Characteristics and outcome among 14,933 adult cases of in-hospital cardiac arrest: A nationwide study with the emphasis on gender and age

Neurological function before and after an in-hospital cardiac arrest - A nationwide registry-based cohort study

BACKGROUND

According to the Utstein Registry Template for in-hospital cardiac arrest (IHCA), a good neurological outcome is defined as either Cerebral Performance Category (CPC) 1-2 at discharge from hospital or unchanged CPC compared to baseline. However, the latter alternative has rarely been described in IHCA. This study aimed to examine CPC at admission to hospital, the occurrence of post-arrest neurological deterioration, and the factors associated with such deterioration.

METHODS

We studied adult IHCA survivors registered in the Swedish Registry of Cardiopulmonary Resuscitation between 2007 and 2022. The CPC was assessed based on information from admission and discharge from hospital. The data were analyzed using descriptive statistics and significance tests.

RESULTS

One in ten IHCA had a CPC score > 1 at admission to hospital. Out of 7,677 IHCA who survived until hospital discharge and had full CPC data, 6,774 (88%) had preserved CPC, 150 (2%) had improved CPC, and 753 (10%) had deteriorated CPC. Among the factors significantly associated with deteriorated neurological function are IHCA in a general ward or intensive care unit, non-shockable rhythm, no ECG surveillance, and a higher proportion of intra-arrest and post-resuscitation treatments (all p-values < 0,05).

CONCLUSION

Most patients had preserved neurological function compared to admission. Factors associated with deteriorated neurological function are mainly concordant with established risk factors for adverse outcomes and are primarily intra-arrest and post-resuscitation, making deterioration hard to predict. Further, every tenth survivor was admitted with CPC more than 1, stressing the use of unchanged CPC as an outcome in IHCA.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Investigation of mortality rates and the factors affecting survival in out-of-hospital cardiac arrest patients

BACKGROUND

It is known that even if spontaneous circulation returns after cardiopulmonary resuscitation(CPR) in geriatric out-of-hospital cardiac arrests(OHCA), the overall one-year survival rate of these patients is very low. In our study, we aimed to investigate the factors affecting survival in OHCA cases.

METHODS

OHCA patients over 18 years of age were examined in two different groups as 18-64 years old and over 65 years old. Demographic data, comorbidities, cardiac arrest rhythms and minutes, and the number of days they were hospitalized in the intensive care unit were recorded.

RESULTS

The mean age was 65.9 ± 15.8 years and 39.9% (n = 110) of the patients were female. The number of intensive care unit stays was significantly higher in the over-65 age group (p = 0.011). The mortality rate and one-year survival rate were significantly lower in the over-65 age group (p < 0.001). Median CPR time was 21 min (IQR:14-32) in the entire patient population. The duration of CPR was 22 min (IQR:14-35) in patients with in-hospital mortality, and 15 min (IQR:13-25) in patients discharged from the hospital. In this comparison, the difference is statistically significant (p = 0.008).

CONCLUSION

In our study, it was determined that especially over 65 years of age, coronary artery disease, and post-arrest CPR duration were determinant and predictive factors in in-hospital and long-term survival.

Association between cardiopulmonary resuscitation audit results with in-situ simulation and in-hospital cardiac arrest outcomes and key performance indicators

INTRODUCTION

In-situ simulation (ISS) is a method to evaluate the performance of hospital units in performing cardiopulmonary resuscitation (CPR). It is conducted by placing a high-fidelity mannequin at hospital units with simulated scenarios and having each unit's performance evaluated. However, little is known about its impact on actual patient outcomes. Therefore, we aimed to evaluate the association between the ISS results and actual outcomes of patients with in-hospital cardiac arrest (IHCA).

METHODS

This retrospective study was conducted by reviewing Siriraj Hospital's CPR ISS results in association with the data of IHCA patients between January 2012 and January 2019. Actual outcomes were determined by patients' outcomes (sustained return of spontaneous circulation (ROSC) and survival to hospital discharge) and arrest performance indicators (time-to-first-epinephrine and time-to-defibrillation). These outcomes were investigated for association with the ISS scores in multilevel regression models with hospital units as clusters.

RESULTS

There were 2146 cardiac arrests included with sustained ROSC rate of 65.3% and survival to hospital discharge rate of 12.9%. Higher ISS scores were significantly associated with improved sustained ROSC rate (adjusted odds ratio 1.32 (95%CI 1.04, 1.67); p = 0.01) and a decrease in time-to-defibrillation (-0.42 (95%CI -0.73, -0.11); p = 0.009). Although higher scores were also associated with better survival to hospital discharge and a decrease in time-to-first-epinephrine, most models for these outcomes failed to reach statistical significance.

CONCLUSION

CPR ISS results were associated with some important patient outcomes and arrest performance indicators. Therefore, it may be an appropriate performance evaluation method that can guide the direction of improvement.

A more conservative test of sex differences in the treatment and outcome of in-hospital cardiac arrest

BACKGROUND

Studies investigating sex disparities related to treatment and outcome of in-hospital cardiac arrest (IHCA) have produced divergent findings and have typically been unable to adjust for outstanding confounding variables.

OBJECTIVES

The aim was to examine sex differences in treatment and survival following IHCA, using a comprehensive set of control variables including e.g., age, comorbidity, and patient-level socioeconomic status.

METHODS

This retrospective study was based on data from the Swedish Register of Cardiopulmonary Resuscitation and Statistics Sweden. In the primary analyses, logistic regression models and ordinary least square regressions were estimated.

RESULTS

The study included 24,217 patients and the majority (70.4%) were men. In the unadjusted analyses, women had a lower chance of survival after cardiopulmonary resuscitation (CPR) attempt, at hospital discharge (with good neurological function) and at 30 days (p<0.01). In the adjusted regression models, female sex was associated with a higher chance of survival after the CPR attempt (B = 1.09, p<0.01) and at 30-days (B = 1.09, p<0.05). In contrast, there was no significant association between sex and survival to discharge with good neurological outcome. Except for treatment duration (B=-0.07, p<0.01), no significant associations between sex and treatment were identified.

