Racial disparities in outcomes following PEA and asystole in-hospital cardiac arrests

Impact of Social Vulnerability on Cardiac Arrest Mortality in the United States, 2016 to 2020

BACKGROUND

Cardiac arrest is 1 of the leading causes of morbidity and mortality, with an estimated 340 000 out-of-hospital and 292 000 in-hospital cardiac arrest events per year in the United States. Survival rates are lower in certain racial and socioeconomic groups.

METHODS AND RESULTS

We performed a county-level cross-sectional longitudinal study using the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research multiple causes of death data set between 2016 and 2020 among individuals of all ages whose death was attributed to cardiac arrest. The Social Vulnerability Index is a composite measure that includes socioeconomic vulnerability, household composition, disability, individuals from racial and ethnic minority groups status and language, and housing and transportation domains. We examined the impact of social determinants on cardiac arrest mortality stratified by age, race, ethnicity, and sex in the United States. All age-adjusted mortality rate (cardiac arrest AAMRs) are reported as per 100 000. Overall cardiac arrest AAMR during the study period was 95.6. The cardiac arrest AAMR was higher for men compared with women (119.6 versus 89.9) and for the Black population compared with the White population (150.4 versus 92.3). The cardiac arrest AAMR increased from 64.8 in counties in quintile 1 of Social Vulnerability Index to 141 in quintile 5, with an average increase of 13% (95% CI, 9.8%-16.9%) in AAMR per quintile increase.

CONCLUSIONS

Mortality from cardiac arrest varies widely, with a >2-fold difference between the counties with the highest and lowest social vulnerability, highlighting the differential burden of cardiac arrest deaths throughout the United States based on social determinants of health.

A novel structured debriefing program for consensus determinations of in-hospital cardiac arrest predictability and preventability

AIM

Hospital rapid response systems aim to stop preventable cardiac arrests, but defining preventability is a challenge. We developed a multidisciplinary consensus-based process to determine in-hospital cardiac arrest (IHCA) preventability based on objective measures.

METHODS

We developed an interdisciplinary ward IHCA debriefing program at an urban quaternary-care academic hospital. This group systematically reviewed all IHCAs weekly, reaching consensus determinations of the IHCA's cause and preventability across three mutually exclusive categories: 1) unpredictable (no evidence of physiologic instability < 1 h prior to and within 24 h of the arrest), 2) predictable but unpreventable (meeting physiologic instability criteria in the setting of either a poor baseline prognosis or a documented goals of care conversation) or 3) potentially preventable (remaining cases).

RESULTS

Of 544 arrests between 09/2015 and 11/2023, 339 (61%) were deemed predictable by consensus, with 235 (42% of all IHCAs) considered potentially preventable. Potentially preventable arrests disproportionately occurred on nights and weekends (70% vs 55%, p = 0.002) and were more frequently respiratory than cardiac in etiology (33% vs 15%, p < 0.001). Despite similar rates of ROSC across groups (67-70%), survival to discharge was highest in arrests deemed unpredictable (31%), followed by potentially preventable (21%), and then those deemed predictable but unpreventable which had the lowest survival rate (16%, p = 0.007).

CONCLUSIONS

Our IHCA debriefing procedures are a feasible and sustainable means of determining the predictability and potential preventability of ward cardiac arrests. This approach may be useful for improving quality benchmarks and care processes around pre-arrest clinical activities.

Are There Racial Disparities in Perioperative Pain? A Retrospective Study of a Gynecological Surgery Cohort

PURPOSE

The purpose of this study was to examine whether racial disparities exist in immediate postoperative pain scores and intraoperative analgesic regimens in a single surgical cohort.

DESIGN

A single-center, retrospective analysis.

METHODS

This retrospective study of a single surgical cohort was conducted via chart review of the existing electronic health record. A total of 203 patients who underwent minimally invasive hysterectomy were included in the analysis. Three initially reviewed patient records were excluded from the final analysis due to the small size of their racial cohorts (two Asian or Pacific Islander and one Native American). The White patients (n = 103) and Black patients (n = 100) were compared for differences in pain scores in the postanesthesia care unit (PACU). The patients' intraoperative analgesic regimens were also compared.

