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Bernard S, Pashun RA, Varma B, Yuriditsky E. Physiology-Guided Resuscitation: Monitoring and Augmenting Perfusion during Cardiopulmonary Arrest. J Clin Med 2024; 13:3527. [PMID: 38930056 PMCID: PMC11205151 DOI: 10.3390/jcm13123527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/08/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
Given the high morbidity and mortality associated with cardiopulmonary arrest, there have been multiple trials aimed at better monitoring and augmenting coronary, cerebral, and systemic perfusion. This article aims to elucidate these interventions, first by detailing the physiology of cardiopulmonary resuscitation and the available tools for managing cardiopulmonary arrest, followed by an in-depth examination of the newest advances in the monitoring and delivery of advanced cardiac life support.
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Affiliation(s)
| | | | | | - Eugene Yuriditsky
- Division of Cardiology, New York University Grossman School of Medicine, New York, NY 10016, USA; (S.B.); (R.A.P.)
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2
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Deb S, Drennan IR, Turner L, Cheskes S. Association of coronary angiography with ST-elevation and no ST-elevation in patients with refractory ventricular fibrillation - A substudy of the DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE-VF randomized control trial). Resuscitation 2024; 198:110163. [PMID: 38447909 DOI: 10.1016/j.resuscitation.2024.110163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Refractory ventricular fibrillation or pulseless ventricular tachycardia (rVF/pVT) during out-of-hospital cardiac arrest (OHCA) is associated with poor survival. Double sequential defibrillation (DSED) and vector change (VC) improved survival for rVF/pVT in the DOSE-VF RCT. However, the role of angiography and percutaneous coronary intervention (angiography/PCI) during the trial is unknown. OBJECTIVES To determine the incidence of ST-elevation (STE) and no ST-elevation (NO-STE) on post-arrest ECG and the use of angiography/PCI in patients with rVF/pVT during the DOSE-VF RCT. METHOD Adults (≥18-years) with rVF/pVT OHCA randomized in the DOSE-VF RCT who survived to hospital admission were included. The primary analysis compared the proportion of angiography in STE and NO-STE. We performed regression modelling to examine association between STE, the interaction with defibrillation strategy, and survival to discharge controlling for known covariates. RESULTS We included 151 patients, 74 (49%) with STE and 77 (51%) with NO-STE. The proportion of angiography was higher in the STE cohort than NO-STE (87.8% vs 44.2%, p < 0.001); similarly the proportion of PCI was also higher (75.7% vs 9.1%, p < 0.001). Survival to discharge was similar between STE and NO-STE (63.5% vs 51.9%, p = 0.15). Use of angiography/PCI did not differ between defibrillation strategies. Decreased age (OR 0.95, 95% CI 0.92-0.98; p = 0.001) and angiography (OR 9.33, 95% CI 3.60-26.94; p < 0.001) were predictors of survival; however, STE was not. CONCLUSION We found high rates of angiography/PCI in patients with STE compared to NO-STE, however similar rates of survival. Angiography was an independent predictor of survival. Improved rates of survival employing DSED and VC were independent of angiography/PCI.
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Affiliation(s)
- Saswata Deb
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Sunnybrook Research Institute, Toronto, Canada.
| | - Ian R Drennan
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Sunnybrook Research Institute, Toronto, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Sunnybrook Centre for Prehospital Medicine, Toronto, Canada.
| | - Linda Turner
- Sunnybrook Centre for Prehospital Medicine, Toronto, Canada.
| | - Sheldon Cheskes
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Sunnybrook Centre for Prehospital Medicine, Toronto, Canada.
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3
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Mehta A, Vavilin I, Nguyen AH, Batchelor WB, Blumer V, Cilia L, Dewanjee A, Desai M, Desai SS, Flanagan MC, Isseh IN, Kennedy JLW, Klein KM, Moukhachen H, Psotka MA, Raja A, Rosner CM, Shah P, Tang DG, Truesdell AG, Tehrani BN, Sinha SS. Contemporary approach to cardiogenic shock care: a state-of-the-art review. Front Cardiovasc Med 2024; 11:1354158. [PMID: 38545346 PMCID: PMC10965643 DOI: 10.3389/fcvm.2024.1354158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/13/2024] [Indexed: 05/02/2024] Open
Abstract
Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.
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Affiliation(s)
- Aditya Mehta
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Ilan Vavilin
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Andrew H. Nguyen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Wayne B. Batchelor
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Vanessa Blumer
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Lindsey Cilia
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Aditya Dewanjee
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mehul Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Michael C. Flanagan
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Iyad N. Isseh
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Jamie L. W. Kennedy
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Katherine M. Klein
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Hala Moukhachen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Mitchell A. Psotka
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Anika Raja
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Palak Shah
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Daniel G. Tang
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Alexander G. Truesdell
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Behnam N. Tehrani
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Sinha
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
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Tamis-Holland JE, Menon V, Johnson NJ, Kern KB, Lemor A, Mason PJ, Rodgers M, Serrao GW, Yannopoulos D. Cardiac Catheterization Laboratory Management of the Comatose Adult Patient With an Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e274-e295. [PMID: 38112086 DOI: 10.1161/cir.0000000000001199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Out-of-hospital cardiac arrest is a leading cause of death, accounting for ≈50% of all cardiovascular deaths. The prognosis of such individuals is poor, with <10% surviving to hospital discharge. Survival with a favorable neurologic outcome is highest among individuals who present with a witnessed shockable rhythm, received bystander cardiopulmonary resuscitation, achieve return of spontaneous circulation within 15 minutes of arrest, and have evidence of ST-segment elevation on initial ECG after return of spontaneous circulation. The cardiac catheterization laboratory plays an important role in the coordinated Chain of Survival for patients with out-of-hospital cardiac arrest. The catheterization laboratory can be used to provide diagnostic, therapeutic, and resuscitative support after sudden cardiac arrest from many different cardiac causes, but it has a unique importance in the treatment of cardiac arrest resulting from underlying coronary artery disease. Over the past few years, numerous trials have clarified the role of the cardiac catheterization laboratory in the management of resuscitated patients or those with ongoing cardiac arrest. This scientific statement provides an update on the contemporary approach to managing resuscitated patients or those with ongoing cardiac arrest.