CONCLUSIONS

No signs of treatment disparities or discrimination related to sex were identified. However, women had a better chance of surviving IHCA compared to men. The finding that women went from having a survival disadvantage (unadjusted analysis) to a survival advantage (adjusted analysis) attests to the importance of including a comprehensive set of control variables, when examining sex differences.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Clinical characteristics, causes and predictors of outcomes in patients with in-hospital cardiac arrest: results from the SURVIVE-ARREST study

INTRODUCTION

In-hospital cardiac arrest (IHCA) is acutely life-threatening and remains associated with high mortality and morbidity. Identifying predictors of mortality after IHCA would help to guide acute therapy.

METHODS

We determined patient characteristics and independent predictors of 30-day in-hospital mortality, neurological outcome, and discharge/referral pathways in patients experiencing IHCA in a large tertiary care hospital between January 2014 and April 2017. Multivariable Cox regression model was fitted to assess predictors of outcomes.

RESULTS

A total of 368 patients with IHCA were analysed (median age 73 years (interquartile range 65-78), 123 (33.4%) women). Most patients (45.9%) had an initial non-shockable rhythm and shockable rhythms were found in 20.9%; 23.6% of patients suffered from a recurrent episode of cardiac arrest. 172/368 patients died within 30 days (46.7%). Of 196/368 patients discharged alive after IHCA, the majority (72.9%, n = 143) had a good functional neurological outcome (modified Rankin Scale ≤ 3 points). In the multivariable analysis, return of spontaneous circulation without mechanical circulatory support (hazard ratio (HR) 0.36, 95% confidence interval (CI) 0.21-0.64), invasive coronary angiography and/or percutaneous intervention (HR 0.56, 95% CI 0.34-0.92), and antibiotic therapy (HR 0.87, 95% CI 0.83-0.92) were associated with a lower risk of 30-day in hospital mortality.

CONCLUSION

In the present study, IHCA was survived in ~ 50% in a tertiary care hospital, although only a minority of patients presented with shockable rhythms. The majority of IHCA survivors (~ 70%) had a good neurological outcome. Recovery of spontaneous circulation and presence of treatable acute causes of the arrest are associated with better survival. Clinical Characteristics, Causes and Predictors of Outcomes in Patients with In-Hospital Cardiac Arrest: Results from the SURVIVE-ARREST Study.

ABBREVIATIONS

CPR, cardiopulmonary resuscitation; IHCA, In-hospital cardiac arrest; MCS, mechanical circulatory support; PCI, percutaneous coronary intervention; ROSC, return of spontaneous circulation; SBP, systolic blood pressure.

Pre-arrest Prediction of Survival Following In-hospital Cardiac Arrest: A Systematic Review of Diagnostic Test Accuracy Studies

AIM

To evaluate the test accuracy of pre-arrest clinical decision tools for in-hospital cardiac arrest survival outcomes.

METHODS

We searched Medline, Embase, and Cochrane Library from inception through January 2022 for randomized and non-randomized studies. We used the Quality Assessment of Diagnostic Accuracy Studies framework to evaluate risk of bias, and Grading of Recommendations Assessment, Development and Evaluation methodology to evaluate certainty of evidence. We report sensitivity, specificity, positive predictive outcome, and negative predictive outcome for prediction of survival outcomes. PROSPERO CRD42021268005.

RESULTS

We searched 2517 studies and included 23 studies using 13 different scores: 12 studies investigating 8 different scores assessing survival outcomes and 11 studies using 5 different scores to predict neurological outcomes. All were historical cohorts/ case control designs including adults only. Test accuracy for each score varied greatly. Across the 12 studies investigating 8 different scores assessing survival to hospital discharge/ 30-day survival, the negative predictive values (NPVs) for the prediction of survival varied from 55.6% to 100%. The GO-FAR score was evaluated in 7 studies with NPVs for survival with cerebral performance category (CPC) 1 ranging from 95.0% to 99.2%. Two scores assessed survival with CPC ≤2 and these were not externally validated. Across all prediction scores, certainty of evidence was rated as very low.

CONCLUSIONS

We identified very low certainty evidence across 23 studies for 13 different pre-arrest prediction scores to outcome following IHCA. No score was sufficiently reliable to support its use in clinical practice. We identified no evidence for children.

Cardiopulmonary Resuscitation Training for Healthcare Professionals: A Scoping Review

SUMMARY STATEMENT

The optimal strategy for training cardiopulmonary resuscitation (CPR) for healthcare professionals remains to be determined. This scoping review aimed to describe the emerging evidence for CPR training for healthcare professionals.We screened 7605 abstracts and included 110 studies in this scoping review on CPR training for healthcare professionals. We assessed the included articles for evidence for the following topics: training duration, retraining intervals, e-learning, virtual reality/augmented reality/gamified learning, instructor-learner ratio, equipment and manikins, other aspects of contextual learning content, feedback devices, and feedback/debriefing. We found emerging evidence supporting the use of low-dose, high-frequency training with e-learning to achieve knowledge, feedback devices to perform high-quality chest compressions, and in situ team simulations with debriefings to improve the performance of provider teams.

