The influence of cardiopulmonary resuscitation without defibrillation on serum levels of cardiac enzymes: A time course study of out-of-hospital cardiac arrest survivors

Galectin-3 Predicts Long-Term Risk of Cerebral Disability and Mortality in Out-of-Hospital Cardiac Arrest Survivors

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is associated with high mortality and cerebral disability in survivors. Current models of risk prediction and survival are mainly based on resuscitation duration. We examined the prognostic value of circulating biomarkers in predicting mortality and severe cerebral disability for OHCA survivors, alongside traditional clinical risk indicators.

METHODS

Biomarkers including BNP, troponin I, and galectin-3 were measured at hospital admission in resuscitated OHCA patients. Prognostic significance for mortality and cerebral disability involving circulating biomarkers, resuscitation duration, demographics, and laboratory and clinical characteristics was examined via univariate and multivariate Cox proportional hazards regression models. The incremental prognostic value of the index covariates was examined through model diagnostics, focusing on the Akaike information criterion (AIC) and Harrell's concordance statistic (c-statistic).

RESULTS

In a combinatorial analysis of 144 OHCA survivors (median follow-up 5.7 years (IQR 2.9-6.6)), BNP, galectin-3, arterial pH, and resuscitation time were significant predictors of all-cause death and severe cerebral disability, whereas troponin I levels were not. Multivariate regression, adjusting for BNP, arterial pH, and resuscitation time, identified galectin-3 as an independent predictor of long-term mortality. Multiple linear regression models also confirmed galectin-3 as the strongest predictor of cerebral disability. The incorporation of galectin-3 into models for predicting mortality and cerebral disability enhanced fit and discrimination, demonstrating the incremental value of galectin-3 beyond traditional risk predictors.

CONCLUSIONS

Galectin-3 is a significant, independent long-term risk predictor of cerebral disability and mortality in OHCA survivors. Incorporating galectin-3 into current risk stratification models may enhance early prognostication and guide targeted clinical interventions.

The Prognostic Value of Troponin-T in Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: A COACT Substudy

Background

In out-of-hospital cardiac arrest (OHCA) without ST-elevation, predictive markers that can identify those with a high risk of acute coronary syndrome are lacking.

Methods

In this post hoc analysis of the Coronary Angiography after Cardiac Arrest (COACT) trial, the baseline, median, peak, and time-concentration curves of troponin-T (cTnT) (T-AUC) in OHCA patients without ST-elevation were studied. cTnT values were obtained at predefined time points at 0, 3, 6, 12, 24, 36, 28, and 72 hours after admission. All patients who died within the measurement period were not included. The primary outcome was the association between cTnT and 90-day survival. Secondary outcomes included the association of cTnT and acute thrombotic occlusions, acute unstable lesions, and left ventricular function.

Results

In total, 352 patients were included in the analysis. The mean age was 64 ± 13 years (80.4% men). All cTnT measures were independent prognostic factors for mortality after adjustment for potential confounders age, sex, history of coronary artery disease, witnessed arrest, time to BLS, and time to return of spontaneous circulation (eg, for T-AUC: hazard ratio, 1.44; 95% CI, 1.06-1.94; P = .02; P value for all variables ≤.02). Median cTnT (odds ratio [OR], 1.58; 95% CI, 1.18-2.12; P = .002) and T-AUC (OR, 2.03; 95% CI, 1.25-3.29; P = .004) were independent predictors for acute unstable lesions. Median cTnT (OR, 1.62; 95% CI, 1.17-2.23; P = .003) and T-AUC (OR, 2.16; 95% CI, 1.27-3.68; P = .004) were independent predictors for acute thrombotic occlusions. CTnT values were not associated with the left ventricular function (eg, for T-AUC: OR, 2.01; 95% CI, 0.65-6.19; P = .22; P value for all variables ≥.14).

Conclusion

In OHCA patients without ST-segment elevation, cTnT release during the first 72 hours after return of spontaneous circulation was associated with clinical outcomes.

