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Holmstrom L, Salmasi S, Chugh H, Uy-Evanado A, Sorenson C, Bhanji Z, Seifer BM, Sargsyan A, Salvucci A, Jui J, Reinier K, Chugh SS. Survivors of Sudden Cardiac Arrest Presenting With Pulseless Electrical Activity: Clinical Substrate, Triggers, Long-Term Prognosis. JACC Clin Electrophysiol 2022; 8:1260-1270. [PMID: 36057529 DOI: 10.1016/j.jacep.2022.06.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/13/2022] [Accepted: 06/28/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The proportion of sudden cardiac arrest (SCA) presenting as pulseless electrical activity (PEA) is rising, and survival remains low. The pathophysiology of PEA-SCA is poorly understood, and current clinical practice lacks specific options for the management of survivors. OBJECTIVES In this study, the authors sought to investigate clinical profile, triggers, and long-term prognosis in survivors of SCA presenting with PEA. METHODS The community-based Oregon SUDS (Sudden Unexpected Death Study) (since 2002) and Ventura PRESTO (Prediction of Sudden Death in Multi-ethnic Communities) (since 2015) studies prospectively ascertain all out-of-hospital SCAs of likely cardiac etiology. Lifetime clinical history and detailed evaluation of SCA events is available. We evaluated all SCA survivors with PEA as the presenting rhythm. RESULTS The study population included 201 PEA-SCA survivors. Of these, 97 could be contacted for access to their clinical records. Among the latter, the mean age was 67 ± 17 years and 58 (60%) were male. After in-hospital examinations, 29 events (30%) were associated with acute myocardial infarction, and 5 (5%) had bradyarrhythmias. Among the remaining 63 patients (65%), specific triggers remained undetermined, although 31 (49%) had a previous history of heart failure. Of the 201 overall survivors, 91 (45%) were deceased after a mean follow-up of 4.2 ± 4.0 years. Survivors under the age of 40 years had an excellent long-term prognosis. CONCLUSIONS Survivors of PEA-SCA are a heterogeneous group with high prevalence of multiple comorbidities, especially heart failure. Surprisingly good long-term survival was observed in young individuals. Acute myocardial infarction as the precipitating event was common, but triggers remained undetermined in the majority. Provision of individualized care to PEA survivors requires a renewed investigative focus on PEA-SCA.
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Affiliation(s)
- Lauri Holmstrom
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA; Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Shiva Salmasi
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Harpriya Chugh
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Audrey Uy-Evanado
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Chad Sorenson
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Ziana Bhanji
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Bai Madison Seifer
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Ariik Sargsyan
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | | | - Jonathan Jui
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Kyndaron Reinier
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Sumeet S Chugh
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA; Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Health System, Los Angeles, California, USA.
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2
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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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3
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Verma BR, Sharma V, Shekhar S, Kaur M, Khubber S, Bansal A, Singh J, Ahuja KR, Nazir S, Chetrit M, Menon V, Reed G, Kapadia S. Coronary Angiography in Patients With Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: A Systematic Review and Meta-Analysis. JACC Cardiovasc Interv 2021; 13:2193-2205. [PMID: 33032706 DOI: 10.1016/j.jcin.2020.07.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/09/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The authors conducted a meta-analysis to study clinical outcomes in patients who underwent early versus nonearly coronary angiography (CAG) in the setting of out-of-hospital cardiac arrest (OHCA) without ST-segment elevation. BACKGROUND The benefit of performing early CAG in patients with OHCA without STE remains disputed. METHODS MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from inception until February 21, 2020. Early and nonearly CAG patients were identified on the basis of the definitions mentioned in respective published studies. The primary outcome studied was 30-day mortality. Secondary outcomes were neurological status and the rate of percutaneous coronary intervention (PCI) following cardiac arrest. RESULTS Of 4,516 references, 11 studies enrolling 3,581 patients were included in the final meta-analysis. Random-effects analysis showed no differences in 30-day mortality (risk ratio [RR]: 0.86; 95% confidence interval [CI]: 0.71 to 1.04; p = 0.12; I2 = 74%), neurological status (RR: 1.08; 95% CI: 0.94 to 1.24; p = 0.28; I2 = 69%), and rate of PCI (RR: 1.22; 95% CI: 0.94 to 1.59; p = 0.13; I2 = 67%) between the 2 groups. Diabetes mellitus, chronic renal failure, previous PCI, and lactate level were found to be significant predictors of 30-day mortality on meta-regression (p < 0.05). CONCLUSIONS This analysis shows that there is no significant difference in 30-day mortality, neurological status, or rate of PCI among patients with OHCA without STE treated with early versus nonearly CAG. Thirty-day mortality is determined by presentation comorbidities rather than revascularization.
