|Year : 2015 | Volume
| Issue : 1 | Page : 27-31
Echocardiographic study of left ventricular function in HIV-infected Nigerians
Kelechukwu Uwanuruochi1, BJ Onwubere2, BC Anisiuba2
1 Department of Medicine, Federal Medical Centre, Umuahia, Abia, Nigeria
2 Department of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
|Date of Web Publication||3-Dec-2014|
Dr. Kelechukwu Uwanuruochi
Department of Medicine, Federal Medical Centre, Umuahia, PMB 7001
Source of Support: None, Conflict of Interest: None
Context: Left ventricular function in HIV/AIDS patients from South-East Nigeria has not been reported. Aims: We sought to determine the prevalence and spectrum of left ventricular function abnormalities in patients with HIV infection in the University of Nigeria Teaching Hospital (UNTH), Enugu, South-East Nigeria. Settings and Design: This was a descriptive, cross-sectional study of patients with HIV/AIDS at UNTH, Enugu from September 2006 to July 2007. Methods and Material: Sixty-six HIV-infected patients being managed at the antiretroviral therapy clinic and who had no other cardiovascular risk factor other than HIV infection were consecutively recruited. They were matched for sex, and age with seronegative healthy controls. Clinical and echocardiographic evaluation was carried out to assess the left ventricular function. Statistical Analysis Used: The findings were analyzed with statistical package for social sciences (SPSS) version 10.0. Results: The patients consisted of 29 males and 37 females aged between 23 and 62 years. Left ventricular systolic dysfunction was identified in 9 (13.6%) of 66 HIV-infected patients and 1 (4.3%) of 23 controls (P = 0.201) while left ventricular diastolic dysfunction (reversed fi lling pattern) was identifi ed in 19 (28.8%) and 3 (13.0%) of the HIV-infected patients and controls, respectively (0.021). Left ventricular hypertrophy was seen in 2 (3.0%) patients but in only 1 (4.3%) control (P = 0.647), while left ventricular dilatation was absent in all the patients and controls. Conclusions: Systolic function does not vary significantly between our patients with HIV/AIDS and sero-negative controls. This calls for further investigation of cardiac function in Nigerian HIV/AIDS patients.
Keywords: Echocardiographic; HIV-infected Nigerians; left ventricular function
|How to cite this article:|
Uwanuruochi K, Onwubere B J, Anisiuba B C. Echocardiographic study of left ventricular function in HIV-infected Nigerians. West Afr J Radiol 2015;22:27-31
|How to cite this URL:|
Uwanuruochi K, Onwubere B J, Anisiuba B C. Echocardiographic study of left ventricular function in HIV-infected Nigerians. West Afr J Radiol [serial online] 2015 [cited 2022 Sep 25];22:27-31. Available from: https://www.wajradiology.org/text.asp?2015/22/1/27/146145
| Introduction|| |
Cardiac involvement did not feature prominently in the early stages of the HIV epidemic. It was first reported by Austran et al. in 1983.  However, over the years, there has been a clear and growing body of evidence for cardiac dysfunction in a significant proportion of HIV patients. , Most studies have come from Europe and North America. Okeahialam and Anjorin  in Jos have reported 9% of AIDS patients being in overt congestive cardiac failure while Ige et al.,  has also reported that systolic dysfunction is significantly more frequent in HIV-infected children. A few other studies have also been conducted in Nigeria. , There has been no published report from South-East Nigeria. Our study sought to verify the pattern and prevalence of echocardiographic left ventricular function abnormalities in our local HIV population.
| Materials and Methods|| |
This was a descriptive and a cross-sectional study of patients with HIV/AIDS seen at the clinics and wards of University of Nigeria Teaching Hospital (UNTH), Enugu, from September 2006 to July 2007. UNTH is a tertiary hospital located in Enugu, the regional capital of the former Eastern region and presently the capital of Enugu state. Enugu is an educational, governmental, industrial and trade centre located at the foot of the Udi Plateau at the intersection of roads from Aba, Onitsha and Abakaliki. UNTH receives referrals from the entire South-eastern and neighboring states.