FINDINGS

There were no significant differences between races in the postoperative pain scores in the PACU or in the analgesia administered by the anesthesia provider intraoperatively.

CONCLUSIONS

In this specific population, there was no evidence of racial disparities in postoperative pain or intraoperative analgesia administration. Further research is needed to understand the unique factors of the perioperative period, to see if the absence of disparities in this study is repeated in other cohorts, and to mitigate any disparities that are found.

Impact of social vulnerability on cardiac arrest mortality in the United States, 2016-2020

Importance

Cardiac arrest is one of the leading causes of morbidity and mortality, with an estimated 340,000 out-of-hospital and 292,000 in-hospital cardiac arrest events per year in the U.S. Survival rates are lower in certain racial and socioeconomic groups.

Objective

To examine the impact of social determinants on cardiac arrest mortality among adults stratified by age, race, and sex in the U.S.

Design

A county-level cross-sectional longitudinal study using death data between 2016 and 2020 from the Centers for Disease Control and Prevention's (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) database.

Setting

Using the multiple causes of death dataset from the CDC's WONDER database, cardiac arrests were identified using the International Classification of Diseases (ICD), tenth revision, clinical modification codes.

Participants

Individuals aged 15 years or more whose death was attributed to cardiac arrest.

Exposures

Social vulnerability index (SVI), reported by the CDC, is a composite measure that includes socioeconomic vulnerability, household composition, disability, minority status and language, and housing and transportation domains.

Main outcomes and measures

Cardiac arrest mortality per 100,000 adults.

Results

Overall age-adjusted cardiac arrest mortality (AAMR) during the study period was 95.6 per 100,000 persons. The AAMR was higher for men as compared with women (119.6 vs. 89.9 per 100,000) and for Black, as compared with White, adults (150.4 vs. 92.3 per 100,000). The AAMR increased from 64.8 per 100,000 persons in counties in Quintile 1 (Q1) of SVI to 141 per 100,000 persons in Quintile 5, with an average increase of 13% (95% CI: 9.8-16.9) in AAMR per quintile increase.

Conclusion and relevance

Mortality from cardiac arrest varies widely, with a more than 2-fold difference between the counties with the highest and lowest social vulnerability, highlighting the differential burden of cardiac arrest deaths throughout the U.S. based on social determinants of health.

Racial and Ethnic Disparities in Management and Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction

Background The role of race and ethnicity in the outcomes of cardiac arrest (CA) complicating acute myocardial infarction (AMI) is incompletely understood. Methods and Results This was a retrospective cohort study of adult admissions with AMI-CA from the National Inpatient Sample (2012-2017). Self-reported race/ethnicity was classified as White, Black, and others (Hispanic, Asian or Pacific Islander, Native American, Other). Outcomes of interest included in-hospital mortality, coronary angiography, percutaneous coronary intervention, palliative care consultation, do-not-resuscitate status use, hospitalization costs, hospital length of stay, and discharge disposition. Of the 3.5 million admissions with AMI, CA was noted in 182 750 (5.2%), with White, Black, and other races/ethnicities constituting 74.8%, 10.7%, and 14.5%, respectively. Black patients admitted with AMI-CA were more likely to be female, with more comorbidities, higher rates of non-ST-segment-elevation myocardial infarction, and higher neurological and renal failure. Admissions of patients of Black and other races/ethnicities underwent coronary angiography (61.9% versus 70.2% versus 73.1%) and percutaneous coronary intervention (44.6% versus 53.0% versus 58.1%) less frequently compared to patients of white race (p<0.001). Admissions of patients with AMI-CA had significantly higher unadjusted mortality (47.4% and 47.4%) as compared with White patients admitted (40.9%). In adjusted analyses, Black race was associated with lower in-hospital mortality (odds ratio [OR], 0.95; 95% CI, 0.91-0.99; P=0.007) whereas other races had higher in-hospital mortality (OR, 1.11; 95% CI, 1.08-1.15; P<0.001) compared with White race. Admissions of Black patients with AMI-CA had longer length of hospital stay, higher rates of palliative care consultation, less frequent do-not-resuscitate status use, and fewer discharges to home (all P<0.001). Conclusions Racial and ethnic minorities received less frequent guideline-directed procedures and had higher in-hospital mortality and worse outcomes in AMI-CA.