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Affiliation(s)
- Beni R Verma
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Vikram Sharma
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Shashank Shekhar
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Manpreet Kaur
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Shameer Khubber
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Agam Bansal
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Jarmanjeet Singh
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Keerat Rai Ahuja
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Salik Nazir
- Department of Cardiology, University of Toledo, Toledo, Ohio
| | - Michael Chetrit
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Venu Menon
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Grant Reed
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Samir Kapadia
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio.
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4
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Ambinder DI, Patil KD, Kadioglu H, Wetstein PS, Tunin RS, Fink SJ, Tao S, Agnetti G, Halperin HR. Pulseless Electrical Activity as the Initial Cardiac Arrest Rhythm: Importance of Preexisting Left Ventricular Function. J Am Heart Assoc 2021; 10:e018671. [PMID: 34121419 PMCID: PMC8403333 DOI: 10.1161/jaha.119.018671] [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] [Indexed: 12/25/2022]
Abstract
Background Pulseless electrical activity (PEA) is a common initial rhythm in cardiac arrest. A substantial number of PEA arrests are caused by coronary ischemia in the setting of acute coronary occlusion, but the underlying mechanism is not well understood. We hypothesized that the initial rhythm in patients with acute coronary occlusion is more likely to be PEA than ventricular fibrillation in those with prearrest severe left ventricular dysfunction. Methods and Results We studied the initial cardiac arrest rhythm induced by acute left anterior descending coronary occlusion in swine without and with preexisting severe left ventricular dysfunction induced by prior infarcts in non-left anterior descending coronary territories. Balloon occlusion resulted in ventricular fibrillation in 18 of 34 naïve animals, occurring 23.5±9.0 minutes following occlusion, and PEA in 1 animal. However, all 18 animals with severe prearrest left ventricular dysfunction (ejection fraction 15±5%) developed PEA 1.7±1.1 minutes after occlusion. Conclusions Acute coronary ischemia in the setting of severe left ventricular dysfunction produces PEA because of acute pump failure, which occurs almost immediately after coronary occlusion. After the onset of coronary ischemia, PEA occurred significantly earlier than ventricular fibrillation (<2 minutes versus 20 minutes). These findings support the notion that patients with baseline left ventricular dysfunction and suspected coronary disease who develop PEA should be evaluated for acute coronary occlusion.
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Affiliation(s)
- Daniel I Ambinder
- Division of Cardiology Department of Medicine Johns Hopkins University Baltimore MD
| | - Kaustubha D Patil
- Division of Cardiology Department of Medicine Johns Hopkins University Baltimore MD
| | - Hikmet Kadioglu
- Division of Cardiology Department of Medicine Johns Hopkins University Baltimore MD
| | - Pace S Wetstein
- Division of Cardiology Department of Medicine Johns Hopkins University Baltimore MD
| | - Richard S Tunin
- Division of Cardiology Department of Medicine Johns Hopkins University Baltimore MD
| | - Sarah J Fink
- Division of Cardiology Department of Medicine Johns Hopkins University Baltimore MD
| | - Susumu Tao
- Division of Cardiology Department of Medicine Johns Hopkins University Baltimore MD
| | - Giulio Agnetti
- Division of Cardiology Department of Medicine Johns Hopkins University Baltimore MD.,DIBINEM University of Bologna Bologna Italy
| | - Henry R Halperin
- Division of Cardiology Department of Medicine Johns Hopkins University Baltimore MD.,Departments of Biomedical Engineering and Radiology Johns Hopkins University Baltimore MD
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5
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Kosmopoulos M, Bartos JA, Yannopoulos D. ST-Elevation Myocardial Infarction Complicated by Out-of-Hospital Cardiac Arrest. Interv Cardiol Clin 2021; 10:359-368. [PMID: 34053622 DOI: 10.1016/j.iccl.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
5-10% of ST-elevated myocardial infarctions (STEMI) present with out-of-hospital cardiac arrest (OHCA). Although this subgroup of patients carries the highest in-hospital mortality among the STEMI population, it is the least likely to undergo coronary angiography and revascularization. Due to the concomitant neurologic injury, patients with OHCA STEMI require prolonged hospitalization and adjustments to standard MI management. This review systematically assesses the course of patients with OHCA STEMI from development of the arrest to hospital discharge, assesses the limiting factors for their treatment access, and presents the evidence-based optimal intervention strategy for this high-risk MI population.