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Kataoka N, Imamura T. Letter by Kataoka, et al. Regarding Article, "Evaluation of Plasma Xanthine Oxidoreductase (XOR) Activity in Patients with Cardiopulmonary Arrest". Int Heart J 2024; 65:165. [PMID: 38296571 DOI: 10.1536/ihj.23-258] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Naoya Kataoka
- Second Department of Internal Medicine, University of Toyama
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6
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Ferraz Costa G, Santos I, Sousa J, Beirão S, Teixeira R. Coronary angiography after out-of-hospital cardiac arrest without ST-segment elevation: a systematic review and meta-analysis of randomised trials. Coron Artery Dis 2024; 35:67-75. [PMID: 37861181 DOI: 10.1097/mca.0000000000001298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) has a poor prognosis. The optimal timing and role of early coronary angiography (CAG) in OHCA patients without ST-segment elevation remains unclear. The goal of this study is to compare an early CAG versus delayed CAG strategy in OHCA patients without ST elevation. METHODS We systematically searched PubMed, Embase and Cochrane databases, in June 2022, for randomised controlled trials (RCTs) comparing early versus delayed early CAG. A random effects meta-analysis was performed. RESULTS A total of seven RCTs were included, providing a total of 1625 patients: 816 in an early strategy and 807 in a delayed strategy. In terms of outcomes assessed, our meta-analysis revealed a similar rate of all-cause mortality (pooled odds ratio [OR] 1.22 [0.99-1.50], P = 0.06, I 2 = 0%), neurological status (pooled OR 0.94 [0.74-1.21], = 0.65, I 2 = 0%), need of renal replacement therapy (pooled OR 1.11 [0.78-1.74], P = 0.47, I 2 = 0%) and major bleeding events (pooled OR 1.51 [0.95-2.40], P = 0.08, I 2 = 69%). CONCLUSION According to our meta-analysis, in patients who experienced OHCA without ST elevation, early CAG is not associated with reduced mortality or an improved neurological status.
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Affiliation(s)
- Gonçalo Ferraz Costa
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra
| | - Iolanda Santos
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - João Sousa
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Sofia Beirão
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Rogério Teixeira
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra
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7
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Rab T. DRACULA-A mnemonic for unfavorable resuscitation features in cardiac arrest patients. Catheter Cardiovasc Interv 2023; 102:917-918. [PMID: 37698379 DOI: 10.1002/ccd.30835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 08/31/2023] [Indexed: 09/13/2023]
Affiliation(s)
- Tanveer Rab
- Interventional Cardiology, Cardiac Catheterization Laboratory, Emory Decatur Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
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8
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Haxhija Z, Seder DB, May TL, Hassager C, Friberg H, Lilja G, Ceric A, Nielsen N, Dankiewicz J. External validation of the CREST model to predict early circulatory-etiology death after out-of-hospital cardiac arrest without initial ST-segment elevation myocardial infarction. BMC Cardiovasc Disord 2023; 23:311. [PMID: 37340361 DOI: 10.1186/s12872-023-03334-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 06/06/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND The CREST model is a prediction model, quantitating the risk of circulatory-etiology death (CED) after cardiac arrest based on variables available at hospital admission, and intend to guide the triage of comatose patients without ST-segment-elevation myocardial infarction after successful cardiopulmonary resuscitation. This study assessed performance of the CREST model in the Target Temperature Management (TTM) trial cohort. METHODS We retrospectively analyzed data from resuscitated out-of-hospital cardiac arrest (OHCA) patients in the TTM-trial. Demographics, clinical characteristics, and CREST variables (history of coronary artery disease, initial heart rhythm, initial ejection fraction, shock at admission and ischemic time > 25 min) were assessed in univariate and multivariable analysis. The primary outcome was CED. The discriminatory power of the logistic regression model was assessed using the C-statistic and goodness of fit was tested according to Hosmer-Lemeshow. RESULTS Among 329 patients eligible for final analysis, 71 (22%) had CED. History of ischemic heart disease, previous arrhythmia, older age, initial non-shockable rhythm, shock at admission, ischemic time > 25 min and severe left ventricular dysfunction were variables associated with CED in univariate analysis. CREST variables were entered into a logistic regression model and the area under the curve for the model was 0.73 with adequate calibration according to Hosmer-Lemeshow test (p = 0.602). CONCLUSIONS The CREST model had good validity and a discrimination capability for predicting circulatory-etiology death after resuscitation from cardiac arrest without ST-segment elevation myocardial infarction. Application of this model could help to triage high-risk patients for transfer to specialized cardiac centers.
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Affiliation(s)
- Zana Haxhija
- Department of Clinical Sciences, Anesthesia and Intensive Care, Lund University, Skane University Hospital, Malmo, Sweden.
- Division of Anesthesia and Intensive Care, Department of Clinical sciences Lund, Lund University, Skane University Hospital, Carl Bertil Laurells gata 9, Malmo, 205 02, Sweden.
