Recurrent out-of-hospital cardiac arrest

Sex Differences in Out-of-Hospital Cardiac Arrest Survival Trends

BACKGROUND

Out-of-hospital cardiac arrest survival rates have improved over time. This study established whether improvements were similar for women and men, and to what extent resuscitation characteristics or in-hospital procedures contributed to sex differences in temporal trends.

METHODS AND RESULTS

This retrospective cohort study included 3386 women and 8564 men from North Holland, the Netherlands, who experienced an out-of-hospital cardiac arrest from a cardiac cause in 2005 to 2017. Yearly rates of 30-day survival and secondary outcomes were calculated. Sex differences in temporal trends were evaluated with age-adjusted Poisson regression analysis, including interaction for sex and out-of-hospital cardiac arrest year. Resuscitation characteristics and in-hospital procedures were added to the model, and a spline at 2013 was considered. During the study period, the average 30-day survival was 24.9% in men and 15.7% in women. The 30-day survival rate increased in men (20% to 27.2%; P<0.001) but not in women (15.0% to 11.6%; P=0.40). The increase in the 30-day survival rate was 3% higher per year in men than in women (rate ratio, 1.03 [95% CI, 1.00-1.05]), with a stronger difference after 2013. Men had a larger increase in survival rate to the hospital arrival than women in 2005 to 2013, and, after 2013, an advantage over women in survival rate after hospital arrival. The sex differences were partly explained by differing trends in shockable initial rhythm (eg, adjusted rate ratio, 1.01 [95% CI, 0.99-1.03] for 30-day survival) and provision of in-hospital procedures.

CONCLUSIONS

Changes in rates of 30-day survival, survival to hospital arrival, and, after 2013, survival from hospital arrival to 30 days were more beneficial in men than women. The differences in trends were partly explained by shockable initial rhythm and in-hospital procedures.

Predicting recurrent cardiac arrest in individuals surviving Out-of-Hospital cardiac arrest

BACKGROUND

Despite improvements in short-term survival for Out-of-Hospital Cardiac Arrest (OHCA) in the past two decades, long-term survival is still not well studied. Furthermore, the contribution of different variables on long-term survival have not been fully investigated.

AIM

Examine the 1-year prognosis of patients discharged from hospital after an OHCA. Furthermore, identify factors predicting re-arrest and/or death during 1-year follow-up.

METHODS

All patients 18 years or older surviving an OHCA and discharged from the hospital were identified from the Swedish Register for Cardiopulmonary Resuscitation (SRCR). Data on diagnoses, medications and socioeconomic factors was gathered from other Swedish registers. A machine learning model was constructed with 886 variables and evaluated for its predictive capabilities. Variable importance was gathered from the model and new models with the most important variables were created.

RESULTS

Out of the 5098 patients included, 902 (∼18%) suffered a recurrent cardiac arrest or death within a year. For the outcome death or re-arrest within 1 year from discharge the model achieved an ROC (receiver operating characteristics) AUC (area under the curve) of 0.73. A model with the 15 most important variables achieved an AUC of 0.69.

CONCLUSIONS

Survivors of an OHCA have a high risk of suffering a re-arrest or death within 1 year from hospital discharge. A machine learning model with 15 different variables, among which age, socioeconomic factors and neurofunctional status at hospital discharge, achieved almost the same predictive capabilities with reasonable precision as the full model with 886 variables.

Recurrent Out-of-Hospital Sudden Cardiac Arrest: Prevalence and Clinical Factors

BACKGROUND

Despite improvements in management following survival from sudden cardiac arrest (SCA) and wide availability of implantable cardioverter defibrillators for secondary prevention, a subgroup of individuals will suffer multiple distinct episodes of SCA. The objective of this study was to characterize and evaluate the burden of recurrent out-of-hospital SCA among survivors of SCA in a single large US community.

METHODS

SCA cases were prospectively ascertained in the Oregon Sudden Unexpected Death Study. Individuals that experienced recurrent SCA were identified both prospectively and retrospectively.

RESULTS

We ascertained 6649 individuals with SCA (2002-2020) and 924 (14%) survived to hospital discharge. Of these, 88 survivors (10%) experienced recurrent SCA. Of the nonsurvivors (n=5725), 35 had suffered a recurrent SCA. Of the total 123 SCA cases with recurrent SCA, >60% occurred at least 1 year after the initial SCA (median 23 months, range: 6 days to 31 years). SCA occurred despite a secondary prevention implantable cardioverter defibrillator in 22% (n=26). Prevalence of coronary disease (36% versus 25%), hypertension (69% versus 43%), diabetes (44% versus 21%), and chronic kidney disease (35% versus 14%) was significantly higher in recurrent SCA versus single SCA survivors (n=80, P=0.01). Among individuals with no secondary prevention implantable cardioverter defibrillators before recurrent SCA, the majority had apparently reversible etiologies identified at initial SCA, with one-quarter undergoing coronary revascularization and over half diagnosed with noncoronary cardiac etiologies.