Prognostic Effect of Underlying Chronic Kidney Disease and Renal Replacement Therapy on the Outcome of Patients after Out-of-Hospital Cardiac Arrest: A Nationwide Observational Study

Background and Objectives: This study assessed the prognostic value of underlying chronic kidney disease (CKD) and renal replacement therapy (RRT) on the clinical outcomes from out-of-hospital cardiac arrest (OHCA). Materials and Methods: This retrospective study was conducted utilizing the population-based OHCA data of South Korea between 2008 and 2018. Adult (>18 years) OHCA patients with a medical cause of cardiac arrest were included and classified into three categories based on the underlying CKD and RRT: (1) non-CKD group; (2) CKD without RRT group; and (3) CKD with RRT group. A total of 13,682 eligible patients were included (non-CKD, 9863; CKD without RRT, 1778; CKD with RRT, 2041). From the three comparison subgroups, data with propensity score matching were extracted. The influence of CKD and RRT on patient outcomes was assessed using propensity score matching and multivariate logistic regression analyses. The primary outcome was survival at hospital discharge and the secondary outcome was a good neurological outcome at hospital discharge. Results: The two CKD groups (CKD without RRT and CKD with RRT) showed no significant difference in survival at hospital discharge compared with the non-CKD group (CKD without RRT vs. non-CKD, p > 0.05; CKD with RRT vs. non-CKD, p > 0.05). The non-CKD group had a higher chance of having good neurological outcomes than the CKD groups (non-CKD vs. CKD without RRT, p < 0.05; non-CKD vs. CKD with RRT, p < 0.05) whereas there was no significant difference between the two CKD groups (CKD without RRT vs. CKD with RRT, p > 0.05). Conclusions: Compared with patients without CKD, the underlying cause of CKD—regardless of RRT—may be linked to poor neurological outcomes. Underlying CKD and RRT had no effect on the survival at hospital discharge.

Etiologies of In-hospital cardiac arrest: a systematic review and meta-analysis

BACKGROUND

Etiologies of in-hospital cardiac arrest (IHCA) in general wards may differ from etiologies of out-of-hospital cardiac arrest (OHCA) given the different clinical characteristics of these patient populations. An appreciation for the causes of IHCA may allow the clinician to appropriately target root causes of arrest.

METHODS

MEDLINE/PubMed, EMBASE, and Google Scholar were queried from inception until May 31, 2021. Studies reporting etiologies of IHCA were included. A random effects meta-analysis of extracted data was performed using Review Manager 5.4.

RESULTS

Of 12,451 citations retrieved from the initial literature search, 9 were included in the meta-analysis. The most frequent etiologies of cardiac arrest were hypoxia (26.46%, 95% confidence interval [CI] 14.19% to 38.74%), acute coronary syndrome (ACS) (18.23%, 95% CI 13.91% to 22.55%), arrhythmias (14.95%, 95% CI 0% to 34.92%), hypovolemia (14.81%, 95% CI 6.98% to 22.65%), infection (14.36%, 95% CI 9.46% to 19.25%), and heart failure (12.64%, 95% CI 6.47% to 18.80%). Cardiac tamponade, electrolyte disturbances, pulmonary embolism, neurological causes, toxins, and pneumothorax were less frequent causes of IHCA. Initial rhythm was unshockable (pulseless electrical activity or asystole) in 69.83% of cases and shockable (ventricular tachycardia or ventricular fibrillation) in 21.75%.

CONCLUSION

The most prevalent causes of IHCA among the general wards population are hypoxia, ACS, hypovolemia, arrythmias, infection, heart failure, three of which (arrhythmia, infection, heart failure) are not part of the traditional "H's and T's" of cardiac arrest. Other causes noted in the "H's and T's" of advanced cardiac life support do not appear to be important causes of IHCA.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Clinical outcomes of in-hospital cardiac arrest in a tertiary hospital and factors related to 28-day survival: A retrospective cohort study

OBJECTIVES:

METHODS:

RESULTS:

CONCLUSIONS:

Quality of Cardiopulmonary Resuscitation and 5-Year Survival Following in-Hospital Cardiac Arrest

PURPOSE

To improve cardiac arrest survival, international resuscitation guidelines emphasize measuring the quality of cardiopulmonary resuscitation (CPR). We aimed to investigate CPR quality during in-hospital cardiac arrest (IHCA) and study long-term survival outcomes.

PATIENTS AND METHODS

This was a cohort study of IHCA from December 2011 until November 2014. Data were collected from the hospital switch board, patient records, and from defibrillators. Impedance data from defibrillators were analyzed manually at the level of single compressions. Long-term survival at 1-, 3-, and 5 years is reported.

RESULTS

The study included 189 IHCAs; median (interquartile range (IQR)) time to first rhythm analysis was 116 (70-201) seconds and median (IQR) time to first defibrillation was 133 (82-264) seconds. Median (IQR) chest compression rate was 126 (119-131) per minute and chest compression fraction (CCF) was 78% (69-86). Thirty-day survival was 25%, while 1-year-, 3-year-, and 5-year survival were 21%, 14%, and 13%, respectively. There was no significant association between any survival outcomes and CCF, whereas chest compression rate was associated with survival to 30 days and 3 years. Overall, 5-year survival was associated with younger age (median 68 vs 74 years, p=0.003), less comorbidity (Charlson comorbidity index median 3 vs 5, p<0.001), and witnessed cardiac arrest (96% vs 77%, p=0.03).

CONCLUSION

We established a systematic collection of IHCA CPR quality data to measure and improve CPR quality and long-term survival outcomes. Median time to first rhythm check/defibrillation was <3 minutes, but median chest compression rate was too fast and median CCF slightly below 80%. More than half of 30-day survivors were still alive at 5 years.

Age and sex differences in outcomes after in-hospital cardiac arrest

INTRODUCTION

While specific factors have been associated with outcomes after in-hospital cardiac arrest, the association between sex and outcomes remains debated. Moreover, age-specific sex differences in outcomes have not been fully characterized in this population.

METHODS

Adult patients (≥18 years) with an index in-hospital cardiac arrest were included from the Danish In-Hospital Cardiac Arrest Registry (DANARREST) from January 1st, 2017 to December 31st, 2018. Population-based registries were used to obtain data on patient characteristics, cardiac arrest characteristics, and outcomes. Unadjusted and adjusted estimates for return of spontaneous circulation (ROSC), survival to 30 days, survival to one year, duration of resuscitation, and post-cardiac arrest time-to-death were computed.

