The epidemiology of out-of-hospital 'sudden' cardiac arrest

Current trends in the management of out of hospital cardiac arrest (OHCA)

Sudden cardiac arrest remains a relevant problem with a significant number of deaths worldwide. Although survival rates have more than tripled over the last 20 years (4% in 2001 vs. 14% in 2020), survival rates with good neurological outcomes remain persistently low, representing a major socioeconomic problem. Every minute of delay from patient collapse to start cardiopulmonary resuscitation (CPR) and early defibrillation reduces the chance of survival by approximately 10-12%. Therefore, the time to treatment is a crucial factor in the prognosis of patients with out-of-hospital cardiac arrest (OHCA). Research teams working in the pre-hospital setting are therefore looking for ways to improve the transmission of information from the site of an emergency event and to make it easier for emergency medical dispatch centres (EMDC) to recognise life-threatening conditions with minimal deviation. For emergency unit procedures already at the scene of the event, methods are being sought to efficiently and temporarily replace a non-functioning cardiopulmonary system. In the case of traumatic cardiac arrest (TCA), the focus is mainly on effective affecting non-compressible haemorrhage.

Association of coronary angiography with ST-elevation and no ST-elevation in patients with refractory ventricular fibrillation - A substudy of the DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE-VF randomized control trial)

BACKGROUND

Refractory ventricular fibrillation or pulseless ventricular tachycardia (rVF/pVT) during out-of-hospital cardiac arrest (OHCA) is associated with poor survival. Double sequential defibrillation (DSED) and vector change (VC) improved survival for rVF/pVT in the DOSE-VF RCT. However, the role of angiography and percutaneous coronary intervention (angiography/PCI) during the trial is unknown.

OBJECTIVES

To determine the incidence of ST-elevation (STE) and no ST-elevation (NO-STE) on post-arrest ECG and the use of angiography/PCI in patients with rVF/pVT during the DOSE-VF RCT.

METHOD

Adults (≥18-years) with rVF/pVT OHCA randomized in the DOSE-VF RCT who survived to hospital admission were included. The primary analysis compared the proportion of angiography in STE and NO-STE. We performed regression modelling to examine association between STE, the interaction with defibrillation strategy, and survival to discharge controlling for known covariates.

RESULTS

We included 151 patients, 74 (49%) with STE and 77 (51%) with NO-STE. The proportion of angiography was higher in the STE cohort than NO-STE (87.8% vs 44.2%, p < 0.001); similarly the proportion of PCI was also higher (75.7% vs 9.1%, p < 0.001). Survival to discharge was similar between STE and NO-STE (63.5% vs 51.9%, p = 0.15). Use of angiography/PCI did not differ between defibrillation strategies. Decreased age (OR 0.95, 95% CI 0.92-0.98; p = 0.001) and angiography (OR 9.33, 95% CI 3.60-26.94; p < 0.001) were predictors of survival; however, STE was not.

CONCLUSION

We found high rates of angiography/PCI in patients with STE compared to NO-STE, however similar rates of survival. Angiography was an independent predictor of survival. Improved rates of survival employing DSED and VC were independent of angiography/PCI.

Characteristics of the most severely ill and injured patients in a Norwegian helicopter emergency medical service: a retrospective cohort study

BACKGROUND

Physician-staffed helicopter emergency medical services (HEMS) are dispatched to a variety of incidents, ranging from less serious to life-threatening. The skillset of a physician may be important to provide appropriate care for the most critically ill and severely injured patients. A better understanding of these patients may therefore be important to optimize dispatch criteria, training, and equipment setups for HEMS units. The aim of this study was to describe the characteristics of patients with the national advisory committee on aeronautics (NACA) score 5 and 6, primarily by diagnostic group and interventions performed.

