IJCS | Volume 31, Nº5, September / October 2018

539 Roever et al. HIV and cardiovascular disease Int J Cardiovasc Sci. 2018;31(5)538-543 Review Article hypertension anddiabeteswere independently associated with a higher risk for death during ART. 13 Such findings show the immediate need to create resources to raise that population’s awareness about those risk factors. Of the cardiovascular diseases that affect HIV-infected people undergoing ART, ischemic and non-ischemic myocardial diseases stand out. 14,15 Ischemic cardiovascular diseases Regarding the ischemic diseases that affect HIV- infected people, acute myocardial infarction stands out. In addition, the incidence of sudden cardiac death of HIV- infected patients is significantly higher as compared to that of the general population with similar risk factors. 16 In the D:A:D study, acute myocardial infarction accounted for more than 50% of the causes of death due to cardiovascular diseases, followed by stroke. 13 In addition, as age advantages, the mortality rate due to those causes increases from 0.27 per 1,000 among young people to 16.99 per 1,000 in people aged over 70 years. 17 Corroborating those data, the mortality due to acute myocardial infarction of HIV-infected people was shown to be as much as three times higher than that of people of their same age. 18,19 According to a recently published study, HIV-infected people are at a higher risk for cardiovascular diseases as compared to the general population of the United States. In addition, seropositive males develop a higher risk of cardiovascular diseases throughout life, while women are at lower risk as compared to the general population of the United States. 20 Of the risk factors associated with acute myocardial infarction in HIV-infected people, the following are worth noting: age, male sex, smoking habit, hypertension, diabetes mellitus, dyslipidemia, moderate to high Framingham score, and use of protease inhibitors for at least 18 months. 19,21 Disorders of the heart’s electrical conduction system People with HIV infection have a change in the heart’s electrical conduction system. The major findings have shown a prevalence of prolonged QT interval on the electrocardiogram ranging from 28% to 65%. 22,23 In addition, regardless of the autonomic dysfunction or ART, there is a greater risk for ventricular arrhythmias and mortality due to prolonged QT interval in HIV- infected patients on combined ART. 24 Moreover, autonomic cardiac dysfunction has been shown in that population. Individuals infected with HIV undergoingART have increased sympathetic activity and a consequent increase in heart rate variability, shown by the heart rate values at rest. 25,26 Those data indicate an autonomic system imbalance, in which the sympathetic activity overlaps the parasympathetic activity. Pulmonary hypertension Pulmonary hypertension related to HIV has a conflicting epidemiology. In developing countries, its prevalence ranges from 0.6% to 13%, while in developed countries, it is 0.5%. 27,28 Pulmonary hypertension related to HIV can occur in any stage of the infection and associates with neither CD4+ cell levels nor viral load. 29 The most frequent symptom of pulmonary hypertension is dyspnea, but other symptoms, such as lower limb edema, syncope, fatigue, dry cough and chest pain, can be reported. 30 For individuals classified as NYHA functional class III-IV, the prognosis tends to be unfavorable, with a survival time of three years. 31 Although there is no cure, the condition can be treated. The options include support treatment, such as oxygen therapy, diuretics and oral anticoagulants, and specific medications for pulmonary hypertension, such as prostaglandins, endothelin receptor antagonists and calcium channel blockers. 30 Special care should be taken regarding the interaction between ART and the medications for pulmonary hypertension, mainly calcium channel blockers. Cardiomyopathy With the advent of ART, cardiomyopathy became frequent in HIV-infected people. The prevalence of systolic and diastolic dysfunction is approximately 8.3% and 43.3%, respectively. 32 In addition, myocarditis and dilated cardiomyopathy are observed in that population. Cardiomyopathy is associated with the increase in mortality caused by heart failure, 33 and is usually associated with socioeconomic status, long use of ART, low lymphocyte count (mainly CD4+ cell), high viral load and low serum level of selenium. 34 The assessment of HIV-infected individuals with cardiomyopathy should follow the recommendations for the general population. However, factors that can require specific therapies, such as opportunistic diseases, cardiotoxic drugs and coronary artery disease, should be investigated. 35