Identifying prognostic factors and developing accurate outcome predictions for in-hospital cardiac arrest by using artificial neural networks

BACKGROUND

Accurate estimation of neurological outcomes after in-hospital cardiac arrest (IHCA) provides crucial information for clinical management. This study used artificial neural networks (ANNs) to determine the prognostic factors and develop prediction models for IHCA based on immediate preresuscitation parameters.

METHODS

The derived cohort comprised 796 patients with IHCA between 2006 and 2014. We applied ANNs to develop prediction models and evaluated the significance of each parameter associated with favorable neurological outcomes. An independent dataset of 108 IHCA patients receiving targeted temperature management was used to validate the identified parameters. The generalizability of the models was assessed through fivefold cross-validation. The performance of the models was assessed using the area under the curve (AUC).

RESULTS

ANN model 1, based on 19 baseline parameters, and model 2, based on 11 prearrest parameters, achieved validation AUCs of 0.978 and 0.947, respectively. ANN model 3 based on 30 baseline and prearrest parameters achieved an AUC of 0.997. The key factors associated with favorable outcomes were the duration of cardiopulmonary resuscitation; initial cardiac arrest rhythm; arrest location; and whether the patient had a malignant disease, pneumonia, and respiratory insufficiency. On the basis of these parameters, the validation performance of the ANN models achieved an AUC of 0.906 for IHCA patients who received targeted temperature management.

CONCLUSION

The ANN models achieved highly accurate and reliable performance for predicting the neurological outcomes of successfully resuscitated patients with IHCA. These models can be of significant clinical value in assisting with decision-making, especially regarding optimal postresuscitation strategies.

Better Nurse Staffing Is Associated With Survival for Black Patients and Diminishes Racial Disparities in Survival After In-Hospital Cardiac Arrests

BACKGROUND

Racial disparities in survival among patients who had an in-hospital cardiac arrest (IHCA) have been linked to hospital-level factors.

OBJECTIVES

To determine whether nurse staffing is associated with survival disparities after IHCA.

RESEARCH DESIGN

Cross-sectional data from (1) the American Heart Association's Get With the Guidelines-Resuscitation database; (2) the University of Pennsylvania Multi-State Nursing Care and Patient Safety Survey; and (3) The American Hospital Association annual survey. Risk-adjusted logistic regression models, which took account of the hospital and patient characteristics, were used to determine the association of nurse staffing and survival to discharge for black and white patients.

SUBJECTS

A total of 14,132 adult patients aged 18 and older between 2004 and 2010 in 75 hospitals in 4 states.

RESULTS

In models that accounted for hospital and patient characteristics, the odds of survival to discharge was lower for black patients than white patients [odds ratio (OR)=0.70; 95% confidence interval (CI), 0.61-0.82]. A significant interaction was found between race and medical-surgical nurse staffing for survival to discharge, such that each additional patient per nurse lowered the odds of survival for black patients (OR=0.92; 95% CI, 0.87-0.97) more than white patients (OR=0.97; 95% CI, 0.93-1.00).

CONCLUSIONS

Our findings suggest that disparities in IHCA survival between black and white patients may be linked to the level of medical-surgical nurse staffing in the hospitals in which they receive care and that the benefit of being admitted to hospitals with better staffing may be especially pronounced for black patients.

Racial disparities in survival outcomes following pediatric in-hospital cardiac arrest

BACKGROUND

Among adults with in-hospital cardiac arrest (IHCA), overall survival is lower in black patients compared to white patients. Data regarding racial differences in survival for pediatric IHCA are unknown.

METHODS

Using 2000-2017 data from the American Heart Association Get With the Guidelines-Resuscitation® registry, we identified children >24 h and <18 years of age with IHCA due to an initial pulseless rhythm. We used generalized estimation equation to examine the association of black race with survival to hospital discharge, return of spontaneous circulation (ROSC), and favorable neurologic outcome at discharge.

