Change to a primary PCI program increases number of patients offered reperfusion therapy and significantly reduces mortality: a real life experience evaluating the initiation of a primary PCI service at a single center without on site heart surgery in Western Norway

Guideline-Recommended Time Less Than 90 Minutes From ECG to Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction Is Associated with Major Survival Benefits, Especially in Octogenarians: A Contemporary Report in 11 226 Patients from NORIC

Background

Using contemporary data from NORIC (Norwegian Registry of Invasive Cardiology) we investigated the predictive value of patient age and time from ECG diagnosis to sheath insertion (ECG‐2‐sheath) in primary percutaneous coronary intervention for ST‐segment–elevation myocardial infarction (STEMI).

Methods and Results

Data from 11 226 patients collected from all centers offering 24/7/365 primary percutaneous coronary intervention service were explored. For patients aged <80 years the mortality rates were 5.6% and 7.6% at 30 days and 1 year, respectively. For octogenarians the corresponding rates were 15.0% and 24.2%. The Cox hazard ratio was 2.02 (1.93–2.11, P value <0.0001) per 10 years of patient age. Time from ECG‐2‐sheath was significantly associated with mortality with a 3.6% increase per 30 minutes of time. Using achievement of time goal <90 minutes in patients aged >80 years and mortality at 30 days, mortality was 10.5% and 17.7% for <90 or ≥90 minutes, respectively. The number needed to prevent 1 death was 39 in the whole population and 14 in the elderly.

Restricted mean survival gains during median 938 days of follow‐up in patients with ECG‐2‐sheath time <90 minutes were 24 and 76 days for patients aged <80 and ≥80 years, respectively.

Conclusions

Time from ECG‐diagnosis to sheath insertion is strongly correlated with mortality. This applies especially to octogenarians who derive the most in terms of absolute mortality reduction.

Registration

URL: https://helsedata.no/en/forvaltere/norwegian‐institute‐of‐public‐health/norwegian‐registry‐of‐invasive‐cardiology/.

Should advanced age be a limiting factor in providing therapeutic hypothermia to cardiac arrest survivors? A single-center observational study

As octogenarians represent the fastest growing segment of the elderly population and the incidence of out-of-hospital cardiac arrest (OHCA) increases with age, the outcome benefit of therapeutic hypothermia (TH) in comatose cardiac arrest survivors is of great interest. The first randomized controlled trials of TH excluded all patients older than 75 years and there exists considerable uncertainty whether the positive findings from these studies apply to older patients. This is a retrospective study of all unconscious OHCA survivors from 2002 to 2008 treated with TH in our intensive care unit who fulfilled the Hypothermia After Cardiac Arrest study inclusion criteria (witnessed, shockable OHCA receiving bystander-cardiopulmonary resuscitation (CPR), interval from collapse to ambulance arrival <15 minutes, and return of spontaneous circulation [ROSC] within 60 minutes) but with no upper age limit. Good cerebral outcome was defined as a Glasgow-Pittsburgh Cerebral Performance Category 1-2. The median age of the 113 OHCA survivors studied was 62 years (18-89 years), and 77% were men. Median time from collapse to ROSC was 15 minutes (3-50 minutes). Bystander CPR was performed in 76% and immediate postresuscitation coronary angiography in 63%. The overall good outcome rate was 70%. Both lower age and shorter time to ROSC, as well as bystander CPR and the time period after implementation of the ERC 2005 guidelines were associated with good outcome. Still, 54% of all patients aged >75 years achieved good outcome. Although age seems to influence outcome, we found that more than half of comatose OHCA survivors above 75 years showed a favorable outcome. Hence, our data do not support a limitation of postresuscitation TH based on age alone but highlights the need for more clinical trials of TH in the advanced age group.

Factors predicting the use of therapeutic hypothermia and survival in unconscious out-of-hospital cardiac arrest patients admitted to the ICU

INTRODUCTION

Therapeutic hypothermia (TH) after out-of-hospital cardiac arrest (OHCA) was adopted early in Norway. Since 2004 the general recommendation has been to cool all unconscious OHCA patients treated in the intensive care unit (ICU), but the decision to cool individual patients was left to the responsible physician. We assessed factors that were associated with use of TH and predicted survival.

METHOD

We conducted a retrospective observational study of prospectively collected cardiac arrest and ICU registry data from 2004 to 2008 at three university hospitals.

RESULTS

A total of 715 unconscious patients older than 18 years of age, who suffered OHCA of both cardiac and non-cardiac causes, were included. With an overall TH use of 70%, the survival to discharge was 42%, with 90% of the survivors having a favourable cerebral outcome. Known positive prognostic factors such as witnessed arrest, bystander cardio pulmonary resuscitation (CPR), shockable rhythm and cardiac origin were all positive predictors of TH use and survival. On the other side, increasing age predicted a lower utilisation of TH: Odds Ratio (OR), 0.96 (95% CI, 0.94 to 0.97); as well as a lower survival: OR 0.96 (95% CI, 0.94 to 0.97). Female gender was also associated with a lower use of TH: OR 0.65 (95% CI, 0.43 to 0.97); and a poorer survival: OR 0.57 (95% CI, 0.36 to 0.92). After correcting for other prognostic factors, use of TH remained an independent predictor of improved survival with OR 1.91 (95% CI 1.18-3.06; P <0.001). Analysing subgroups divided after initial rhythm, these effects remained unchanged for patients with shockable rhythm, but not for patients with non-shockable rhythm where use of TH and female gender lost their predictive value.

CONCLUSIONS

Although TH was used in the majority of unconscious OHCA patients admitted to the ICU, actual use varied significantly between subgroups. Increasing age predicted both a decreased utilisation of TH as well as lower survival. Further, in patients with a shockable rhythm female gender predicted both a lower use of TH and poorer survival. Our results indicate an underutilisation of TH in some subgroups. Hence, more research on factors affecting TH use and the associated outcomes in subgroups of post-resuscitation patients is needed.

Good outcome in every fourth resuscitation attempt is achievable--an Utstein template report from the Stavanger region

AIM OF THE STUDY

Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the western world. We wanted to study changes in survival over time and factors linked to this in a region which have already reported high survival rates.

METHODS

We used a prospectively collected Utstein template database to identify all resuscitation attempts in adult patients with OHCA of presumed cardiac origin. We included 846 resuscitation attempts and compared survival to discharge with good outcome in two time periods (2001-2005 vs. 2006-2008).

RESULTS

We found no significant differences between the two time periods for mean age (71 and 70 years (p=0.309)), sex distribution (males 70% and 71% (p=0.708)), location of the OHCA (home 64% and 63% (p=0.732)), proportion of shockable rhythms (44% and 47% (p=0.261)) and rate of return of spontaneous circulation (38% and 43% (p=0.136)), respectively. Bystander cardiopulmonary resuscitation (CPR), however, increased significantly from 60% to 73% (p<0.0001), as did the overall rate of survival to discharge from 18% to 25% (p=0.018). In patients with a shockable first rhythm, rate of survival to discharge increased significantly from 37% to 48% (p=0.036). In witnessed arrest with shockable rhythm survival to discharge increased from 37% to 52% (p=0.0105).

CONCLUSION

Overall, good outcome is now achievable in every fourth resuscitation attempt and in every second resuscitation attempt when patients have a shockable rhythm. The reason for the better outcomes is most likely multi-factorial and linked to improvements in the local chain of survival.