RESULTS

A total of 3266 patients were included, of which 2041 (62%) patients were male with a median age of 73 years (quartiles: 64, 80). Among 1225 (38%) female patients, the median age was 76 years (quartiles: 67, 83). Younger age was associated with higher odds of ROSC and survival. Sex was not associated with ROSC and survival in the unadjusted analyses. In the adjusted analyses, women had 1.32 (95%CI: 1.12, 1.54) times the odds of survival to 30 days and 1.26 (95%CI: 1.02, 1.57) times the odds of survival to one year compared to men. The overall association between sex and survival did not vary substantially across age categories, although female sex was associated with a higher survival within certain age categories. Among patients who did not achieve ROSC, female sex was associated with a shorter duration of resuscitation, which was more pronounced in younger age categories.

CONCLUSIONS

In this study of patients with in-hospital cardiac arrest, female sex was associated with a shorter duration of resuscitation among patients without ROSC but a higher survival to 30 days and one year. While the overall association between sex and outcomes did not vary substantially across age categories, female sex was associated with a higher survival within certain age categories.

Higher 1-year mortality in women admitted to intensive care units after cardiac arrest: A nationwide overview from the Netherlands between 2010 and 2018

PURPOSE

We study sex differences in 1-year mortality of out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) patients admitted to the intensive care unit (ICU).

DATA

A retrospective cohort analysis of OHCA and IHCA patients registered in the NICE registry in the Netherlands. The primary and secondary outcomes were 1-year and hospital mortality, respectively.

RESULTS

We included 19,440 OHCA patients (5977 women, 30.7%) and 13,461 IHCA patients (4889 women, 36.3%). For OHCA, 1-year mortality was 63.9% in women and 52.6% in men (Hazard Ratio [HR] 1.28, 95% Confidence Interval [95% CI] 1.23-1.34). For IHCA, 1-year mortality was 60.0% in women and 57.0% in men (HR 1.09, 95% CI 1.04-1.14). In OHCA, hospital mortality was 57.4% in women and 46.5% in men (Odds Ratio [OR] 1.42, 95% CI 1.33-1.52). In IHCA, hospital mortality was 52.0% in women and 48.2% in men (OR 1.11, 95% CI 1.03-1.20).

CONCLUSION

Women admitted to the ICU after cardiac arrest have a higher mortality rate than men. After left-truncation, we found that this sex difference persisted for OHCA. For IHCA we found that the effect of sex was mainly present in the initial phase after the cardiac arrest.

European Resuscitation Council Guidelines 2021: Epidemiology of cardiac arrest in Europe

In this section of the European Resuscitation Council Guidelines 2021, key information on the epidemiology and outcome of in and out of hospital cardiac arrest are presented. Key contributions from the European Registry of Cardiac Arrest (EuReCa) collaboration are highlighted. Recommendations are presented to enable health systems to develop registries as a platform for quality improvement and to inform health system planning and responses to cardiac arrest.

Post-cardiac arrest syndrome in adult hospitalized patients

Adult In-hospital Cardiac Arrest (IHCA) is defined as the loss of circulation of an in-patient. Following high-quality cardiopulmonary resuscitation (CPR), if the return of spontaneous circulation (ROSC) is achieved, the post-cardiac arrest syndrome develops (PCAS). This review is intended to discuss the current diagnosis and treatment of PCAS. To approach this topic, a bibliography search was conducted through direct digital access to the scientific literature published in English and Spanish between 2014 and 2020, in MedLine, SciELO, Embase and Cochrane. This search resulted in 248 articles from which original articles, systematic reviews, meta-analyses and clinical practice guidelines were selected for a total of 56 documents. The etiologies may be divided into 56% of in-hospital cardiac, and 44% of non-cardiac arrests. The incidence of this physiological collapse is up to 1.6 cases/1,000 patients admitted, and its frequency is higher in the intensive care units (ICU), with an overall survival rate of 13% at one year. The primary components of PCAS are brain injury, myocardial dysfunction and the persistence of the precipitating pathology. The mainstays for managing PCAS are the prevention of cardiac arrest, ventilation support, control of peri-cardiac arrest arrythmias, and interventions to optimize neurologic recovery. A knowledgeable healthcare staff in PCAS results in improved patient survival and future quality of life. Finally, there is clear need to do further research in the Latin American Population.

The outcome of in- and out-hospital cardiopulmonary arrest in the older population: a scoping review

Aim

We aimed to collect the available evidence on outcome regarding survival and quality of life after CPR following both IHCA and OHCA in the older population.

Findings

Hospital survival rates following IHCA and OHCA in the older population improved in the recent decade, though do not exceed 28.5% and 11.1%, respectively. The effect of age on outcome remains controversial and age should not be used as the sole decision criterium whether to initiate CPR.

Message

Future research should study frailty and resilience as an independent predictor regardless of age, and add broader, extensive QoL measures as outcome variables.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00454-y.

Purpose

We aimed to collect the available evidence on outcome regarding survival and quality of life after cardiopulmonary resuscitation (CPR) following both in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) in the older population.

Methods

A scoping review was performed studying published reviews after 2008, focusing on outcome of CPR in patients aged ≥ 70 years following IHCA and OHCA. In addition, 11 (IHCA) and 19 (OHCA) eligible studies published after the 2 included reviews were analyzed regarding: return of spontaneous circulation, survival until hospital discharge, long-term survival, neurological outcome, discharge location or other measurements for quality of life (QoL).

Results

The survival until hospital discharge ranged between 11.6 and 28.5% for IHCA and 0–11.1% for OHCA, and declined with increasing age. The same trend was seen regarding 1-year survival rates with 5.7–25.0% and 0–10% following IHCA and OHCA, respectively. A good neurological outcome defined as a Cerebral Performance Category (CPC) 1–2 was found in 11.5–23.6% (IHCA) and up to 10.5% (OHCA) of all patients. However, the proportion of CPC 1–2 among patients surviving until hospital discharge was 82–93% (IHCA) and 77–91.6% (OHCA). Few studies included other QoL measures as an outcome variable. Other risk factors aside from age were identified, including nursing home residency, comorbidity, non-shockable rhythm, non-witnessed arrest. The level of frailty was not studied as a predictor of arrest outcome in the included studies.

