CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 2, March 2012
94
AFRICA
Heart failure from any cause can result in pericardial effusion.
Since many of our patients presented with heart failure (61%),
some of the pericardial effusion may have been due in part to the
heart failure
per se
.
Small and large effusions are often different in aetiology.
Small pericardial effusion around the heart is usually part of the
effusive process that involves the pleura and the peritoneum, also
known as capillary leak syndrome.
2, 21
The syndrome is probably
related to enhanced cytokine expression (e.g. TNF-alfa) in the
later stages of HIV infection. On the other hand, large pericardial
effusions in HIV disease may be related to opportunistic infec-
tions or to malignancy. Most often a clear aetiology is difficult
to establish, although several studies from Africa have reported
Mycobacterium tuberculosis
as the main cause.
11,22
In the multi-centre Investigation of the Management of
Pericarditis In Africa (IMPI Africa) registry, microbiological
evidence of tuberculosis was obtained in only 7% of the total 185
patients who were suspected of having tuberculous pericarditis,
23
further showing the difficulties in establishing the aetiology of
pericardial effusion. Other important causes of large pericardial
effusions include pyogenic infection, lymphomas and Kaposi’s
sarcoma.
24,25
For the seven-month data-collection period, we found only
six patients with large pericardial effusions. This is low when
compared to 28 similar cases that were collected in a period of 18
months in 1989 in our own hospital.
11
It is possible that the preva-
lence of large pericardial effusions has reduced with the use of
HAART, as has been previously reported by other investigators.
26
Second most common disease at presentation was hyper-
tensive heart disease. Several reports have suggested that HIV
patients are at a higher risk of becoming hypertensive than the
general population.
27
We found hypertensive heart disease in
34% of the patients. Interestingly, these patients had a longer
duration of HIV infection and had used HAART for a longer
time. Both HIV infection and use of HAART have been implicat-
ed as predisposing factors for hypertension.
7,8
The mechanisms
of development of hypertension in HIV-infected patients may
include vasculitis in small, medium and large vessels in the form
of leukocytoclastic vasculitis, and aneurysm of large vessels such
as the carotid, femoral and abdominal aorta, causing impairment
of flow to the renal arteries.
27
The use of HAART has also been associated with the devel-
TABLE 4. PREDICTORS OF ECHOCARDIOGRAPHIC DIAGNOSES IN HIV-INFECTED PATIENTS PRESENTING
WITH CARDIAC SYMPTOMS
Echo diagnosis
Univariate
Multivariate
OR (95% CI)
p-value
OR (95% CI)
p
-value
Small effusion
Age (years)
Pulse rate (beats/min)
Hb (g/dl)
Cholesterol (mmol/l)
Creatinine (µmol/l)
WBC (
×
10
9
/l)
CD
4
(cells/
µ
l)
HIV duration (months)
Duration HAART (months)
0.958 (0.921–0.998)
1.051 (1.022–1.082)
0.807 (0.701–0.930)
0.604 (0.436–0.837)
1.002 (1.000–1.004)
1.210 (1.041–1.406)
0.995 (0.992–0.997)
0.990 (0.976–1.004)
0.986 (0.966–1.006)
0.037
0.001
0.003
0.002
0.027
0.013
<
0.001
0.156
0.166
NS
1.051 (1.013–1.090)
NS
NS
1.002 (1.000–1.004)
1.276 (1.042–1.562)
0.996 (0.993–0.999)
NS
NS
0.009
0.066
0.018
0.004
Large effusion
Age (years)
Gender (men vs women)
SBP (mmHg)
Cholesterol (mmol/l)
HIV duration (months)
0.907 (0.820–1.003)
0.433 (0.082–2.273)
0.968 (0.927–1.010)
0.461 (0.207–1.028)
0.959 (0.904–1.017)
0.057
0.322
0.134
0.058
0.159
0.890 (0.792–0.999)
0.049
Hypertensive heart disease
Age (years)
Gender (men vs women)
Use of HAART (yes/no)
Duration of HAART (months)
BMI (kg/m
2
)
Pulse rate (beats/min)
Hb (g/dl)
Cholesterol (mmol/l)
Creatinine (
µ
mol/l)
HIV duration (months)
1.174 (1.101–1.251)
0.486 (0.205–1.150)
1.697 (0.717–4.017)
1.023 (1.002–1.044)
1.123 (1.029–1.226)
0.946 (0.914–0.978)
1.219 (1.064–1.396)
1.626 (1.223–2.163)
1.002 (1.000–1.003)
1.010 (0.998–1.021)
<
0.001
0.101
0.229
0.029
0.010
0.001
0.004
0.001
0.046
0.092
1.199 (1.106–1.300)
NS
NS
NS
NS
NS
1.321 (1.052–1.658)
NS
1.004 (1.002–1.007)
NS
<
0.001
0.017
0.002
Pulmonary hypertension
HIV duration (months)
SBP (mmHg)
DBP (mmHg)
Cholesterol (mmol/l)
0.981 (0.954–1.009)
0.969 (0.939–1.000)
0.962 (0.928–0.996)
0.676 (0.430–1.062)
0.190
0.050
0.030
0.089
NS
NS
NS
NS
Dilated cardiomyopathy
Age (years)
BMI (kg/m
2
)
Pulse rate (beats/min)
SBP (mmHg)
DBP (mmHg)
Cholesterol (mmol/l)
CD
4
(cells/
µ
l)
HIV duration (months)
0.921 (0.853–0.994)
0.899 (0.777–1.040)
1.033 (0.998–1.069)
0.965 (0.932–1.000)
0.951 (0.914–0.990)
0.594 (0.342–1.033)
0.988 (0.980–0.997)
0.977 (0.944–1.012)
0.034
0.154
0.062
0.050
0.013
0.065
0.010
0.195
NS
NS
NS
NS
NS
NS
0.988 (0.978–0.998)
NS
0.021
