Highly active antiretroviral therapy (HAART) plays a critical role in suppressing viral titers and increasing CD4+ lymphocyte counts, which translate to significant reduced morbidity and mortality among HIV patients [
The available information on stroke in African HIV-infected patients comes from South Africa [
The majority of Central African HIV-infected patients do not have access to drugs of the first line and are not systematically on HAART till now. It is not established whether the HIV infection itself [
The objective of this study was to evaluate the prevalence, the risk factors, and the cardiometabolic comorbidities of ischemic stroke among HIV-infected Central African patients.
This cross-sectional study was carried out on HIV-infected patients managed at the Department of Internal Medicine of the Teaching Hospital of Kinshasa, DRC, over a period from 1st January 2004 through 30th May 2008. The Teaching Hospital of Kinshasa is 1500-bed public university hospital that serves a black urban population of 6 million people. The climate is tropical. The study protocol designed according to the Helsinki Declaration II was approved by the local ethics committee.
Anthropometry recorded weight, height, waist circumference (WC), hip circumference (HC) and body mass index (BMI = weight, kg/height, m²) using standard methods in participants with light clothes and without shoes as described elsewhere [
Laboratory investigations included haemoglobin, hematocrit, glucose, total cholesterol (TC), triglycerides (TG), HDL-cholesterol (HDL-C), CD4+ count, uric acid, antibodies against oxidized LDL-cholesterol, HIV RNA viral load, serological tests for syphilis,
Cardiovascular evaluation comprised clinical symptoms, CKMB, troponin, electrocardiograms (ECG), transthoracic echocardiography, and coronary angiograms.
Radiological investigations included chest radiograph, brain CT scan, and carotid echo-Doppler studies using 7.5 Mhz transducer of Biosound echographer (Biosound Inc., Indianapolis, Ind, USA) and are described elsewhere.
Total obesity was defined by BMI ≥ 25 kg/m² hypertension was defined as SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg [
As detailed in the IDF report from April 2005 [
The cardiometabolic consequences included arterial hypertension, type 2 diabetes, myocardial infarction, stroke, long QTc ≥ 0.420 ms, gout/hyperuricaemia, and subclinical atherosclerosis [
HIV-infection characteristics included ELISA HIV-1 seropositivity, CD4+ count, WHO stages [
Student’s
A
There were 54 men and 62 women with a female to male ratio 1.2 : 1. The mean age of male patients (45.3 ± 8.5 years;
Stroke was the first clinical manifestation of HIV infection in 12 patients. Isolated hemiparesis, hemianopia, and aphasia were present in 4 patients, 3 patients, and 10 patients, respectively.
CT scan revealed ischemic stroke in the majority of cases (
HIV-related dilated cardiomyopathy, atrial fibrillation, elevated circulating immune complexes, protein C deficiency, protein S deficiency, disseminated intravascular coagulation, D-dimer ≥500 ug/L, elevated highly sensitive C-reactive protein, insulin resistance, elevated level of antibodies against oxidized LDL-cholesterol, and antiphospholipid syndrome were similarly (
There was a significant association between lower level of CD4+ count, higher levels of WC, HC, glucose, hematocrit, pulse pressure, and the presence of ischemic stroke (Table
Association between waist circumference (WC), hip circumference (HC), fasting glucose, hematocrit, pulse pressure, and ischemic stroke among HIV/AIDS patients.
Variables of interest | Presence of ischemic stroke mean ± SD | Absence of ischemic stroke mean ± SD | |
---|---|---|---|
WC (cm) | 119.6 ± 5.8 | 98.7 ± 19.2 | <.0001 |
HC (cm) | 118.8 ± 5.1 | 105.8 ± 16.6 | .002 |
Fasting glucose (mg/dL) | 140.4 ± 10.9 | 116.4 ± 36.9 | .010 |
Hematocrit (%) | 39.6 ± 0.04 | 32.9 ± 7.8 | <.001 |
Pulse pressure (mmHg) | 86.1 ± 8 | 47.1 ± 16.4 | <.0001 |
CD4+ count (cells/mm3) | 107.6 ± 1.7 | 207.6 ± 179.4 | .024 |
Viral load | 132.103 ± 12.103 | 132.103 ± 258.03 | 1.000 |
WC: waist circumference; HC:hip circumference.
