2017 American Heart Association Focused Update on Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Cardiopulmonary resuscitation is a lifesaving technique for victims of sudden cardiac arrest. Despite advances in resuscitation science, basic life support remains a critical factor in determining outcomes. The American Heart Association recommendations for adult basic life support incorporate the most recently published evidence and serve as the basis for education and training for laypeople and healthcare providers who perform cardiopulmonary resuscitation.

A Review of Automated Methods for Detection of Myocardial Ischemia and Infarction Using Electrocardiogram and Electronic Health Records

There is a growing body of research focusing on automatic detection of ischemia and myocardial infarction (MI) using computer algorithms. In clinical settings, ischemia and MI are diagnosed using electrocardiogram (ECG) recordings as well as medical context including patient symptoms, medical history, and risk factors-information that is often stored in the electronic health records. The ECG signal is inspected to identify changes in the morphology such as ST-segment deviation and T-wave changes. Some of the proposed methods compute similar features automatically while others use nonconventional features such as wavelet coefficients. This review provides an overview of the methods that have been proposed in this area, focusing on their historical evolution, the publicly available datasets that they have used to evaluate their performance, and the details of their algorithms for ECG and EHR analysis. The validation strategies that have been used to evaluate the performance of the proposed methods are also presented. Finally, the paper provides recommendations for future research to address the shortcomings of the currently existing methods and practical considerations to make the proposed technical solutions applicable in clinical practice.

Duration of resuscitation efforts for in-hospital cardiac arrest by predicted outcomes: Insights from Get With The Guidelines - Resuscitation

BACKGROUND

The duration of resuscitation efforts has implications for patient survival of in-hospital cardiac arrest (IHCA). It is unknown if patients with better predicted survival of IHCA receive longer attempts at resuscitation.

METHODS

In a multicenter observational cohort of 40,563 adult non-survivors of resuscitation efforts for IHCA between 2000 and 2012, we determined the pre-arrest predicted probability of survival to discharge with good neurologic status, categorized into very low (<1%), low (1-3%), average (>3%-15%), and above average (>15%). We then determined the association between predicted arrest survival probability and the duration of resuscitation efforts.

RESULTS

The median duration of resuscitation efforts among all non-survivors was 19min (interquartile range 13-28min). Overall, the median duration of resuscitation efforts was longer in non-survivors with a higher predicted probability of survival with good neurologic status (median of 16, 17, 20, and 23min among the groups predicted to have very low, low, average, and above probabilities, respectively; P<0.001). However, the duration of resuscitation was often discordant with predicted survival, including longer than median duration of resuscitation efforts in 40.4% of patients with very low predicted survival and shorter than median duration of resuscitation efforts in 31.9% of patients with above average predicted survival.

CONCLUSIONS

The duration of resuscitation efforts in patients with IHCA was generally consistent with their predicted survival. However, nearly a third of patients with above average predicted outcomes received shorter than average (less than 19min) duration of resuscitation efforts.

A comparison of the universal TOR Guideline to the absence of prehospital ROSC and duration of resuscitation in predicting futility from out-of-hospital cardiac arrest

INTRODUCTION

The Universal Termination of Resuscitation (TOR) Guideline accurately identifies potential out-of-hospital cardiac arrest (OHCA) survivors. However, implementation is inconsistent with some Emergency Medical Service (EMS) agencies using absence of return of spontaneous circulation (ROSC) as sole criterion for termination.

OBJECTIVE

To compare the performance of the Universal TOR Guideline with the single criterion of no prehospital ROSC. Second, to determine factors associated with survival for patients transported without a ROSC. Lastly, to compare the impact of time to ROSC as a marker of futility to the Universal TOR Guideline.

DESIGN

Retrospective, observational cohort study.

PARTICIPANTS

Non-traumatic, adult (≥18 years) OHCA patients of presumed cardiac etiology treated by EMS providers.

SETTING

ROC-PRIMED and ROC-Epistry post ROC-PRIMED databases between 2007 and 2011.

OUTCOMES

Primary outcome was survival to hospital discharge and the secondary outcome was functional survival. We used multivariable regression to evaluate factors associated with survival in patients transported without a ROSC.

RESULTS

36,543 treated OHCAs occurred of which 9467 (26%) were transported to hospital without a ROSC. Patients transported without a ROSC who met the Universal TOR Guideline for transport had a survival of 3.0% (95% CI 2.5-3.4%) compared to 0.7% (95% CI 0.4-0.9%) in patients who met the Universal TOR Guideline for termination. The Universal TOR Guideline identified 99% of survivors requiring continued resuscitation and transportation to hospital including early identification of survivors who sustained a ROSC after extended durations of CPR.

CONCLUSION

Using absence of ROSC as a sole predictor of futility misses potential survivors. The Universal TOR Guideline remains a strong predictor of survival.

ICU Use and Quality of Care for Patients With Myocardial Infarction and Heart Failure

BACKGROUND

Quality of care for acute myocardial infarction (AMI) and heart failure (HF) varies across hospitals, but the factors driving variation are incompletely understood. We evaluated the relationship between a hospital's ICU or coronary care unit (CCU) admission rate and quality of care provided to patients with AMI or HF.

METHODS

A retrospective cohort study of Medicare beneficiaries hospitalized in 2010 with AMI or HF was performed. Hospitals were grouped into quintiles according to their risk- and reliability-adjusted ICU admission rates for AMI or HF. We examined the rates that hospitals failed to deliver standard AMI or HF processes of care (process measure failure rates), 30-day mortality, 30-day readmissions, and Medicare spending after adjusting for patient and hospital characteristics.

