BEWARE OF A PHENOMENON -ACUTE CORONARY SYNDROME IN APPARENTLY YOUNG AND HEALTHY RETROPOSITIVE PATIENTS: UROLOGICAL PERSPECTIVE

A 40 year old young thin lady presented with left flank pain and lower urinary tract symptoms and on an off fever.She was retro-positive and was on HAART. On evaluation; she was fit for anaesthesia and CD- 4 count was also good.

Imaging wise she had left staghorn calculus with normally excreting kidney and left lower ureteric calculus.We attributed her LUTS to the lower ureteric calculus as her urine culture and sensitivity reports were normal.

During the procedure(URS AND PCNL); while starting the case only she had signsof cornoary syndrome in the form of elevated ST segment.The procdure was abandoned and the patient was shifted to higher centre with Cardiac ICU under the care of our cardiologist.

The patient was treated conservatively with thrombolysis and is presnetly stable except for mild hematuria resulting because of cystoscopy  and aggravated by the heparinisation.

The patient was not a known case of cardiac disease and didnot have pre-existing hypertension.

After searching for the literature we came across the entity called Acute Coronary Syndrome in HIV infected people.

HIV-1 virions appear to infect myocardial cells in patchy distributions without a clear direct association between HIV-1 and cardiac myocyte dysfunction.Retrovirus also causes inflammatory vascular diseases.

Cardiovascular manifestations of HIV have been altered by the introduction of highly active antiretroviral therapy (HAART) regimens. On one hand, HAART has significantly modified the course of HIV disease, lengthened survival, and improved the quality of life of HIV-infected patients. On the other hand, the early data have raised concerns that HAART is associated with an increase in both peripheral and coronary arterial diseases.

Acute coronary syndromes may be observed with increasing frequency among HIV patients receiving therapy with protease inhibitors as part of HAART regimens.

This syndrome can happen in an apprently young individuals with HIV without any preexisting factors.The ECG changes also may be nonspecific and the manifestation also can be vague.

As depicted in the above figure in the women ; there can be atypical symptoms and absence of biochemical markers.This is a dangerous situtation especially for invasive urological procedures because the patients can be apparently young and healthy. Perioperatively if they get ACS... the management of ACS will lead to aggravation of hematuria, clot retention , repeated clot evcautaion, repeated blood transfusion etc.

The retrovirus and also the HAART can lead to premature atherogenesis and lead to cardiac catastrophe.The urologist can be caugth off guard and may need to face an embarrassing situation explaining the turn of the events postoperatively  to the patient and the attendnats.Therefeore pre-operative cardiac consulattaion and screening and proper counselling of such patinets forms an essential part of managing such patients operatively. There no conclusive protocoals or guidelines about  cardiac screening of young HIV positive patients before  any surgical procedures.    

A careful cardiological screening is needed for patients who are being evaluated for or who are receiving HAART regimens. A tight collaboration between cardiologists and urologists may be useful in such situation.