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Affiliation(s)
- Marinos Kosmopoulos
- Cardiovascular Division, Center for Resuscitation Medicine, University of Minnesota Medical School, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Jason A Bartos
- Cardiovascular Division, Center for Resuscitation Medicine, University of Minnesota Medical School, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Demetris Yannopoulos
- Cardiovascular Division, Center for Resuscitation Medicine, University of Minnesota Medical School, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA.
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6
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Abstract
PURPOSE OF REVIEW Early coronary angiogram (CAG) remains a cornerstone in postcardiac arrest management as coronary disease (CAD)-related cardiac arrest is the leading cause of sudden death in adults. The opportunity to treat the cause early on with immediate CAG may improve outcome in cardiac arrest patients with AMI. Identifying the patients who will benefit from such an early invasive strategy is an unanswered question. Recent and ongoing trials may improve the level of evidence on this problematic, especially for some subgroup; however, current guidelines remain founded upon a very heterogeneous level of evidence. RECENT FINDINGS The key variable to argue for immediate CAD remains the pattern of the ECG monitored after return of spontaneous of circulation (ROSC). ST-segment elevation (STE) on postresuscitation ECG is the strongest argument to rule for an early CAG strategy. In other situations, identifying the best candidates for early CAG is very challenging. Different approaches including elements, such as circumstances of cardiac arrest and expected outcomes. may also drive the strategy. SUMMARY This review aims to provide an overview of these different discussion points. The indication for early CAG should rely on multiple factors and an individual approach.
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7
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McFadden P, Reynolds JC, Madder RD, Brown M. Diagnostic test accuracy of the initial electrocardiogram after resuscitation from cardiac arrest to indicate invasive coronary angiographic findings and attempted revascularization: A systematic review and meta-analysis. Resuscitation 2021; 160:20-36. [PMID: 33444708 DOI: 10.1016/j.resuscitation.2020.11.039] [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: 07/29/2020] [Revised: 11/16/2020] [Accepted: 11/27/2020] [Indexed: 02/07/2023]
Abstract
AIM Conduct a diagnostic test accuracy systematic review and meta-analysis of the post-return of spontaneous circulation (ROSC) electrocardiogram (ECG) to indicate an acute-appearing coronary lesion and revascularization. METHODS We searched PubMed, EMBASE, CINAHL, Cochrane Library, and Web of Science through February 18, 2020. Two investigators screened titles and abstracts, extracted data, and assessed risks of bias using QUADAS-2. We estimated sensitivity (Sn), specificity (Sp), and likelihood ratios (LR) for all reported ECG features to indicate all reported reference standards. Random-effects meta-analysis pooled comparable studies without critical risk of bias. GRADE methodology evaluated the certainty of evidence. RESULTS Overall, 48 studies reported 94 combinations of ECG features and reference standards with wide variation in their definitions. Most studies had risks of bias from selection for coronary angiography and blinding to the ECG and/or reference standard. Meta-analysis combined 6 studies for STE and acute coronary lesion (Sn 0.70 [95% CI 0.54-0.82]; Sp 0.85 [95% CI 0.78-0.90]; LR + 4.7 [95% CI 3.3-6.7]; LR- 0.4 [95% CI 0.2-0.6]) and 4 studies for STE and revascularization (Sn 0.53 [95% CI 0.47-0.58]; Sp 0.86 [95% CI 0.80-0.91]; LR + 3.9 [95% CI 2.8-5.5]; LR- 0.5 [95% CI 0.5-0.6]). Overall certainty of evidence was low with substantial heterogeneity. CONCLUSIONS Based on low certainty evidence, STE had good classification for acute coronary lesion and fair classification for revascularization. STE was more specific than sensitive for these outcomes and no single ECG feature excluded them. Uniform definitions and terminology would greatly facilitate the interpretation of subsequent studies.