METHODS

Retrospective cohort study on aggregated data from the HEMS-base in Trondheim, Norway. All patients with NACA score 5 and 6 in the 10-year period from 2013 to 2022 were included. Patients with return of spontaneous circulation (ROSC) after successful cardiopulmonary resuscitation were described separately from non-cardiac arrest patients.

RESULTS

Out of 9546 patient encounters, 2598 patients were included, with 1640 in the NACA 5 and 958 in NACA 6 group. Patient age was median 63 (interquartile range 45-74) and 64% of the patients were male. Post-ROSC patients accounted for 24% of patients. Of the non-cardiac arrest patients, the most frequent aetiology was trauma (16%), cardiac (15%), neurologic (14%) and respiratory (11%). The most common physician-requiring advanced interventions were general anaesthesia (22%), intubation (21%), invasive blood pressure monitoring (21%) and ventilator treatment (18%). The mean number of advanced interventions per mission were consistent during the study period (1,78, SD 0,25).

CONCLUSION

Twenty-seven percent of all HEMS dispatches were to NACA 5 and 6 patients. Twenty-four percent of these were post-ROSC patients. Sixty-three percent of all patients received at least one advanced physician-requiring intervention and the average number of interventions were consistent during the last 10 years. Hence, the competence a physician-staffed HEMS resource provide is utilized in a high number of critically ill and injured patients.

Sudden Death In Sports: Modern Concepts

Regular physical activity provides significant health benefits and reduces the risk of premature death from any cause, including cardiovascular diseases (CVD). However, physical activity may provoke sudden cardiac death (SCD), especially in presence of unrecognized diseases. It is essential to identify risk factors that contribute to SCD in athletes and to implement effective prevention of such episodes. For this purpose, SCD registries are being created, medical terminology is being unified, and schedules of medical examination are being developed. The best strategy to combat SCD during sport activities is a combination of primary prevention by screening examination to identify athletes with CVD at risk and a proper planning of first aid measures during sports events, including the availability of an automatic external defibrillator on site.

Myocardial scarring and recurrence of ventricular arrhythmia in patients surviving an out-of-hospital cardiac arrest

INTRODUCTION

Prediction of recurrent ventricular arrhythmia (VA) in survivors of an out-of-hospital cardiac arrest (OHCA) is important, but currently difficult. Risk of recurrence may be related to presence of myocardial scarring assessed with late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Our study aims to characterize myocardial scarring as defined by LGE-CMR in survivors of a VA-OHCA and investigate its potential role in the risk of new VA events.

METHODS

Between 2015 and 2022, a total of 230 VA-OHCA patients without ST-segment elevation myocardial infarction had CMR before implantable cardioverter-defibrillator implantation for secondary prevention at Copenhagen University Hospital, Rigshospitalet, and Hospital Clínic, University of Barcelona, of which n = 170 patients had a conventional (no LGE protocol) CMR and n = 60 patients had LGE-CMR (including LGE protocol). Scar tissue including core, border zone (BZ) and BZ channels were automatically detected by specialized investigational software in patients with LGE-CMR. The primary endpoint was recurrent VA.

RESULTS

After exclusion, n = 52 VA-OHCA patients with LGE-CMR and a mean left ventricular ejection fraction of 49 ± 16% were included, of which 18 (32%) patients reached the primary endpoint of VA. Patients with recurrent VA in exhibited greater scar mass, core mass, BZ mass, and presence of BZ channels compared with patients without recurrent VA. The presence of BZ channels identified patients with recurrent VA with 67% sensitivity and 85% specificity (area under the ROC curve (AUC) 0.76; 95% CI: 0.63-0.89; p < .001) and was the strongest predictor of the primary endpoint.

CONCLUSIONS

The presence of BZ channels was the strongest predictor of recurrent VA in patients with an out of-hospital cardiac arrest and LGE-CMR.

