Improved outcomes for out-of-hospital cardiac arrest patients treated by emergency life-saving technicians compared with basic emergency medical technicians: A JCS-ReSS study report

BACKGROUND

Emergency life-saving technicians (ELSTs) are specially trained prehospital medical providers believed to provide better care than basic emergency medical technicians (BEMTs). ELSTs are certified to perform techniques such as administration of advanced airways or adrenaline and are considered to have more knowledge; nevertheless, ELSTs' effectiveness over BEMTs regarding out-of-hospital cardiac arrest (OHCA) remains unclear. We investigated whether the presence of an ELST improves OHCA patient outcomes.

METHODS

In a retrospective study of adult OHCA patients treated in Japan from 2011 to 2015, we compared two OHCA patient groups: patients transported with at least one ELST and patients transported by only BEMTs. The primary outcome measure was one-month favorable neurological outcomes, defined as Cerebral Performance Category ≤ 2. A multivariable logistic regression model was used to calculate odds ratios (ORs) and their confidence intervals (CIs) to evaluate the effect of ELSTs.

RESULTS

Included were 552,337 OHCA patients, with 538,222 patients in the ELST group and 14,115 in the BEMT group. The ELST group had a significantly higher odds of favorable neurological outcomes (2.5% vs. 2.1%, adjusted OR 1.39, 95% CI 1.17-1.66), one-month survival (4.9% vs. 4.1%, adjusted OR 1.37, 95% CI 1.22-1.54), and return of spontaneous circulation (8.1% vs. 5.1%, adjusted OR 1.90, 95% CI 1.72-2.11) compared with the BEMT group. However, ELSTs' limited procedure range (adrenaline administration or advanced airway management) did not promote favorable neurological outcomes.

CONCLUSIONS

Compared with the BEMT group, transport by the ELST group was associated with better neurological outcomes in OHCA.

Precision and Safety of an Intravascular Temperature Management System for Postcardiac Arrest Syndrome Patients: A Multicenter Clinical Trial (COOL-ARREST JP)

Rapid induction and maintaining a target temperature of 32.0–36.0°C within a narrow range for <24 hours are essential, but those are very hard to perform in postcardiac arrest syndrome (PCAS) patients. We investigated the usability of an intravascular temperature management (IVTM) system with neurolept-anesthesia (NLA; droperidol and fentanyl). Single-arm, prospective multicenter trial was carried out in the seven university and the three affiliated hospitals. In the 24 comatose PCAS patients, the target temperature (33.0°C) was rapidly induced and maintained for 24 hours using an IVTM system with NLA. The rewarming speed was 0.1°C/h until 36.5°C and was maintained for 24 hours. The primary end point was the ability to achieve ≤34.0°C for <3 hours after starting cooling, and the secondary end points were the cooling rate, deviation from the target temperature, and adverse events. Cerebral Performance Category (CPC) score at 14 days was also evaluated. Statistical analyses were performed by SPSS software, using the intention-to-treat data sets. The target temperature of ≤34.0°C was reached by 45 minutes (35–73 minutes) and was within 3 hours in all patients. The cooling rate from 36.4°C to 33.0°C was 2.7°C/h (2.4–3.6°C/h). The temperature of 33.1°C (33.1–33.1°C) and 36.7°C (36.6–36.9°C) for 24 hours each was held during the maintenance and the after rewarming phases, respectively. Temperature deviations >0.2°C from 33.0°C in the maintenance phase occurred once each in two patients. The favorable neurological outcomes (CPC1, 2) were relatively good (50%). Five patients experienced serious adverse events; none was device related. We rapidly achieved therapeutic hypothermia within a narrow temperature range without major complications using the IVTM system with NLA in PCAS patients.

Association between the ratio of serum n-3 to n-6 polyunsaturated fatty acids and acute coronary syndrome in non-obese patients with coronary risk factor: a multicenter cross-sectional study

Background

Previous studies have reported that being overweight, obese, or underweight is a risk factor for ischemic cardiovascular disease (CVD); however, CVD also occurs in subjects with ideal body mass index (BMI). Recently, the balance of n-3/n-6 polyunsaturated fatty acids (PUFAs) has received attention as a risk marker for CVD but, so far, no study has been conducted that investigates the association between BMI and the balance of n-3/n-6 PUFAs for CVD risk.

Methods

We evaluated the association between n-3/n-6 PUFA ratio and acute coronary syndrome (ACS) in three BMI-based groups (< 25: low BMI, 25–27.5: moderate BMI, and ≥ 27.5: high BMI) that included 1666 patients who visited the cardiovascular medicine departments of five hospitals located in urban areas in Japan.

Results

The prevalence of ACS events was 9.2, 7.3, and 10.3% in the low, moderate, and high BMI groups, respectively. We analyzed the relationship between ACS events and several factors, including docosahexaenoic acid/arachidonic acid (DHA/AA) ratio by multivariate logistic analyses. In the low BMI group, a history of smoking (odds ratio [OR]: 2.47, 95% confidence interval [CI]: 1.40–4.35) and low DHA/AA ratio (OR: 0.30, 95% CI: 0.12–0.74) strongly predicted ACS. These associations were also present in the moderate BMI group but the magnitude of the association was much weaker (ORs are 1.47 [95% CI: 0.54–4.01] for smoking and 0.63 [95% CI: 0.13–3.10] for DHA/AA). In the high BMI group, the association of DHA/AA (OR: 1.98, 95% CI: 0.48–8.24) was reversed and only high HbA1c (OR: 1.46, 95% CI: 1.03–2.08) strongly predicted ACS. The interaction test for OR estimates (two degrees of freedom) showed moderate evidence for reverse DHA/AA ratio–ACS associations among the BMI groups (P = 0.091).

Conclusions

DHA/AA ratio may be a useful marker for risk stratification of ACS, especially in non-obese patients.

