Age and benefit of early coronary angiography after out-of-hospital cardiac arrest in patients presenting with shockable rhythm: Insights from the Sudden Death Expertise Center registry

BACKGROUND

Little is known about the association between provision of post-resuscitation care and prognosis of out-of-hospital cardiac arrest (OHCA) in elderly patients. Previous studies have suggested futility after 65 years of age.

OBJECTIVES

We aimed to evaluate the association of early coronary angiogram (CAG) followed if necessary by percutaneous coronary intervention (PCI), with favorable outcome after OHCA among elderly patients, compared to younger patients.

METHODS

Using a large French registry, we included all OHCA patients with an initial shockable rhythm, transported to hospital from 2011 to 2015. Favorable outcome was defined as hospital discharge with Cerebral Performance Category (CPC) 1 or 2. and were evaluated by multivariate logistic regression. Subgroup analyses were performed according to age groups: <65, 65-75 and >75 years.

RESULTS

Among 1502 included patients, 31% were older than 65 and 12% older than 75 years. An early CAG was performed in 79%, 88% and 76% of patients below 65, between 65 and 75 and above 75, respectively (P = 0.002). The rate of patients discharged with CPC1 or 2 was 42% below 65, 38% between 65 and 75 and 24% above 75 (P < 0.001). Among the whole population, early CAG (OR = 6.4, 95% CI = 3.9-10.5, P < 0.001) was associated with favorable outcome. In subgroups analysis, CAG was associated with favorable outcome among patients <65 and 65-75. In patients >75, there was a trend towards a favorable outcome (OR2.9, 95CI = 0.9-9.1).

CONCLUSIONS

In a large registry of OHCA survivors, the early CAG use was associated with a better prognosis. This benefit was persistent up to 75 years of age, suggesting that age alone should not guide the decision for early invasive strategy.

Comparison of two sedation regimens during targeted temperature management after cardiac arrest

PURPOSE

Although guidelines on post-resuscitation care recommend the use of short-acting agents for sedation during targeted temperature management (TTM) after cardiac arrest (CA), the potential advantages of this strategy have not been clinically demonstrated.

METHODS

We compared two sedation regimens (propofol-remifentanil, period P2, vs midazolam-fentanyl, period P1) among comatose TTM-treated CA survivors. Management protocol, apart from sedation and neuromuscular blockers use, did not change between the two periods. Baseline severity was assessed with Cardiac-Arrest-Hospital-Prognosis (CAHP) score. Time to awakening was measured starting from discontinuation of sedation at the end of rewarming. Awakening was defined as delayed when it occurred after more than 48 h.

RESULTS

460 patients (134 in P2, 326 in P1) were included. CAHP score did not significantly differ between P2 and P1 (P = 0.93). Sixty percent of patients awoke in both periods (81/134 vs. 194/326, P = 0.85). Median time to awakening was 2.5 (IQR 1-9) hours in P2 vs. 17 (IQR 7-60) hours in P1. Awakening was delayed in 6% of patients in P2 vs. 29% in P1 (p < 0.001). After adjustment, P2 was associated with significantly lower odds of delayed awakening (OR 0.08, 95% CI 0.03-0.2; P < 0.001). Patients in P2 had significantly more ventilator-free days (25 vs. 24 days; P = 0.007), and lower catecholamine-free days within day 28. Survival and favorable neurologic outcome at discharge did not differ across periods.

CONCLUSIONS

During TTM following resuscitation from CA, sedation with propofol-remifentanil was associated with significantly earlier awakening and more ventilator-free days as compared with midazolam-fentanyl.

Use of Neuromuscular Blockers During Therapeutic Hypothermia After Cardiac Arrest: A Nursing Protocol

BACKGROUND

Neuromuscular blockers used to prevent shivering during therapeutic hypothermia in comatose patients after out-of-hospital cardiac arrest are associated with adverse events.

OBJECTIVE

To assess the influence of a nurse-implemented protocol on use of neuromuscular blockers in patients treated with 24-hour therapeutic hypothermia after out-of-hospital cardiac arrest.

METHODS

A before and after study was done in a 24-bed cardiac arrest center. During the before period, paralysis was maintained by continuous infusion of vecuronium during therapeutic hypothermia. During the after period, a nurse-implemented protocol was used to strictly control use of neuromuscular blockers. The primary outcome measure was duration of infusion of neuromuscular blockers; secondary end points included rates of ventilator-associated pneumonia and intensive care unit mortality.

RESULTS

Among the 22 patients in the before group and the 23 patients in the after group, most were men (78%) with a median age of 66 years. Baseline characteristics were similar between the 2 groups. Median duration of sedation was 36 hours, shorter in the after group (34 hours) than in the before group (38 hours; P = .02). Median duration of infusion of neuromuscular blockers was significantly shorter in the after group (6 hours) than in the before group (33 hours; P < .001). Ventilator-associated pneumonia occurred more frequently in the before group (45%) than in the after group (13%; P = .02). Overall intensive care unit mortality rate was 58%, similar in both groups (P = .44).

CONCLUSION

Use of a nurse-implemented protocol to reduce use of neuromuscular blockers is feasible.

Sudden Cardiac Death During Sports Activities in the General Population

Regular exercise reduces cardiovascular and overall mortality. Participation in sports is an important determinant of cardiovascular health and fitness. Regular sports activity is associated with a smaller risk of sudden cardiac death (SCD). However, there is a small risk of sports-related SCD. Sports-related SCD accounts for approximately 5% of total SCD. SCD among athletes comprises only a fraction of all sports-related SCD. Sport-related SCD has a male predominance and an average age of affliction of 45 to 50 years. Survival is better than for other SCD. This review summarizes links between sports and SCD and discusses current knowledge and controversies.

[Sudden cardiac death: A better understanting for a better prevention]

Sudden cardiac death is defined as a natural and unexpected death, in a previous apparently healthy individual. It represents a major public health issue, with up to 50% of the cardiovascular mortality. Using data from the Paris Sudden Death Expertise Centre registry, this article summarises the main cardiovascular abnormalities associated with sudden cardiac death, the different preventives approaches, and provides a systematic diagnostic approach.