Cardiovascular manifestations of people living with HIV/AIDS: Report from a hot spot in eastern India

Objective To study the profile and characteristics of cardiovascular abnormalities among patients living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) at a tertiary care hospital in India. The association of cardiovascular abnormalities with the CD4 count and disease stages, according to the World Health Organization (WHO) classification, was also analyzed. Methods A total of 200 patients with HIV/AIDS were compared with 50 healthy controls. All patients underwent blood investigations, chest X-ray, electrocardiography, and echocardiography. Results The mean age of the patients was 38.66 ± 9.22 years, with a male-to-female ratio of 3.25:1. Echocardiographic abnormalities were found in 52% of the patients and 12% of the controls, with the most common abnormality being left ventricular diastolic dysfunction. Echocardiographic abnormalities were markedly more common in patients with a CD4 count of <200/μL. The advanced stage of the disease, according to the WHO classification, was also associated with an increased incidence of echocardiographic abnormalities. Conclusions Cardiovascular abnormalities in the form of electrocardiogram and ECHO findings were present in 54.5% and 52% of patients, respectively. Echocardiographic findings showed significant correlation with CD4 count and WHO disease stage.

Glycaemic Control and Cardiovascular Outcomes in Diabetes : Review

While type 1 diabetes mellitus (DM) is characterised by insulin deficiency due to pancreatic beta-cell destruction; type 2 DM is characterised by a state of longstanding insulin resistance (IR); compensatory hyperinsulinaemia and varying degrees of elevated plasma glucose levels (PG); associated with clustering of cardiovascular (CV) risk and the development of macrovascular disease prior to the diagnosis of DM. Coronary artery disease (CAD) accounts for 70of mortality and morbidity in patients with diabetes. Studies in diabetes care have helped prevent or reduce microvascular complications in type 1 and 2 diabetes. However the same cannot be said about macrovascular disease. Despite all data concerning the association between diabetes and cardiovascular disease (CVD); the exact mechanism by which diabetes is linked to atherosclerosis is incompletely understood; and this is especially true in the case of hyperglycaemia. The positive effect of intensive glucose management in comparison to non-intensive glucose control is far from proven. The DCCT and UKPDS studies have shown that while glycaemic control is important for preventing long-term macrovascular complications; early glucose control is far more rewarding (metabolic memory). Later trials such as ACCORD; ADVANCE and VADT do not advocate tight glycaemic control. In fact; the ACCORD trial has shown increased mortality with tight glucose control. Tight glucose control may be beneficial in selected patients with short disease duration; long life expectancy and no CVD. In critically ill patients; a blood glucose target of 140-180 mg is fairly reasonable and achievable. The ESC/EASD guidelines of October 2013; like those of the ADA; AHA and ACC; continue to endorse a treatment target for glucose control in diabetes of HbAlc level 7; based predominantly on microvascular disease with acknowledged uncertainty regarding the effect of the intensive glucose control on CVD risk. Management of hyperglycaemia in diabetics should not be considered in isolation; diabetics require multifactorial intervention for hypertension; dyslipidaemia and microalbuminuria besides hyperglycaemia. In fact; the combined use of antihypertensives; aspirin and lipid-lowering agents makes it difficult to discern the beneficial effects of antihyperglycaemic therapy

Role of HDL-C in health and disease.

Reverse cholesterol transport by high density lipoprotein cholesterol (HDL-C) has been traditionally considered to be the most important mechanism by which HDL-C protects against atherosclerosis. Recently HDL-C has been shown to have cardioprotective effects at many levels which include prevention of low density lipoprotein cholesterol (LDL-C) oxidation, vascular wall inflammation and thrombosis. Apolipoprotein A-1 (ApoA-1) is major constituent of HDL and is synthesised in the liver and intestine. ApoA-1 is lipidated by ATP binding cassette transporter (ABC A-1) which is rate limiting step in HDL biogenesis. Once in the plasma, the nascent HDL undergoes intensive remodelling. The HDL-C has important biological effects on endothelial cells, monocytes, Tlymphocytes, and platelets. Currently, the HDL is being tested as a therapeutic agent with beneficial role being shown in coronary artery disease, diabetes mellitus. The reconstituted HDL (rHDL) is being tried also in neural damage.

Left ventricular systolic and diastolic dysfunction and their relationship with microvascular complications in normotensive, asymptomatic patients with type 2 diabetes mellitus.