Association of Fine Particulate Matter Exposure With Bystander-Witnessed Out-of-Hospital Cardiac Arrest of Cardiac Origin in Japan

IMPORTANCE

Out-of-hospital cardiac arrests (OHCAs) are a major public health concern and a leading cause of death worldwide. Exposure to ambient air pollution is associated with increases in morbidity and mortality and has been recognized as a leading contributor to global disease burden.

OBJECTIVE

To examine the association between short-term exposure to particulate matter with a diameter of 2.5 μm or smaller (PM2.5) and the incidence of OHCAs of cardiac origin and with the development of initial cardiac arrest rhythm.

DESIGN, SETTING, AND PARTICIPANTS

This case-control study used data from cases registered between January 1, 2005, and December 31, 2016, in the All-Japan Utstein Registry, a prospective, nationwide, population-based database for OHCAs across all 47 Japanese prefectures. These OHCA cases included patients who had bystander-witnessed OHCAs and for whom emergency medical services responders initiated resuscitation before hospital transfer. A case-crossover design was employed for the study analyses. A prefecture-specific, conditional logistic regression model to estimate odds ratios was applied, and a random-effects meta-analysis was used to obtain prefecture-specific pooled estimates. All analyses were performed from May 7, 2019, to January 23, 2020.

MAIN OUTCOMES AND MEASURES

The main outcome was the association of short-term PM2.5 exposure with the incidence of bystander-witnessed OHCAs of cardiac origin. The differences in the distribution of initial cardiac arrest rhythm in OHCAs among those with exposure to PM2.5 were also examined.

RESULTS

In total, 103 189 OHCAs witnessed by bystanders were included in the final analysis. Among the patients who experienced such OHCAs, the mean (SD) age was 75 (15.5) years, and 62 795 (60.9%) were men. Point estimates of the percentage increase for a 10-μg/m3 increase in PM2.5 at lag0-1 (difference in mean PM2.5 concentrations measured on the case day and 1 day before) demonstrated a statistically significantly higher incidence of OHCA across most of the 47 prefectures, without significant heterogeneity (I2 = 20.1%; P = .12). A stratified analysis found an association between PM2.5 exposure and OHCAs (% increase, 1.6; 95% CI, 0.1%-3.1%). An initial shockable rhythm, such as ventricular fibrillation or pulseless ventricular tachycardia (% increase, 0.6; 95% CI, -2.0% to 3.2%), was not associated with PM2.5 exposure. However, an initial nonshockable rhythm, such as pulseless electrical activity and asystole, was associated with PM2.5 exposure (% increase, 1.4; 95% CI, 0.1%-2.7%).

CONCLUSIONS AND RELEVANCE

Findings from this study suggest that increased PM2.5 concentration is associated with bystander-witnessed OHCA of cardiac origin that commonly presents with nonshockable rhythm. The results support measures to reduce PM2.5 exposure to prevent OHCAs of cardiac origin.

Quality indicators of palliative care for acute cardiovascular diseases

BACKGROUND

Although recent attention to palliative care for patients with cardiovascular diseases has been increasing, there are no specific recommendations on detailed palliative care practices. We proceed on a discussion of the appropriateness and applicability of potential quality indicators for acute cardiovascular diseases according to our previous systematic review.

METHODS

We created a multidisciplinary panel of 20 team members and 7 external validation clinicians composed of clinical cardiologists, a nutritionist, a physiotherapist, a clinical psychologist, a critical and emergent care specialist, a catheterization specialist, a primary care specialist, a palliative care specialist, and nurses. After crafting potential indicators, we performed a Delphi rating, ranging from "1 = minimum" to "9 = maximum". The criterion for the adoption of candidate indicators was set at a total mean score of seven or more. Finally, we subcategorized these indicators into several domains by using exploratory factor analysis.

RESULTS

Sixteen of the panel members (80%) were men (age, 49.5 ± 13.7 years old). Among the initial 32 indicators, consensus was initially reached on total 23 indicators (71.8%), which were then summarized into 21 measures by selecting relatively feasible time variations. The major domains were "symptom palliation" and "supporting the decision-making process". Factor analysis could not find optimal model. Narratively-developed seven sub-categories included "presence of palliative care team", "patient-family relationship", "multidisciplinary team approach", "policy of approaching patients", "symptom screening and management", "presence of ethical review board", "collecting and providing information for decision-maker", and "determination of treatment strategy and the sharing of the care team's decision".

CONCLUSION

In this study we developed 21 quality indicators, which were categorized into 2 major domains and 7 sub-categories. These indicators might be useful for many healthcare providers in the initiation and enhancement of palliative care practices for acute cardiovascular diseases in Japan.

Benefit and harm of intravenous vasodilators across the clinical profile spectrum in acute cardiogenic pulmonary oedema patients

BACKGROUND

The absence of high quality, large-scale data that indicates definitive mortality benefits does not allow for firm conclusions on the role of intravenous vasodilators in acute heart failure. We aimed to investigate the associations between intravenous vasodilators and clinical outcomes in acute heart failure patients, with a specific focus on patient profiles and type of vasodilators.

METHODS

Data of 26,212 consecutive patients urgently hospitalised for a primary diagnosis of acute heart failure between 2009 and 2015 were extracted from a government-funded multicentre data registration system. Propensity scores were calculated with multiple imputations and 1:1 matching performed between patients with and without vasodilator use. The primary endpoint was inhospital mortality.

RESULTS

On direct comparison of the vasodilator and non-vasodilator groups after propensity score matching, there were no significant differences in the inhospital mortality rates (7.5% vs. 8.8%, respectively; P=0.098) or length of intensive/cardiovascular care unit stay and hospital stay between the two groups. However, there was a substantial difference in baseline systolic blood pressure by vasodilator type; favourable impacts of vasodilator use on inhospital mortality were observed among patients who had higher systolic blood pressures and those who had no atrial fibrillation on admission. Furthermore, when compared to nitrates, the use of carperitide (natriuretic peptide agent) was significantly associated with worse outcomes, especially in patients with intermediate systolic blood pressures.