Conclusions

Hospital survival rates following IHCA and OHCA in the older population improved in the recent decade, though do not exceed 28.5% and 11.1%, respectively. The effect of age on outcome remains controversial and age should not be used as the sole decision criterium whether to initiate CPR. Future research should study frailty and resilience as an independent predictor regardless of age, and add broader, extensive QoL measures as outcome variables.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00454-y.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Effect of gender on out-of-hospital cardiac arrest survival: a registry-based study

OBJECTIVE

The aim of the study was to compare outcomes after out-of-hospital cardiac arrest (OHCA) between comparable female and male OHCA cohorts in a large nationwide registry.

METHODS

This was a national multicentre retrospective, case-control propensity score-matched study based on French National Cardiac Arrest Registry data from 1 July 2011 to 21 September 2017. Female and male survival rates at D30 were compared.

RESULTS

At baseline 66 395 OHCA victims were included, of which 34.3% were women. At hospital admission, survival was 18.2% for female patients and 20.2% for male patients [odds ratio (OR), 1.138 (1.092-1.185)]; at 30 days, survival was 4.3 and 5.9%, respectively [OR, 1.290 (1.191-1.500)]. After matching (14 051 patients within each group), female patients received less advanced life support by mobile medical team (MMT), they also had a longer no-flow duration and shorter resuscitation effort by MMT than male patients. However, 15.3% of female patients vs. 9.1% of male patients were alive at hospital admission [OR, 0.557 (0.517-0.599)] and 3.2 vs. 2.6% at D30 [OR, 0.801 (0.697-0.921)], with no statistically significant difference in neurological outcome [OR, 0.966 (0.664-1.407)].

CONCLUSIONS

In this large nationwide matched OHCA study, female patients had a better chance of survival with no significant difference in neurological outcome. We also noticed that female patients received delayed care with a shorter resuscitation effort compared to men; these complex issues warrant further specific investigation. Encouraging bystanders to act as quickly as possible and medical teams to care for female patients in the same way as male patients should increase survival rates.

Factors associated with shockable versus non-shockable rhythms in patients with in-hospital cardiac arrest

AIM

To identify factors associated with the initial rhythm in patients with in-hospital cardiac arrest and to assess whether potential differences in outcomes based on the initial rhythm can be explained by patient and event characteristics.

METHODS

Adult patients (≥18 years old) with in-hospital cardiac arrest in 2017 and 2018 were included from the Danish In-Hospital Cardiac Arrest Registry (DANARREST). We used population-based registries to obtain data on comorbidities, cardiac procedures, and medications. Unadjusted and adjusted risk ratios (RRs) for initial rhythm, return of spontaneous circulation (ROSC), and survival were estimated in separate models including an incremental number of prespecified variables.

RESULTS

A total of 3422 patients with in-hospital cardiac arrest were included, of which 639 (19%) had an initial shockable rhythm. Monitored cardiac arrest, witnessed cardiac arrest, and specific cardiac diseases (i.e. ischemic heart disease, dysrhythmias, and valvular heart disease) were associated with initial shockable rhythm. Conversely, higher age, female sex, and specific non-cardiovascular comorbidities (e.g. overweight and obesity, renal disease, and pulmonary cancer) were associated with an initial non-shockable rhythm. Initial shockable rhythm remained strongly associated with increased ROSC (RR = 1.63, 95%CI 1.51-1.76), 30-day survival (RR = 2.31, 95%CI 2.02-2.64), and 1-year survival (RR = 2.36, 95%CI 2.02-2.76) compared to initial non-shockable rhythm in the adjusted analyses.

CONCLUSION

In this study, specific patient and cardiac arrest characteristics were associated with initial rhythm in patients with in-hospital cardiac arrest. However, differences in patient and cardiac arrest characteristics did not fully explain the association with survival for initial shockable rhythm compared to a non-shockable rhythm.

Association between sex and mortality in adults with in-hospital and out-of-hospital cardiac arrest: A systematic review and meta-analysis

OBJECTIVES

Conflicting data exists regarding the association between sex and mortality in adults with in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA). We therefore conducted a meta-analysis to investigate the association between sex and mortality in adults with IHCA and OHCA.

METHODS

We systematically searched MEDLINE and Cochrane databases to identify studies reporting sex-specific mortality in adults following IHCA or OHCA from inception to April 2020. Data were pooled using random-effects models. The primary outcome of interest was in-hospital (or 30-day) all-cause mortality.

RESULTS

We included 21 observational studies with a total of 1,029,978 adult patients - 622,085 men and 407,893 women. Seven studies included patients only with IHCA and 14 studies included patients only with OHCA. Female sex was associated with significantly higher mortality following OHCA [odds ratio (OR) 1.56, 95% confidence interval (CI) 1.32-1.84, p < 0.001) and a trend toward higher mortality following IHCA (OR 1.10, 95%CI 1.00-1.20, p = 0.052).

CONCLUSIONS

In adults with cardiac arrest, female sex was associated with significantly higher mortality following OHCA and a trend toward higher mortality following IHCA.