| | - David B Seder
- Department of Critical Care Services, Maine Medical Center, Portland Maine, USA
| | - Teresa L May
- Department of Critical Care Services, Maine Medical Center, Portland Maine, USA
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hans Friberg
- Department of Clinical Sciences, Anesthesia and Intensive Care, Lund University, Skane University Hospital, Malmo, Sweden
| | - Gisela Lilja
- Department of Clinical sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Ameldina Ceric
- Department of Clinical Sciences, Anesthesia and Intensive Care, Lund University, Skane University Hospital, Malmo, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences, Anesthesia and Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences, Cardiology, Lund University, Skane University Hospital, Lund, Sweden
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9
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Leeper B, Kern KB, Liu S, Sun X. Electrocardiographic Characteristics Fail to Predict Acute Coronary Occlusions in Out-of-Hospital Cardiac-Arrest Patients Without ST-Segment Elevation. Resuscitation 2023; 188:109826. [PMID: 37178897 DOI: 10.1016/j.resuscitation.2023.109826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/05/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND A minority of out-of-hospital cardiac arrest patients have an acutely occluded coronary artery without manifesting ST-segment elevation on their post-resuscitation ECG. Identifying such patients is an issue to providing timely reperfusion therapy. We aimed to evaluate the usefulness of the initial post-resuscitation electrocardiogram in out-of-hospital-cardiac-arrest patients for selection to perform early coronary angiography. METHODS The study population consisted of 74 of the 99 randomized patients from the PEARL clinical trial with both ECG and angiographic data. The purpose of this study was to investigate initial post-resuscitation electrocardiogram findings from out-of-hospital cardiac arrest patients without ST-segment elevation for any association with the presence of acute coronary occlusions. Secondarily, we aimed to observe the distribution of abnormal electrocardiogram findings and survival to hospital discharge of subjects. RESULTS Initial post-resuscitation electrocardiogram findings, including ST-depression, T-wave inversion, bundle branch block, non-specific changes, were not associated with the presence of an acutely occluded coronary. Normal post-resuscitation electrocardiogram findings were associated with patient survival to hospital discharge but were not associated with the presence or absence of an acute coronary occlusion. CONCLUSIONS Electrocardiogram findings cannot exclude or identify the presence of an acutely occluded coronary in out-of-hospital-cardiac-arrest patients without ST-segment elevation. An acutely occluded coronary may be present regardless of normal electrocardiogram findings.
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Affiliation(s)
| | - Karl B Kern
- University of Arizona Sarver Heart Center and
| | - Shen Liu
- College of Public Health, 1501 N. Campbell Avenue, Tucson, Arizona 85724
| | - Xiaoxiao Sun
- College of Public Health, 1501 N. Campbell Avenue, Tucson, Arizona 85724
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10
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Vallabhajosyula S, Verghese D, Henry TD, Katz JN, Nicholson WJ, Jaber WA, Jentzer JC. Contemporary Management of Concomitant Cardiac Arrest and Cardiogenic Shock Complicating Myocardial Infarction. Mayo Clin Proc 2022; 97:2333-2354. [PMID: 36464466 DOI: 10.1016/j.mayocp.2022.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 06/08/2022] [Accepted: 06/24/2022] [Indexed: 12/03/2022]
Abstract
Cardiogenic shock (CS) and cardiac arrest (CA) are the most life-threatening complications of acute myocardial infarction. Although there is a significant overlap in the pathophysiology with approximately half the patients with CS experiencing a CA and approximately two-thirds of patients with CA developing CS, comprehensive guideline recommendations for management of CA + CS are lacking. This paper summarizes the current evidence on the incidence, pathophysiology, and short- and long-term outcomes of patients with acute myocardial infarction complicated by concomitant CA + CS. We discuss the hemodynamic factors and unique challenges that need to be accounted for while developing treatment strategies for these patients. A summary of expert-based step-by-step recommendations to the approach and treatment of these patients, both in the field before admission and in-hospital management, are presented.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Dhiran Verghese
- Section of Advanced Cardiac Imaging, Division of Cardiovascular Medicine, Department of Medicine, Harbor UCLA Medical Center, Torrance, CA, USA; Department of Cardiovascular Medicine, NCH Heart Institute, Naples, FL, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital Health Network, Cincinnati, OH, USA
| | - Jason N Katz
- Divisions of Cardiovascular Diseases and Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - William J Nicholson
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Wissam A Jaber
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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11
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Tehrani BN, Sherwood MW, Rosner C, Truesdell AG, Ben Lee S, Damluji AA, Desai M, Desai S, Epps KC, Flanagan MC, Howard E, Ibrahim N, Kennedy J, Moukhachen H, Psotka M, Raja A, Saeed I, Shah P, Singh R, Sinha SS, Tang D, Welch T, Young K, deFilippi CR, Speir A, O'Connor CM, Batchelor WB. A Standardized and Regionalized Network of Care for Cardiogenic Shock. JACC. HEART FAILURE 2022; 10:768-781. [PMID: 36175063 PMCID: PMC10404382 DOI: 10.1016/j.jchf.2022.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The benefits of standardized care for cardiogenic shock (CS) across regional care networks are poorly understood. OBJECTIVES The authors compared the management and outcomes of CS patients initially presenting to hub versus spoke hospitals within a regional care network. METHODS The authors stratified consecutive patients enrolled in their CS registry (January 2017 to December 2019) by presentation to a spoke versus the hub hospital. The primary endpoint was 30-day mortality. Secondary endpoints included bleeding, stroke, or major adverse cardiovascular and cerebrovascular events. RESULTS Of 520 CS patients, 286 (55%) initially presented to 34 spoke hospitals. No difference in mean age (62 years vs 61 years; P = 0.38), sex (25% vs 32% women; P = 0.10), and race (54% vs 52% white; P = 0.82) between spoke and hub patients was noted. Spoke patients more often presented with acute myocardial infarction (50% vs 32%; P < 0.01), received vasopressors (74% vs 66%; P = 0.04), and intra-aortic balloon pumps (88% vs 37%; P < 0.01). Hub patients were more often supported with percutaneous ventricular assist devices (44% vs 11%; P < 0.01) and veno-arterial extracorporeal membrane oxygenation (13% vs 0%; P < 0.01). Initial presentation to a spoke was not associated with increased risk-adjusted 30-day mortality (adjusted OR: 0.87 [95% CI: 0.49-1.55]; P = 0.64), bleeding (adjusted OR: 0.89 [95% CI: 0.49-1.62]; P = 0.70), stroke (adjusted OR: 0.74 [95% CI: 0.31-1.75]; P = 0.49), or major adverse cardiovascular and cerebrovascular events (adjusted OR 0.83 [95% CI: 0.50-1.35]; P = 0.44). CONCLUSIONS Spoke and hub patients experienced similar short-term outcomes within a regionalized CS network. The optimal strategy to promote standardized care and improved outcomes across regional CS networks merits further investigation.