CONCLUSIONS

At least 10% of SCA survivors had recurrent SCA, and a large subgroup suffered their repeat SCA despite treatment for an apparently reversible etiology. A renewed focus on careful assessment of cardiac substrate as well as management of coronary disease, hypertension, diabetes, and chronic kidney disease in SCA survivors could reduce recurrent SCA.

Sex differences in incidence of out-of-hospital cardiac arrest across ethnic and socioeconomic groups: A population-based cohort study in the Netherlands

BACKGROUND

Insight into the occurrence of out-of-hospital cardiac arrest (OHCA) within general populations may help to target prevention strategies. Case registries suggest that there may be substantial differences in emergency medical service (EMS)-attended OHCA incidence between men and women, but relative sex differences across ethnic groups and socioeconomic (SES) groups have not been studied. We investigated sex differences in OHCA incidence, overall and across these subgroups.

METHODS

We performed a retrospective population-based cohort study, combining individual-level data on ethnicity and income (as SES measure) from Statistics Netherlands of all men and women aged ≥25 years living in one study region in the Netherlands on 01-01-2009 (n = 1,688,285) with prospectively collected EMS-attended OHCA cases (n = 5676) from the ARREST registry until 31-12-2015. We calculated age-standardised incidence rates of OHCA. Sex differences were assessed with Cox proportional hazards regression analyses, adjusted for age, ethnicity and income, in the overall population, and across ethnic and SES groups.

RESULTS

The age-standardised incidence rate of OHCA was lower in women than in men (30.9 versus 87.3 per 100,000 person-years), corresponding with a hazard ratio (HR) of 0.33 (95% confidence interval [CI] 0.31-0.35). These sex differences in hazard for OHCA existed in all income quintiles (HR range: 0.30-0.35) and ethnic groups (HR range: 0.19-0.40), except among Moroccans (HR 0.89, 95% CI 0.51-1.57).

CONCLUSION

Women have a substantial, yet lower OHCA incidence rate than men. The magnitude of these sex differences did not vary across social strata.

The economic impact of sudden cardiac arrest

BACKGROUND

There are 20,000 sudden cardiac arrests (SCAs) in Australia annually, with 90% case-fatality.

OBJECTIVE

The present study calculated both the health and economic impact of SCAs in Victoria, Australia.

METHODS

Data on all SCAs attended by Ambulance Victoria from July 2017 to June 2018 were collected regarding age, gender, and survival to hospital, discharge and 12 months. Pre-SCA employment status of all patients was modelled using age and gender-matched Australian economic data. A Markov state-transition model with a five-year horizon calculated health and economic impact in years of life lived (YLL), productivity-adjusted life years (PALYs) and gross domestic product (GDP) lost. A counterfactual Markov state-transition model assessed outcomes of an identical cohort of patients who did not experience SCA. All values were discounted by 5%.

RESULTS

In 12 months, 4637 people suffered SCAs in Victoria, of whom 1516 (32.7%) were working at the time. 695 patients (15.0%) survived to hospital, 325 (7.0%) to discharge, and 303 (6.5%) to 12 months. In five years following their SCA, the cohort lost 15,922 years of life and 2327 PALYs. Reduced productivity led to GDP losses of AUD$448 million (92.8% relative reduction). Extrapolated to the 20,000 SCAs occurring across all of Australia, total GDP losses approached AUD$2 billion.

CONCLUSION

The health and economic burden of SCAs is high, predominantly underpinned by very high mortality. Annual national losses approach AUD$2 billion (USD$1.42 billion) and are comparable to productivity losses from all cancers combined. Prioritising research and state-of-the-art care for SCA patients appears economically sound.

Sudden Cardiac Arrest Survivorship: A Scientific Statement From the American Heart Association

Cardiac arrest systems of care are successfully coordinating community, emergency medical services, and hospital efforts to improve the process of care for patients who have had a cardiac arrest. As a result, the number of people surviving sudden cardiac arrest is increasing. However, physical, cognitive, and emotional effects of surviving cardiac arrest may linger for months or years. Systematic recommendations stop short of addressing partnerships needed to care for patients and caregivers after medical stabilization. This document expands the cardiac arrest resuscitation system of care to include patients, caregivers, and rehabilitative healthcare partnerships, which are central to cardiac arrest survivorship.

Sudden Cardiac Death: Who Is at Risk?

Sudden cardiac death (SCD) is a leading cause of death in the United States. Despite improvements in therapy, the incidence of SCD as a proportion of overall cardiovascular death remains relatively unchanged. This article aims to answer the question, "Who is at risk for SCD?" In the process, it reviews the definition, pathophysiology, epidemiology, and risk factors of SCD. Patients at risk for SCD and appropriate treatment strategies are discussed.