What Do We Know About Young Adult Cardiac Patients' Experience? A Systematic Review

Background: Studies interested in patients coping with a cardiac illness usually focus on children, teenagers, and adults above the age of 55. Apart from the field of congenital heart diseases, there is a general lack of literature regarding young adult cardiac patients (18-55 years old) who seem to cope with psychosocial issues. Therefore, the objective of this paper was to gather all the research carried out concerning the psychological experiences of young adult cardiac patients. Methods and Results: A comprehensive, systematic review was conducted on quantitative, qualitative, and mixed-method studies in PsycINFO, PubMed, ScienceDirect, and Cochrane Library databases. Out of the 10,747 articles found, 32 were included. While we aimed to include many cardiac diseases, coronary patients dominated the data. Five main themes emerged: emotional states (depression, anxiety, emotional distress, and stress), quality of life (health-related quality of life, physical functioning, and sexuality), adjusting to the medical environment (coping with the disease, health behavior change, financial barriers, and interactions with medical professionals), social life (social support and work), and identity (parenthood, new challenges, and new meanings). The results highlighted that their levels of depression, anxiety, stress, and quality of life were sometimes worse than in the general population and than in older and younger patients coping with a cardiac illness. Social isolation, identity changes, work, and parenthood were the specific challenges that this population had to face. Furthermore, young adult cardiac patients showed worse health behavior profiles than the general population and felt that they lacked information from professionals, especially regarding sexuality. Compared to men, women had worse psychosocial outcomes, especially regarding depression, stress, emotional distress, and quality of life. Conclusions: Young adult cardiac patients are to be considered with their own identity and challenges. They may be in need of specific interventions, some dedicated to women, and better communication is necessary with their families and professional caregivers so as to improve the patient's mental health, quality of life, coping skills, and adherence.

Cardiac arrest after pulmonary aspiration in hospitalised patients: a national observational study

OBJECTIVE

To study characteristics and outcomes among patients with in-hospital cardiac arrest (IHCA) due to pulmonary aspiration.

DESIGN

A retrospective observational study based on data from the Swedish Registry of Cardiopulmonary Resuscitation (SRCR).

SETTING

The SRCR is a nationwide quality registry that covers 96% of all Swedish hospitals. Participating hospitals vary in size from secondary hospitals to university hospitals.

PARTICIPANTS

The study included patients registered in the SRCR in the period 2008 to 2017. We compared patients with IHCA caused by pulmonary aspiration (n=127), to those with IHCA caused by respiratory failure of other causes (n=2197).

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was 30-day survival. Secondary outcome was sustained return of spontaneous circulation (ROSC) defined as ROSC at the scene and admitted alive to the intensive care unit.

RESULTS

In the aspiration group 80% of IHCA occurred on general wards, as compared with 63.6% in the respiratory failure group (p<0.001). Patients in the aspiration group were less likely to be monitored at the time of the arrest (18.5% vs 38%, p<0.001) and had a significantly lower rate of sustained ROSC (36.5% vs 51.6%, p=0.001). The unadjusted 30-day survival rate compared with the respiratory failure group was 7.9% versus 18.0%, p=0.024. In a propensity score analysis (including variables; year, age, gender, location of arrest, initial heart rhythm, ECG monitoring, witnessed collapse and a previous medical history of; cancer, myocardial infarction or heart failure) the OR for 30-day survival was 0.46 (95% CI 0.19 to 0.94).

CONCLUSIONS

In-hospital cardiac arrest preceded by pulmonary aspiration occurred more often on general wards among unmonitored patients. These patients had a lower 30-day survival rate compared with IHCA caused by respiratory failure of other causes.

Development of a Real-Time Risk Prediction Model for In-Hospital Cardiac Arrest in Critically Ill Patients Using Deep Learning: Retrospective Study

BACKGROUND

Cardiac arrest is the most serious death-related event in intensive care units (ICUs), but it is not easily predicted because of the complex and time-dependent data characteristics of intensive care patients. Given the complexity and time dependence of ICU data, deep learning-based methods are expected to provide a good foundation for developing risk prediction models based on large clinical records.

OBJECTIVE

This study aimed to implement a deep learning model that estimates the distribution of cardiac arrest risk probability over time based on clinical data and assesses its potential.

METHODS

A retrospective study of 759 ICU patients was conducted between January 2013 and July 2015. A character-level gated recurrent unit with a Weibull distribution algorithm was used to develop a real-time prediction model. Fivefold cross-validation testing (training set: 80% and validation set: 20%) determined the consistency of model accuracy. The time-dependent area under the curve (TAUC) was analyzed based on the aggregation of 5 validation sets.

RESULTS

The TAUCs of the implemented model were 0.963, 0.942, 0.917, 0.875, 0.850, 0.842, and 0.761 before cardiac arrest at 1, 8, 16, 24, 32, 40, and 48 hours, respectively. The sensitivity was between 0.846 and 0.909, and specificity was between 0.923 and 0.946. The distribution of risk between the cardiac arrest group and the non-cardiac arrest group was generally different, and the difference rapidly increased as the time left until cardiac arrest reduced.

CONCLUSIONS

A deep learning model for forecasting cardiac arrest was implemented and tested by considering the cumulative and fluctuating effects of time-dependent clinical data gathered from a large medical center. This real-time prediction model is expected to improve patient's care by allowing early intervention in patients at high risk of unexpected cardiac arrests.

Impact of Sex on Survival and Neurologic Outcomes in Adults With In-Hospital Cardiac Arrest

Data regarding the impact of sex on clinical outcomes in adults with in-hospital cardiac arrest (IHCA) have yielded conflicting results. We aimed to study the impact of female sex on mortality and poor neurologic outcomes in adults with IHCA. The study population included 680 consecutive patients hospitalized with IHCA who underwent ACLS-guided resuscitation from 2012 to 2018 at an academic tertiary medical center. The primary outcome of interest was in-hospital mortality. Secondary outcome of interest was favorable neurological outcome, defined as a Glasgow Outcome Score of 4 or 5. Of the 680 patients studied, 418 (61.5%) were men and 262 (38.5%) were women. Women had lower rates of coronary artery disease, previous myocardial infarction, and peripheral artery disease, and higher rates of chronic obstructive pulmonary disease and depression. Although location of cardiac arrest, initial rhythm, and duration of cardiopulmonary resuscitation were similar in both groups, women had lower rates of defibrillation. Rates of return of spontaneous circulation and receipt of targeted temperature management were similar in men and women. With respect to outcomes, women were noted to have significantly higher rates of in-hospital mortality (87.5% vs 78.0%; p = 0.001) and lower rates of favorable neurologic outcome (10.0% vs 15.8%, p = 0.030) compared with men. In multivariable analyses, female sex was independently associated with nearly two-fold higher rates of in-hospital mortality [odds ratio (OR) 1.93, 95% confidence interval (CI) 1.22-3.04, p = 0.005] and a trend toward lower rates of favorable neurologic outcome (OR 0.63, 95% CI 0.38-1.04, p = 0.071). In conclusion, in this prospective, contemporary registry of adults with IHCA, female sex was independently associated with nearly twofold higher rates of in-hospital mortality and a trend toward lower rates of favorable neurologic outcomes.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