Ethical review: The project was reviewed and approved by the University of Nigeria Teaching Hospital Ethical Committee.
Sample size: Applying Fisher's formula  , n = z2pq/d 2 , with n = minimum sample size, z = 95% confidence level i.e. 1.96, and using level of precision (d) as 0.075,  P = maximum prevalence reported in a study of a similar population  (13.6%), and q = 1-p, a minimum sample size of 80 was obtained.
Patient selection: Patients aged 15 years and above with confirmed HIV-positive serology were eligible. The patients were recruited prior to commencement of anti-retroviral therapy. The exclusion criteria included all patients that had medical history of cardiovascular disease, patients who were on medications with cardiovascular effects, patients that were pregnant or in the puerperal period, patients who smoked or abused alcohol and those who had diseases that affect the cardiovascular system.
Clinical evaluation: The clinical evaluation and collection of samples were carried out at the antiretroviral therapy clinic of UNTH, Enugu. Patients were invited to participate in this cross-sectional study. Study subjects were interviewed by the investigator using a standard proforma to obtain demographic data and clinical history including history of hypertension, diabetes, among other risk factors. Physical examinations including blood pressure measurements using a standard sphygmomanometer (ACCOSON: cuff 12 × 25 cm) was carried out. HIV screening (by enzyme immunoassay), confirmatory (by Western-Blot electrophoresis), fasting blood sugar and CD4 cell counts of patients were part of investigations for patients benefiting from the antiretroviral therapy scheme. The CD4 cell counts were obtained using the flow cytometry method. Control cases of similar age and sex distributions were recruited from member of the hospital community and among those undergoing medical fitness screening. Echocardiography was done using the Hewlett-Packard SONOS 2000 machine and transducer of frequency 3.5 MHz. M mode, 2-dimensional, pulsed wave and continuous wave Doppler assessment was done with the subject in the left lateral position. Measurements were taken according to guidelines for two-dimensional echocardiography of the American Society of Echocardiography Committee on Standards.  The parasternal long axis (PLA) view was taken at third or fourth intercostal spaces. The M-mode tracing of the left ventricle was obtained from the PLA view with the cursor at a level just below the mitral valve leaflets. Doppler recording was obtained with the sample volume located between the tips of mitral leaflets. Parameters that were measured include the aortic root diameter, left atrial diameter, left ventricular end-diastolic dimension, left ventricular end-systolic dimension, septal wall thickness, posterior wall thickness, left ventricular isovolumic relaxation time, left ventricular deceleration time, and peak velocities of early (E) and late (A) ventricular filling. Using standard criteria  , the following measurements were derived: Left ventricular end-diastolic volume, Left ventricular end-systolic volume, Stroke volume, Ejection fraction, Fractional shortening, Left ventricular mass, Left ventricular mass index and Early to late diastolic peak velocity ratio.
Standardized criteria for defining abnormalities
For left ventricular hypertrophy, a partition value of 125 g/m 2 was used for men and 110 g/m 2 for women. 
Isolated (without dilatation) left ventricular systolic dysfunction was diagnosed in the presence of fractional shortening of less than 28% and normal left ventricular dimensions. 
In this study, diastolic dysfunction was diagnosed as impaired relaxation with an E/A ratio < 1. Note must however be taken that the various indices of LV diastolic function have incremental value and utilization of multiple parameters is therefore desirable in the assessment of LV diastolic dysfunction. 
We analyzed our data using the Statistical Package for Social Sciences (SSPS) version 15. The level of significance was P < 0.05.
| Results|| |
A total of 89 individuals made up of 51 (57.3%) females and 38 (42.7%) males took part in the study. The demographic and clinical features of the subjects and controls are described in [Table 1].
The gender distribution of the study population is described in [Table 2].