RESULTS

Hospitals in the lowest quintile had ICU admission rates < 29% for AMI or < 8% for HF. Hospitals in the top quintile had rates > 61% for AMI or > 24% for HF. Hospitals in the highest quintile had higher process measure failure rates for some but not all process measures. Hospitals in the top quintile had greater 30-day mortality (14.8% vs 14.0% [P = .002] for AMI; 11.4% vs 10.6% [P < .001] for HF), but no differences in 30-day readmissions or Medicare spending were seen compared with hospitals in the lowest quintile.

CONCLUSIONS

Hospitals with the highest rates of ICU admission for patients with AMI or HF delivered lower quality of care and had higher 30-day mortality for these conditions. Hospitals with high ICU use may be targets to improve care delivery.

National Trends in Ambulatory Oral Anticoagulant Use

BACKGROUND

Four direct oral anticoagulants (DOACs) have been brought to market for the treatment of nonvalvular atrial fibrillation and venous thromboembolism. Many forces, including numerous positive trial results, emerging safety concerns, marketing, and promotion, may shape DOAC adoption by providers. However, relatively little is known regarding their ambulatory utilization compared with warfarin, as well as the degree to which they have decreased under-treatment of atrial fibrillation.

METHODS

We used the IMS Health National Disease and Therapeutic Index, a nationally representative audit of outpatient office visits, to estimate the use of warfarin and DOACs between 2009 and 2014.

RESULTS

Overall, visits with anticoagulation use increased from 2.05 (95% confidence interval [CI], 1.82-2.27) to 2.83 (95% CI, 2.49-3.17) million (M) quarterly visits (P < .001). Of these, DOAC use has grown to 4.21M (95% CI, 3.63M-4.79M; 38.2% of total) treatment visits in 2014 since their introduction in 2010. Use of all oral anticoagulants in treatment visits for atrial fibrillation has increased from 0.88M (95% CI, 0.74M-1.02M) to 1.72M (95% CI, 1.47M-1.97M; P < .001), with similar DOAC and warfarin use in 2014. Atrial fibrillation visits with anticoagulant use increased from 51.9% (95% CI, 50.4%-53.8%) to 66.9% (95% CI, 65.0%-69.3%) between 2009 and 2014 (P < .001). In 2014, rivaroxaban was the most commonly prescribed DOAC for atrial fibrillation (47.9% of office visits), followed by apixaban (26.5%) and dabigatran (25.5%).

CONCLUSIONS

Direct oral anticoagulants have been adopted rapidly, matching the use of warfarin, and are associated with increased use of oral anticoagulation for patients with atrial fibrillation.

Digoxin: its role in contemporary medicine

Digoxin has been a key therapeutic for heart failure and atrial tachyarrhythmias for over 200 years following Withering's groundbreaking work depicting the therapeutic benefit of the common botanical foxglove in his 1785 monograph. The use of digoxin preceded any randomised evidence or even basic understanding of its mechanism of action. Over the past two decades, there has been mounting evidence further challenging the safety and efficacy of digoxin, while multiple other therapies for both heart failure and atrial tachyarrhythmias have proven to be more effective and safe. Altogether, digoxin still has an important role in contemporary pharmacotherapeutics, though its role remains controversial and should be reserved for selective patients and clinical situations, with careful attention to serum concentrations.

Management of Arrhythmias in Cardiac Sarcoidosis

The prevalence of cardiac involvement in sarcoidosis is under-recognized and is associated with multiple complications, including conduction block, arrhythmias, and sudden death. The comparative roles of common therapies have been inadequately studied. The purpose of this review is to examine the literature regarding treatments utilized to manage arrhythmias associated with cardiac sarcoidosis.

Abstract 322: Duration of Resuscitation Efforts for In-Hospital Cardiac Arrest by Predicted Survival Outcomes: Insights from Get With The Guidelines - Resuscitation

Background. The duration of cardiopulmonary resuscitation has implications for patient survival of in-hospital cardiac arrest (IHCA). However, the duration of resuscitation efforts should be balanced against the probability of patient survival. It is unknown whether the duration of attempted resuscitation for IHCA is associated with the predicted probability of patient survival.

Methods. We identified 40,563 non-survivors of resuscitation efforts for IHCA within the Get With The Guidelines [[Unable to Display Character: &#8211;]] Resuscitation Registry between 2000 and 2012. In these patients, we determined the pre-arrest predicted probability of survival to discharge with good neurologic status using the previously validated GO-FAR score. Using this tool, predicted survival was categorized into very low (<1%), low (1-3%), average (>3% to 15%), and above average (>15%). Duration of resuscitation efforts were measured in minutes from the onset of cardiac arrest to termination of resuscitation efforts. We then compared the duration of resuscitation efforts by predicted survival categories.

Results. Among 40,563 non-survivors of IHCA, the predicted survival to discharge was very low in 4801 (11.8%) patients, low in 8889 (21.9%), average in 19910 (49.1%) patients, and above average in 6963 (17.2%) patients. The median duration of attempted resuscitation was 19 minutes and the duration of attempted resuscitation was longer in non-survivors with a higher predicted probability of survival (median duration in minutes from very low to above average categories of predicted survival, 16 vs 17 vs 20 vs 23, P<.001). However, the duration of attempted resuscitation was often discordant with predicted survival (Figure), including shorter than median duration of attempted resuscitation in 31.9% of patients with above average predicted survival.

Conclusions. In a national cohort of non-survivors of IHCA, the duration of attempted resuscitation correlated overall with predicted arrest survival. However, nearly a third of patients with above average predicted survival received shorter than average attempted resuscitation efforts. Emphasis on an adequate duration of attempted resuscitation, particularly among patients with better than average predicted outcomes, may have implications for improving in-hospital cardiac arrest outcomes.