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Affiliation(s)
- Behnam N Tehrani
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA.
| | | | - Carolyn Rosner
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Alexander G Truesdell
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Virginia Heart, Falls Church, Virginia, USA
| | | | | | - Mehul Desai
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Shashank Desai
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Kelly C Epps
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | | | - Edward Howard
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Virginia Heart, Falls Church, Virginia, USA
| | - Nasrien Ibrahim
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Jamie Kennedy
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Hala Moukhachen
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Mitchell Psotka
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Anika Raja
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Ibrahim Saeed
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Virginia Heart, Falls Church, Virginia, USA
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Ramesh Singh
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | | | - Daniel Tang
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Timothy Welch
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Karl Young
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | | | - Alan Speir
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
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12
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Owyang CG, Abualsaud R, Agarwal S, Del Rios M, Grossestreuer AV, Horowitz JM, Johnson NJ, Kotini-Shah P, Mitchell OJL, Morgan RW, Moskowitz A, Perman SM, Rittenberger JC, Sawyer KN, Yuriditsky E, Abella BS, Teran F. Latest in Resuscitation Research: Highlights From the 2021 American Heart Association's Resuscitation Science Symposium. J Am Heart Assoc 2022; 11:e026191. [PMID: 36172932 DOI: 10.1161/jaha.122.026191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Clark G Owyang
- Division of Pulmonary and Critical Care Medicine Weill Cornell Medicine/New York Presbyterian Hospital New York NY.,Department of Emergency Medicine Weill Cornell Medicine/New York Presbyterian Hospital New York NY
| | - Rana Abualsaud
- Department of Emergency Medicine Weill Cornell Medicine/New York Presbyterian Hospital New York NY
| | - Sachin Agarwal
- Division of Neurocritical Care & Hospitalist Neurology Columbia University Irving Medical Center New York NY
| | - Marina Del Rios
- Department of Emergency Medicine University of Iowa Iowa City IA
| | | | - James M Horowitz
- Division of Cardiology, Department of Medicine NYU Langone Health New York NY
| | - Nicholas J Johnson
- Department of Emergency Medicine and Division of Pulmonary, Critical Care, and Sleep Medicine University of Washington Seattle WA
| | - Pavitra Kotini-Shah
- Department of Emergency Medicine University of Illinois at Chicago Chicago IL
| | - Oscar J L Mitchell
- Division of Pulmonary, Allergy, and Critical Care Medicine University of Pennsylvania Philadelphia PA
| | - Ryan W Morgan
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Ari Moskowitz
- Division of Critical Care Medicine Montefiore Medical Center New York NY
| | - Sarah M Perman
- Department of Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Jon C Rittenberger
- Department of Emergency Medicine Guthrie-Robert Packer Hospital, Geisinger Commonwealth Medical College Scranton PA
| | - Kelly N Sawyer
- Department of Emergency Medicine University of Pittsburgh Pittsburgh PA
| | - Eugene Yuriditsky
- Division of Cardiology, Department of Medicine NYU Langone Health New York NY
| | - Benjamin S Abella
- Department of Emergency Medicine Center for Resuscitation Science, University of Pennsylvania Philadelphia PA
| | - Felipe Teran
- Department of Emergency Medicine Weill Cornell Medicine/New York Presbyterian Hospital New York NY
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13
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Tehrani BN, Drakos SG, Billia F, Batchelor WB, Luk A, Stelling K, Tonna J, Rosner C, Hanff T, Rao V, Brozzi NA, Baran DA. The Multicenter Collaborative to Enhance Biologic Understanding, Quality, and Outcomes in Cardiogenic Shock (VANQUISH Shock): Rationale and Design. Can J Cardiol 2022; 38:1286-1295. [PMID: 35288292 PMCID: PMC10625804 DOI: 10.1016/j.cjca.2022.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/27/2022] [Accepted: 03/07/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite efforts to advance therapies in cardiogenic shock (CS), outcomes remain poor. This is likely due to several factors, including major gaps in our understanding of the pathophysiology, phenotyping of patients, and challenges with conducting adequately powered clinical studies. An unmet need exists for a comprehensive multicentre "all-comers" prospective registry to facilitate characterising contemporary presentation, treatment (in a device-agnostic fashion), and short- and intermediate-term outcomes and quality of life (QOL) of CS patients. METHODS The Multicenter Collaborative to Enhance Biological Understanding, Quality and Outcomes in Cardiogenic Shock (VANQUISH Shock) registry is a prospective observational registry that will study unrestricted adult patients with a primary diagnosis of CS at 4 North American centres with multidisciplinary shock programs. Both acute myocardial infarction (AMI-CS) and acute heart failure (HF-CS) etiologies will be included, and the registry will be device agnostic and widely inclusive. The primary end point will be survival at 30 days after hospital discharge. Secondary outcomes will include in-hospital adverse events and survival to 6 and 12 months. Patients will also undergo neurologic and health-related QOL assessments with the Cerebral Performance Category (CPC) and Short-Form 36 (SF-36) health survey tools before discharge and during follow-up. Serial biospecimens will facilitate biomarker studies. CONCLUSIONS The VANQUISH Shock registry provides a unique opportunity to study the pathophysiology, contemporary management, clinical course, and outcomes of CS. By capturing detailed and high-quality longitudinal data, the registry will address existing knowledge gaps and serve as a springboard for future mechanistic clinical studies to advance the field.
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Affiliation(s)
| | | | - Filio Billia
- Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada.
| | | | - Adriana Luk
- Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kelly Stelling
- Sentara Norfolk General Hospital, Norfolk, Virginia, USA
| | | | | | | | - Vivek Rao
- Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nicolas A Brozzi
- Cleveland Clinic Heart, Vascular, and Thoracic Institute, Weston, Florida, USA
| | - David A Baran
- Cleveland Clinic Heart, Vascular, and Thoracic Institute, Weston, Florida, USA.