RESULTS

Overall, 2940 pediatric patients (898 black, 2042 white) at 224 hospitals with IHCA were included. The mean age was 3.0 years, 57% were male and 16% had an initial shockable rhythm. Age, sex, interventions in place at the time of arrest and cardiac arrest characteristics did not differ significantly by race. The overall survival to discharge was 36.9%, return of spontaneous circulation (ROSC) was 73%, and favorable neurologic survival was 20.8%. Although black race was associated with lower rates of ROSC compared to white patients (69.5% in blacks vs. 74.6% in whites; risk-adjusted OR 0.79, 95% CI 0.67-0.94, P = 0.016), black race was not associated with survival to discharge (34.7% in blacks vs. 37.8% in whites; risk-adjusted OR 0.96, 95% CI 0.80-1.15, P = 0.68) or favorable neurologic outcome (18.7% in blacks vs. 21.8% in whites, risk-adjusted OR 0.98, 95% CI 0.80-1.20, p = 0.85).

CONCLUSIONS

In contrast to adults, we did not find evidence for racial differences in survival outcomes following IHCA among children.

Five-year trends in maternal cardiac arrest in Maryland: 2013-2017

BACKGROUND

The United States (US) maternal mortality rate (MMR) continues to increase. Until recently, the MMR in Maryland (MD) was consistently higher than the national average. Maternal cardiac arrest (MCA) is a rare condition, but can lead to devastating consequences. The incidence of MCA in the US is approximately 6-8 per 100,000 deliveries. To our knowledge there is no contemporary review of MCA in MD. Our primary aim was to determine the incidence of MCA in MD over a 5-year period. Secondary aims were to explore the causes of MCA, as well as characterize maternal and fetal survival.

MATERIALS AND METHODS

Maternal cardiac arrests in Maryland were identified using diagnostic codes and a statewide administrative database for the fiscal years 2013 through 2017. MCA incidence and mortality rates were compared with previously reported national data from 1998 to 2011. Demographic characteristics, medical co-morbidities, obstetric complications, mode of delivery, and fetal outcomes were collected for all patients. The apparent cause of MCA was determined for each patient. Complications and procedures performed in MCAs were also recorded.

RESULTS

In MD, 36 of 47 acute care hospitals provided maternity care. There were 32 cases of MCA in 332,483 deliveries, an estimated incidence rate of 10 per 100,000 deliveries (95% CI = 5-18). The most common apparent cause of MCA was hemorrhage. Maternal survival was 59.4%, while fetal survival was 93.8%. No significant differences were observed in MCA by age group. The incidence of MCA was significantly higher among non-Caucasian patients (24/177,727) when compared to Caucasian patients (8/154,732)(p =.01).

DISCUSSION

Maternal cardiac arrest in Maryland appears to be comparable to the US average, with similar maternal survival rates. Non-Caucasian patients appear to have a disproportionately high rate of these complications. While maternal mortality is high for MCA, fetal survival is excellent. Continued efforts and attention are needed to prevent MCA in underserved minorities and treat postpartum hemorrhage, the leading contributor to MCA over the past decade.

Racial and Ethnic Disparities in Postcardiac Arrest Targeted Temperature Management Outcomes

OBJECTIVES

To evaluate racial and ethnic disparities in postcardiac arrest outcomes in patients undergoing targeted temperature management.

DESIGN

Retrospective study.

SETTING

ICUs in a single tertiary care hospital.

PATIENTS

Three-hundred sixty-seven patients undergoing postcardiac arrest targeted temperature management, including continuous electroencephalogram monitoring.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Clinical variables examined in our clinical cohort included race/ethnicity, age, time to return of spontaneous circulation, cardiac rhythm at time of arrest, insurance status, Charlson Comorbidity Index, and time to withdrawal of life-sustaining therapy. CT at admission and continuous electroencephalogram monitoring during the first 24 hours were used as markers of early injury. Outcome was assessed as good (Cerebral Performance Category 1-2) versus poor (Cerebral Performance Category 3-5) at hospital discharge. White non-Hispanic ("White") patients were more likely to have good outcomes than white Hispanic/nonwhite ("Non-white") patients (34.4 vs 21.7%; p = 0.015). In a multivariate model that included age, time to return of spontaneous circulation, initial rhythm, combined electroencephalogram/CT findings, Charlson Comorbidity Index, and insurance status, race/ethnicity was still independently associated with poor outcome (odds ratio, 3.32; p = 0.003). Comorbidities were lower in white patients but did not fully explain outcomes differences. Nonwhite patients were more likely to exhibit signs of early severe anoxic changes on CT or electroencephalogram, higher creatinine levels and receive dialysis, but had longer duration to withdrawal of lifesustaining therapy. There was no significant difference in catheterizations or MRI scans. Subgroup analysis performed with patients without early electroencephalogram or CT changes still revealed better outcome in white patients.