A nationwide overview of 1-year mortality in cardiac arrest patients admitted to intensive care units in the Netherlands between 2010 and 2016

AIM

Worldwide, cardiac arrest (CA) remains a major cause of death. Most post-CA patients are admitted to the intensive care unit (ICU). The aim of this study is to describe mortality rates and possible changes in mortality rates in patients with CA admitted to the ICU in the Netherlands between 2010 and 2016.

METHODS

In this study, we included all adult CA patients registered in the National Intensive Care Evaluation (NICE) registry who were admitted to ICUs in the Netherlands between 2010 and 2016. The primary outcome was 1-year mortality which was analysed by Cox regression. The secondary outcomes were ICU mortality and hospital mortality. Hospital mortality was analysed by binary logistic regression analysis. Patients were stratified by whether they experienced in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA). Finally, the outcome over calendar time was assessed for both groups.

RESULTS

We included 26,056 CA patients: 10,618 (40.8%) IHCA patients and 14,482 (55.6%) OHCA patients. The 1-year mortality rate was 57.5%: 59% for IHCA and 56.4% for OHCA, p < 0.01. This mortality rate remained stable between 2010 and 2016 for IHCA (p = 0.31) and declined for OHCA patients (p = 0.01). The hospital mortality rate was 50.3%: 50.5% for IHCA and 50.2% for OHCA, p = 0.66. This mortality rate remained stable between 2010-2016 for IHCA (p = 0.21) and decreased for OHCA patients (p < 0.01). An additional analysis with calendar year as a continuous variable showed a mortality decline of 1.56% per calendar year for 1-year mortality.

CONCLUSION

This nationwide registry cohort study reported a 57.5% 1-year mortality rate for CA patients admitted to the ICU between 2010 and 2016. We reported a decline in 1-year mortality for OHCA patients in these years.

Pre-arrest and intra-arrest prognostic factors associated with survival after in-hospital cardiac arrest: systematic review and meta-analysis

OBJECTIVE

To determine associations between important pre-arrest and intra-arrest prognostic factors and survival after in-hospital cardiac arrest.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, PubMed, Embase, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception to 4 February 2019. Primary, unpublished data from the United Kingdom National Cardiac Arrest Audit database.

STUDY SELECTION CRITERIA

English language studies that investigated pre-arrest and intra-arrest prognostic factors and survival after in-hospital cardiac arrest.

DATA EXTRACTION

PROGRESS (prognosis research strategy group) recommendations and the CHARMS (critical appraisal and data extraction for systematic reviews of prediction modelling studies) checklist were followed. Risk of bias was assessed by using the QUIPS tool (quality in prognosis studies). The primary analysis pooled associations only if they were adjusted for relevant confounders. The GRADE approach (grading of recommendations assessment, development, and evaluation) was used to rate certainty in the evidence.

RESULTS

The primary analysis included 23 cohort studies. Of the pre-arrest factors, male sex (odds ratio 0.84, 95% confidence interval 0.73 to 0.95, moderate certainty), age 60 or older (0.50, 0.40 to 0.62, low certainty), active malignancy (0.57, 0.45 to 0.71, high certainty), and history of chronic kidney disease (0.56, 0.40 to 0.78, high certainty) were associated with reduced odds of survival after in-hospital cardiac arrest. Of the intra-arrest factors, witnessed arrest (2.71, 2.17 to 3.38, high certainty), monitored arrest (2.23, 1.41 to 3.52, high certainty), arrest during daytime hours (1.41, 1.20 to 1.66, high certainty), and initial shockable rhythm (5.28, 3.78 to 7.39, high certainty) were associated with increased odds of survival. Intubation during arrest (0.54, 0.42 to 0.70, moderate certainty) and duration of resuscitation of at least 15 minutes (0.12, 0.07 to 0.19, high certainty) were associated with reduced odds of survival.

CONCLUSION

Moderate to high certainty evidence was found for associations of pre-arrest and intra-arrest prognostic factors with survival after in-hospital cardiac arrest.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018104795.

Subphenotypes of Cardiac Arrest Patients Admitted to Intensive Care Unit: a latent profile analysis of a large critical care database

Cardiac arrest (CA) may occur due to a variety of causes with heterogeneity in their clinical presentation and outcomes. This study aimed to identify clinical patterns or subphenotypes of CA patients admitted to the intensive care unit (ICU). The clinical and laboratory data of CA patients in a large electronic healthcare database were analyzed by latent profile analysis (LPA) to identify whether subphenotypes existed. Multivariable Logistic regression was used to assess whether mortality outcome was different between subphenotypes. A total of 1,352 CA patients fulfilled the eligibility criteria were included. The LPA identified three distinct subphenotypes: Profile 1 (13%) was characterized by evidence of significant neurological injury (low GCS). Profile 2 (15%) was characterized by multiple organ dysfunction with evidence of coagulopathy (prolonged aPTT and INR, decreased platelet count), hepatic injury (high bilirubin), circulatory shock (low mean blood pressure and elevated serum lactate); Profile 3 was the largest proportion (72%) of all CA patients without substantial derangement in major organ function. Profile 2 was associated with a significantly higher risk of death (OR: 2.09; 95% CI: 1.30 to 3.38) whilst the mortality rates of Profiles 3 was not significantly different from Profile 1 in multivariable model. LPA using routinely collected clinical data could identify three distinct subphenotypes of CA; those with multiple organ failure were associated with a significantly higher risk of mortality than other subphenotypes. LPA profiling may help researchers to identify the most appropriate subphenotypes of CA patients for testing effectiveness of a new intervention in a clinical trial.