There was a significant association between high SES males 29.6%,
Univariate risk factors of ischemic stroke among HIV/AIDS patients.
Variables of interest | Presence of stroke | Absence of stroke | |
---|---|---|---|
High SES | 17 (100) | 19 (19.2) | <.0001 |
Men | 16 (94.1) | 38 (38.4) | <.0001 |
Physical inactivity | 16 (94.1) | 45 (45.5) | <.0001 |
Smoking | 17 (100) | 9 (9.1) | <.0001 |
Excessive alcohol | 16 (94.1) | 28 (28.6) | <.0001 |
Total obesity | 16 (94.1) | 36 (46.2) | <.0001 |
Hypertension | 17 (100) | 17 (16.2) | <.0001 |
Heart failure | 16 (94.1) | 9 (9.1) | <.0001 |
Myocardial infarction | 16 (94.1) | 2 (2) | <.0001 |
Type 2 diabetes | 16 (94.1) | 5 (5.1) | <.0001 |
Gout | 16 (94.1) | 0 (0) | <.0001 |
Autoimmunity | 16 (94.1) | 36 (46.2) | <.0001 |
Pulse pressure ≥60 mmHg | 16 (94.1) | 18 (18.2) | <.0001 |
ARV exposure | 17 (100) | 34 (34.3) | <.0001 |
We found that the majority (
Several clinical, imaging, and autopsy studies have observed a greater-than-chance association between HIV infection and stroke [
Uncontrolled hypertension was identified as the possible cause of hemorrhagic stroke. This situation may be explained by the decline of most of the conditions conferring an increased risk of intracerebral haemorrhage in recent years [
For the findings to be meaningful, one has to compare our data with those on young black HIV-positive patients [
Young age, autoimmunity, and metabolic syndrome, identified as independent risk factors of ischemic stroke in this study, may explain atherosclerosis in these black Central African HIV/AIDS patients. Approximately 50% of atherosclerotic coronary artery disease in developed populations occurs in the absence of traditional risk factors, such as smoking, hypertension, diabetes mellitus, and hypercholesterolemia [
The present study shows that all HIV/AIDS patients had elevated hs-CRP levels and antibodies against oxidized LDL cholesterol in terms of oxidative stress, proinflammatory and chronic inflammation. Chronic inflammation may act independently or synergistically with traditional atherosclerotic risk factors in the pathogenesis of atherosclerotic stroke and may also be associated with a hypercoagulable state (elevated D-Dimer, high hematocrit, protein C deficiency, protein S deficiency) in these HIV/AIDS patients [
The present findings confirm the unclear role of autoimmunity as directly pathogenic or simple marker of arterial disease in stroke of HIV/AIDS patients. A host tissue component may become antigenic when altered by a drug or proatherosclerotic effects of HIV infection-related endothelial dysfunction [
The limitations of this study are related to the observational design and cross-sectional nature of the current analyses as well as the small size of stroke cases and the clinical status of the population studied. In this respect, the results reported herein are only associations from which no conclusions regarding causality can be drawn. Further studies with HIV negatives are needed to demonstrate the independent role of HIV infection itself from HAART and metabolic factors. Early assessment of the vascular status, continuous monitoring of drugs, and Preventive Cardiology approach in HIV-infected patients are suggested.
In this hospital-based study, mild or minor ischemic strokes probably went undetected.
Stroke in patients with HIV/AIDS was not associated with opportunistic infections and tumors. Autoimmunity, younger age, and metabolic syndrome are associated with ischemic stroke. Early assessment of the vascular status, continuous monitoring of drugs, and Preventive Cardiology approach in HIV-infected patients are suggested.