CONCLUSIONS

Racial/ethnic disparity in outcome persists despite a strictly protocoled targeted temperature management. Nonwhite patients are more likely to arrive with more severe anoxic brain injury, but this does not account for all the disparity.

Deviations from AHA guidelines during pediatric cardiopulmonary resuscitation are associated with decreased event survival

BACKGROUND

Deviations (DEVs) from resuscitation guidelines are associated with worse outcomes after adult in-hospital cardiac arrest (IHCA), but impact during pediatric IHCA is unknown.

METHODS

Retrospective cohort study of prospectively collected data from the American Heart Association's Get With The Guidelines-Resuscitation registry. Children who had an index IHCA of ≥1 min from 2000 to 2014 were included. DEVs are defined by the registry by category (airway, medications, etc.) A composite measure termed circulation DEV(C-DEV), defined as at least one process deviation in the following categories: medications, defibrillation, vascular access, or chest compressions, was the primary exposure variable. Primary outcome was survival to hospital discharge. Mixed-effect models with random intercept for each hospital assessed the relationship of DEVs with survival to hospital discharge. Robustness of findings was assessed via planned secondary analysis using propensity score matching.

RESULTS

Among 7078 eligible index IHCA events, 1200 (17.0%) had DEVs reported. Airway DEVs (466; 38.8%) and medication DEVs (321; 26.8%) were most common. C-DEVs were present in 629 (52.4%). Before matching, C-DEVs were associated with decreased rate of ROSC (aOR = 0.53, CI95: 0.43-0.64, p < 0.001) and survival to hospital discharge (aOR = 0.71, CI95: 0.60-0.86, p < 0.001). In the matched cohort (C-DEV n = 573, no C-DEV n = 1146), C-DEVs were associated with decreased rate of ROSC (aOR 0.76, CI95 0.60-0.96, p = 0.02), but no association with survival to hospital discharge (aOR 1.01, CI95 0.81-1.25, p = 0.96).

CONCLUSIONS

DEVs were common in this cohort of pediatric IHCA. In a propensity matched cohort, while survival to hospital discharge was similar between groups, events with C-DEVs were less likely to achieve ROSC.

Racial Differences in Long-Term Outcomes Among Older Survivors of In-Hospital Cardiac Arrest

BACKGROUND

Black patients have worse in-hospital survival than white patients after in-hospital cardiac arrest (IHCA), but less is known about long-term outcomes. We sought to assess among IHCA survivors whether there are additional racial differences in survival after hospital discharge and to explore potential reasons for differences.

METHODS

This was alongitudinal study of patients ≥65 years of age who had an IHCA and survived until hospital discharge between 2000 and 2011 from the national Get With The Guidelines-Resuscitation registry whose data could be linked to Medicare claims data. Sequential hierarchical modified Poisson regression models evaluated the proportion of racial differences explained by patient, hospital, and unmeasured factors. Our exposure was black or white race. Our outcome was survival at 1, 3, and 5 years.

RESULTS

Among 8764 patients who survived to discharge, 7652 (87.3%) were white and 1112 (12.7%) were black. Black patients with IHCA were younger, more frequently female, sicker with more comorbidities, less likely to have a shockable initial cardiac arrest rhythm, and less likely to be evaluated with coronary angiography after initial resuscitation. At discharge, black patients were also more likely to have at least moderate neurological disability and less likely to be discharged home. Compared with white patients and after adjustment only for hospital site, black patients had lower 1-year (43.6% versus 60.2%; relative risk [RR], 0.72), 3-year (31.6% versus 45.3%; RR, 0.71), and 5-year (23.5% versus 35.4%; RR, 0.67; all P<0.001) survival. Adjustment for patient factors explained 29% of racial differences in 1-year survival (RR, 0.80; 95% confidence interval, 0.75-0.86), and further adjustment for hospital treatment factors explained an additional 17% of racial differences (RR, 0.85; 95% confidence interval, 0.80-0.92). Approximately half of the racial difference in 1-year survival remained unexplained, and the degree to which patient and hospital factors explained racial differences in 3-year and 5-year survival was similar.