Approach to cardiopulmonary resuscitation induced consciousness, an emergency medicine perspective

BACKGROUND

Cardiopulmonary resuscitation (CPR) remains the key intervention following cardiac arrest because of its ability to continue circulation. Recent focus on high quality compressions during CPR has coincided with more frequent encounters of CPR Induced Consciousness (CPRIC). CPRIC represents a poorly understood patient experience during CPR and defined as signs of consciousness and pain perception during CPR.

METHODS

Articles were selected using PubMed, MEDLINE, CINAHL and Scopus search for the keywords "cardiopulmonary resuscitation", "consciousness", "awareness", "resuscitation", "cardio-cerebral resuscitation", "agitation" and "patient experience" yielding 336 articles. Results and their references were assessed for relevance. Articles were filtered by English language and the keyword. Case reports and case series were included. All remaining articles were reviewed and findings were discussed.

RESULTS

A total of ten articles were selected, which included data on 123 cases. Sample size varied per study from 1 to 112. Studies included cases of out-of-hospital cardiac arrest and in hospital cardiac arrest. Compressions were manually provided in most cases. Patient total recall was reported in 40% of cases. Use of sedation was reported in 40% of cases.

CONCLUSIONS

There is need for continued research to better describe, explain and manage the phenomena of CPRIC. From the articles reviewed here, it is clear that further investigation has the potential to properly elucidate the patient experience including lasting psychological effects of CPRIC. Importantly, there is need for more than recognition of CPRIC from national authorities. Future research efforts should focus on establishing guidelines for the use of sedation and physical restraints, as well as the potential impact of treating CPRIC on survival.

Decision-making in cardiac arrest: physicians' and nurses' knowledge and views on terminating resuscitation

Introduction

Many cardiopulmonary resuscitation (CPR) attempts are unsuccessful and must be terminated. On the contrary, premature termination results in a self-fulfilling prophecy. This study aimed to investigate 1) physicians’ self-assessed competence in terminating CPR, 2) physicians’ and nurses’ knowledge of the European Resuscitation Council guidelines on termination, and 3) single factors leading to termination.

Methods

Questionnaires were distributed at advanced cardiac life support (ACLS) courses at a university hospital in Denmark. Participants included ACLS health care providers, ie, physicians and nurses from cardiac arrest teams, intensive care and anesthetic units or medical wards with a duty to provide ACLS. Physicians were divided into junior physicians (house officers) and experienced physicians (specialist registrars and consultants).

Results

Overall, 308 participants responded (104 physicians and 204 nurses, response rate: 98%). Among physicians, 37 (36%) did not feel competent to decide when to terminate CPR (junior physicians: n=16, 64%, compared with experienced physicians: n=21, 28%, P=0.002). Two (2%) physicians and one (0.5%) nurse were able to state the contents of termination guidelines. Several factors were reported to impact termination, including absence of a pupillary light reflex (physicians: 17%, nurses: 22%) and cardiac standstill on echocardiography (physicians: 18%, nurses: 20%). Moreover, nine (9%) physicians and 35 (17%) nurses would terminate prolonged CPR despite a shockable rhythm present.

Conclusion

One-third of all physicians did not feel competent to decide when to terminate CPR. Physicians’ and nurses’ knowledge of termination guidelines was poor, and both professions reported unvalidated or controversial factors as a single reason for terminating CPR.

Survival of in-hospital cardiac arrest in men and women in a large Swedish cohort

BACKGROUND

Cardiac arrest is more common in men than women and a few studies have shown inferior 30-day survival for men than for women. The difference might relate to patient characteristics, intra arrest factors or post arrest care.

AIM

To assess differences in 30-day survival between men and women after an in-hospital cardiac arrest (IHCA).

MATERIAL AND METHODS

All patients ≥18 years suffering an IHCA at Karolinska University Hospital between 2007 and 2017 were included. Data regarding the IHCA, patient characteristics, Charlson co-morbidity index (CCI) and 30-day survival were obtained from electronic patient records. Differences in survival between men and women were assessed with adjusted logistic regression models and presented as Odds Ratios with 95% Confidence Intervals (OR, 95% CI). Adjustments included age, CCI, place of cardiac arrest, first rhythm, ECG-surveillance and witnessed or not.

RESULTS

In all, 1639 patients suffered an IHCA, of whom 650 (40%) were women and 193 (30%) of them survived to 30 days compared to 28% of the men. No differences were found in the studied patient characteristics, intra arrest factors or post-ROSC treatments. Men had similar survival as women (crude OR 0.93 95% CI 0.74-1.15 and adjusted OR 0.77 95% CI 0.58-1.03 respectively).

CONCLUSION

This cohort study illuminates an almost equal distribution in characteristics and treatment as well as outcome, 30-day survival after IHCA between men and women. However, our study confirms previous findings of disadvantageous prerequisites among women, but also indicates that preceeding vital signs differ which might indicate residual confounding.

Échographie et prise en charge de l’arrêt cardiaque

L’arrêt cardiorespiratoire (ACR) est une situation fréquente pour les structures d’urgences et de réanimation, et l’utilisation de l’échographie y est recommandée par les sociétés savantes. Elle doit impérativement se faire sans augmentation des temps d’interruption du massage cardiaque externe. Après formation, elle permet de détecter rapidement et facilement la présence d’une contractilité myocardique qui est un élément pronostique important pouvant aider dans la décision d’arrêter la RCP. Le recours à des protocoles bien établis avec des équipes entraînées permet d’éviter une interruption prolongée de la RCP. Cependant, aucune étude humaine de grande ampleur n’a permis de décrire de manière fiable pendant l’ACR la sémiologie échographique des causes curables que constituent l’hypovolémie, l’embolie pulmonaire, la tamponnade et le pneumothorax compressif.