Five-year survival of patients after out-of-hospital cardiac arrest depending on age

Extracorporeal Membrane Oxygenation for Cardiac Arrest: Does Age Matter?

OBJECTIVES

The impact of age on hospital survival for patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest (CA) is unknown. We sought to characterize the association between older age and hospital survival after ECPR, using a large international database.

DESIGN

Retrospective analysis of the Extracorporeal Life Support Organization registry.

PATIENTS

Patients 18 years old or older who underwent ECPR for CA between December 1, 2016, and October 31, 2020.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was adjusted odds ratio (aOR) of death after ECPR, analyzed by age group (18-49, 50-64, 65-74, and > 75 yr). A total of 5,120 patients met inclusion criteria. The median age was 57 years (interquartile range, 46-66 yr). There was a significantly lower aOR of survival for those 65-74 (0.68l 95% CI, 0.57-0.81) or those greater than 75 (0.54; 95% CI, 0.41-0.69), compared with 18-49. Patients 50-64 had a significantly higher aOR of survival compared with those 65-74 and greater than 75; however, there was no difference in survival between the two youngest groups (aOR, 0.91; 95% CI, 0.79-1.05). A sensitivity analysis using alternative age categories (18-64, 65-69, 70-74, and ≥ 75) demonstrated decreased odds of survival for age greater than or equal to 65 compared with patients younger than 65 (for age 65-69: odds ratio [OR], 0.71; 95% CI, 0.59-0.86; for age 70-74: OR, 0.84; 95% CI, 0.67-1.04; and for age ≥ 75: OR, 0.64; 95% CI, 0.50-0.81).

CONCLUSIONS

This investigation represents the largest analysis of the relationship of older age on ECPR outcomes. We found that the odds of hospital survival for patients with CA treated with ECPR diminishes with increasing age, with significantly decreased odds of survival after age 65, despite controlling for illness severity and comorbidities. However, findings from this observational data have significant limitations and further studies are needed to evaluate these findings prospectively.

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.

Age, pre-arrest neurological condition, and functional status as outcome predictors in out-of-hospital cardiac arrest: Secondary analysis of the Jerusalem Cohort Study data

PURPOSE

Investigate the relation between age, baseline neurological and functional status, and survival after out-of-hospital cardiac arrest (OHCA).

METHODS

Data analysis from the Jerusalem District Resuscitation Study. Patients >80 years and those 18-80 years with OHCA from 4/2005-12/2010 were compared.

PRIMARY OUTCOME

survival at four time points; secondary outcomes: neurological and functional status at hospital discharge, and relationship between survival, age and pre-arrest activities of daily living (ADL) and Cerebral Performance Category (CPC) scores (higher scores indicate worse function in both).

RESULTS

3,211 patients (1,259 >80 years, 1952 aged 18-80) with median follow-up 5.9 years (range 0.1-11.1 years) were included. Survival was better for younger patients at all four time points, including 7.8% versus 2.5% at hospital discharge, 4.6% versus 0.2% at late follow-up. Functional status at discharge was also better, 4.8 ± 5.4 versus 9.0 ± 4.7, p<0.001, and more young patients had CPC1/2, 60.7% versus 32.2%, p = 0.004. Older patients who survived to emergency department admission had increased mortality per year of age (2.6%, hazard ratio [HR] 1.026, 95% confidence interval [CI] 1.006-1.048 versus 1.7%, HR 1.017, 95% CI 1.010-1.025), per point in pre-arrest ADL (3.0%, HR 1.030, 95% CI 1.007-1.054 versus 5.8%, HR 1.058, 95% CI 1.036-1.080), and per point in pre-arrest CPC (24%, HR 1.242, 95% CI 1.097-1.406 versus 37%, HR 1.370 95% CI 1.232-1.524).

CONCLUSION

Patient independence before arrest may be a more crucial determinant of resuscitation outcome than older age alone. Discussion of end-of-life preferences is particularly important for older individuals with functional and cognitive decline.

Relationship between age and outcomes of comatose cardiac arrest survivors in a setting without withdrawal of life support

AIM OF THE STUDY

Previous studies on the relationship between age and outcomes after cardiac arrest were performed in settings where the majority of patients died after the withdrawal of life support (WLS). We examined the association between age and outcomes of comatose cardiac arrest survivors in a setting where WLS was not performed.