CONCLUSIONS

In acute heart failure patients, vasodilator use was not universally associated with improved inhospital outcomes; rather, its effect depended on individual clinical presentation: patients with higher systolic blood pressure and no atrial fibrillation seemed to benefit maximally from vasodilators.

TRIAL REGISTRATION

UMIN-CTR identifier, UMIN000013128.

Association Between Therapeutic Hypothermia and Outcomes in Patients with Non-shockable Out-of-Hospital Cardiac Arrest Developed After Emergency Medical Service Arrival (SOS-KANTO 2012 Analysis Report)

BACKGROUND/OBJECTIVE

The outcomes of patients with non-shockable out-of-hospital cardiac arrest (non-shockable OHCA) are poorer than those of patients with shockable out-of-hospital cardiac arrest (shockable OHCA). In this retrospective study, we selected patients from the SOS-KANTO 2012 study with non-shockable OHCA that developed after emergency medical service (EMS) arrival and analyzed the effect of therapeutic hypothermia (TH) on non-shockable OHCA patients.

METHODS

Of 16,452 patients who have definitive data on the 3-month outcome in the SOS-KANTO 2012 study, we selected 241 patients who met the following criteria: age ≥ 18 years, normal spontaneous respiration or palpable pulse upon emergency medical services arrival, no ventricular fibrillation or pulseless ventricular tachycardia before hospital arrival, and achievement of spontaneous circulation without cardiopulmonary bypass. Patients were divided into two groups based on the presence or absence of TH and were analyzed.

RESULTS

Of the 241 patients, 49 underwent TH. Univariate analysis showed that the 1-/3-month survival rates and favorable 3-month cerebral function outcome rates in the TH group were significantly better than the non-TH group (46% vs 19%, respectively, P < 0.001, 35% vs 12%, respectively, P < 0.001, 20% vs 7%, respectively, P = 0.01). Multivariate logistic regression analysis showed that TH was a significant, independent prognostic factor for cerebral function outcome.

CONCLUSIONS

In this study, TH was an independent prognostic factor for the 3-month cerebral function outcome. Even in patients with non-shockable OHCA, TH may improve outcome if the interval from the onset of cardiopulmonary arrest is relatively short, and adequate cardiopulmonary resuscitation is initiated immediately after onset.

Public-access defibrillation and neurological outcomes in patients with out-of-hospital cardiac arrest in Japan: a population-based cohort study

BACKGROUND

More than 80% of public-access defibrillation attempts do not result in sustained return of spontaneous circulation in patients who have had an out-of-hospital cardiac arrest (OHCA) and a shockable heart rhythm before arrival of emergency medical service (EMS) personnel. Neurological and survival outcomes in such patients have not been evaluated. We aimed to assess the neurological status and survival outcomes in such patients.

METHODS

This is a retropective analysis of a cohort study from a prospective, nationwide, population-based registry of 1 299 784 patients who had an OHCA event between Jan 1, 2005, and Dec 31, 2015 in Japan. The primary outcome was favourable neurological outcome (Cerebral Performance Category of 1 or 2) at 30 days after the OHCA and the secondary outcome was survival at 30 days following the OHCA. This study is registered with the University Hospital Medical Information Network Clinical Trials Registry, UMIN000009918.

FINDINGS

We identified 28 019 patients with bystander-witnessed OHCA and shockable heart rhythm who had received CPR from a bystander. Of these, 2242 (8·0%) patients did not achieve return of spontaneous circulation with CPR plus public-access defibrillation, and 25 087 (89·5%) patients did not achieve return of spontaneous circulation with CPR alone before EMS arrival. The proportion of patients with a favourable neurological outcome was significantly higher in those who received public-access defibrillation than those who did not (845 [37·7%] vs 5676 [22·6%]; adjusted odds ratio [OR] after propensity score-matching, 1·45 [95% CI 1·24-1·69], p<0·0001). The proportion of patients who survived at 30 days after the OHCA was also significantly higher in those who received public-access defibrillation than those who did not (987 [44·0%] vs 7976 [31·8%]; adjusted OR after propensity score-matching, 1·31 [95% CI 1·13-1·52], p<0·0001).

INTERPRETATION

Our findings support the benefits of public-access defibrillation and greater accessibility and availability of automated external defibrillators in the community.

FUNDING

None.

Geographical Differences and the National Meeting Effect in Patients with Out-of-Hospital Cardiac Arrests: A JCS-ReSS Study Report

The "national meeting effect" refers to worse patient outcomes when medical professionals attend academic meetings and hospitals have reduced staffing. The aim of this study was to examine differences in outcomes of patients with out-of-hospital cardiac arrest (OHCA) admitted during, before, and after meeting days according to meeting location and considering regional variation of outcomes, which has not been investigated in previous studies. Using data from a nationwide, prospective, population-based, observational study in Japan, we analyzed adult OHCA patients who underwent resuscitation attempts between 2011 and 2015. Favorable one-month neurological outcomes were compared among patients admitted during the relevant annual meeting dates of three national scientific societies, those admitted on identical days the week before, and those one week after the meeting dates. We developed a multivariate logistic regression model after adjusting for confounding factors, including meeting location and regional variation (better vs. worse outcome areas), using the "during meeting days" group as the reference. A total of 40,849 patients were included in the study, with 14,490, 13,518, and 12,841 patients hospitalized during, before, and after meeting days, respectively. The rates of favorable neurological outcomes during, before, and after meeting days was 1.7, 1.6, and 1.8%, respectively. After adjusting for covariates, favorable neurological outcomes did not differ among the three groups (adjusted OR (95% CI) of the before and after meeting dates groups was 1.03 (0.83-1.28) and 1.01 (0.81-1.26), respectively. The "national meeting effect" did not exist in OHCA patients in Japan, even after comparing data during, before, and after meeting dates and considering meeting location and regional variation.