Data-driven sudden cardiac arrest research in Europe: Experts' perspectives on ethical challenges and governance strategies

Background

Observational studies using large-scale databases and biobanks help improve prevention and treatment of sudden cardiac arrest (SCA) but the lack of guidance on data protection issues in this setting may harm patients' rights and the research enterprise itself. This qualitative study explored the ethical aspects of observational SCA research, as well as solutions.

Methods

European experts in SCA research, medical ethics and health law reflected on this topic through semi-structured interviews (N = 29) and a virtual roundtable conference (N = 18). The ESCAPE-NET project served as a discussion case. Findings were coded and thematically analysed.

Results

The first theme concerned the potential benefits and harms (at individual and group level) of observational data-based SCA studies and included the following sub-themes: societal value, scientific validity, data privacy, disclosure of genetic findings, stigma and discrimination, and medicalisation of sudden death. The second theme involved governance through 'privacy by design', 'privacy by policy' and associated regulation and oversight. Sub-themes were: de-identification of data, informed consent (broad and deferred), ethics review, and harmonisation.

Conclusions

Researchers and scientific societies should be aware that ethico-legal issues may arise during data-driven studies in SCA and other emergencies. These can be mitigated by combining technical data protection safeguards with appropriate informed consent policies and proportional ethics oversight. To ensure responsible conduct of data research in emergency medicine, we recommend the establishment of 'codes of conduct' which should be developed in interdisciplinary groups and together with patient representatives.

Coronary angiography findings in resuscitated and refractory out-of-hospital cardiac arrest: A systematic review and meta-analysis

INTRODUCTION

Coronary angiography (CAG) frequently reveals coronary artery disease (CAD) after out-of-hospital cardiac arrest (OHCA), but its use is not standardized and often reported in different subpopulations. This systematic review and meta-analysis accurately describes angiographic features in resuscitated and refractory OHCA.

METHODS

PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched up to October 31, 2022. Studies reporting coronary angiography findings after OHCA were considered eligible. The primary outcome was location and rate of coronary lesions. Coronary angiography findings with 95% confidence intervals were pooled with a meta-analysis of proportion.

RESULTS

128 studies (62,845 patients) were included. CAG, performed in 69% (63-75%) of patients, found a significant CAD in 75% (70-79%), a culprit lesion in 63% (59-66%), and a multivessel disease in 46% (41-51%). Compared to patients with return of spontaneous circulation, refractory OHCA was associated with more severe CAD due to a higher rate of left main involvement (17% [12-24%] vs 5.7% [3.1-10%]; p = 0.002) and acute occlusion of left anterior descending artery (27% [17-39%] vs 15% [13-18%]; p = 0.02). Nonshockable patients without ST-elevation were those receiving CAG less frequently, despite significant disease in 54% (31-76%). Left anterior descending artery was the most frequently involved (34% [30-39%]).

CONCLUSIONS

Patients with OHCA have a high prevalence of significant CAD caused by acute and treatable coronary lesions. Refractory OHCA was associated with more severe coronary lesions. CAD was also present in patients with nonshockable rhythm and without ST elevation. However, heterogeneity of studies and selection of patients undergoing CAG limit the certainty of findings.

Hypothermia for neuroprotection in adults after cardiac arrest

BACKGROUND

Good neurological outcome after cardiac arrest is difficult to achieve. Interventions during the resuscitation phase and treatment within the first hours after the event are critical for a favourable prognosis. Experimental evidence suggests that therapeutic hypothermia is beneficial, and several clinical studies on this topic have been published. This review was originally published in 2009; updated versions were published in 2012 and 2016.

OBJECTIVES

To evaluate the benefits and harms of therapeutic hypothermia after cardiac arrest in adults compared to standard treatment.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 30 September 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults comparing therapeutic hypothermia after cardiac arrest with standard treatment (control). We included studies with adults cooled by any method, applied within six hours of cardiac arrest, to target body temperatures of 32 °C to 34 °C. Good neurological outcome was defined as no or only minor brain damage allowing people to live an independent life.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was 1. neurological recovery. Our secondary outcomes were 2. survival to hospital discharge, 3. quality of life, 4. cost-effectiveness and 5.

