Antiretroviral
Therapy Does Not Improve HIV-associated Pulmonary Arterial Hypertension,
but High CD4 Cell Count Reduces Mortality
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| SUMMARY:
Despite the advent of combination highly active antiretroviral
therapy (HAART), people with HIV still develop pulmonary
arterial hypertension, a potentially fatal condition
characterized by obstruction causing high blood pressure
in the small arteries of the lungs. HAART alone did
not improve pulmonary hypertension, researchers reported
in the January
2, 2009 issue of AIDS, but people with higher
CD4 counts had a better prognosis, underlining the benefit
of starting treatment before serious immune deficiency
develops. |
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By
Liz Highleyman
Bruno
Degano from Hôpital Antoine-Béclère in Paris
and colleagues examined baseline characteristics and outcomes
of HIV-associated pulmonary arterial hypertension, aiming to determine
variables affecting survival in the HAART
era.
Over time, pulmonary hypertension can cause damage to the right
ventricle of the heart, which can result in heart failure. Prior
research has shown that HIV infection
is a risk factor for pulmonary hypertension, but it is not clear
whether HAART affects its occurrence or outcome.
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| Pulmonary
hypertension can be described as the increased pressure
the heart must pump against to move the blood from the
right side of the heart to the lungs for oxygenation
through the pulmonary arteries. |
|
This
retrospective analysis included data from 77 consecutive HIV positive
patients treated at the French Reference Centre for Pulmonary
Hypertension between October 2000 and January 2008 who had no
other known risk factors for pulmonary arterial hypertension.
At the time of pulmonary arterial hypertension diagnosis, 81%
of the patients were on HAART, 79% had a CD4 count > 200 cells/mm3,
and 49% had undetectable HIV viral load; about half were coinfected
with hepatitis B or C. The remainder started combination antiretroviral
therapy during pulmonary hypertension management, regardless of
HIV disease stage or CD4 count.
Results
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22%
of patients had mild symptoms of heart failure such as angina
(chest pains) and shortness of breath (New York Heart Association
functional class II). |
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69%
had more advanced symptoms that limited daily activities (class
III). |
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9%
had severe limitations, such as experiencing symptoms even
while at rest (class IV). |
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The
median 6-minute walk distance was 375 meters (about 1230 feet). |
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Median
pulmonary vascular resistance was 689 dyn s/cm5. |
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50
patients started specific therapy for pulmonary arterial hypertension,
which led to improvements in walk distance and hemodynamic
parameters. |
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Among
patients who received HAART but not specific pulmonary hypertension
therapy, walk distance improved by 18% but hemodynamics did
not change. |
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Overall
survival rates were 88% at 1 year, 72% at 3 years, and 63%
at 5 years. |
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In
a multivariate analysis, having a CD4 cell count > 200
cells/mm3 and a cardiac index more than 2.8 l/min per m2 were
independent predictors of survival. |
Based on these findings, the investigators concluded, "In
patients with [HIV-associated pulmonary arterial hypertension],
HAART seems unable to improve hemodynamic parameters."
"Prognosis in [HIV-associated pulmonary arterial hypertension]
is mainly related to CD4 lymphocyte count and cardiac function,"
they added.
While the outcomes seen here were better than those from some
prior studies of people with HIV, the authors noted in their discussion,
survival was significantly lower than that of HIV negative people
(5-year survival 63% vs 85%).
Centre
National de Référence de l'Hypertension Artérielle
Pulmonaire, Service de Pneumologie, Hôpital Antoine-Béclère,
Assistance Publique-Hôpitaux de Paris, Université
Paris-Sud 11, Clamart, France.
2/5/10
Reference
B
Degano, M Guillaume, L Savale, and others. HIV-associated pulmonary
arterial hypertension: survival and prognostic factors in the
modern therapeutic era. AIDS 24(1): 67-75 (Abstract).
January 2, 2009.