Association Between Prehospital Supraglottic Airway Compared With Bag-Mask Ventilation and Glasgow-Pittsburgh Cerebral Performance Category 1 in Patients With Out-of-Hospital Cardiac Arrest

BACKGROUND

This study examined the association between prehospital supraglottic airway (SGA) and/or epinephrine compared with bag-mask ventilation (BMV) and Glasgow-Pittsburgh cerebral performance category (CPC) 1 status in patients with out-of-hospital cardiac arrest (OHCA) using a large, nationwide, population-based registry dataset.Methods and Results:This was a post hoc analysis of the All-Japan Utstein Registry. We included patients with OHCA of cardiac origin aged ≥18 years with resuscitation performed by emergency medical services (EMS) between January 2011 and December 2015. The primary endpoint was favorable neurological outcome (CPC 1). The patients were divided into 4 groups according to the prehospital management performed by EMS: BMV group received only basic life support (BLS); epinephrine group received BLS plus epinephrine; SGA group received BLS plus SGA; and combined group received BLS plus epinephrine and SGA. Univariate and multivariable logistic regression analyses were performed for the primary endpoint. Among the 106,434 patients with OHCA, 48,847 received only BMV, 8,958 received BLS+epinephrine, 25,467 received BLS+SGA, and 15,551 received BLS+epinephrine+SGA. Using the BMV group as the reference, multivariable analysis showed that the epinephrine, SGA, and combined groups were independently associated with a reduced incidence of favorable neurological outcomes.

CONCLUSIONS

Our results indicated that compared with BLS, patients in the prehospital SGA and/or epinephrine groups had a significantly reduced incidence of CPC 1 status.

Impact of Trigger on Outcome of Takotsubo Syndrome - Multi-Center Registry From Tokyo Cardiovascular Care Unit Network

Background: The relationship between outcome and trigger in takotsubo syndrome (TTS) has been recently discussed, but the data are still limited. Methods and Results: We enrolled 745 consecutive patients with TTS from the Tokyo Cardiovascular Care Unit Network registry. The patients were divided into 4 groups based on trigger: (1) medical illness, 202 (27%); (2) physical activity, trauma and injury, 54 (7%); (3) emotional trigger, 199 (27%); and (4) unidentifiable trigger, 290 (39%). Compared with other groups, the medical illness group had the lowest percentage of female patients (68%, 85%, 89%, and 79%, respectively; P<0.001) and the highest mean patient age (75±11 years, 72±11, 73±12, and 75±11 years, respectively; P=0.02). In-hospital all-cause mortality was higher (11%) in this group (0%, 2%, and 2%, respectively; P<0.001). On multivariate logistic regression analysis, the medical illness group independently predicted all-cause death (OR, 4.73; 95% CI: 1.33-16.87); although there was no significant difference in cardiac deaths between the 4 groups. Conclusions: TTS has a wide spectrum of outcome depending on the trigger. The medical illness trigger was a powerful predictor of outcome but the main cause of death is not cardiac complication.

P850Clinical difference of recent myocardial infarction compared with acute myocardial infarction - Insights from Tokyo CCU network multicenter registry

Background

Although the patient's characteristics and outcome of acute myocardial infarction (AMI) have been sufficiently investigated and primary percutaneous coronary intervention (PCI) has been recognized as established treatment strategy, those of recent myocardial infarction (RMI) have not been fully evaluated.

Purpose

The purpose of the present study was to clarify clinical characteristics and in-hospital outcomes of RMI patients from the database of the Tokyo CCU network multicenter registry.

Methods

In Tokyo CCU network multicenter registry database from 2013 to 2016, 15788 consecutive patients were registered as AMI (within 24 hours from onset) and RMI (within 2–30 days from onset). However 1246 patients were excluded because of inadequate data. And we excluded 66 cases because of out of onset period and 129 cases that strongly suspected of involvement of vasospastic events. Therefore, remaining 14347 patients were categorized to RMI group (n=1853) and AMI group (n=12494), and analyzed.

Results

Compared with AMI group, average age was older (70.4±12.9 vs 68.0±13.4 years, p<0.001), male was less (72.4 vs 76.4%, p<0.001), chest pain as chief complaint was less (75.2 vs 83.6%, p<0.001), prevalence of diabetes mellitus was higher (35.9 vs 31.0%, p<0.001), multi-vessel coronary disease was more (54.7 vs 44.6%, p<0.001), patients undergoing PCI was less (79.0 vs 91.2%, p<0.001), and the incidence of mechanical complication was more in RMI group (3.0 vs 1.5%, p<0.001). Although 30-day mortality was equivalent between 2 groups (5.3 vs 5.8%, p=0.360), the major cause of death in AMI group was cardiogenic shock, while in the RMI group it was a mechanical complication. On Kaplan-Meier analysis, the 2 groups had significantly different cumulative incidence of death due to cardiogenic shock (p=0.006, Log-rank test) and mechanical complication (p=0.021, Log-rank test). Furthermore death due to mechanical complication in AMI group was plateau after about 1 week from hospitalization, whereas in RMI group it continued to increase.

Kaplan-Meier analysis

Conclusions

RMI patients had distinctive clinical features in backgrounds and treatment strategies compared with AMI patients, and the major cause of death of RMI patients was different from that of AMI patients. Furthermore, even though treatment during hospitalization of RMI patients was well done, death due to mechanical complications continued to increase.

P2623Measurement of liver fibrosis marker: type IV collagen 7S among patients with acute heart failure and its relationship with the Enhanced Liver Fibrosis (ELF) score

Background

Hemodynamic disturbance in acute heart failure (HF) can cause injury to extra-cardiac organs such as the liver. Organ injury in HF might evoke a profibrotic response, which could adversely affect the prognosis.