Case report: Maternal cardiac arrest at 12 hours postpartum

Maternal cardiac arrest is a rare occurrence. In this case report, we present a detailed account of a 37-year-old pregnant woman with preeclampsia with severe features who underwent cesarean delivery. The patient experienced dyspnea and hypoxia at 12 hours postpartum, leading to cardiac arrest in the maternity ward. Advanced cardiac life support measures, including 15 minutes of chest compressions, were performed until spontaneous circulation was restored. This study explores the underlying factors contributing to maternal cardiac arrest during the postpartum period. Additionally, it highlights the effective strategies employed by our multidisciplinary team in managing and resolving this critical medical event.

Bio-physiological susceptibility of the brain, heart, and lungs to systemic ischemia reperfusion and hyperoxia-induced injury in post-cardiac arrest rats

Cardiac arrest (CA) patients suffer from systemic ischemia-reperfusion (IR) injury leading to multiple organ failure; however, few studies have focused on tissue-specific pathophysiological responses to IR-induced oxidative stress. Herein, we investigated biological and physiological parameters of the brain and heart, and we particularly focused on the lung dysfunction that has not been well studied to date. We aimed to understand tissue-specific susceptibility to oxidative stress and tested how oxygen concentrations in the post-resuscitation setting would affect outcomes. Rats were resuscitated from 10 min of asphyxia CA. Mechanical ventilation was initiated at the beginning of cardiopulmonary resuscitation. We examined animals with or without CA, and those were further divided into the animals exposed to 100% oxygen (CA_Hypero) or those with 30% oxygen (CA_Normo) for 2 h after resuscitation. Biological and physiological parameters of the brain, heart, and lungs were assessed. The brain and lung functions were decreased after CA and resuscitation indicated by worse modified neurological score as compared to baseline (222 ± 33 vs. 500 ± 0, P < 0.05), and decreased PaO2 (20 min after resuscitation: 113 ± 9 vs. baseline: 128 ± 9 mmHg, P < 0.05) and increased airway pressure (2 h: 10.3 ± 0.3 vs. baseline: 8.1 ± 0.2 mmHg, P < 0.001), whereas the heart function measured by echocardiography did not show significant differences compared before and after CA (ejection fraction, 24 h: 77.9 ± 3.3% vs. baseline: 82.2 ± 1.9%, P = 0.2886; fractional shortening, 24 h: 42.9 ± 3.1% vs. baseline: 45.7 ± 1.9%, P = 0.4658). Likewise, increases of superoxide production in the brain and lungs were remarkable, while those in the heart were moderate. mRNA gene expression analysis revealed that CA_Hypero group had increases in Il1b as compared to CA_Normo group significantly in the brain (P < 0.01) and lungs (P < 0.001) but not the heart (P = 0.4848). Similarly, hyperoxia-induced increases in other inflammatory and apoptotic mRNA gene expression were observed in the brain, whereas no differences were found in the heart. Upon systemic IR injury initiated by asphyxia CA, hyperoxia-induced injury exacerbated inflammation/apoptosis signals in the brain and lungs but might not affect the heart. Hyperoxia following asphyxia CA is more damaging to the brain and lungs but not the heart.

The first case series analysis on efficacy of esmolol injection for in-hospital cardiac arrest patients with refractory shockable rhythms in China

Background: This study assessed the effects of esmolol injection in patients with in-hospital cardiac arrest (IHCA) with refractory ventricular fibrillation (VF)/pulseless ventricular tachycardia (pVT).

Methods: From January 2018 to December 2021, 29 patients with IHCA with refractory shockable rhythm were retrospectively reviewed. Esmolol was administered after advanced cardiovascular life support (ACLS)-directed procedures, and outcomes were assessed.