ADVERSE EVENTS

We used GRADE to assess certainty.

MAIN RESULTS

We found 12 studies with 3956 participants reporting the effects of therapeutic hypothermia on neurological outcome or survival. There were some concerns about the quality of all the studies, and two studies had high risk of bias overall. When we compared conventional cooling methods versus any type of standard treatment (including a body temperature of 36 °C), we found that participants in the therapeutic hypothermia group were more likely to reach a favourable neurological outcome (risk ratio (RR) 1.41, 95% confidence interval (CI) 1.12 to 1.76; 11 studies, 3914 participants). The certainty of the evidence was low. When we compared therapeutic hypothermia with fever prevention or no cooling, we found that participants in the therapeutic hypothermia group were more likely to reach a favourable neurological outcome (RR 1.60, 95% CI 1.15 to 2.23; 8 studies, 2870 participants). The certainty of the evidence was low. When we compared therapeutic hypothermia methods with temperature management at 36 °C, there was no evidence of a difference between groups (RR 1.78, 95% CI 0.70 to 4.53; 3 studies; 1044 participants). The certainty of the evidence was low. Across all studies, the incidence of pneumonia, hypokalaemia and severe arrhythmia was increased amongst participants receiving therapeutic hypothermia (pneumonia: RR 1.09, 95% CI 1.00 to 1.18; 4 trials, 3634 participants; hypokalaemia: RR 1.38, 95% CI 1.03 to 1.84; 2 trials, 975 participants; severe arrhythmia: RR 1.40, 95% CI 1.19 to 1.64; 3 trials, 2163 participants). The certainty of the evidence was low (pneumonia, severe arrhythmia) to very low (hypokalaemia). There were no differences in other reported adverse events between groups.

AUTHORS' CONCLUSIONS

Current evidence suggests that conventional cooling methods to induce therapeutic hypothermia may improve neurological outcomes after cardiac arrest. We obtained available evidence from studies in which the target temperature was 32 °C to 34 °C.

Prognostic value of early and late spontaneous conversion into a shockable rhythm for patients with out-of-hospital cardiac arrest

BACKGROUND

The prognostic significance of conversion into a shockable rhythm in patients who experienced out-of-hospital cardiac arrest (OHCA) with an initially nonshockable rhythm is controversial, perhaps due to the timing of rhythm conversion not being considered previously. We aimed to compare the different prognoses of patients with OHCA and early and late conversion of their rhythm into a shockable rhythm.

METHODS

This was a single-centre retrospective cohort study. We enrolled patients with OHCA who were sent to a medical centre in central Taiwan from 2016 to 2020. Patients <18 years old, those with cardiac arrest due to trauma or a circumstantial cause, and those for whom resuscitation was not attempted were excluded. Patients were divided into two groups in accordance with presentation with an initially shockable rhythm. Those with an initially nonshockable rhythm were divided into three subgroups: early-conversion, late-conversion, and nonconversion groups. The primary outcome was the neurological functional status upon discharge from hospital.

RESULTS

A total of 1645 patients with OHCA were included: initially shockable rhythm group, 339; early conversion group, 68; late-conversion group, 166; and nonconversion group, 1072. After adjustment, multivariate logistic regression revealed that a favourable neurological outcome was more common in the early conversion group than the nonconversion group (odds ratio [OR] 2.4; 95% confidence interval [CI], 1.1-5.3; p = 0.035), whereas the late-conversion group did not significantly differ from the nonconversion group (OR 0.5; 95% CI, 0.1-1.5; p = 0.211). The proportions of sustained return of spontaneous circulation and survival to discharge were also higher in the early conversion group than the late-conversion group (OR 2.9 95% CI 1.6-5.5, p = 0.001 and OR 4.5, 1.8-11.0, p = 0.001, respectively).