METHODS

This single-centre retrospective observational study included adult comatose cardiac arrest survivors treated with targeted temperature management. In Korea, WLS is not permitted unless the patient is pronounced brain-dead. The primary outcome was poor neurologic outcome at hospital discharge, defined as Cerebral Performance Categories scores of 3-5. The secondary outcomes were in-hospital and six-month mortalities.

RESULTS

A total of 534 patients were analysed. In multivariate analysis, age was not associated with in-hospital mortality (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.99-1.02), but it was independently associated with neurologic outcome at hospital discharge (OR, 1.03; 95% CI, 1.02-1.05) and six-month mortality (OR, 1.05; 95% CI, 1.03-1.07). When age was categorised into 10-year intervals, age groups less than 61-70 years had significantly lower OR for poor neurologic outcome compared with the reference group (61-70 years), while the OR for poor neurologic outcome in age groups greater than 70 years did not differ from that in the reference group.

CONCLUSION

In a setting where WLS is not performed, we found that age was not associated with in-hospital mortality but was independently associated with neurologic outcome at hospital discharge and six-month mortality.

A Descriptive Analysis of Therapeutic Hypothermia Application Across Adult Age Groups

Therapeutic hypothermia (TH) has been recommended for comatose adults recovering from out-of-hospital cardiac arrest (OHCA) for a decade. However, TH has never been evaluated in a randomized control trial in patients aged 75 or older. How the administration of TH varies across age groups experiencing an OHCA is unknown. The objective was to describe the use of TH across predefined age groups with an emphasis on geriatric OHCA survivors using data compiled through Cardiac Arrest Registry to Enhance Survival (CARES). We hypothesized that TH provision would decline in patients aged 75 or older. This was a secondary analysis of prospectively collected and verified registry data. The study was Institutional Review Board exempt. Through December 2013, CARES had 130,852 completed records for consideration. All nontraumatic adult index arrests of presumed cardiac etiology with attempted resuscitation were study eligible. Sustained return of spontaneous circulation with survival to hospital admission was a prerequisite for inclusion. Exclusion criteria were as follows: records before November 2010 when TH became a mandatory reporting field; pre-existing Do Not Resuscitate directive; missing TH status or outcome classification; and OHCA location and timing variables potentially affecting treatment decisions or eligibility. All records in our final sample were categorized (TH or no TH) for descriptive analysis. Our final sample size was 11,533. The percentage of patients <75 who received TH was 58.5% (95% CI: 57.5-59.6) and 46.4% (95% CI: 44.5-48.3) for those 75 or older. There was no difference in the rate of TH across the age groups from <25 to 65-74 (p = 0.205). Treatment rates significantly decreased from age 75-84 to 95+ (p < 0.001). There is a significant decline in the provision of TH at age 75 years within CARES. Further research is needed to determine if age is an independent predictor of TH underutilization in the elderly.

Resuscitation and post resuscitation care of the very old after out-of-hospital cardiac arrest is worthwhile

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis. As comorbidity and frailty increase with age; ethical dilemmas may arise when OHCA occur in the very old.

OBJECTIVES

We aimed to investigate mortality, neurological outcome and post resuscitation care in octogenarians (≥80) to assess whether resuscitation and post resuscitation care should be avoided.

METHODS

During 2007-2011 consecutive OHCA-patients were attended by the physician-based Emergency Medical Services-system in Copenhagen. Pre-hospital data based on Utstein-criteria, and data on post resuscitation care were collected. Primary outcome was successful resuscitation; secondary endpoints were 30-day mortality and neurological outcome (Cerebral Performance Category (CPC)).