Results: Among the 29 cases, the rates of sustained return of spontaneous circulation (ROSC), 24-h ROSC, and 72-h ROSC were 79%, 62%, and 59%, respectively. Of those patients, 59% ultimately survived to discharge. Four patients with cardiac insufficiency died. The duration from CA to esmolol infusion was significantly shorter for patients in the survival group (SG) than for patients in the dead group (DG) (12 min, IQR: 8.5–19.5 vs. 23.5 min, IQR: 14.4–27 min; p = 0.013). Of those patients, 76% (22 of 29) started esmolol administration after the second dose of amiodarone. No significant difference was observed in the survival rate between this group and groups administered an esmolol bolus simultaneously or before the second dose of amiodarone (43% vs. 64%, p = 0.403). Of those patients, 31% (9 of 29) were administered an esmolol bolus for defibrillation attempts ≤ 5, while the remaining 69% of patients received an esmolol injection after the fifth defibrillation attempt. No significant differences were observed in the rates of ≥ 24-h ROSC (67% vs. 60%, p = 0.73), ≥ 72-h ROSC (67% vs. 55%, p = 0.56), and survival to hospital discharge (67% vs. 55%, p = 0.56) between the groups administered an esmolol bolus for defibrillation attempts ≤ 5 and defibrillation attempts > 5.

Conclusion: IHCA patients with refractory shockable rhythms receiving esmolol bolus exhibited a high chance of sustained ROSC and survival to hospital discharge. Patients with end-stage heart failure tended to have attenuated benefits from beta-blockers. Further large-scale, prospective studies are necessary to determine the effects of esmolol in patients with IHCA with refractory shockable rhythms.

Kinetics of 2 different high-sensitive troponins during targeted temperature management in out-of-hospital cardiac arrest patients with acute myocardial infarction: a post hoc sub-study of a randomised clinical trial

Introduction

Short term hypothermia has been suggested to have cardio protective properties in acute myocardial infarction (AMI) by reducing infarct size as assessed by troponins. There are limited data on the kinetics of these biomarkers in comatose out-of-hospital cardiac arrest (OHCA) patients, with and without AMI, undergoing targeted temperature management (TTM) in the ICU.

Purpose

The aim of this post hoc analyses was to evaluate and compare the kinetics of two high-sensitivity cardiac troponins in OHCA survivors, with and without acute myocardial infarction (AMI), during TTM of different durations [24 h (standard) vs. 48 h (prolonged)].

Methods

In a sub-cohort (n = 114) of the international, multicentre, randomized controlled study “TTH48” we measured high-sensitive troponin T (hs-cTnT), high-sensitive troponin I (hs-cTnI) and CK-MB at the following time points: Arrival, 24 h, 48 h and 72 h from reaching the target temperature range of 33 ± 1 °C. All patients diagnosed with an AMI at the immediate coronary angiogram (CAG)—18 in the 24-h group and 25 in the 48-h group—underwent PCI with stent implantation. There were no stent thromboses.

Results

Both the hs-cTnT and hs-cTnI changes over time were highly influenced by the cause of OHCA (AMI vs. non-AMI). In contrast to non-AMI patients, both troponins remained elevated at 72 h in AMI patients. There was no difference between the two time-differentiated TTM groups in the kinetics for the two troponins.

Conclusion

In comatose OHCA survivors with an aetiology of AMI levels of both hs-cTnI and hs-cTnT remained elevated for 72 h, which is in contrast to the well-described kinetic profile of troponins in normotherm AMI patients. There was no difference in kinetic profile between the two high sensitive assays. Different duration of TTM did not influence the kinetics of the troponins.

Trial registration: Clinicaltrials.gov Identifier: NCT01689077, 20/09/2012.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02778-4.

Feasibility and beneficial effects of an early goal directed therapy after cardiac arrest: evaluation by conductance method

Although beneficial effects of an early goal directed therapy (EGDT) after cardiac arrest and successful return of spontaneous circulation (ROSC) have been described, clinical implementation in this period seems rather difficult. The aim of the present study was to investigate the feasibility and the impact of EGDT on myocardial damage and function after cardiac resuscitation. A translational pig model which has been carefully adapted to the clinical setting was employed. After 8 min of cardiac arrest and successful ROSC, pigs were randomized to receive either EGDT (EGDT group) or therapy by random computer-controlled hemodynamic thresholds (noEGDT group). Therapeutic algorithms included blood gas analysis, conductance catheter method, thermodilution cardiac output and transesophageal echocardiography. Twenty-one animals achieved successful ROSC of which 13 pigs survived the whole experimental period and could be included into final analysis. cTnT and LDH concentrations were lower in the EGDT group without reaching statistical significance. Comparison of lactate concentrations between 1 and 8 h after ROSC exhibited a decrease to nearly baseline levels within the EGDT group (1 h vs 8 h: 7.9 vs. 1.7 mmol/l, P < 0.01), while in the noEGDT group lactate concentrations did not significantly decrease. The EGDT group revealed a higher initial need for fluids (P < 0.05) and less epinephrine administration (P < 0.05) post ROSC. Conductance method determined significant higher values for preload recruitable stroke work, ejection fraction and maximum rate of pressure change in the ventricle for the EGDT group. EGDT after cardiac arrest is associated with a significant decrease of lactate levels to nearly baseline and is able to improve systolic myocardial function. Although the results of our study suggest that implementation of an EGDT algorithm for post cardiac arrest care seems feasible, the impact and implementation of EGDT algorithms after cardiac arrest need to be further investigated.