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Affiliation(s)
- Patrick McFadden
- Spectrum Health Department of Emergency Medicine, Grand Rapids, MI, USA
| | - Joshua C Reynolds
- Michigan State University College of Human Medicine, Department of Emergency Medicine, 15 Michigan Street NE, Suite 736D, Grand Rapids, MI 49503, USA.
| | - Ryan D Madder
- Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI, USA
| | - Michael Brown
- Michigan State University College of Human Medicine, Department of Emergency Medicine, 15 Michigan Street NE, Suite 736D, Grand Rapids, MI 49503, USA
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8
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Cassina T, Clivio S, Putzu A, Villa M, Moccetti T, Fortuna D, Casso G. Neurological outcome and modifiable events after out-of-hospital cardiac arrest in patients managed in a tertiary cardiac centre: A ten years register. Med Intensiva 2020; 44:409-419. [DOI: 10.1016/j.medin.2019.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 05/08/2019] [Accepted: 05/18/2019] [Indexed: 01/30/2023]
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9
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Nikolaou NI. No ST-segment elevation after return of spontaneous circulation and non-shockable initial rhythm of cardiac arrest. To cath or not to cath? Resuscitation 2020; 155:239-241. [DOI: 10.1016/j.resuscitation.2020.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 11/30/2022]
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10
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Immediate coronary angiogram in out-of-hospital cardiac arrest patients with non-shockable initial rhythm and without ST-segment elevation — Is there a clinical benefit? Resuscitation 2020; 155:226-233. [DOI: 10.1016/j.resuscitation.2020.06.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/01/2020] [Accepted: 06/17/2020] [Indexed: 12/13/2022]
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11
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Jentzer JC, Herrmann J, Prasad A, Barsness GW, Bell MR. Utility and Challenges of an Early Invasive Strategy in Patients Resuscitated From Out-of-Hospital Cardiac Arrest. JACC Cardiovasc Interv 2020; 12:697-708. [PMID: 31000007 DOI: 10.1016/j.jcin.2019.01.245] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/09/2019] [Accepted: 01/15/2019] [Indexed: 12/16/2022]
Abstract
Out-of-hospital cardiac arrest (OHCA) is frequently triggered by acute myocardial ischemia. Coronary angiography is an important component of post-resuscitation care for patients with OHCA without an evident noncardiac cause, to identify underlying coronary artery disease and allow revascularization. Most patients undergoing coronary angiography after OHCA have obstructive coronary artery disease, and nearly one-half of patients have acute coronary occlusion. Early coronary angiography and percutaneous coronary intervention after OHCA have been associated with improved survival in observational studies, but these studies demonstrate selection bias, and randomized trials are lacking. Selection of patients for coronary angiography after OHCA can be challenging, particularly in comatose patients whose outcomes are driven primarily by anoxic brain injury. As for other patients with acute coronary syndromes, patients with ST-segment elevation after OHCA have a high probability of acute coronary occlusion warranting emergent coronary angiography. Patients with cardiogenic shock after OHCA are a high-risk population also requiring emergent coronary angiography. Among patients in stable condition after OHCA without ST-segment elevation, other clinical predictors can be used to identify those needing early coronary angiography to identify obstructive coronary artery disease. Despite the challenges with early neurological prognostication in comatose patients with OHCA, those with multiple objective markers of poor prognosis appear less likely to benefit from revascularization, and early coronary angiography may be reasonably deferred in appropriately selected patients meeting these criteria. The authors propose an algorithm to guide patient selection for coronary angiography after OHCA that combines clinical predictors of acute coronary occlusion and early clinical predictors of severe brain injury.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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12
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The quest continues to identify coronary occlusion in OHCA without ST elevation. Resuscitation 2019; 146:258-260. [PMID: 31682899 DOI: 10.1016/j.resuscitation.2019.10.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/25/2019] [Indexed: 12/17/2022]
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13
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Pareek N, Kordis P, Webb I, Noc M, MacCarthy P, Byrne J. Contemporary Management of Out-of-hospital Cardiac Arrest in the Cardiac Catheterisation Laboratory: Current Status and Future Directions. Interv Cardiol 2019; 14:113-123. [PMID: 31867056 PMCID: PMC6918505 DOI: 10.15420/icr.2019.3.2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 07/22/2019] [Indexed: 02/06/2023] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) is an important cause of mortality and morbidity in developed countries and remains an important public health burden. A primary cardiac aetiology is common in OHCA patients, and so patients are increasingly brought to specialist cardiac centres for consideration of coronary angiography, percutaneous coronary intervention and mechanical circulatory support. This article focuses on the management of OHCA in the cardiac catheterisation laboratory. In particular, it addresses conveyance of the OHCA patient direct to a specialist centre, the role of targeted temperature management, pharmacological considerations, provision of early coronary angiography and mechanical circulatory support.