CONCLUSIONS

Black survivors of IHCA have lower long-term survival compared with white patients, and about half of this difference is not explained by patient factors or treatments after IHCA. Further investigation is warranted to better understand to what degree unmeasured but modifiable factors such as postdischarge care account for unexplained disparities.

Temporal Changes in the Racial Gap in Survival After In-Hospital Cardiac Arrest

Importance

Previous studies have found marked differences in survival after in-hospital cardiac arrest by race. Whether racial differences in survival have narrowed as overall survival has improved remains unknown.

Objectives

To examine whether racial differences in survival after in-hospital cardiac arrest have narrowed over time and if such differences could be explained by acute resuscitation survival, postresuscitation survival, and/or greater temporal improvement in survival at hospitals with higher proportions of black patients.

Design, Setting, and Participants

In this cohort study from Get With the Guidelines-Resuscitation, performed from January 1, 2000, through December 31, 2014, a total of 112 139 patients with in-hospital cardiac arrest who were hospitalized in intensive care units or general inpatient units were studied. Data analysis was performed from April 7, 2015, to May 24, 2017.

Exposure

Race (black or white).

Main Outcomes and Measures

The primary outcome was survival to discharge. Secondary outcomes were acute resuscitation survival and postresuscitation survival. Multivariable hierarchical (2-level) regression models were used to calculate calendar-year rates of survival for black and white patients after adjusting for baseline characteristics.

Results

Among 112 139 patients with in-hospital cardiac arrest, 30 241 (27.0%) were black (mean [SD] age, 61.6 [16.4] years) and 81 898 (73.0%) were white (mean [SD] age, 67.5 [15.2] years). Risk-adjusted survival improved over time in black (11.3% in 2000 and 21.4% in 2014) and white patients (15.8% in 2000 and 23.2% in 2014; P for trend <.001 for both), with greater survival improvement among black patients on an absolute (P for trend = .02) and relative scale (P for interaction = .01). A reduction in survival differences between black and white patients was attributable to elimination of racial differences in acute resuscitation survival (black individuals: 44.7% in 2000 and 64.1% in 2014; white individuals: 47.1% in 2000 and 64.0% in 2014; P for interaction <.001). Compared with hospitals with fewer black patients, hospitals with a higher proportion of black patients with in-hospital cardiac arrest achieved larger survival gains over time.

Conclusions and Relevance

A substantial reduction in racial differences in survival after in-hospital cardiac arrest has occurred that has been largely mediated by elimination of racial differences in acute resuscitation survival and greater survival improvement at hospitals with a higher proportion of black patients. Further understanding of the mechanisms of this improvement could provide novel insights for the elimination of racial differences in survival for other conditions.

Real-time compression feedback for patients with in-hospital cardiac arrest: a multi-center randomized controlled clinical trial

Objective

To determine if real-time compression feedback using a non-automated hand-held device improves patient outcomes from in-hospital cardiac arrest (IHCA).

Methods

We conducted a prospective, randomized, controlled, parallel study (no crossover) of patients with IHCA in the mixed medical–surgical intensive care units (ICUs) of eight academic hospitals. Patients received either standard manual chest compressions or compressions performed with real-time feedback using the Cardio First Angel™ (CFA) device. The primary outcome was sustained return of spontaneous circulation (ROSC), and secondary outcomes were survival to ICU and hospital discharge.

Results

One thousand four hundred fifty-four subjects were randomized; 900 were included. Sustained ROSC was significantly improved in the CFA group (66.7% vs. 42.4%, P < 0.001), as was survival to ICU discharge (59.8% vs. 33.6%) and survival to hospital discharge (54% vs. 28.4%, P < 0.001). Outcomes were not affected by intra-group comparisons based on intubation status. ROSC, survival to ICU, and hospital discharge were noted to be improved in inter-group comparisons of non-intubated patients, but not intubated ones.

