1. Insert Program or Hospital Logo Introduction The current preferred prenatal regimen to reduce mother-to-child human immune deficiency virus (HIV) transmission consists of a combination of three generally safe and effective antiretroviral (ART) agents which includes two nucleoside reverse transcriptase inhibitors (NRTIs) and a protease inhibitor (PI): zidovudine (ZDV), lamivudine (LMV), and ritonavir-boosted lopinavir (LPV/RTV) 1. While in HIV-infected adults, the PIs have been associated with cardiac toxicity, there are no reports in women who use them for perinatal HIV prevention. We report the first case of cardiac toxicity in an HIV-infected pregnant woman who developed right bundle branch block (RBBB) and myocardial ischemia (MI) which was most likely due to LPV/RTV use. She recovered after cessation of ART. Myocardial Ischemia and Heart Block Secondary to Lopinavir/Ritonavir Therapy in a Pregnant Patient John P. Kelley MD, Lemuel O. Aigbivabalu MD, Amyn K. Jiwani MD, Janak A Patel MD UTMB Pediatrics, PGY-3 Results Our patient had MI since she presented with typical chest pain, had elevated levels of cardiac enzymes, and EKG showing T wave abnormality and RBBB. We strongly suspect that the cardiac injury was related to LPV/RTV use. Other than HIV and use of ART agents, our patient had none of the typical risk factors that would predispose her to myocardial injury during pregnancy (6.2 per 100,000 deliveries): Age > 35, black race, hypertension, diabetes mellitus, thrombophilia, smoking, or obesity. 2 In HIV-infected persons, PI use has been associated with increased PR- and QRS-interval prolongation, atrioventricular and bundle branch blocks, torsades de pointes, and MI. 3-6 The Data Collection on Adverse Events of Anti-HIV Drugs (DAD) study found that 1.5% of the 23,437 participants developed a first MI; the relative risk of developing MI was 1.16 per year of PI use whereas the annual relative risk of exposure to non-nucleoside reverse transcriptase inhibitors (NNRTIs) was not significant (RR 1.05). 4 Data from the French Hospital Database also showed the increased risk of MI with cumulative use of all PIs (OR 1.15 per year) except saquinavir. 5 The risks were particularly highest with LPV/RTV (OR 1.33 per year) and with amprenavir/fosaprenavir with or without RTV (OR 1.53 per year). Exposure to the NNRTIs ZDV and stavudine was associated with increased (OR 1.09 per year). No effect was found with all other NNRTIs such as LMV. Charbit et al showed that adjusted odds ratio of complete bundle branch block was 2.71 in patients taking PIs. 6 The patients with the heart blocks were asymptomatic. Description of intervention/study Conclusions In conclusion, among the three antiretroviral agents used by our patient, above studies clearly point to LPV/RTV as the most likely agent responsible for the cardiac toxicity. Our case highlights the need for obstetricians and others managing HIV-infected pregnant women to exercise vigilance for cardiac injury. Prospective studies are needed to systematically evaluate the incidence of symptomatic and asymptomatic cardiac toxicities associated with PI use in pregnant women. References 1. NIH Guidelines. Public Health Service Task Force. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States: August 2012. Available at http://aidsinfo.nih.gov/guidelines.http://aidsinfo.nih.gov/guidelines 2. James AH, Jamison MG, Biswas MS, et al. Acute myocardial infarction in pregnancy: a United States population-based study. Circulation 2006; 113:1564. 3. Soliman EZ, et al. INSIGHT SMART Study Group. Boosted protease inhibitors and the electrocardiographic measures of QT and PR durations. AIDS. 2011; 25:367-377. 4. Friis-Moeller N, et al. Data Collection on Adverse Events of Anti-HIV Drugs (DAD) Study Group. Combination antiretroviral therapy and the risk of myocardial infarction [published correction appears in N Engl J Med. 2004;350:955]. N Engl J Med. 2003;349:1993-2003. 5. Lang S, Mary-Krause M, Cotte L, et al. French Hospital Database on HIV-ANRS CO4. Impact of individual antiretroviral drugs on the risk of myocardial infarction in human immunodeficiency virus-infected patients. Arch Intern Med. 2010; 170:1228-1238. 6. Charbit B, Gayat E, Voiriot P, et al. Effects of HIV protease inhibitors on cardiac conduction velocity in unselected HIV-infected patients. Clinical Pharmacology and Therapeutics. 2011; 90:442-448. 2013 Texas Pediatric Society Electronic Poster Contest A 22-year-old HIV-infected woman began HIV treatment consisting of zidovudine, lamivudine and LPV/RTV at 10 weeks of gestation. Within an hour after delivery, she developed severe sternal chest pain, sweating and breathing difficulty. Electrocardiogram (EKG) showed right bundle branch block and inverted T-waves. Cardiac enzymes (serum creatinine kinase and myocardial band) were elevated. A day after stopping antiretroviral medications, her chest pain and cardiac enzymes improved. Eventually, the clinical symptoms and EKG study returned to normal.