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Affiliation(s)
- Nilesh Pareek
- King’s College Hospital NHS Foundation TrustLondon, UK
- School of Cardiovascular Medicine & Sciences, BHF Centre of ExcellenceKing’s College London, UK
| | | | - Ian Webb
- King’s College Hospital NHS Foundation TrustLondon, UK
| | - Marko Noc
- University Medical CentreLjubljana, Slovenia
| | - Philip MacCarthy
- School of Cardiovascular Medicine & Sciences, BHF Centre of ExcellenceKing’s College London, UK
| | - Jonathan Byrne
- King’s College Hospital NHS Foundation TrustLondon, UK
- School of Cardiovascular Medicine & Sciences, BHF Centre of ExcellenceKing’s College London, UK
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14
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Harhash AA, Huang JJ, Howe CL, Hsu CH, Kern KB. Coronary angiography and percutaneous coronary intervention in cardiac arrest survivors with non-shockable rhythms and no STEMI: A systematic review. Resuscitation 2019; 143:106-113. [DOI: 10.1016/j.resuscitation.2019.08.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 08/08/2019] [Accepted: 08/15/2019] [Indexed: 12/20/2022]
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15
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Reardon PM, Hickey M, English SW, Hibbert B, Simard T, Hendin A, Yadav K. Optimizing the Early Resuscitation After Out-of-Hospital Cardiac Arrest. J Intensive Care Med 2019; 35:1556-1563. [PMID: 31512559 DOI: 10.1177/0885066619873318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Resuscitation after out-of-hospital cardiac arrest can be one of the most challenging scenarios in acute-care medicine. The devastating effects of postcardiac arrest syndrome carry a substantial morbidity and mortality that persist long after return of spontaneous circulation. Management of these patients requires the clinician to simultaneously address multiple emergent priorities including the resuscitation of the patient and the efficient diagnosis and management of the underlying etiology. This review provides a concise evidence-based overview of the core concepts involved in the early postcardiac arrest resuscitation. It will highlight the components of an effective management strategy including addressing hemodynamic, oxygenation, and ventilation goals as well as carefully considering cardiac catheterization and targeted temperature management. An organized approach is paramount to providing effective care to patients in this vulnerable time period.