Methods

Among 189 patients with acute HF, we simultaneously determined the liver fibrosis marker, type IV collagen 7S (P4NP 7S) and the Enhanced Liver Fibrosis (ELF) Score consisting of tissue inhibitor of metalloproteinases 1 (TIMP-1), amino-terminal propeptide of type III procollagen (PIIINP) and hyaluronic acid (HA) on admission and at discharge.

Results

During hospitalization, P4NP 7S and ELF score significantly decreased from 7.1 ng/mL to 6.1 ng/mL (P<0.001) and 10.39 to 10.13 (P<0.001), respectively. P4NP 7S and ELF score were correlated with each other on admission (r=0.4, P<0.001) and at discharge (r=0.4, P<0.001). %Change of (Δ) P4NP 7S during hospitalization was correlated with ΔBNP and ΔELF score (r=0.3, P<0.001 and r=0.4, P<0.001, respectively). Among the components of ELF score, PIIINP and HA were correlated with P4NP 7S on admission (r=0.5, P<0.001 and r=0.3, P<0.001, respectively) and at discharge (r=0.4, P<0.001 and r=0.3, P<0.001, respectively). ΔP4NP 7S was also correlated with ΔTIMP-1, ΔPIIINP and ΔHA (r=0.3, P<0.001, r=0.4, P<0.001 and r=0.3, P<0.001, respectively). Each patient was followed up up to 365 days after discharge. 69 patients died or were hospitalized for HF. When the patients were divided into two groups according to the median value of each marker at discharge, the cumulative 1-year incidences of all cause death or HF hospitalization were 32.0% and 45.5% in P4NP 7S-low and P4NP 7S-high group, respectively (log-rank P=0.051) and 43.2% and 34.9% in ELF score-low and ELF score-high group, respectively (log-rank P=0.44). After adjustment by the clinically relevant factors including age, sex, hemoglobin, sodium and left ventricular ejection fraction, P4NP 7S showed independent prognostic value (adjusted hazard ratio: 1.12, P=0.02), while ELF score did not (adjusted hazard ratio: 1.04, P=0.79).

Conclusion

Parallel elevation of P4NP 7S and ELF score were documented during acute phase of HF. P4NP 7S at discharge may identify patients at high risk for subsequent HF related events.

P6359Utility of collagen-derived peptides as markers of organ injury in patients with acute heart failure: a prospective cohort study

Background

Organ injury in heart failure (HF) might evoke profibrotic response, which might adversely affect prognosis.In patients with HF, liver fibrogenesis marker, type IV collagen 7S (P4NP 7S), correlates with pulmonary artery pressure and right-side cardiac pressure such as right atrial and ventricular pressure. The present study aimed to investigate the prognostic utility of two collagen markers (N-terminal propeptide of procollagen III [PIIINP] and P4NP 7S) in patients with acute HF.

Methods and results

We conducted a prospective cohort study including 390 patients admitted for HF to three territorial hospitals. The pre-specified primary outcome measure was cardiac death and HF hospitalization at early (90-day) and late (365-day) post-discharge period. Follow-up ratio was 99% at 90 day and 97% at 365 day, respectively. Cardiac death and HF hospitalization occurred in 61 and 114 patients at 90 days and 365 days, respectively. The dichotomization the patients based on the median value of the collagen marker at discharge revealed that patients with high P4NP 7S correlated with significant excess risk relative to those with low P4NP 7S for 90-day (adjusted hazard ratio [HR]; 1.89, 95% confidence interval [CI]); 1.11–3.26, P=0.02) and 365-day (adjusted HR; 1.50, 95% CI; 1.02–2.21, P=0.04) outcome. 10% increase in P4NP 7S was associated with 8% increase for primary outcome measure at 90 day (P=0.04). P4NP 7S showed incremental prognostic value on top of the conventional prognostic factors including age, sex, estimated glomerular filtration rate (eGFR), ejection fraction (EF) <40%, B-type natriuretic peptide (BNP), hemoglobin and sodium <140mmol/L (P=0.038 for net reclassification improvement, P=0.0068 for integrated discrimination improvement). PIIINP weakly correlated with P4NP 7S (Spearman's r=0.24, P<0.0001), but it neither correrated with the marked excess risk not associated with significant excess risk for 90 and 365-day primary outcome measure nor enhanced the discrimination.

Conclusions

This study suggests a possible role of P4NP 7S in the risk stratification of patients with acute HF.

Acknowledgement/Funding

None

P2666Association of out-of-hospital cardiac arrest occurrence time and the survival in all-Japan utstein registry: difference between international resuscitation guidelines 2005 and 2010

Background/Introduction

Previous studies have shown that out-of-hospital cardiac arrest (OHCA) occurring at night have poor outcomes compared with OHCA occurring during daytime. On the other hand, nationwide OHCA outcomes have gradually improved in Japan.

Purpose

We sought to examine whether one-month survival of OHCA differed between daytime and nighttime occurrences, and they differed between the periods of International Resuscitation Guidelines 2005 and 2010.

Methods

Using the All-Japan Utstein Registry between 2005 and 2015, adult OHCA patients whose collapse was witnessed by a bystander and the call-to-hospital admission interval was shorter than 120 min were included in this study. OHCA patients were divided by period of the International Resuscitation Guideline 2005 and 2010. Guideline 2005 included years from 2006 to 2010, while Guideline 2010 included years from 2011 to 2015. The primary outcome was one-month survival with favorable neurological outcome, defined as Cerebral Performance Category scale of 1 or 2. Daytime, evening, and night were defined as 0700 to 1459 h, 1500 to 2259 h, and 2300 to 0659 h, respectively.