CONCLUSION

In patients who experience OHCA and have an initially nonshockable rhythm, early conversion into a shockable rhythm resulted in a better prognosis, whereas late conversion was not significantly different from nonconversion.

Heart Rate and Mortality After Resuscitation in Patients With Out-of-Hospital Cardiac Arrest - Insights From the SOS-KANTO Registry

BACKGROUND

Heart rate (HR) predicts outcomes in patients with acute coronary syndrome (ACS), whereas the impact of HR on outcomes after out-of-hospital cardiac arrest (OHCA) remains unclear. This study aimed to investigate the impact of HR after resuscitation on outcomes after OHCA and whether the impact differs with OHCA etiology.

METHODS AND RESULTS

Of 16,452 patients suffering from OHCA, this study analyzed 741 adults for whom HR after resuscitation was recorded by 12-lead electrocardiogram upon hospital arrival. Etiology of OHCA was categorized into 3 groups: ACS, non-ACS, and non-cardiac. Patients in each etiology group were further divided into tachycardia (>100 beats/min) and non-tachycardia (≤100 beats/min). The impact of HR on outcomes was evaluated in each group. Among the 741 patients, the mean age was 67.6 years and 497 (67.1%) patients were male. The primary outcome - 3-month all-cause mortality - was observed in 55.8% of patients. Tachycardia after resuscitation in patients with ACS was significantly associated with higher all-cause mortality at 3 months (P=0.002), but there was no significant association between tachycardia and mortality in non-ACS and non-cardiac etiology patients. In a multivariate analysis model, the incidence of tachycardia after resuscitation independently predicted higher 3-month all-cause mortality in OHCA patients with ACS (hazard ratio: 2.17 [95% confidence interval: 1.05-4.48], P=0.04).

CONCLUSIONS

Increased HR after resuscitation was associated with higher mortality only in patients with ACS.

Sex Differences in Incidence and Outcome of Out-of-Hospital Cardiac Arrest Within a Local Health Network

Introduction

Sex and gender differences in presentation and characteristics of out-of-hospital cardiac arrest (OHCA) are established in cohorts with presumed cardiac aetiology but not non-cardiac etiology. This study investigated the effect of sex on incidence and outcome of OHCA according to presumed and adjudicated aetiology within a local health network.

Methods

Population-based observational cohort study of emergency medical services (EMS) attended OHCAs within an Australian local health network. Cases identified from an EMS registry between 2012-2016 were linked to a hospital registry. Age-standardised incidence and baseline characteristics were stratified by sex for EMS-treated OHCA, non-EMS witnessed presumed cardiac and obvious non-cardiac sub-cohorts, and hospitalised cases. Logistic regression was used to explore the primary outcome of survival to hospital discharge.

Results

We identified 2,024 EMS-attended and 780 EMS-treated OHCAs. The non-EMS witnessed sub-cohorts comprised 504 presumed cardiac and 168 obvious non-cardiac OHCAs. Adjudicated aetiology was recorded in 123 hospitalised cases. Age-standardised incidence for women was almost half that of men across all groups. Across cohorts, women were generally older and arrested with a non-shockable initial rhythm in an area of low socioeconomic status. There was no sex difference in the primary outcome for the main EMS-treated cohort or in the non-cardiac sub-cohorts. The sex difference in outcome in the presumed cardiac sub-cohort was not present after multivariable adjustment.

Conclusions

There are sex differences in incidence and outcome of EMS-treated OHCA that appear to be driven by differences in susceptibility to cardiac arrhythmias and underlying etiology, rather than treatment delays or disparities.

Postresuscitation care and prognostication after cardiac arrest-Does sex matter?

Background

There are conflicting results concerning sex-specific differences in the post-cardiac arrest period. We investigated the sex distribution of patients after successful cardiopulmonary resuscitation (CPR), differences in treatment, complications, outcome and sex-specific performance of biomarkers for prognostication of neurological outcome.