Diagnostic and prognostic utility of cardiac troponin in post-cardiac arrest care

BACKGROUND

Cardiac troponin is routinely tested in the post-cardiac arrest setting, but its utility in identifying ischaemic aetiology and predicting left ventricular systolic dysfunction (LVSD) and survival is not known.

METHODS

In a retrospective single center registry, we identified 145 consecutive patients who had achieved return of spontaneous circulation after cardiac arrest and had undergone serial cardiac troponin T (cTnT) testing, echocardiogram, and expert adjudication of aetiology. Initial and peak cTnT were evaluated for assessing ischaemic aetiology, LVSD, and survival to discharge using area under the receiver operating characteristic curve (AUROC).

RESULTS

Mean age was 61 ± 14 years and 71% were men. Of the 145 arrests, 19% had an ischaemic aetiology, 68% had LVSD post-arrest, and 55% survived to discharge. All patients had a positive initial cTnT at 0.01 ng/mL (clinical cut-off). Even at higher cut-offs of 10×, 100× and 1000×, initial cTnT performed poorly (AUROC 0.57, 0.56, and 0.56) and peak cTnT performed modestly (AUROC 0.55, 0.61, and 0.62) as diagnostic tests for ischaemic aetiology. Similarly, even at higher cut-offs, initial (AUROC 0.60, 0.62, 0.55) and peak (AUROC 0.57, 0.61, and 0.62) cTnT performed poorly to modestly at predicting LVSD. The test performed poorly for predicting survival to discharge (AUROC for all <0.6).

CONCLUSIONS

At both current and several-fold higher thresholds, cTnT does not perform sufficiently well to guide clinical decision-making or predict patient outcomes. Routine post-cardiac arrest testing of cTnT should be reevaluated.

High-sensitive cardiac troponin hs-TnT levels in sudden deaths related to atherosclerotic coronary artery disease

INTRODUCTION

Ischemic heart disease (IHD) related to atherosclerotic coronary artery disease (CAD) is one of the most prevalent causes of death in Europe. Postmortem evaluation of IHD remains a challenge because of possible non-specific autopsy finding in some autopsy cases, especially in early myocardial ischemia. High-sensitive cardiac troponin T (hs-TnT) is used today in clinical practice as the "gold standard" to diagnose the myocardial ischemia, and might also be applied as an ancillary tool for post-mortem evaluation.

PURPOSE

The goal of this study is to evaluate the diagnostic value of post-mortem serum hs-TnT assay in cases of sudden death related to IHD. We will also investigate the influence of cardiopulmonary resuscitation (CPR) attempts on post-mortem hs-TnT levels.

METHODS

The hs-TnT values in serum were retrospectively analysed in 85 autopsy data. 52 cases with clinical history and morphological results suggesting cardiac ischemia were included in the study group (mean age 53.5; age range 34-75) and 33 cases in the control group (mean age 40.4; age range 15-69). The group's statistical comparison was performed using logistic regression model.

RESULTS

Our study showed a significant non-linear association between hs-TnT serum values and post-mortem diagnosis of sudden deaths related to IHD (p-value 0.005). The shape of the relationship is showing that the probability of death due to IHD increases quickly with a light level of hs-TnT (maximum around 90ng/L) then decreases slightly while remaining at high in values. No significant difference in the hs-TnT serum values was found between the CPR and the non-CPR cases (p-value 0.304).