Conclusion

Use of the CFA compression feedback device improved event survival and survival to ICU and hospital discharge.

Trial registration

The study was registered with Clinicaltrials.gov (NCT02845011), registered retrospectively on July 21, 2016.

Characteristics and outcomes of in-hospital cardiac arrest in adults hospitalized with acute coronary syndrome in China

AIMS

This retrospective study aims to analyze and explore the clinical characteristics, risk factors, and in-hospital outcomes - including return of spontaneous circulation (ROSC) and survival to discharge - of hospitalized patients admitted with acute coronary syndrome (ACS) suffering cardiac arrest.

METHODS

ACS patients admitted to three tertiary hospitals in Fujian, China, were evaluated retrospectively from January 1, 2012 to December 30, 2016. Data were collected, based on the Utstein Style, for all cases of attempted resuscitation for IHCA. We analyzed patient characteristics, pre-event variables, event variables, and the main outcomes, including ROSC and survival to discharge, and identified the influencing factors on the outcomes.

RESULTS

The total number of ACS admissions across the three hospitals during this study period was 21,337. Among these admissions, 320 ACS patients experienced IHCA (incidence: 1.50%); 134 (41.9%) patients experienced ROSC; and 68 (21.2%) survived to discharge. The findings indicated that four factors were associated with ROSC, including age <70 years-old, shockable rhythm, duration of resuscitation (≤15 min and 16-30 min), and PCI. Five factors were associated with survival to discharge, including age <70 years-old, shockable rhythm, the duration of resuscitation (≤15 min and 16-30 min), Killip ≤ II, and CCI ≤ 2.

CONCLUSION

Younger age, shockable rhythm, and shorter duration of resuscitation were all factors demonstrated to be a predictor of ROSC and survival to hospital discharge.

Validation of the Cardiac Arrest Survival Postresuscitation In-hospital (CASPRI) score in an East Asian population

BACKGROUND

The Cardiac Arrest Survival Postresuscitation In-hospital (CASPRI) score is a useful tool for predicting neurological outcome following in-hospital cardiac arrest (IHCA), and was derived from a cohort selected from the Get With The Guidelines-Resuscitation registry between 2000 and 2009 in the United States. In an East Asian population, we aimed to identify the factors associated with outcomes of resuscitated IHCA patients and assess the validity of the CASPRI score.

METHODS

A retrospective study was conducted in a single centre in Taiwan. Patients with IHCA between 2006 and 2014 were screened.

RESULTS

Among the 796 included patients, 94 (11.8%) patients achieved neurologically intact survival. Multivariable logistic regression analyses identified factors significantly associated with neurological outcome. Six of these factors were also components of the CASPRI score, including duration of resuscitation, neurological status before IHCA, malignant disease, initial arrest rhythms, renal insufficiency and age. In univariate logistic regression analysis, the CASPRI score was significantly associated with neurological outcome (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.80-0.87); the area under the receiver operating characteristics curve was 0.79 (95% CI: 0.74-0.84).

CONCLUSION

In this retrospective study conducted in a single centre at Taiwan, we identified the common prognosticators of IHCA shared by both East Asian and Western societies. As a composite prognosticator, CASPRI score predicts outcomes with excellent accuracy among successfully resuscitated IHCA patients in an East Asian population. This tool allows accurate IHCA prognostication in an East Asian population.