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Affiliation(s)
- Peter M Reardon
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Hickey
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Shane W English
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, 6363University of Ottawa, Ottawa Ontario Canada
| | - Benjamin Hibbert
- Division of Cardiology, 27339University of Ottawa Heart Institute, Ottawa, Ontario, Canada.,Department of Cellular and Molecular Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Trevor Simard
- Division of Cardiology, 27339University of Ottawa Heart Institute, Ottawa, Ontario, Canada.,Department of Cellular and Molecular Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Ariel Hendin
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
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16
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Kang SB, Kong SYJ, Shin SD, Ro YS, Song KJ, Hong KJ, Kim TH. Effect of cancer history on post-resuscitation treatments in out-of-hospital cardiac arrest. Resuscitation 2019; 137:61-68. [PMID: 30771449 DOI: 10.1016/j.resuscitation.2019.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/15/2019] [Accepted: 02/01/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES There is growing evidence that optimal post-resuscitation treatment is a significant factor for overall survival and neurological outcomes in out-of-hospital cardiac arrest (OHCA). However, there is also growing evidence of disparities in treatments in vulnerable populations such as elderly individuals or patients with underlying diseases, including cancer. AIM The aim of this study was to evaluate the influence of cancer status on post-resuscitation therapies among OHCA patients. MATERIAL AND METHODS This was a cross-sectional observational study based on a nationwide prospective OHCA registry database of Korea. All adult OHCA patients with presumed cardiac etiology and sustained return of spontaneous circulation (ROSC) from 2009 to 2016 were included in this study. Main exposure was history of cancer and primary outcome was post-resuscitation care, including percutaneous coronary intervention (PCI) and targeted temperature management (TTM). Multivariable logistic regression was used to analyze the association between cancer and post-resuscitation treatments. RESULTS A total of 33,760 patients were included for final analysis. Multivariable logistic analysis showed that cancer patients were significantly less likely to receive PCI and TTM compared to those without history of cancer with adjusted odds ratios of 0.29 (95% CI: 0.24-0.37) and 0.66 (0.58-0.77), respectively. CONCLUSION The results of this study suggest that a prior history of cancer may be associated with lower probability to receive potentially beneficial post-resuscitation treatments.
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Affiliation(s)
- Saee Byel Kang
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
| | - So Yeon Joyce Kong
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
| | - Young Sun Ro
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
| | - Kyoung Jun Song
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea.
| | - Ki Jeong Hong
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
| | - Tae Han Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
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17
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Factors determining level of hospital care and its association with outcome after resuscitation from pre-hospital pulseless electrical activity. Scand J Trauma Resusc Emerg Med 2018; 26:98. [PMID: 30454005 PMCID: PMC6245922 DOI: 10.1186/s13049-018-0568-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 11/11/2018] [Indexed: 11/27/2022] Open
Abstract
Background Patients resuscitated from out-of-hospital cardiac arrest (OHCA) with pulseless electrical activity (PEA) as initial cardiac rhythm are not always treated in intensive care units (ICUs): some are admitted to high dependency units with various level of care, others to ordinary wards. Aim of this study was to describe the factors determining level of hospital care after OHCA with PEA, post-resuscitation care and survival. Methods Adult OHCA patients with PEA (n = 221), who were resuscitated in southern Finland between 2010 and 2013 were included, provided patient survived to hospital admission. The patients were divided into four groups according to the level of hospital care provided: ordinary ward and Level 1–3 ICUs. Differences in patient characteristics, post-resuscitation care and survival were compared between the groups. Results Most patients (62.4%) were treated at Level 2 ICUs. Longer time to ROSC and advanced age decreased admission rate to Level 2 or 3 post-resuscitation care, whereas good pre-arrest CPC (1–2) increased the admission rate to Level 2/3 ICUs independently. Treatment with targeted temperature management (TTM) (4.1%) or early coronary angiography (3.2%) were very rare. Prognostic decisions were made earlier in the lower treatment intensity groups (p < 0.01). One-year survival rate was 24.0, 17.1% survived with good neurological outcome. Neurological outcome was better with more intensive care. After adjustment, level of care was not independent predictor for outcome: only return of spontaneous circulation (ROSC) time, cardiac arrest cause and pre-arrest performance affected independently to 1-year survival, age and ROSC for neurologic outcome. Conclusions PEA are usually admitted to Level 2 ICUs for post-resuscitation care in the capital area of Finland. Age, ROSC and pre-arrest CPC were independent predictors for level of post-resuscitation care. TTM and early CAG were rare and provided only for Level 3 ICU patients. Prognostication was earlier in lower level of care units. Good neurologic survival was more common with more intensive level of post-resuscitation care. After adjustment, level of care was not independent predictor for survival or neurologic outcome: only ROSC, cardiac arrest cause and pre-arrest performance predicted 1-year survival; age and ROSC neurologic outcome.