Comparison of echocardiographic parameters between the study subjects and the controls is shown in [Table 3], while spectrum of left ventricular abnormalities is given in [Table 4]. Sample of the echocardiographic images obtained are shown in [Figure 1] and [Figure 2]. The CD4 count results were obtained for 45 patients. The count ranged from 6.00 to 1293.00/μl with a mean of 202.67 ± 225.29/μl. T-cell lymphocyte subset was analyzed for the patients. Systolic and diastolic function was compared across the subsets. There was increased fractional shortening and impaired relaxation in both CD4 subsets compared to seronegative controls [Table 5]. When correlated, e/a ratio significantly correlated with the pulse (r = -0.305, P = 0.006).
|Figure 2: Fusion of A and E waves in a febrile patient with tachycardia. (Note pulse 114/minute)|
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|Table 5: Systolic and Diastolic function parameters compared across CD4 subsets and Controls|
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| Discussion|| |
The observed hemodynamic differences between our patients and the seronegative controls could be attributed to sepsis from immunosuppression and dehydration from chronic diarrhea. Excessive sympathetic stimulation from autonomic imbalance, increased metabolic demand in febrile illnesses and myocarditis would also all contribute to an increase in pulse rate. 
In all, 13.6% of our patients had systolic dysfunction unlike 4.3% of controls but this was not statistically significant. In a recent report, Danbauchi et al.,  found systolic dysfunction in 19 of 40 patients with stage III/IV HIV/AIDS. The higher prevalence in their study is expected considering that they reviewed patients at the later stages of the clinical profile.
Some other workers have reported wide-ranging figures for systolic dysfunction, such as 6.5% prevalence noted by Cardoso and colleagues  and 85.7% prevalence reported by Longo-Mbenza and colleagues.  The differences may be attributed to differences in characteristics of the study population and in definition of cardiac abnormality.
Diastolic dysfunction was noted in 28.8% of HIV-infected patients. On a similar note, Danbauchi et al.,  observed that 12 of 40 patients (30%) with stage III HIV/AIDS had diastolic dysfunction. Longo-Mbenza et al.,  from Congo found diastolic dysfunction in 85.7% of patients with HIV infection. Tachycardia has been noted to reduce compliance  , and this is likely to be the major mechanism by which ventricular filling is impaired in HIV/AIDS.
The lack of systolic dysfunction in many of our patients is explained by increased cardiac contractility in many patients, driven by increase in sympathetic activity due to attendant problems of anemia, dehydration from diarrhea, and fever. A sample echocardiographic image of such a patient. Hyperdynamic left ventricular performance with enhanced contractility in patient subsets has also been reported by Lipshultz et al.  Of course with progression of disease and ongoing infections, it is expected that some patients will go on to develop cardiomyopathy with impaired contractility.
Overall, the prevalence of left ventricular function abnormalities in this study was 39% in HIV/AIDS and 13.0% in control group. Prevalence rates have varied in different reports, depending not only on the population studied but also on the definition of cardiac abnormality as well as method of patient assessment. Herskowitz et al.,  from Maryland in the United States reported a prevalence rate of 17.5% but this did not include patients with diastolic dysfunction. Levy et al.,  in Washington on the other hand reported a 23% prevalence of left ventricular dysfunction among AIDS patients. Their definition of left ventricular dysfunction, however, included left ventricular dilatation as well as hypokinesia.
The 13.0% prevalence rate in our controls is not surprising as Longo-Mbenza et al.,  also found 13.8%, 6.9%, and 3.5% prevalence rates for diastolic dysfunction, left ventricular hypertrophy and ventricular dilatation, respectively, in their seronegative control population.
Diagnosis of diastolic dysfunction was based on E/A ratio. Color Doppler was not used in this study. These are limitations on the assessment of LV diastolic dysfunction. The exclusion criteria also did not include the use of herbal medications, some of which have cardiovascular side effects.
| Conclusion|| |
We report on the left ventricular function in HIV/AIDS patients seen in Enugu, South-East Nigeria. The prevalence of echocardiographic abnormalities compared to age- and sex-matched controls were 13.6% versus 4.34% for left ventricular systolic dysfunction (P = 0.201), 28.8% versus 23.04% for left ventricular diastolic dysfunction (0.021), 3.0% versus 4.34% for left ventricular hypertrophy (P = 0.647) and 39.4% versus 13.04% for overall left ventricular abnormalities (P = 0.028). Left ventricular dilatation was absent in our patients.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]