Survival after in-hospital cardiac arrest among cerebrovascular disease patients

Stroke is a leading cause of death and disability, and while preferences for cardiopulmonary resuscitation (CPR) are frequently discussed, there is limited evidence detailing outcomes after CPR among acute cerebrovascular neurology (inclusive of stroke, subarachnoid hemorrhage (SAH)) patients. Systematic review and meta-analysis of PubMed and Cochrane libraries from January 1990 to December 2016 was conducted among stroke patients undergoing in-hospital CPR. Primary data from studies meeting inclusion criteria at two levels were extracted: 1) studies reporting survival to hospital discharge after CPR with cerebrovascular primary admitting diagnosis, and 2) studies reporting survival to hospital discharge after CPR with cerebrovascular comorbidity. Meta-analysis generated weighted, pooled survival estimates for each population. Of 818 articles screened, there were 176 articles (22%) that underwent full review. Three articles met primary inclusion criteria, with an estimated 8% (95% Confidence Interval (CI) 0.01, 0.14) rate of survival to hospital discharge from a pooled sample of 561 cerebrovascular patients after in-hospital CPR. Twenty articles met secondary inclusion criteria, listing a cerebrovascular comorbidity, with an estimated rate of survival to hospital discharge of 16% (95% CI 0.14, 0.19). All studies demonstrated wide variability in adherence to Utstein guidelines, and neurological outcomes were detailed in only 6 (26%) studies. Among the few studies reporting survival to hospital discharge after CPR among acute cerebrovascular patients, survival is lower than general inpatient populations. These findings synthesize the limited empirical basis for discussions about resuscitation among stroke patients, and highlight the need for more disease stratified reporting of outcomes after inpatient CPR.

Physiologic monitoring of CPR quality during adult cardiac arrest: A propensity-matched cohort study

AIM

The American Heart Association (AHA) recommends monitoring cardiopulmonary resuscitation (CPR) quality using end tidal carbon dioxide (ETCO2) or invasive hemodynamic data. The objective of this study was to evaluate the association between clinician-reported physiologic monitoring of CPR quality and patient outcomes.

METHODS

Prospective observational study of index adult in-hospital CPR events using the AHA's Get With The Guidelines - Resuscitation Registry. Physiologic monitoring was defined using specific database questions regarding use of either ETCO2 or arterial diastolic blood pressure (DBP) to monitor CPR quality. Logistic regression was used to evaluate the association between physiologic monitoring and outcomes in a propensity score matched cohort.

RESULTS

In the matched cohort, (monitored n=3032; not monitored n=6064), physiologic monitoring of CPR quality was associated with a higher rate of return of spontaneous circulation (ROSC; OR 1.22, CI95 1.04-1.43, p=0.017) compared to no monitoring. Survival to hospital discharge (OR 1.04, CI95 0.91-1.18, p=0.57) and survival with favorable neurological outcome (OR 0.97, CI95 0.75-1.26, p=0.83) were not different between groups. Of index events with only ETCO2 monitoring indicated (n=803), an ETCO2 >10mmHg during CPR was reported in 520 (65%), and associated with improved survival to hospital discharge (OR 2.41, CI95 1.35-4.30, p=0.003), and survival with favorable neurological outcome (OR 2.31, CI95 1.31-4.09, p=0.004) compared to ETCO2 ≤10mmHg.

CONCLUSION

Clinician-reported use of either ETCO2 or DBP to monitor CPR quality was associated with improved ROSC. An ETCO2 >10mmHg during CPR was associated with a higher rate of survival compared to events with ETCO2 ≤10mmHg.

Racial Disparities in Comorbidities, Complications, and Maternal and Fetal Outcomes in Women With Preeclampsia/eclampsia

OBJECTIVE

The mechanisms leading to worse outcomes in African-American (AA) women with preeclampsia/eclampsia remain unclear. Our objective was to identify racial differences in maternal comorbidities, peripartum characteristics, and maternal and fetal outcomes.

METHODS/RESULTS

When compared to white women with preeclampsia/eclampsia, AA women had an increased unadjusted risk of inpatient maternal mortality (OR 3.70, 95% CI: 2.19-6.24). After adjustment for covariates, in-hospital mortality for AA women remained higher than that for white women (OR 2.85, 95% CI: 1.38-5.53), while the adjusted risk of death among Hispanic women did not differ from that for white women. We also found an increased risk of intrauterine fetal death (IUFD) among AA women. When compared to white women with preeclampsia, AA women had an increased unadjusted odds of IUFD (OR 2.78, 95% CI: 2.49-3.11), which remained significant after adjustment for covariates (adjusted OR 2.45, 95% CI: 2.14-2.82). In contrast, IUFD among Hispanic women did not differ from that for white women after adjusting for covariates.

CONCLUSIONS AND RELEVANCE

Our data suggest that African-American women are more likely to have risk factors for preeclampsia and more likely to suffer an adverse outcome during peripartum care. Future research should examine whether controlling co-morbidities and other risk factors will help to alleviate racial disparities in outcomes in this cohort of women.