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14
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Harhash AA, Kluge MA, Muthukrishnan A, Noc M, Radsel P, Jentzer JC, Seder DB, Lee K, Lotun K, Stub D, Hsu CH, Kern KB. Coronary angiographic findings for out-of-hospital cardiac arrest survivors presenting with nonshockable rhythms and no ST elevation post resuscitation. Resuscitation 2022; 178:63-68. [PMID: 35870556 DOI: 10.1016/j.resuscitation.2022.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/27/2022] [Accepted: 07/18/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recent guidelines suggest that coronary angiography (CAG) should be considered for out-of-hospital cardiac arrest (OHCA) survivors, including those without ST elevation (STE) and without shockable rhythms. However, there is no prospective data to support CAG for survivors with nonshockable rhythms and no STE post resuscitation. METHODS This was a re-analysis of the PEARL study (randomized OHCA survivors without STE to early CAG versus not). Patients were subdivided by initial rhythm as nonshockable (Nsh) vs shockable (Sh). The primary outcome was coronary angiographic evidence of acute culprit lesion, with secondary outcomes being survival to hospital discharge and neurological recovery. RESULTS The PEARL study included 99 patients with OHCA from a presumed cardiac etiology, 24 with nonshockable and 75 with shockable rhythms. There was no difference in the frequency of CAG between the two groups [71% (Nsh) and 75% (Sh); p = 0.79], presence of CAD [81% (Nsh) and 68% (sh); p = 0.37, or culprit lesions identified in each group [50% (Nsh) and 45% (Sh); p = 0.78. Nonshockable patients had worse discharge survival [33% (Nsh) vs 57% (Sh); p = 0.04] and those survived, had worse neurological recovery [30% (Nsh) vs 54% (Sh); p = 0.02] compared to shockable patients. CONCLUSIONS OHCA survivors presenting with nonshockable rhythms and no STE post resuscitation had similar prevalence of culprit coronary lesions to those with shockable rhythms. CAG may be considered in patients with OHCA without STE regardless of initial presenting rhythm. There was no benefit of emergent CAG both in shockable and non-shockable rhythms.
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Affiliation(s)
- A A Harhash
- University of Vermont Medical Center, Burlington, VT, United States
| | - M A Kluge
- University of Vermont Medical Center, Burlington, VT, United States
| | - A Muthukrishnan
- University of Vermont Medical Center, Burlington, VT, United States
| | - M Noc
- Center for Intensive Medicine, University Medical Center Ljubljana, Slovenia
| | - P Radsel
- Center for Intensive Medicine, University Medical Center Ljubljana, Slovenia
| | - J C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - D B Seder
- Department of Critical Care Services, Maine Medical Center, ME, United States
| | - K Lee
- University of Arizona Sarver Heart Center, Tucson, AZ, United States
| | - K Lotun
- University of Arizona Sarver Heart Center, Tucson, AZ, United States
| | - D Stub
- Alfred Hospital & Monash University, Melbourne, Australia
| | - C-H Hsu
- University of Arizona Sarver Heart Center, Tucson, AZ, United States
| | - K B Kern
- University of Arizona Sarver Heart Center, Tucson, AZ, United States.
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15
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Vallabhajosyula S. Integration of electrical, mechanical, and hemodynamic information prior to coronary angiography in cardiac arrest. Resuscitation 2022; 172:127-129. [PMID: 35090968 DOI: 10.1016/j.resuscitation.2022.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 01/17/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States.
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16
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Youn CS, Yi H, Kim YJ, Song H, Kim N, Kim WY. Early Identification of Resuscitated Patients with a Significant Coronary Disease in Out-of-Hospital Cardiac Arrest Survivors without ST-Segment Elevation. J Clin Med 2021; 10:jcm10235688. [PMID: 34884390 PMCID: PMC8658463 DOI: 10.3390/jcm10235688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/27/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
This study aimed to develop a machine learning (ML)-based model for identifying patients who had a significant coronary artery disease among out-of-hospital cardiac arrest (OHCA) survivors without ST-segment elevation (STE). This multicenter observational study used data from the Korean Hypothermia Network prospective registry (KORHN-PRO) gathered between October 2015 and December 2018. We used information available before targeted temperature management (TTM) as predictor variables, and the primary outcome was a significant coronary artery lesion in coronary angiography (CAG). Among 1373 OHCA patients treated with TTM, 331 patients without STE who underwent CAG were enrolled. Among them, 127 patients (38.4%) had a significant coronary artery lesion. Four ML algorithms, namely regularized logistic regression (RLR), random forest classifier (RF), CatBoost classifier (CBC), and voting classifier (VC), were used with data collected before CAG. The VC model showed the highest accuracy for predicting significant lesions (area under the curve of 0.751). Eight variables (older age, male, initial shockable rhythm, shorter total collapse duration, higher glucose and creatinine, and lower pH and lactate) were significant to ML models. These results showed that ML models may be useful in developing early predictive tools for identifying high-risk patients with a significant stenosis in CAG.
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Affiliation(s)
- Chun-Song Youn
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (C.-S.Y.); (H.S.)
| | - Hahn Yi
- Asan Medical Center, Asan Institute for Life Sciences, Seoul 05505, Korea;
| | - Youn-Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea;
| | - Hwan Song
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (C.-S.Y.); (H.S.)
| | - Namkug Kim
- Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
- Correspondence: (N.K.); (W.-Y.K.)
| | - Won-Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea;
- Correspondence: (N.K.); (W.-Y.K.)