Results

Among 479,046 cases, 20.3% revealed OHCA occurring at night. OHCA patients occurring at night had lower rate of bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator use than those occurring at both daytime and evening. In addition, of those who received bystander CPR, higher rate of patients received CPR by family members. OHCA patients occurring at night in both guideline periods had significantly worse one-month survival than those occurring during daytime (reference) (adjusted odds ratio, 0.69, 0.64; 95% confidence interval 0.65–0.72, 0.61–0.67; P<0.001, P<0.001, Guideline 2005 and 2010 respectively). OHCA patients occurring during daytime in Guideline 2010 had better one-month survival than those in Guideline 2005 (adjusted odds ratio, 1.29; 95% confidence interval 1.24–1.34; P<0.001).

Conclusions

One-month survival with favorable neurological outcome in OHCA patients occurring at night remains to be significantly worse than those occurring during daytime, even improved by the periods during daytime. CPR training for the family members should be more expanded and strengthened against the night time imperfection.

P2622Use of intravenous vasodilators in patients hospitalized with acute heart failure: insights from Tokyo cardiovascular care unit network database

Background

Despite recommendations from clinical practice guidelines, there is scant evidence confirming the effects of vasodilators on clinical outcomes in patients with acute heart failure (AHF).

Purpose

We sought to investigate the effects of intravenous vasodilators on clinical outcomes and to identify the potential patient populations that would benefit from its use.

Methods

Data of 26 212 consecutive patients urgently hospitalized for AHF between 2009 and 2015 were extracted from a multicenter data registration system (Tokyo Cardiovascular Care Unit Network Database, including 72 institutions within the Tokyo metropolitan area in Japan). Patients who did not present with typical AHF episodes, including those without pulmonary congestion on physical and/or chest X-ray and serum B-type natriuretic peptide level <500 pg/ml, as well as those who had hypotension and/or hypoperfusion (systolic blood pressure [SBP] <100 mmHg) as dominant presentation, were excluded. Propensity scores were calculated with multiple imputation and 1:1 matching performed between patients with and without vasodilators. The primary endpoint was in-hospital mortality and the secondary endpoints were length of intensive/cardiovascular care unit (ICU/CCU) stay and hospital stay.

Results

Overall, 8 863 patients were included in the present analysis; they were predominantly male (57%) with a median age of 79 (interquartile range: 70–86) years. Compared with the group without vasodilator use, the vasodilator group had higher SBPs and heart rates and higher frequency of assisted ventilation use, but lower frequency of intravenous diuretics use. After propensity score matching, there were no significant differences in in-hospital mortality rates (7.8% vs. 8.9% in patients without vasodilators, p=0.16) or in length of ICU/CCU stay (5.8 days vs. 5.4 days, p=0.44) and hospital stay (22.7 days vs. 23.8 days, p=0.22) between the groups. However, in subgroup analyses, favorable impacts of vasodilator use on in-hospital mortality were observed among patients who had higher SBPs and among those who had no atrial fibrillation upon admission (Figure). In addition, vasodilators were likely to be more effective in AHF patients with SBP increasing; while levels below 140 mmHg of SBP appeared to be associated with an increased risk for mortality among patients treated with vasodilators compared with those without vasodilators.

Figure 1

Conclusions

In patients with AHF, vasodilator use was not universally associated with improved in-hospital outcomes; however, its effect was dependent of individual clinical presentation. Detailed phenotyping might aid tailoring of treatment strategies for patients with AHF.

Acknowledgement/Funding

the Tokyo Metropolitan Government

P1701Sex-related difference in receiving bystander cardiopulmonary resuscitation and clinical outcome among out-of-hospital cardiac arrest patients

Background

Early studies from US and Europe have reported that female out-of-hospital cardiac arrest (OHCA) patients were less likely to receive bystander cardiopulmonary resuscitation (CPR). However, little is known about sex-related difference in receiving CPR and clinical outcome among adult OHCA patients in Japan.

Methods

This study was a nation-wide, population-based observational study of OHCA in Japan from 2011 to 2015. We included all adult cardiogenic OHCA patients. We excluded patients witnessed by emergency medical services (EMS) from the present analysis. To account for the age-related difference, we stratified by age category: 18–39, 40–64, 65–79, and ≥80. To examine the association between patient sex and neurological outcome at 30-day, we fitted multivariable logistic regression model with adjustment for age, bystander CPR status, first document rhythm, dispatcher instruction and EMS response time.

Results

There were 339,317 adult cardiogenic, not EMS-witnessed OHCA patients (median age, 80; female, 43.5%) in Japan from 2011 to 2015. Overall, 171,122 (50.4%) received CPR by citizen, 34,283 (10.1%) had initial shockable rhythm, and 11,421 (3.4%) had favorable neurological status at 30-day. Female patients were more likely to receive bystander CPR (vs. male; 53.8% vs. 47.8%), and were less likely to have initial shockable rhythm (5.2% vs. 13.9%) and favorable neurological status at 30-day (1.8% vs. 4.6%) (all; p<0.001). With stratification by age category, elderly female patients (aged ≥65) were more likely to received bystander CPR (P<0.001), whereas male patients were more likely to received bystander CPR among patients aged <40. Multivariable logistic regression analysis showed that female patients had a lower rate of favorable neurological status at 30-day, compared to male patients in all age categories (all; P<0.05).

Sex difference in bystander CPR Overall Male (n=191,672) Female (n=147,645) p-value All (n=339,317) 50.4% 47.8% 53.8% <0.001 Aged 18–39 (n=6,216) 56.0% 56.9% 53.5% 0.02 Aged 40–64 (n=50,320) 48.5% 48.5% 48.3% 0.69 Aged 65–80 (n=105,141) 46.5% 45.5% 48.3% <0.001 Aged ≥80 (n=177,640) 53.2% 49.0% 56.7% <0.001

OR for neurological outcome at 30-day

Conclusion

Unlike the situation in Europe and US, female OHCA patients, especially elderly female, were more likely to receive bystander CPR in Japan. However, female patients had worse clinical outcome after OHCA. Further investigations including in-hospital treatment are needed to clarify the sex-difference in clinical outcome after OHCA.