CONCLUSION

The measurement of hs-TnT serum values might be considered as an ancillary tool for the evaluation of death related to IHD, while taking necessary precautions in the interpretation of the results.

Cardiac troponins and NT-proBNP in the forensic setting: Overview of sampling site, postmortem interval, cardiopulmonary resuscitation, and review of the literature

The possible use of biochemical markers in the postmortem diagnosis of myocardial ischemia is well known in the forensic setting, though several issues have limited its widespread adoption. The study presented herein focuses of N-terminal pro-B-type natriuretic peptide, troponin T, and troponin I, and the possible influence due to sampling site chosen, postmortem interval elapsed, and cardiopulmonary resuscitation attempts. Comparisons were performed between antemortem serum levels of these markers and postmortem levels measured in pericardial fluid and postmortem serum samples obtained from different sampling sites (n=16). Levels of these markers were also compared in cases characterized by various postmortem intervals (n=48, consisting of 24 ischemic heart disease cases and 24 controls) as well as in cases with and without cardiopulmonary resuscitation (n=22, consisting of 14 cases of hanging and 8 cases of drug intoxication). Our results indicate that N-terminal pro-B-type natriuretic peptide, troponin T, and troponin I values determined in postmortem serum from femoral blood (collected up to 24h after death) do not differ significantly from those measured in venous blood antemortem serum samples (collected at the upper limbs). In addition, our results reveal that the time elapsed after death should always be taken into consideration when cardiac troponins are measured in postmortem samples. Lastly, our findings reveal the absence of statistically significant differences between levels of the tested biomarkers (in postmortem serum from femoral blood) in cases without cardiopulmonary resuscitation compared to cases with cardiopulmonary resuscitation (at least for postmortem intervals up to 24h).

Prognostic value of high-sensitivity troponin T levels in patients with ventricular arrhythmias and out-of-hospital cardiac arrest: data from the prospective FINNRESUSCI study

Introduction

Myocardial dysfunction is common after out-of-hospital cardiac arrest (OHCA) and high-sensitivity troponin T (hs-TnT) levels may provide incremental prognostic information to established risk indices.

Methods

A total of 155 patients with OHCA and a shockable rhythm (98% ventricular fibrillation; OHCA-VF/VT) had blood samples drawn within six hours of admission. Blood samples were also available after 24 hours, 48 hours, and 96 hours in subsets of patients. The endpoints of the study were hospital mortality and neurological status and mortality after one year.

Results

Admission hs-TnT levels were higher than the 99-percentile of the general population (14 ng/L) in all patients (range 18 to 17837 ng/L). Admission hs-TnT levels were associated with acute coronary artery occlusion, time to return of spontaneous circulation, heart failure, and renal function. Admission hs-TnT levels were higher in one-year non-survivors compared to survivors (median 747 (quartile 1 to 3, 206 to 1061) ng/L versus 345 (184 to 740) ng/L, P =0.023) and in patients with a poor versus a favorable neurological outcome (739 (191 to 1061) ng/L versus 334 (195 to 716) ng/L, P =0.028). However, hs-TnT measurements did not add prognostic information to established risk variables in multivariate analyses. hs-TnT levels measured during the hospitalization for OHCA-VF/VT correlated closely with admission levels (r ≥0.63) and were inferior to Simplified Acute Physiology Score II (SAPS II) scores for the prediction of events during follow-up. hs-TnT dynamics did not discriminate between survivors and non-survivors or between a poor versus a favorable neurological outcome.

Conclusion

hs-TnT levels are elevated in critically ill patients with OHCA-VF/VT, but do not improve risk prediction.