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17
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Rozen G, Elbaz-Greener G, Marai I, Heist EK, Ruskin JN, Carasso S, Birati EY, Amir O. The relationship between the body mass index and in-hospital mortality in patients admitted for sudden cardiac death in the United States. Clin Cardiol 2021; 44:1673-1682. [PMID: 34786725 PMCID: PMC8715398 DOI: 10.1002/clc.23730] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/07/2021] [Accepted: 09/14/2021] [Indexed: 12/13/2022] Open
Abstract
While obesity has been shown to be associated with elevated risk for Sudden Cardiac Death (SCD), studies examining its effect on outcomes in SCD victims have shown conflicting results. We aimed to describe the body mass index (BMI) distribution in a nationwide cohort of patients admitted for an out of hospital SCD (OHSCD), and the relationship between BMI and in‐hospital mortality. We drew data from the U.S. National Inpatient Sample (NIS), to identify cases of OHSCD. Patients were divided into six groups based on their BMI (underweight, normal weight, overweight, obese I, obese II, extremely obese). Socio‐demographic and clinical data were collected, mortality and length of stay were analyzed. Multivariate analysis was performed to identify predictors of mortality. Among a weighted total of 2330 hospitalizations for OHSCD in patients with documented BMI, the mean age was 62.3 ± 29 years, 52.4% were male and 62% were white. The overall rate of in‐hospital mortality was 69.3%. A U‐shaped relationship between the BMI and mortality was documented, as patients with 25 < BMI < 40 exhibited significantly lower mortality (60.7%) compared to the other BMI groups (75.2%), p < .001. BMI of 25 kg/m2 and below or 40 kg/m2 and above, were independent predictors of in‐hospital mortality in a multivariate analysis along with prior history of congestive heart failure and Deyo Comorbidity Index of ≥2. A U‐shaped relationship between the BMI and in‐hospital mortality was documented in patients hospitalized for an out of hospital sudden cardiac death in the United States in the recent years.
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Affiliation(s)
- Guy Rozen
- Division of Cardiovascular Medicine, Hillel Yaffe Medical Center, Hadera, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.,Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gabby Elbaz-Greener
- Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ibrahim Marai
- Division of Cardiovascular Medicine, Baruch Padeh Medical Center, Poriya, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Zafed, Israel
| | - E Kevin Heist
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeremy N Ruskin
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shemy Carasso
- Division of Cardiovascular Medicine, Baruch Padeh Medical Center, Poriya, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Zafed, Israel
| | - Edo Y Birati
- Division of Cardiovascular Medicine, Baruch Padeh Medical Center, Poriya, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Zafed, Israel
| | - Offer Amir
- Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Zafed, Israel
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18
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Elbaz-Greener G, Carasso S, Maor E, Gallimidi L, Yarkoni M, Wijeysundera HC, Abend Y, Dagan Y, Lerman A, Amir O. Clinical Predictors of Mortality in Prehospital Distress Calls by Emergency Medical Service Subscribers. J Clin Med 2021; 10:jcm10225355. [PMID: 34830638 PMCID: PMC8624120 DOI: 10.3390/jcm10225355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/02/2021] [Accepted: 11/15/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Introduction: Most studies rely on in-hospital data to predict cardiovascular risk and do not include prehospital information that is substantially important for early decision making. The aim of the study was to define clinical parameters in the prehospital setting, which may affect clinical outcomes. (2) Methods: In this population-based study, we performed a retrospective analysis of emergency calls that were made by patients to the largest private emergency medical services (EMS) in Israel, SHL Telemedicine Ltd., who were treated on-site by the EMS team. Demographics, clinical characteristics, and clinical outcomes were analyzed. Mortality was evaluated at three time points: 1, 3, and 12 months’ follow-up. The first EMS prehospital measurements of the systolic blood pressure (SBP) were recorded and analyzed. Logistic regression analyses were performed. (3) Results: A total of 64,320 emergency calls were included with a follow-up of 12 months post index EMS call. Fifty-five percent of patients were men and the mean age was 70.2 ± 13.1 years. During follow-up of 12 months, 7.6% of patients died. Age above 80 years (OR 3.34; 95% CI 3.03–3.69, p < 0.005), first EMS SBP ≤ 130 mm Hg (OR 2.61; 95% CI 2.36–2.88, p < 0.005), dyspnea at presentation (OR 2.55; 95% CI 2.29–2.83, p < 0001), and chest pain with ischemic ECG changes (OR 1.95; 95% CI 1.71–2.23, p < 0.001) were the highest predictors of 1 month mortality and remained so for mortality at 3 and 12 months. In contrast, history of hypertension and first EMS prehospital SBP ≥ 160 mm Hg were significantly associated with decreased mortality at 1, 3 and 12 months. (4) Conclusions: We identified risk predictors for all-cause mortality in a large cohort of patients during prehospital EMS calls. Age over 80 years, first EMS-documented prehospital SBP < 130 mm Hg, and dyspnea at presentation were the most profound risk predictors for short- and long-term mortality. The current study demonstrates that in prehospital EMS call settings, several parameters can be used to improve prioritization and management of high-risk patients.
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Affiliation(s)
- Gabby Elbaz-Greener
- Hadassah Medical Center, Cardiology Department, Faculty of Medicine, Hebrew University Jerusalem, Jerusalem 91905, Israel; (M.Y.); (O.A.)
- Correspondence: ; Tel.: +972-(2)6776564; Fax: +972-(2)6411028
| | - Shemy Carasso
- Baruch-Pade Poriya Medical Center, Cardiology Department, Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 52100, Israel;
| | - Elad Maor
- Leviev Heart Center, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel;
| | - Lior Gallimidi
- SHL Telemedicine Ltd., Tel-Aviv 67891, Israel; (L.G.); (Y.A.); (Y.D.); (A.L.)
| | - Merav Yarkoni
- Hadassah Medical Center, Cardiology Department, Faculty of Medicine, Hebrew University Jerusalem, Jerusalem 91905, Israel; (M.Y.); (O.A.)
| | - Harindra C. Wijeysundera
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | - Yitzhak Abend
- SHL Telemedicine Ltd., Tel-Aviv 67891, Israel; (L.G.); (Y.A.); (Y.D.); (A.L.)
| | - Yinon Dagan
- SHL Telemedicine Ltd., Tel-Aviv 67891, Israel; (L.G.); (Y.A.); (Y.D.); (A.L.)
| | - Amir Lerman
- SHL Telemedicine Ltd., Tel-Aviv 67891, Israel; (L.G.); (Y.A.); (Y.D.); (A.L.)
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN 55902, USA
| | - Offer Amir
- Hadassah Medical Center, Cardiology Department, Faculty of Medicine, Hebrew University Jerusalem, Jerusalem 91905, Israel; (M.Y.); (O.A.)