RESULTS

2509 OHCA-patients with attempted resuscitation were recorded, 22% (n=558) were octogenarians/nonagenarians. 166 (30% of all octogenarians with resuscitation attempted) octogenarians were successfully resuscitated compared to 830 (43% with resuscitation attempted) patients <80 years. 30-day mortality in octogenarians was significantly higher after adjustment for prognostic factors (HR=1.61 CI: 1.22-2.13, p<0.001). Octogenarians received fewer coronary angiographies (CAG) (14 vs. 37%, p<0.001), and had lower odds of receiving CAG by multivariate logistic regression (OR: 0.19, CI: 0.08-0.44, p<0.001). A favorable neurological outcome (CPC 1/2) in survivors to discharge was found in 70% (n=26) of octogenarians compared to 86% (n=317, p=0.03) in the younger patients.

CONCLUSION

OHCA in octogenarians was associated with a significantly higher mortality rate after adjustment for prognostic factors. However, the majority of octogenarian survivors were discharged with a favorable neurological outcome. Withholding resuscitation and post resuscitation care in octogenarians does not seem justified.

Post resuscitation care of out-of-hospital cardiac arrest patients in the Nordic countries: a questionnaire study

Background

Aim of this study was to compare post resuscitation care of out-of-hospital cardiac arrest (OHCA) patients in Nordic (Denmark, Finland, Iceland, Norway, Sweden) intensive care units (ICUs).

Methods

An online questionnaire was sent to Nordic ICUs in 2012 and was complemented by an additional one in 2014.

Results

The first questionnaire was sent to 188 and the second one to 184 ICUs. Response rates were 51 % and 46 %. In 2012, 37 % of the ICUs treated all patients resuscitated from OHCA with targeted temperature management (TTM) at 33 °C. All OHCA patients admitted to the ICU were treated with TTM at 33 °C more often in Norway (69 %) compared to Finland (20 %) and Sweden (25 %), p 0.02 and 0.014. In 2014, 63 % of the ICUs still use TTM at 33 °C, but 33 % use TTM at 36 °C. Early coronary angiography (CAG) and possible percutaneous coronary intervention (PCI) was routinely provided for all survivors of OHCA in 39 % of the hospitals in 2012 and in 28 % of the hospitals in 2014. Routine CAG for all actively treated victims of OHCA was performed more frequently in Sweden (51 %) and in Norway (54 %) compared to Finland (13 %), p 0.014 and 0.042.

Conclusions

Since 2012, TTM at 36 °C has been implemented in some ICUs, but TTM at 33 °C is used in majority of the ICUs. TTM at 33 or 36 °C and primary CAG are not routinely provided for all OHCA survivors and the criteria for these and ICU admission are variable. Best practices as a uniform approach to the optimal care of the resuscitated patient should be sought in the Nordic Countries.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-015-0141-z) contains supplementary material, which is available to authorized users.

The relationship between age and outcome in out-of-hospital cardiac arrest patients

AIM

To determine the association between age and outcome in a large multicenter cohort of out-of-hospital cardiac arrest patients.

METHODS

Retrospective, observational, cohort study of out-of-hospital cardiac arrest from the CARES registry between 2006 and 2013. Age was categorized into 5-year intervals and the association between age group and outcomes (return of spontaneous circulation (ROSC), survival and good neurological outcome) was assessed in univariable and multivariable analysis. We performed a subgroup analysis in patients who had return of spontaneous circulation.

RESULTS

A total of 101,968 people were included. The median age was 66 years (quartiles: 54, 78) and 39% were female. 31,236 (30.6%) of the included patients had sustained ROSC, 9761 (9.6%) survived to hospital discharge and 8058 (7.9%) survived with a good neurological outcome. The proportion of patients with ROSC was highest in those with age <20 years (34.1%) and lowest in those with age 95-99 years (23.5%). Patients with age <20 years had the highest proportion of survival (16.7%) and good neurological outcome (14.8%) whereas those with age 95-99 years had the lowest proportion of survival (1.7%) and good neurological outcome (1.2%). In the full cohort and in the patients with ROSC there appeared to be a progressive decline in survival and good neurological outcome after the age of approximately 45-64 years. Age alone was not a good predictor of outcome.

CONCLUSIONS

Advanced age is associated with outcomes in out-of-hospital cardiac arrest. We did not identify a specific age threshold beyond which the chance of a meaningful recovery was excluded.

Mortality and neurological outcome in the elderly after target temperature management for out-of-hospital cardiac arrest

AIM

To assess older age as a prognostic factor in patients resuscitated from out-of-hospital-cardiac arrest (OHCA) and the interaction between age and level of target temperature management.