Acknowledgement/Funding

None

P5607Clinical characteristics and treatment strategy for acute aortic dissection in Tokyo Acute Aortic Disease Super-Network System

Introduction

Acute aortic dissection (AAD) is one of the most fatal cardiovascular diseases. The prevalence of AAD is reported to be low. The clinical data of AAD from representative cardiovascular centers are not enough to show the whole range of clinical feature of AAD. We have to know the exact prevalence and clinical pictures of AAD under the new system, the Tokyo AAD Super-Network System (TAAD-SNS), for strategy of emergency transport and treatment of AAD which would cover the entire metropolitan area of Tokyo. TAAD-SNS started in 2011, and after slight modification, the new system of AAD re-started in 2013. The aim of this study is to elucidate the whole range of clinical characteristics and recent trends of treatment of AAD.

Methods

Out of 73 hospitals included in Tokyo CCU Network system, 41 hospitals are chosen for TAAD-SNS. These hospitals provide around-the-clock surgery. In this system, the availability of surgical division is monitored in real time. All of the patients suspected of AAD are transferred directly or from primary care hospital to the hospitals of TAAD-SNS.

Results

After exclusion of 237 patients with cardiopulmonary arrest on arrival, 4877 consecutive patients (2923 male, mean age of 69±14 y/o) were admitted to the hospitals with diagnosis of AAD from 2013 to 2016. Prevalence of AAD in Tokyo was about 10 patients per 100,000 populations in every year. After exclusion of 37 patients undetermined into type A or B, 4840 patients (2694 with type A and 2146 with type B) were analyzed. Among the type A patients, 1752 (65%) were classified into type of patent false lumen (classic-type), 721 (27%) of closed false lumen (intramural hematoma: IMH-type), and 221 (8%) were undetermined. Among the type B, 880 (41%) were classified into classic-type, 1129 (53%) of IMH-type, and 137 (6%) were undetermined. Both among type A and B, mean ages were younger in classic-type than in IMH-type (type A: 66±14 vs. 73±12 y/o, p<0.05; type B: 64±15 vs. 72±12 y/o, p<0.05). Prevalence of male population and risk factor of hypertension was higher in type B than in type A both among classic-type and IMH-type. Systolic blood pressure at the emergency room was lower in type A than in type B among both classic-type and IMH-type (classic-type: 124±34 vs. 161±38 mmHg, IMH-type: 130±51 vs. 163±56 mmHg). In-hospital mortality of surgical treatment for type A classic-type and type A IMH-type, conservative strategy for type B classic-type and type B IMH-type was 9.6%, 4.2%, 3.1% and 1.7%, respectively. Stentgraft implantation for type B AAD started and shows a favorable in-hospital mortality compared to the operative treatment (Stentgraft vs. surgery in type B classic-type: 7.8% vs. 6.5%, in type B IMH-type: 10.7% vs. 11.8%, respectively).

Conclusion

Our study showed that prevalence of AAD was 2–3 times higher than previous reports. We should consider to choose the treatment strategy according to the type of AAD, A or B, classic-type or IMH-type.

Acknowledgement/Funding

Tokyo Metropolitan government

Association between rewarming duration and neurological outcome in out-of-hospital cardiac arrest patients receiving therapeutic hypothermia

AIM

The European Resuscitation Council guidelines recommend a slow rate of rewarming of 0.25 °C/h-0.5 °C/h for out-of-hospital cardiac arrest (OHCA) patients receiving therapeutic hypothermia (TH). Conversely, a very slow rewarming of 1 °C/day is generally applied in Japan. The rewarming duration ranged from less than 24 h up to more than 50 h. No randomized control trials have examined the optimal rewarming speed for TH in OHCA patients. Therefore, we examined the association between the rewarming duration and neurological outcomes in OHCA patients who received TH.

METHODS

This study was a secondary analysis of the Japanese Population-based Utstein-style study with defibrillation and basic/advanced Life Support Education and implementation-Hypothermia (J-PULSE-HYPO) study registry, a multicenter prospective cohort study. Patients suffering from OHCA who received TH (target temperature, 34 °C) after the return of spontaneous circulation from 2005 to 2011 in 14 hospitals throughout Japan were enrolled. The rewarming duration was defined as the time from the beginning of rewarming at a target temperature of 34 °C until reaching 36 °C. The primary outcome was an unfavorable neurological outcome at hospital discharge, i.e., a cerebral performance category of 3-5.

RESULTS

The J-PULSE-HYPO study enrolled 452 OHCA patients. Of these, 328 were analyzed; 79.9% survived to hospital discharge, of which 56.4% had a favorable neurological outcome. Multivariable logistic regression analysis revealed that the rewarming duration was independently associated with unfavorable neurological outcomes [odds ratio (per 5 h), 0.89; 95% confidence interval, 0.79-0.99; p =  0.032].

CONCLUSION

A longer rewarming duration was significantly associated with and was an independent predictor of favorable neurological outcomes in OHCA patients who received TH.

Citizen bystander-patient relationship and 1-month outcomes after out-of-hospital cardiac arrest of cardiac origin from the All-Japan Utstein Registry: a prospective, nationwide, population-based, observational study

OBJECTIVES

The presence of a bystander witness is a crucial predictor of patient survival after out-of-hospital cardiac arrest (OHCA). However, the differences in survival and neurological outcomes among different types of citizen bystanders are not well understood.

DESIGN

We analysed data from the All-Japan Utstein Registry, a prospective, nationwide, population-based, observational study that was started in January 2005.

