Cardiac dysfunction and mortality in HIV-infected children: The Prospective P2C2 HIV Multicenter Study. Pediatric Pulmonary and Cardiac Complications of Vertically Transmitted HIV Infection (P2C2 HIV) Study Group

Abstract

Background: Left ventricular (LV) dysfunction is common in children infected with the human immunodeficiency virus (HIV), but its clinical importance is unclear. Our objective was to determine whether abnormalities of LV structure and function independently predict all-cause mortality in HIV-infected children.

Methods and results: Baseline echocardiograms were obtained on 193 children with vertically transmitted HIV infection (median age, 2.1 years). Children were followed up for a median of 5 years. Cox regression was used to identify measures of LV structure and function predictive of mortality after adjustment for other important demographic and baseline clinical risk factors. The time course of cardiac variables before mortality was also examined. The 5-year cumulative survival was 64%. Mortality was higher in children who, at baseline, had depressed LV fractional shortening (FS) or contractility; increased LV dimension, thickness, mass, or wall stress; or increased heart rate or blood pressure (P0.02 for each). Decreased LV FS (P<0.001) and increased wall thickness (P=0.004) were also predictive of increased mortality after adjustment for CD4 count (P<0.001), clinical center (P<0.001), and encephalopathy (P<0.001). FS showed abnormalities for up to 3 years before death, whereas wall thickness identified a population at risk only 18 to 24 months before death.

Conclusions: Depressed LV FS and increased wall thickness are risk factors for mortality in HIV-infected children independent of depressed CD4 cell count and neurological disease. FS may be useful as a long-term predictor and wall thickness as a short-term predictor of mortality.

Figure 1

Cumulative survival for 193 HIV-infected children according to baseline clinical characteristics and baseline echocardiographic measurements. A, CD4 cell count z score; B, encephalopathy; C, FS z score; D, LV mass z score; E, wall thickness z score; F, enddiastolic dimension z score; G, end-systolic dimension z score; and H, contractility (stress-velocity index) z score.

Figure 2

Longitudinal change in echocardiographic measurements for survivors and nonsurvivors (64 dead and 129 alive). Time trend lines represent mean and 95% CIs according to time before last echocardiogram or death (months). A, FS z score; B, wall thickness z score; C, LV mass z score; D, contractility (stress-velocity index) z score; E, FS (%); F, wall thickness (cm, adjusted for body surface area); G, LV mass (g, adjusted for body surface area); and H, end-systolic dimension z score.