METHODS AND RESULTS

950 patients included in the target temperature management (TTM) trial were randomly allocated to TTM at 33 or 36 °C for 24h. We assessed survival and cerebral outcome (cerebral performance category, CPC and modified Rankin scale, mRS) using age as predictor, dividing patients into 5 age groups: ≤ 65 (median), 66-70, 71-75, 76-80 and >80 years of age. Shockable rhythm decreased with higher age groups, p = 0.001, the same was true for ST segment elevation on ECG at admission, p < 0.01. Increasing age was associated with a higher mortality rate (HR = 1.04 per year, 95% CI = 1.03-1.06, p < 0.001) after adjusting for confounders. Octogenarians had an increased mortality (HR = 3.5, CI: 2.5-5.0, p < 0.001) compared to patients ≤ 65 years of age. Favorable vs. unfavorable outcome measured by CPC and mRS in survivors was different between age groups with adverse outcomes more prevalent in higher age groups (CPC: p = 0.04, mRS: p = 0.001). The interaction between age and target temperature allocation was not statistically significant for either mortality or neurological outcome.

CONCLUSION

Increasing age is associated with significantly increased mortality after OHCA, but mortality rate is not influenced by level of target temperature. Risk of poor neurological outcome also increases with age, but is not modified by level of target temperature.

Short- and long-term outcome in elderly patients after out-of-hospital cardiac arrest: a cohort study

OBJECTIVE

Determinants of outcome and long-term survival are unknown in elderly patients successfully resuscitated after out-of-hospital cardiac arrest. Our aim was to identify factors associated with short- and long-term neurologic outcome in such patients.

DESIGN

Retrospective cohort study.

SETTING

Tertiary hospital in Paris, France.

PATIENTS

Patients aged over 75 admitted in our ICU after an out-of-hospital cardiac arrest between 2000 and 2009.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Two hundred twenty-five patients were included in the study. Fifty-seven patients (25.3%) had a good neurologic outcome at ICU discharge (Cerebral Performance Category 1-2). By multivariate logistic regression analysis, factors associated with good short-term outcome were time from collapse to cardiopulmonary resuscitation less than or equal to 3 minutes (odds ratio = 4.06; 95% CI, 1.49-11.09, p = 0.006) and blood lactate level less than or equal to 5.1 mmol/L (odds ratio = 3.30; 95% CI, 1.05-10.39, p = 0.04), but age less than or equal to 79.5 years and use of induced hypothermia were not. Long-term survivors were assessed for cognitive and functional status (using Cerebral Performance Category and Overall Performance Category scales), and their survival was compared with a large community-based cohort of participants over 75 years. The 1-year survival of ICU survivors (mean follow-up, 28.4 mo) was 69.3% (95% CI, 55.8-79.5) as compared with 95.3% (95% CI, 93.3-97.3) in the control community-based cohort (p< 0.001), resulting in a standardized mortality ratio of 3.49 (95% CI, 2.42-4.85). By multivariate Cox proportional hazard model, factors associated with long-term survival were initial shockable rhythm (hazard ratio = 1.41; 95% CI, 1.01-1.96; p = 0.04), epinephrine cumulate dose less than or equal to 3 mg (hazard ratio = 1.48; 95% CI, 1.06-2.08; p = 0.02), and blood lactate level less than or equal to 5.1 mmol/L (hazard ratio = 2.11; 95% CI, 1.5-2.96; p < 0.001). When available at end of follow-up, 91% and 74% of the patients were classified Cerebral Performance Category 1 and Overall Performance Category 1, respectively.

CONCLUSIONS

Neurologic outcome in successfully resuscitated elderly patients depends on cardiac arrest characteristics rather than age. Short-term survival is 25% with acceptable long-term outcome among survivors.

Neurological outcomes in patients transported to hospital without a prehospital return of spontaneous circulation after cardiac arrest

INTRODUCTION

As emergency medical services (EMS) personnel in Japan are not allowed to perform termination of resuscitation in the field, most patients experiencing an out-of-hospital cardiac arrest (OHCA) are transported to hospitals without a prehospital return of spontaneous circulation (ROSC). As the crucial prehospital factors for outcomes are not clear in patients who had an OHCA without a prehospital ROSC, we aimed to determine the prehospital factors associated with 1-month favorable neurological outcomes (Cerebral Performance Category scale 1 or 2 (CPC 1-2)).