SETTING

The registry includes all patients with OHCA who were transported to the hospital by emergency medical service (EMS) in Japan. The type of citizen bystander was classified as family member, friend, colleague, passerby or other.

PARTICIPANTS

We analysed 210 642 patients in the registry who were 18 years or older and experienced OHCA of cardiac origin witnessed by a citizen bystander between 2005 and 2014.

PRIMARY AND SECONDARY OUTCOME MEASURES

The main outcomes were 1 month survival and 1 month survival with minimal neurological impairment.

RESULTS

Of the citizen bystander-witnessed cases, 65.1% (137 147/210 642) were witnessed by a family member. However, among patients who survived to 1 month and who had a favourable 1 month neurological outcome, much lower proportions (53.9% (10 907/20 239) and 48.9% (5722/11 696)) were witnessed by a family member. Witness by a friend, colleague or passerby was associated with good 1 month neurological function, after controlling for the patient's age, first recorded rhythm, gender, bystander cardiopulmonary resuscitation (CPR), use of a public-access automated external defibrillator, dispatcher instructions, collapse-call time and response time compared with witness by a family member (friend: OR 1.35, 95% CI 1.24 to 1.46, colleague: OR 1.63, 95% CI 1.33 to 1.98, passerby: OR 1.60, 95% CI 1.39 to 1.84).

CONCLUSIONS

One-month survival and favourable1 month neurological outcome of patients with OHCA of cardiac origin witnessed by a family member were worse than those in cases witnessed by a friend, colleague or passerby, independent of the patient characteristics and the response of EMS.

Younger- vs Older-Old Patients with Heart Failure with Preserved Ejection Fraction

OBJECTIVES

Heart failure with preserved ejection fraction (HFpEF) is now recognized as a geriatric syndrome with multifactorial pathophysiology and clinical heterogeneity rather than a solely left ventricular diastolic dysfunction. Because the pathophysiology of HFpEF is suggested to differ by age, this study compared the clinical characteristics and prognostic factors between HFpEF patients aged 65 to 84 years and those aged 85 years or older.

DESIGN

Retrospective cohort study.

SETTING

The Tokyo CCU Network including 73 hospitals in Tokyo, Japan.

PARTICIPANTS

Individuals aged 65 years or older with HFpEF (N = 4305).

MEASUREMENTS

Very old patients were defined as those aged 85 years or older. Potential risk factors for in-hospital mortality were selected by univariate analyses, and those with a P value <.10 were used in multivariate Cox regression analysis with forward selection (likelihood ratio) to identify significant factors.

RESULTS

Prevalence of hypertension was significantly higher in very old patients, whereas prevalence of coronary artery disease, diabetes mellitus, hyperlipidemia, and smoking was significantly higher in patients aged 65 to 84 years. In very old patients, low systolic blood pressure (hazard ratio [HR] = .988), high serum creatinine level (HR = 1.34), and coexisting chronic obstructive pulmonary disease (COPD; HR = 2.01) were identified as independent risk factors for in-hospital mortality. In contrast, low systolic blood pressure (HR = .987) and low body mass index (HR = .935) were identified as independent risk factors in patients aged 65 to 84 years.

CONCLUSION

Significant differences were observed in the clinical characteristics and prognostic factors for in-hospital mortality between HFpEF patients aged 65 to 84 and those 85 years and older. Of note, coexisting COPD was associated with significantly lower survival rate only in patients aged 85 years and older, suggesting the prognostic impact of concomitant pulmonary disease in HFpEF may increase with age. These results have implications for future research and management of older HFpEF patients. J Am Geriatr Soc 00:1-6, 2019. J Am Geriatr Soc 67:2123-2128, 2019.

Confirmed cardiac output on emergency medical services arrival as confounding by indication: an observational study of prehospital airway management in patients with out-of-hospital cardiac arrest

OBJECTIVES

Many registry studies on patients with out-of-hospital cardiac arrest (OHCA) have reported that conventional bag-valve-mask (BVM) ventilation is independently associated with favourable outcomes. This study aimed to compare the data of patients with OCHA with confirmed cardiac output on emergency medical services (EMS) arrival and consider the confounding factors in prehospital airway management studies.

METHODS

This was a cohort study using the registry data for survivors after out-of hospital cardiac arrest in the Kanto region at 2012 in Japan (SOS-KANTO 2012). Survivors who received advanced airway management (AAM) group and a BVM group were compared for confirmed cardiac output on EMS arrival and neurolgical outcome at 1 month. Favourable neurological outcome was defined as a score of one or two on the Cerebral Performance Categories Scale. Multivariable logistic regression was used to adjust the neurological outcome by age, gender, cardiac aetiology, witnessed arrest, shockable rhythm, cardiopulmonary resuscitation performed by a bystander, BVM at prehospital ventilation and presence of confirmed cardiac output on EMS arrival.

RESULTS

A total of 16 452 patients were enrolled in the SOS-KANTO 2012 study, and of those data 12 867 were analysed; 5893 patients comprised the AAM group and 6974 comprised the BVM group. Of the study participants, 386 (2.9%) had confirmed cardiac output on EMS arrival; 340 (2.6%) of the entire study group had a favourable neurological outcome. The proportion of patients with confirmed cardiac output on EMS arrival was significantly higher in the BVM group (272: 3.9%) than in the AAM group (114: 1.9%) (95% CI: 1.65 to 2.25). The proportion of patients with favourable neurological outcomes was 30% (117/386) in those with cardiac output on EMS arrival compared with 1.8% (223/12481) in those without. The OR for a good neurological outcome with BVM decreased from 3.24 (2.49 to 4.20) to 2.60 (1.97 to 3.44) when confirmed cardiac output on EMS arrival was added to the multivariable model analysis.

CONCLUSION

Confirmed cardiac output on EMS arrival should be considered as confounding by indication in observational studies of prehospital airway management.