- Baruch-Pade Poriya Medical Center, Cardiology Department, Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 52100, Israel;
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19
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Kanwar A, Patlolla SH, Singh M, Murphree DH, Sundaragiri PR, Jaber WA, Nicholson WJ, Vallabhajosyula S. Temporal Trends, Predictors and Outcomes of Inpatient Palliative Care Use in Cardiac Arrest Complicating Acute Myocardial Infarction. Resuscitation 2021; 170:53-62. [PMID: 34780813 DOI: 10.1016/j.resuscitation.2021.10.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/21/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Utilization of inpatient palliative care services (PCS) has been infrequently studied in patients with cardiac arrest complicating acute myocardial infarction (AMI-CA). METHODS Adult AMI-CA admissions were identified from the National Inpatient Sample (2000-2017). Outcomes of interest included temporal trends and predictors of PCS use and in-hospital mortality, length of stay, hospitalization costs and discharge disposition in AMI-CA admissions with and without PCS use. Multivariable logistic regression and propensity matching were used to adjust for confounding. RESULTS Among 584,263 AMI-CA admissions, 26,919 (4.6%) received inpatient PCS. From 2000 to 2017 PCS use increased from <1% to 11.5%. AMI-CA admissions that received PCS were on average older, had greater comorbidity, higher rates of cardiogenic shock, acute organ failure, lower rates of coronary angiography (48.6% vs 63.3%), percutaneous coronary intervention (37.4% vs 46.9%), and coronary artery bypass grafting (all p < 0.001). Older age, greater comorbidity burden and acute non-cardiac organ failure were predictive of PCS use. In-hospital mortality was significantly higher in the PCS cohort (multivariable logistic regression: 84.6% vs 42.9%, adjusted odds ratio 3.62 [95% CI 3.48-3.76]; propensity-matched analysis: 84.7% vs. 66.2%, p < 0.001). The PCS cohort received a do- not-resuscitate status more often (47.6% vs. 3.7%), had shorter hospital stays (4 vs 5 days), and were discharged more frequently to skilled nursing facilities (73.6% vs. 20.4%); all p < 0.001. These results were consistent in the propensity-matched analysis. CONCLUSIONS Despite an increase in PCS use in AMI-CA, it remains significantly underutilized highlighting the role for further integrating of these specialists in AMI-CA care.
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Affiliation(s)
- Ardaas Kanwar
- University of Minnesota, Minneapolis, MN, United States
| | - Sri Harsha Patlolla
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Dennis H Murphree
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States
| | - Pranathi R Sundaragiri
- Department of Primary Care Internal Medicine, Wake Forest Baptist Health, High Point, NC, United States
| | - Wissam A Jaber
- Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - William J Nicholson
- Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, United States.
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20
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Harhash AA, May T, Hsu CH, Seder DB, Dankiewicz J, Agarwal S, Patel N, McPherson J, Riker R, Soreide E, Hirsch KG, Stammet P, Dupont A, Forsberg S, Rubertsson S, Friberg H, Nielsen N, Mooney MR, Kern KB. Incidence of cardiac interventions and associated cardiac arrest outcomes in patients with nonshockable initial rhythms and no ST elevation post resuscitation. Resuscitation 2021; 167:188-197. [PMID: 34437992 DOI: 10.1016/j.resuscitation.2021.08.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/02/2021] [Accepted: 08/12/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Out of Hospital Cardiac arrest (OHCA) survivors with ST elevation (STE) with or without shockable rhythms often benefit from coronary angiography (CAG) and, if indicated, percutaneous coronary intervention (PCI). However, the benefits of CAG and PCI in OHCA survivors with nonshockable rhythms (PEA/asystole) and no STE are debated. METHODS Using the International Cardiac Arrest Registry (INTCAR 2.0), representing 44 centers in the US and Europe, comatose OHCA survivors with known presenting rhythms and post resuscitation ECGs were identified. Survival to hospital discharge, neurological recovery on discharge, and impact of CAG with or without PCI on such outcome were assessed and compared with other groups (shockable rhythms with or without STE). RESULTS Total of 2113 OHCA survivors were identified and described as; nonshockable/no STE (Nsh-NST) (n = 940, 44.5%), shockable/no STE (Sh-NST) (n = 716, 33.9%), nonshockable/STE (Nsh-ST) (n = 110, 5.2%), and shockable/STE (Sh-ST) (n = 347, 16.4%). Of Nsh-NST, 13.7% (129) were previously healthy before CA and only 17.3% (161) underwent CAG; of those, 30.4% (52) underwent PCI. A total of 18.6% (174) Nsh-NST patients survived to hospital discharge, with 57.5% (100) of such survivors having good neurological recovery (cerebral performance category 1 or 2) on discharge. Coronary angiography was associated with improved odds for survival and neurological recovery among all groups, including those with NSh-NST. CONCLUSIONS Nonshockable initial rhythms with no ST elevation post resuscitation was the most common presentation after OHCA. Although most of these patients did not undergo coronary angiography, among those who did, 1 in 4 patients had a culprit lesion and underwent revascularization. Invasive CAG should be at least considered for all OHCA survivors, including those with nonshockable rhythms and no ST elevation post resuscitation. BRIEF ABSTRACT Out of hospital cardiac arrest (OHCA) survivors with ST elevation and/or shockable rhythms benefit from coronary angiography and revascularization. Nonshockable cardiac arrest survivors with no ST elevation have the worst prognosis and rarely undergo coronary angiography. Nonshockable rhythms with no ST elevation was the most common presentation after OHCA and among a small subgroup underwent coronary angiography, 1 in 4 patients with had culprit lesion and underwent revascularization. Coronary angiography was associated with high prevalence of acute culprit coronary lesions and should be considered for those with a probably cardiac cause for their arres.
