosis of
having a large pericardial effusion (OR 0.890, 95% CI: 0.792–
0.999,
p
=
0.049) (Table 4). Independent predictors of a small
pericardial effusion were higher resting pulse rate (OR 1.051,
95% CI: 1.013–1.090,
p
=
0.009), low CD
4
cell count (OR 0.996,
95% CI: 0.993–0.999,
p
=
0.004) and high WBC count (OR
1.280, 95% CI: 1.044–1.570,
p
=
0.018) (Table 4).
Hypertensive heart disease:
increasing age was a strong and
independent predictor of HHD. The odds of having HHD
increased by 20% for each additional year of age (OR 1.199,
95% CI: 1.106–1.300,
p
<
0.001). Other independent predictors
were higher haemoglobin level (OR 1.321, 95% CI: 1.052–
1.658,
p
=
0.017) and higher serum creatinine level (OR 1.004,
95% CI: 1.002–1.007,
p
=
0.002) (Table 4). Other variables in the
model were duration of HIV infection, BMI and use of HAART.
Pulmonary hypertension:
SBP, DBP, duration of HIV infection,
cholesterol level, age, gender and use of HAART were entered
into the multivariate analysis. There was no single independent
predictor of pulmonary hypertension.
Dilated cardiomyopathy:
low CD
4
cell count was an independent
predictor of having an echocardiographic diagnosis of DCM (OR
0.988, 95% CI: 0.978–0.998,
p
=
0.021) after adjusting for age,
gender, use of HAART and duration of HIV infection.
Adding source of referral (CTC vs wards) in the multivari-
ate models did not alter the final results, although in univariate
analyses, patients with small pericardial effusions were more
likely to have been from the wards, while patients with a diag-
nosis of HHD were more likely to have come from the care and
treatment centre (results not shown). Alcohol consumption and
cigarette smoking did not show any independent association with
the different diagnoses.
Discussion
Our study documents the frequency of occurrence of echocar-
diographically diagnosed cardiac abnormalities of any cause in
HIV-infected patients who had already presented with cardiac
symptoms. We found pericardial effusion to be the main echo-
cardiographic diagnosis among these patients. Characteristically,
the effusion was small surrounding the heart and with no
echocardiographically determined haemodynamic significance.
Patients with small pericardial effusions were also generally sick,
as evidenced by the presence of tachycardia, high WBC count,
high serum creatinine levels and low CD
4
cell count.
The finding of pericardial effusion among 41% of our
patients was higher than previously reported by other investiga-
tors. Heidenreich
et al.
found the annual incidence of pericardial
effusion among HIV-infected patients to be 11%.
20
In their study
they found the majority of the effusions to be small, asympto-
matic and occurring more often in patients with AIDS. Since our
patients were already symptomatic with cardiac complaints, this
could have resulted in the higher prevalence in our study.
TABLE 3. ECHOCARDIOGRAPHIC INDICES IN THE DIFFERENT DIAGNOSES
Variable
Normal
(
n
=
18)
Small effusion
(
n
=
36)
Large effusion
(
n
=
6)
HHD
(
n
=
35)
PHT
(
n
=
13)
DCM
(
n
=
10)
RV end-diastolic diameter (cm)
2.6
±
0.5
3.2
±
0.7*
2.8
±
0.1
3.1
±
0.5*
3.3
±
0.6*
3.9
±
0.8**
IVSd (cm)
1.02
±
0.19
1.08
±
0.26
0.94
±
0.14
1.35
±
0.27** 1.16
±
0.25 0.83
±
0.12*
PWTd (cm)
0.94
±
0.16
1.04
±
0.26
0.86
±
0.18 1.20
±
0.18** 1.03
±
0.19
0.87
±
0.18
LVIDd (cm)
4.19
±
0.65 5.09
±
0.98* 4.34
±
0.75
4.77
±
0.98
4.82
±
0.97 6.39
±
0.60**
RWT (cm)
0.41
±
0.12
0.43
±
0.15
0.41
±
0.15 0.53
±
0.14* 0.45
±
0.13
0.27
±
0.06**
LV mass index (g/m
2
)
81.9
±
20.7 133.9
±
56.9* 76.2
±
16 145.7
±
52.6** 119
±
43*
148
±
34**
E/A ratio
1.2
±
0.3
1.3
±
0.6
1.5
±
0.5
0.97
±
0.45
1.2
±
0.5
1.7
±
0.6*
MV deceleration time (ms)
192
±
67
160
±
62
170
±
64
189
±
53
182
±
63
103
±
48**
Isovolumic relaxation time (ms)
72
±
24
63
±
18
40
±
11*
85
±
22
73
±
16
54
±
12
Ejection fraction (%)
63
±
6
49
±
16*
65
±
3
58
±
15
55
±
12
30
±
8**
Ejection fraction < 50%,
n
(%)
0 (0)
17 (47)*
0 (0)
11 (31)
4 (31)
10 (100)**
Stroke volume (ml)
62
±
24
66
±
25
48
±
25
85
±
25*
60
±
12
51
±
18
Stroke index (ml/m
2
)
38.8
±
15.7
42.6
±
16.9
30.8
±
17.2 50.3
±
13.3*
36.4
±
7.6
33.2
±
11.5
Cardiac output (l/min)
5.8
±
2.5
6.1
±
2.4
4.8
±
2.5
7.4
±
2.5
5.7
±
1.3
5.4
±
2.2
RV
=
right ventricle, IVSd
=
interventricular septum in diastole, PWTd
=
posterior wall thickness in diastole, LVIDd
=
left ventricular internal diameter
in diastole, RWT
=
relative wall thickness, LV
=
left ventricular, MV
=
mitral valve, HHD = hypertensive heart disease, PHT = pulmonary hypertension,
DCM = dilated cardiomyopathy. *
p
<
0.05 vs normal, **
p
<
0.001 vs normal.