OBJECTIVE: Diabetes mellitus is an established risk factor for cardiovascular events. Aims of the study were to assess left ventricular systolic and diastolic function in asymptomatic patients with type 2 diabetes and evaluate the relations among left ventricular function and specific diabetic complications. METHODS: Seventy-three normotensive patients with type 2 diabetes and no clinical evidence of cardiac disease were studied. Thirty-four healthy subjects served as control group. Echocardiographic studies were performed to assess left ventricular systolic and diastolic function. Microangiopathy was assessed by fundoscopy. Autonomic function was evaluated by standing blood pressure and heart rate response to Valsalva maneuver. RESULTS: Patients with type 2 diabetes had a lower ejection fraction (54 +/- 10.8 vs. 67 +/- 6.1%, p < or = 0.001), E-velocity (50.1 +/- 10.6 vs. 58.4 +/- 6.3 cm/s, p < or = 0.001), and E/A ratio of <1 (54.8 vs. 5.8%, p < or = 0.01) of the mitral diastolic flow compared with the control subjects, respectively. Patients with ejection fraction <50% had higher prevalence of retinopathy (52.9 vs. 26.7%, p < or = 0.05), abnormal blood pressure response to standing (52.9 vs. 7.1%, p < or = 0.001), and proteinuria (70.5 vs. 14.2%, p < or = 0.05). An inverse correlation was found between duration of diabetes and both ejection fraction (r = -0.53, p = 0.05) and E/A ratio (r = 0.36, p = 0.003). E/A ratio of <1 was associated with higher prevalence of retinopathy (45 vs. 18.1%, p < or = 0.05) and abnormal blood pressure response to standing (25 vs. 9%, p < or = 0.05). Multiple logistic regression model showed that diabetes was the strongest independent correlate of diastolic dysfunction (odds ratio 8.91, 95% CI: 4.18-18.52, p < or = 0.001). CONCLUSION: Asymptomatic diabetic patients have reduced left ventricular systolic and diastolic function as compared with healthy subjects. Left ventricular systolic and diastolic abnormalities are correlated with the duration of diabetes and with diabetic microangiopathies, like retinopathy and neuropathy. Diabetes mellitus is the strongest independent correlate of left ventricular diastolic dysfunction.

Prevalence, prognostic importance and therapeutic implications of anemia in heart failure.

BACKGROUND: Despite advances in its management, heart failure, once established, remains highly prevalent and lethal. Anemia can exacerbate the hemodynamic burden in heart failure. The present study was undertaken to assess the presence of anemia and analyze how its control impacts the outcome in heart failure patients. METHODS AND RESULTS: From a cohort of 238 heart failure patients, 55 (231%) patients were found to be anemic. Twenty-nine patients (Group A) were given recombinant human erythropoietin for 12 weeks along with iron, and followed up for a mean period of 24 +/- 6 months. The patients improved substantially in terms of functional capacity (6 min walk test improved from 232 +/- 35 m to 278 +/- 41 m, p < 0.001), hemoglobin level from 10.1 +/- 0.90 gm/dl to 12 +/- 0.7 gm/dl, (p < or = 0.001), and ejection fraction from 33 +/- 7.1% to 41 +/- 6.9% (p < or = 0.001). Twenty-six patients (Group B) who were age- and sex-matched with Group A and had similar degree of functional disability and left ventricular dysfunction as that of Group A were not given erythropoietin and iron. Thus, Group B patients served as controls. In comparison to Group B, Group A patients demonstrated not only higher hemoglobin level (12 +/- 0.7 gm/dl v. 9.8 +/- 0.9 gm/dl, p < or = 0.001), and ejection fraction (41 +/- 6.9% v. 26 +/- 7%, p < or = 0.05), but also better survival (16/29 v. 7/26, p < 0.05, odds ratio 1.27). CONCLUSIONS: Anemia is a significant predictor of poor outcome in patients with heart failure. Administration of erythropoietin can correct anemia and help improve survival.

Current perspectives on statins.

As the epidemic of coronary artery disease rages on round the globe, research is always on to find suitable drugs to reverse the trend. While aspirin, beta-blockers and ACE inhibitors have been shown to reduce coronary mortality and morbidity, statins are rapidly coming to fore as another important cog in the wheel of primary and secondary prevention of coronary artery disease. Newer trial like Heart Protection Study suggests benefit of statin for high risk individuals, irrespective of initial serum cholesterol concentrations. This may be of great relevance in the Indian context taking into consideration the vast majority of coronary artery disease patients having normal to mildly elevated serum cholesterol in contrast to their western counterparts.