Mild dilated cardiomyopathy and increased left ventricular mass predict mortality: the prospective P2C2 HIV Multicenter Study

Abstract

Background: Many HIV-infected children die with cardiac abnormalities. We sought to understand the course of these HIV-associated abnormalities and their impact on all-cause mortality.

Methods: We describe longitudinal changes in left ventricular (LV) structure and function and mortality in 185 children vertically infected with HIV. Serial cardiac data were obtained from 0.1 to 10 years of age. Age- or body surface area-adjusted z scores were calculated for 10 echocardiographic outcomes.

Results: Median age at first echocardiogram was 2 years (range 0.2-9.4 years); median follow-up was 3.6 years (range 0-6.3 years). The 5-year cumulative incidence of congestive heart failure was 12.3%. Mean fractional shortening z scores declined from -0.65 at 1 year of age to -1.47 at 3 years of age without further decline between 3 and 10 years of age. Among children with 2 echocardiograms performed in the first year of follow-up, mild LV dysfunction (fractional shortening of < -2 SD on both echocardiograms) was present in 29 (18%) of 158 children. For these 29 children, the 5-year mortality was 55.4%. Left ventricular mass z scores were elevated at 1 year (mean z score 0.68, P < .001) and remained elevated throughout follow-up. In the 8 children with LV mass z score of > 2 SD on both initial and follow-up echocardiograms, the 5-year mortality was 75%.

Conclusion: In HIV-infected children, LV structure and function progressively deteriorated in the first 3 years of life, resulting in subsequent persistent mild LV dysfunction and increased LV mass. Chronic mild depression of LV function and elevated LV mass were associated with higher all-cause mortality.

Figure 1

A, Longitudinal change in mean LV FS (%) in 185 HIV-infected children and cross-sectional mean FS for 285 control children. B, Summary of the longitudinal change in mean LV FS z score for the 185 HIV-infected children. The vertical bars represent the 95% CIs for the means. Sample sizes at the bottom are the number of echocardiograms performed at each age.

Figure 2

Longitudinal change in mean z scores in 185 HIV-infected children. A, Heart rate. B, Left ventricular mass. C, Left ventricular wall thickness. D, LV contractility. E, LV end-diastolic dimension. F, LV end-systolic dimension. G, LV end-systolic wall stress. H, LV peak-systolic wall stress. The vertical bars represent the 95% CIs for the means.

Figure 3

A, Cumulative mortality among 113 HIV-infected children by degree of LV dysfunction. Twenty-nine patients had a depressed FS z score (<−2 on both studies), 51 had a high-normal z score (>0 on their first 2 sequential echocardiograms or >0 on the first echocardiogram and 0 to −2 on the second study), and 33 had a low-normal z score (0 to −2 on both studies). Mortality was highest in those with a depressed z score. B, Cumulative mortality among 118 HIV-infected children by LV mass z score. Eight children had an elevated LV mass z score (>2 on both studies), 35 had a low-normal z score (<0 on their first 2 sequential echocardiograms or a z score of <0 on the first echocardiogram and 0–2 on the second study), and 75 had a high-normal z score (0–2 on both studies). Mortality was highest in those with an elevated z score.