METHODS

We analyzed the data of 398,121 adult OHCA patients without a prehospital ROSC from a prospectively recorded nationwide Utstein-style Japanese database from 2007 to 2010. The primary endpoint was 1-month CPC 1-2.

RESULTS

The rate of 1-month CPC 1-2 was 0.49%. Multivariate logistic regression analysis indicated that the independent variables associated with CPC 1-2 were the following nine prehospital factors: (1) initial non-asystole rhythm (ventricular fibrillation (VF): adjusted odds ratio (aOR), 9.37; 95% confidence interval (CI), 7.71 to 11.4; pulseless ventricular tachycardia (VT): aOR, 8.50; 95% CI, 5.36 to 12.9; pulseless electrical activity (PEA): aOR, 2.75; 95% CI, 2.40 to 3.15), (2) age <65 years (aOR, 3.90; 95% CI, 3.28 to 4.67), (3) arrest witnessed by EMS personnel (aOR, 2.82; 95% CI, 2.48 to 3.19), (4) call-to-hospital arrival time <24 minutes (aOR, 2.58; 95% CI, 2.22 to 3.01), (5) arrest witnessed by any layperson, (6) physician-staffed ambulance, (7) call-to-response time <5 minutes, (8) prehospital shock delivery, and (9) presumed cardiac cause. When four crucial key factors (with an aOR >2.0 in the regression model: initial non-asystole rhythm, age <65 years, EMS-witnessed arrest, and call-to-hospital arrival time <24 minutes) were present, the rates of 1-month CPC 1-2 and 1-month survival were 16.1% and 23.2% in initial VF, 8.3% and 16.7% in pulseless VT, and 3.8% and 9.4% in PEA, respectively.

CONCLUSIONS

In OHCA patients transported to hospitals without a prehospital ROSC, nine prehospital factors were significantly associated with 1-month CPC 1-2. Of those, four are crucial key factors: initial non-asystole rhythm, age <65 years, EMS-witnessed arrest, and call-to-hospital arrival time <24 minutes.

Pre-arrest predictors of survival after resuscitation from out-of-hospital cardiac arrest in the elderly a systematic review

Background

To enable older people to make decisions about the appropriateness of cardiopulmonary resuscitation (CPR), information is needed about the predictive value of pre-arrest factors such as comorbidity, functional and cognitive status on survival and quality of life of survivors. We systematically reviewed the literature to identify pre-arrest predictors for survival, quality of life and functional outcomes after out-of-hospital (OHC) CPR in the elderly.

Methods

We searched MEDLINE (through May 2011) and included studies that described adults aged 70 years and over needing CPR after OHC cardiac arrest. Prognostic factors associated with survival to discharge and quality of life of survivors were extracted. Two authors independently appraised the quality of each of the included studies. When possible a meta-analysis of odd’s ratios was performed.

Results

Twenty-three studies were included (n = 44,582). There was substantial clinical and statistical heterogeneity and reporting was often inadequate. The pooled survival to discharge in patients >70 years was 4.1% (95% CI 3.0-5.6%). Several studies showed that increasing age was significantly associated with worse survival, but the predictive value of comorbidity was investigated in only one study. In another study, nursing home residency was independently associated with decreased chances of survival. Only a few small studies showed that age is negatively associated with a good quality of life of survivors. We were unable to perform a meta-analysis of possible predictors due to a wide variety in reporting and statistical methods.

Conclusions

Although older patients have a lower chance of survival after CPR in univariate analysis (i.e. 4.1%), older age alone does not seem to be a good criterion for denying patients CPR. Evidence for the predictive value of comorbidities and for the predictive value of age on quality of life of survivors is scarce. Future studies should use uniform methods for reporting data and pre-arrest factors to increase the available evidence about pre arrest factors on the chance of survival. Furthermore, patient-specific outcomes such as quality of life and post-arrest cognitive function should be investigated too.