Prevalence of troponin elevations in patients with cardiac arrest and implications for assessing quality of care in hypothermia centers

The prevalence of troponin elevations in patients with cardiac arrest (CA) using newer generation troponin assays when the ninety-ninth percentile is used has not been well described. We studied patients admitted with CA without ST elevation myocardial infarction (MI). Treatment included a multidisciplinary protocol that included routine use of hypothermia for appropriate patients. Serial assessment of cardiac biomarkers, including troponin I was obtained over the initial 24 to 36 hours. Patients were classified into 1 of 5 groups on the basis of multiples of the ninety-ninth percentile (upper reference limit [URL]), using the peak troponin I value: <1×, 1 to 3×, 3 to 5×, 5 to 10×, and >10×. Serial changes between the initial and second troponin I values were also assessed. A total of 165 patients with CA (mean age 58 ± 16, 67% men) were included. Troponin I was detectable in all but 2 patients (99%); all others had peak troponin I values that were greater than or equal to the URL. Most patients had peak troponin I values >10× URL, including patients with ventricular fibrillation or ventricular tachycardia (85%), asystole (50%), and pulseless electrical activity (59%). Serial changes in troponin I were present in almost all patients: ≥20% change in 162 (98%), ≥30% change in 159 (96%), and an absolute increase of ≥0.02 ng/ml in 85% of patients. In conclusion, almost all patients with CA who survived to admission had detectable troponin I, most of whom met biomarker guideline criteria for MI. Given the high mortality of these patients, these data have important implications for MI mortality reporting at CA treatment centers.

Can early cardiac troponin I measurement help to predict recent coronary occlusion in out-of-hospital cardiac arrest survivors?

OBJECTIVE

Recent guidelines recommend the immediate performance of a coronary angiography when an acute myocardial infarction is suspected as a cause of out-of-hospital cardiac arrest. However, prehospital factors such as postresuscitation electrocardiogram pattern or clinical features are poorly sensitive in this setting. We searched to evaluate if an early measurement of cardiac troponin I can help to detect a recent coronary occlusion in out-of-hospital cardiac arrest.

DESIGN

Retrospective analysis of a prospective electronic registry database.

SETTING

University cardiac arrest center.

PATIENTS

Between January 2003 and December 2008, 422 out-of-hospital cardiac arrest survivors without obvious extra-cardiac cause have been consecutively studied. An immediate coronary angiography has been systematically performed. The primary outcome was the finding of a recent coronary occlusion.

INTERVENTION

First, blood cardiac troponin I levels at admission were analyzed to assess the optimum cutoff for identifying a recent coronary occlusion. Second, a logistic regression was performed to determine early predictive factors of a recent coronary occlusion (including cardiac troponin I) and their respective contribution.

MEASUREMENTS AND MAIN RESULTS

An ST-segment elevation was present in 127 of 422 patients (30%). During coronary angiography, a recent occlusion has been detected in 193 of 422 patients (46%). The optimum cardiac troponin I threshold was determined at 4.66 ng·mL(-1) (sensitivity 66.7%, specificity 66.4%). In multivariate analyses, in addition of smoking and epinephrine initial dose, cardiac troponin I (odds ratio 3.58 [2.03-6.32], p < .001) and ST-segment elevation (odds ratio 10.19 [5.39-19.26], p < .001) were independent predictive factors of a recent coronary occlusion.

CONCLUSIONS

In this large cohort of out-of-hospital cardiac arrest patients, isolated early cardiac troponin I measurement is modestly predictive of a recent coronary occlusion. Furthermore, the contribution of this parameter even in association with other factors does not seem helpful to predict recent occlusion. As a result and given the high benefit of percutaneous coronary intervention for such patients, the dosage of cardiac troponin I at admission could not help in the decision of early coronary angiogram.

Troponin I levels from donors accepted for pediatric heart transplantation do not predict recipient graft survival

BACKGROUND

Troponin I is often obtained during the evaluation of a potential transplant donor heart. It is not clear whether elevations in donor troponin I levels predict adverse outcomes and should thus preclude acceptance of a donor heart. This study examined whether troponin I levels from donors accepted for pediatric heart transplantation predicted graft failure.

METHODS

Deidentified data on heart transplants performed in recipients aged < 21 years between April 2007 and April 2009 was provided by the Organ Procurement and Transplantation Network. Donor troponin I level and recipient outcomes, including survival without retransplantation (graft survival), were examined for statistical correlation.