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18
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Kumar K, Lotun K. The Role of Coronary Catheterization Laboratory in Post-Resuscitation Care of Patients Without ST Elevation Myocardial Infarction. Curr Cardiol Rev 2018; 14:92-96. [PMID: 29737261 PMCID: PMC6088445 DOI: 10.2174/1573403x14666180507154107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/31/2018] [Accepted: 04/25/2018] [Indexed: 11/22/2022] Open
Abstract
Background: Out of hospital cardiac arrest management of patients with non-ST myocardial infarction per current American Heart Association and European Resuscitation Council guidelines leave the decision in regard to early angiography up to the physician operators. Guidelines are clear on the positive impact of early intervention on survival and improvement on left ventricular function in patients presenting with cardiac arrest and ST elevation myocardial infarction on electrocardiogram. This review aims to analyze the data that current guidelines are based upon in regards to out of hospital cardiac arrest with electrocardiogram findings of non-ST elevation myocardial infarction as well as review of other clinical trials that support early angiography and reperfusion strategies. Conclusion: Analysis of current literature shows that early coronary evaluation in patients with no finding of ST elevation on ECG can help improve survival in patients suffering out of hospital cardiac arrest.
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Affiliation(s)
- Kris Kumar
- Department of Internal Medicine, University of Arizona, Tucson, AZ, United States
| | - Kapil Lotun
- Division of Cardiology, University of Arizona, Tucson, AZ, United States
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19
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Jaeger D, Dumas F, Escutnaire J, Sadoune S, Lauvray A, Elkhoury C, Bassand A, Girerd N, Gueugniaud PY, Tazarourte K, Hubert H, Cariou A, Chouihed T. Benefit of immediate coronary angiography after out-of-hospital cardiac arrest in France: A nationwide propensity score analysis from the RéAC Registry. Resuscitation 2018. [DOI: 10.1016/j.resuscitation.2018.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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20
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Wallace DJ, Coppler P, Callaway C, Rittenberger JC, Dezfulian C, Mohan D, Toma C, Elmer J. Selection bias, interventions and outcomes for survivors of cardiac arrest. Heart 2018; 104:1356-1361. [PMID: 29463613 DOI: 10.1136/heartjnl-2017-312528] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/19/2018] [Accepted: 01/22/2018] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Cardiac catheterisation and implantable cardioverter defibrillator (ICD) insertion are increasingly common following cardiac arrest survival. However, much of the evidence for the benefit is observational, leaving open the possibility that biased patient selection confounds the association between these invasive procedures and improved outcome. We evaluated the likelihood of selection bias in the association between cardiac catheterisation or ICD placement and outcome by measuring long-term outcomes overall and in a cause-specific approach that separated cardiac mortality from non-cardiac mortality. METHODS We performed a multivariable survival analysis of a clinical cohort between 2005 and 2013, with follow-up through 2015. We included patients who had out-of-hospital or inhospital cardiac arrest that survived to discharge, and evaluated the association between cardiac catheterisation or ICD insertion and all-cause, cardiovascular and non-cardiovascular mortality. RESULTS Among 678 patients who survived cardiac arrest, we observed lower all-cause mortality among patients who underwent cardiac catheterisation (adjusted HR (aHR) 0.40; P<0.01) or ICD insertion (aHR 0.55; P<0.01). However, cause-specific analysis showed that the benefits of cardiac catheterisation and ICD insertion resulted from reduced non-cardiac causes of death (cardiac catheterisation: aHR 0.24, P<0.01; ICD: aHR 0.58, P<0.01), while reduced cardiac cause of death was not associated with cardiac catheterisation (cardiac catheterisation: aHR 0.75, P=0.33). CONCLUSIONS There is evidence of selection bias in the secondary prevention survival benefit attributable to cardiac catheterisation for patients who survive cardiac arrest. Observational studies that consider its effects on all-cause mortality likely overestimate the potential benefit of this procedure.
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Affiliation(s)
- David J Wallace
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick Coppler
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Clifton Callaway
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jon C Rittenberger
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cameron Dezfulian
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Deepika Mohan
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Catalin Toma
- Division of Cardiology, Department of Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan Elmer
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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