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Affiliation(s)
- Ahmed A Harhash
- University of Arizona Sarver Heart Center, Tucson, AZ, United States; University of Vermont Medical Center, Burlington, VT, United States
| | - Teresa May
- Maine Medical Center, Portland, ME, United States
| | - Chiu-Hsieh Hsu
- University of Arizona College of Public Health, Tucson, AZ, United States
| | | | | | | | - Nainesh Patel
- Lehigh Valley Heart Institute, Allentown, PA, United States
| | - John McPherson
- Vanderbilt University Medical Center, Nashville, TN, United States
| | | | | | | | | | | | | | | | | | - Niklas Nielsen
- Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | | | - Karl B Kern
- University of Arizona Sarver Heart Center, Tucson, AZ, United States.
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21
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Patlolla SH, Sundaragiri PR, Gurumurthy G, Cheungpasitporn W, Rab ST, Vallabhajosyula S. Outcomes of cardiac arrest complicating acute myocardial infarction in patients with current and historical cancer: An 18-year United States cohort study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 38:45-51. [PMID: 34391681 DOI: 10.1016/j.carrev.2021.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Data regarding cardiac arrest (CA) complicating acute myocardial infarction (AMI) in patients with cancers are limited. METHODS Using the HCUP-NIS database (2000-2017), we identified adult admissions with AMI-CA and current or historical cancers to evaluate in-hospital mortality, utilization of coronary angiography, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), mechanical circulatory support (MCS), palliative care consultation, do-not-resuscitate status use, among those with current, historical and without cancer. RESULTS Of 11,622,528 AMI admissions, CA was noted in 584,263 (5.0%). Current and historical cancers were identified in 14,790 (2.5%) and 26,939 (4.6%), respectively. Both current and historical cancer groups were on average older, of white race, had greater comorbidity, and received care at small/medium-sized hospitals compared to those without. The current cancer cohort had the lowest rates of coronary angiography (45.2% vs. 59.2% vs. 63.3%), PCI (32.4% vs. 42.3% vs. 47.0%), MCS (13.5% vs. 16.5% vs. 20.9%) and CABG (4.1% vs. 7.6% vs. 10.2%) compared to the historical cancer and no cancer cohorts (all p < 0.001). Compared to those without, the current (61.1% vs. 44.0%; adjusted odds ratio [OR] 1.25 [95% confidence interval {CI} 1.20-1.31], p < 0.001) and historical cancer cohorts (52.2% vs. 44.0%; adjusted OR 1.05 [95% CI 1.01-1.08], p = 0.003) had higher in-hospital mortality. Cancer admissions had higher rates of palliative care consultations and do-not-resuscitate status. CONCLUSION AMI-CA admissions with cancer were older, had lower utilization of cardiac procedures, and higher rates of palliative care and do-not-resuscitate status and in-hospital mortality compared to those without cancer.
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Affiliation(s)
- Sri Harsha Patlolla
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States of America
| | - Pranathi R Sundaragiri
- Department of Primary Care Internal Medicine, Wake Forest Baptist Health, High Point, NC, United States of America
| | - Gayathri Gurumurthy
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Syed Tanveer Rab
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, United States of America
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, United States of America.
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22
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Gamberini L, Coniglio C, Lupi C, Tartaglione M, Mazzoli CA, Baldazzi M, Cecchi A, Ferri E, Chiarini V, Semeraro F, Gordini G. Resuscitative endovascular occlusion of the aorta (REBOA) for refractory out of hospital cardiac arrest. An Utstein-based case series. Resuscitation 2021; 165:161-169. [PMID: 34089774 DOI: 10.1016/j.resuscitation.2021.05.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/11/2021] [Accepted: 05/16/2021] [Indexed: 12/18/2022]
Abstract
AIMS Out of hospital cardiac arrest (OHCA) is still a leading cause of mortality worldwide. In recent years, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been progressively studied as an adjunct to standard advanced life support (ALS) in both traumatic and non-traumatic refractory OHCA. Since January 2019, the REBOA procedure has been applied to all the patients experiencing both traumatic and non-traumatic refractory OHCA (≥15 min of cardiopulmonary resuscitation) not eligible for ECPR for clinical or logistic reasons. We aimed at describing the feasibility and effects of REBOA performed both in the Emergency Department and in the pre-hospital environment served by the local HEMS for refractory OHCA. METHODS Twenty consecutive patients experiencing refractory OHCA and in whom REBOA was attempted in 2019 and 2020 were included in the study, Utstein data and REBOA specific variables were recorded. RESULTS Successful catheter placement was achieved in 18 out of 20 patients, 11 of these were non-traumatic OHCAs while 7 were traumatic OHCAs, the 2 failures were related to repeated arterial puncture failure. Median time between the EMS dispatch and REBOA catheter placing attempt was 46 min. An increase in etCO2 over 10 mmHg was observed after balloon inflation in 12 out of 18 patients (8/11 non-traumatic and 4/7 traumatic OHCAs), a sustained ROSC was observed in 5 patients (1 traumatic and 4 non-traumatic OHCA) that were subsequently admitted to the ICU. Four out of the 5 patients reached the criteria for brain death in the subsequent 24 h while one patient experienced another episode of refractory cardiac arrest in ICU and subsequently died. CONCLUSION Our data confirm the feasibility of REBOA technique as an adjunct to ALS in both the ED and prehospital phase and most of the treated patients experienced a transient ROSC after balloon inflation while 5 out of 18 experienced a sustained ROSC. However, while in the trauma setting increasing evidence suggests an improved survival when REBOA is applied to refractory OHCA, in non-traumatic OHCA this has yet to be demonstrated and large studies are needed.
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Affiliation(s)
- Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Coniglio
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Cristian Lupi
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Marco Tartaglione
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Alberto Mazzoli
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Marzia Baldazzi
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Alessandra Cecchi
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Enrico Ferri
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Valentina Chiarini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Federico Semeraro
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy.
| | - Giovanni Gordini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
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- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
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23
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Daubert JP, Lee JS, Narayan SM. Prognostication for Sudden Cardiac Arrest Patients Achieving ROSC. J Am Coll Cardiol 2021; 77:372-374. [PMID: 33509393 PMCID: PMC10950326 DOI: 10.1016/j.jacc.2020.11.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 11/30/2020] [Indexed: 11/20/2022]
Affiliation(s)
- James P Daubert
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Joshua S Lee
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sanjiv M Narayan
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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