RESULTS

Overall graft survival in 839 heart transplants was 81% at 2 years. At least 1 troponin I level was recorded in 657 donors before transplant, with a median value of 0.1 ng/ml (range, 0-50 ng/ml). Troponin I level and graft status were not correlated (p = 0.74). A receiver operating characteristic curve showed no association between troponin I and graft status (area under the curve, 0.51; p = 0.98). Graft survival did not differ significantly (p = 0.60) among quartiles of troponin I levels (<0.04, 0.04-<0.1, 0.1-<0.35, ≥ 0.35 ng/ml). A troponin I level ≥ 1 ng/ml was found in 74 transplanted donor hearts; graft survival was not associated with troponin I ≥ 1 (80%) vs < 1 (80%) at 2 years (p = 0.93). Troponin I values were not associated with post-transplant hospital length of stay (r = -0.06; p = 0.10).

CONCLUSIONS

In donor hearts accepted for pediatric heart transplantation, troponin I elevation before procurement is not associated with increased graft failure. The significance of elevated troponin I levels, which occurs in many heart donors, remains unclear and should therefore be considered in the context of other clinical information.

Autonomic dysreflexia and associated acute neurogenic pulmonary edema in a patient with spinal cord injury: a case report and review of the literature

STUDY DESIGN

A case report of a patient with spinal cord injury with autonomic dysreflexia and associated acute neurogenic pulmonary edema.

OBJECTIVE

To further describe autonomic dysreflexia as a potential cause of acute neurogenic pulmonary edema; specifically in a population with spinal cord injury.

SETTING

James A Haley Veterans Hospital, Tampa, FL, USA.

METHODS

A patient with a prior history of C5 AIS (ASIA impairment scale) B spinal cord injury was admitted for bowel preparation before a screening colonoscopy. During the 2-day bowel preparation, the patient developed severe autonomic dysreflexia. Due to persistent hypertension and acute onset respiratory failure, he required transfer to the intensive care setting.

RESULTS

Following a complicated course, the patient expired without a definitive cause of death. Autopsy findings showed gross and microscopic evidence of pulmonary edema.

CONCLUSIONS

To date, the association between autonomic dysreflexia and acute neurogenic pulmonary edema is not described in the spinal cord or rehabilitation literature. The purpose of this case report is to further describe the overlooked and/or under reported incidence of acute neurogenic pulmonary edema associated with episodes of dysreflexia in a population with spinal cord injury.

Cardiac catheterization is underutilized after in-hospital cardiac arrest

BACKGROUND

Indications for immediate cardiac catheterization in cardiac arrest survivors without ST elevation myocardial infarction (STEMI) are uncertain as electrocardiographic and clinical criteria may be challenging to interpret in this population. We sought to evaluate rates of early catheterization after in-hospital ventricular fibrillation (VF) arrest and the association with survival.

METHODS

Using a billing database we retrospectively identified cases with an ICD-9 code of cardiac arrest (427.5) or VF (427.41). Discharge summaries were reviewed to identify in-hospital VF arrests. Rates of catheterization on the day of arrest were determined by identifying billing charges. Unadjusted analyses were performed using Chi-square, and adjusted analyses were performed using logistic regression.

RESULTS

One hundred and ten in-hospital VF arrest survivors were included in the analysis. Cardiac catheterization was performed immediately or within 1 day of arrest in 27% (30/110) of patients and of these patients, 57% (17/30) successfully received percutaneous coronary intervention. Of those who received cardiac catheterization the indication for the procedure was STEMI or new left bundle branch block (LBBB) in 43% (13/30). Therefore, in the absence of standard ECG data suggesting acute myocardial infarction, 57% (17/30) received angiography. Patients receiving cardiac catheterization were more likely to survive than those who did not receive catheterization (80% vs. 54%, p<.05).

CONCLUSION

In patients receiving cardiac catheterization, more than half received this procedure for indications other than STEMI or new LBBB. Cardiac catheterization was associated with improved survival. Future recommendations need to be established to guide clinicians on which arrest survivors might benefit from immediate catheterization.

Hypothermia-induced Brugada-like electrocardiogram pattern

A patient in whom moderate hypothermia developed after prolonged cardiopulmonary resuscitation is described. Hypothermia was manifested by transient electrocardiogram changes, including long QT, precordial J waves, and downsloping ST-segment elevation ending in a negative T wave in leads V(1) and V(2) resembling the Brugada syndrome. The physiopathologic mechanisms of these electrocardiographic findings are discussed.