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Sudden Cardiac Death and Myocardial
Fibrosis, Determined by Autopsy, in Persons with HIV
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Download the PDF here
Download the PDF here
Sudden cardiac death among HIV-infected and -uninfected veterans. Conference on Retroviruses and Opportunistic Infections (CROI). March 4-7, 2019. Seattle. Abstract 32....https://www.natap.org/2019/CROI/croi_10.htm
June 2021
correspondence
In this prospective countywide postmortem investigation of all deaths attributed to out-of-hospital cardiac arrest, we found a higher incidence of presumed sudden cardiac death among persons with known HIV infection than among persons without known HIV infection. Interstitial myocardial fibrosis was also more extensive in HIV-positive persons. One third of apparent sudden cardiac deaths among HIV-positive persons were due to occult drug overdose.
We compared these data with those from the previously reported POST SCD study5 of out-of-hospital cardiac arrests in persons without known HIV infection; autopsy adjudication was used in both studies. In both groups, approximately half the cases of presumed sudden cardiac death were sudden death from arrhythmic causes. However, occult drug overdoses were more than twice as common in the HIV-positive group as in the reference group of persons without known HIV infection. Observed incidence rates of presumed sudden cardiac death were higher among HIV-positive persons. Moreover, among persons with presumed sudden cardiac death and sudden death from arrhythmia, as determined by autopsy, the burden of total and interstitial myocardial fibrosis was higher among HIV-positive persons than among persons in the reference group. We did not find a greater incidence of sudden death from arrhythmia among HIV-positive persons than among persons in the reference group.
Inflammation and immune activation may underlie the increased cardiac fibrosis we observed in the case of sudden deaths in persons with HIV infection.
Abstract
Background
The incidence of sudden cardiac death and sudden death caused by arrhythmia, as determined by autopsy, in persons with human immunodeficiency virus (HIV) infection has not been clearly established.
Methods
Between February 1, 2011, and September 16, 2016, we prospectively identified all new deaths due to out-of-hospital cardiac arrest among persons 18 to 90 years of age, with or without known HIV infection, for comprehensive autopsy and toxicologic and histologic testing. We compared the rates of sudden cardiac death and sudden death caused by arrhythmia between groups.
Results
Of 109 deaths from out-of-hospital cardiac arrest among 610 unexpected deaths in HIV-positive persons, 48 met World Health Organization criteria for presumed sudden cardiac death; of those, fewer than half (22) had an arrhythmic cause. A total of 505 presumed sudden cardiac deaths occurred between February 1, 2011, and March 1, 2014, in persons without known HIV infection. Observed incidence rates of presumed sudden cardiac death were 53.3 deaths per 100,000 person-years among persons with known HIV infection and 23.7 deaths per 100,000 person-years among persons without known HIV infection (incidence rate ratio, 2.25; 95% confidence interval [CI], 1.37 to 3.70).
Observed incidence rates of sudden death caused by arrhythmia were 25.0 and 13.3 deaths per 100,000 person-years, respectively (incidence rate ratio, 1.87; 95% CI, 0.93 to 3.78).
Among all presumed sudden cardiac deaths, death due to occult drug overdose was more common in persons with known HIV infection than in persons without known HIV infection (34% vs. 13%). Persons who were HIV-positive had higher histologic levels of interstitial myocardial fibrosis than persons without known HIV infection.
Conclusions
In this postmortem study, the rates of presumed sudden cardiac death and myocardial fibrosis were higher among HIV-positive persons than among those without known HIV infection. One third of apparent sudden cardiac deaths in HIV-positive persons were due to occult drug overdose. (Supported by the National Heart, Lung, and Blood Institute.)
Among the 47 HIV-positive persons with presumed sudden cardiac death who had postmortem data, sudden deaths from arrhythmia, as determined by autopsy, accounted for 47% (Table 2, and Fig. S1 in the Supplementary Appendix), noncardiac causes accounted for 51%, and one death (2%) was due to a cardiac nonarrhythmic cause (acute myocardial infarction with wall rupture). The most common overall cause of presumed sudden cardiac death among HIV-positive persons was occult drug overdose, which accounted for one third of cases (16 of 48 deaths); for all 16 of these deaths, the primary EMS impression was cardiac arrest without evidence or suspicion of drug use at the scene. Lethal levels of methamphetamines, alcohol, and opiates were the most common causes. Other leading causes were coronary artery disease (23%), cardiomyopathy (11%), hypertrophy (6%), and renal failure (6%).
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