Methods

Prospective observational study including cardiac-arrest (CA) patients treated with mild therapeutic hypothermia (MTH) at 33 °C for 24 h or normothermia. We investigated common complications including pneumonia and acute kidney injury (AKI) and neuron-specific enolase, secretoneurin and tau protein as biomarkers of neurological outcome, which was assessed with the cerebral performance categories score at hospital discharge.

Results

Out of 134 patients 26% were female. Women were significantly older (73 years, interquartile range (IQR) 56–79 years vs. 62 years, IQR 53–70 years; p = 0.038), whereas men showed a significantly higher rate of pneumonia (29% vs. 6%; p = 0.004) and a trend towards higher rates of AKI (62% vs. 45%; p = 0.091). Frequency of MTH treatment was not significantly different (48% vs. 31%; p = 0.081). Female sex was not associated with neurological outcome in multivariable analysis (p = 0.524). There was no significant interaction of sex with prognostication of neurological outcome at 24, 48 and 72 h after CPR. At the respective time intervals p_interaction for neuron-specific enolase was 0.524, 0.221 and 0.519, for secretoneurin 0.893, 0.573 and 0.545 and for tau protein 0.270, 0.635, and 0.110.

Conclusion

The proportion of female patients was low. Women presented with higher age but had fewer complications during the post-CA period. Female sex was not associated with better neurological outcome. The performance of biomarkers is not affected by sex.

Supplementary Information

The online version of this article (10.1007/s00508-022-02026-x) contains supplementary material, which is available to authorized users.

Prognostic Effect of Underlying Chronic Kidney Disease and Renal Replacement Therapy on the Outcome of Patients after Out-of-Hospital Cardiac Arrest: A Nationwide Observational Study

Background and Objectives: This study assessed the prognostic value of underlying chronic kidney disease (CKD) and renal replacement therapy (RRT) on the clinical outcomes from out-of-hospital cardiac arrest (OHCA). Materials and Methods: This retrospective study was conducted utilizing the population-based OHCA data of South Korea between 2008 and 2018. Adult (>18 years) OHCA patients with a medical cause of cardiac arrest were included and classified into three categories based on the underlying CKD and RRT: (1) non-CKD group; (2) CKD without RRT group; and (3) CKD with RRT group. A total of 13,682 eligible patients were included (non-CKD, 9863; CKD without RRT, 1778; CKD with RRT, 2041). From the three comparison subgroups, data with propensity score matching were extracted. The influence of CKD and RRT on patient outcomes was assessed using propensity score matching and multivariate logistic regression analyses. The primary outcome was survival at hospital discharge and the secondary outcome was a good neurological outcome at hospital discharge. Results: The two CKD groups (CKD without RRT and CKD with RRT) showed no significant difference in survival at hospital discharge compared with the non-CKD group (CKD without RRT vs. non-CKD, p > 0.05; CKD with RRT vs. non-CKD, p > 0.05). The non-CKD group had a higher chance of having good neurological outcomes than the CKD groups (non-CKD vs. CKD without RRT, p < 0.05; non-CKD vs. CKD with RRT, p < 0.05) whereas there was no significant difference between the two CKD groups (CKD without RRT vs. CKD with RRT, p > 0.05). Conclusions: Compared with patients without CKD, the underlying cause of CKD—regardless of RRT—may be linked to poor neurological outcomes. Underlying CKD and RRT had no effect on the survival at hospital discharge.

Survival Trends in Adults with Out-of-Hospital Cardiac Arrests after Traffic Collisions in Japan: A Population-Based Study

The 1-month survival rate from out-of-hospital cardiac arrest (OHCA) of cardiac origin has reportedly improved recently, at ≥5%. However, the characteristics of patients with OHCA after a traffic collision have not been adequately evaluated in Japan. We analyzed the All-Japan Utstein Registry data of 12,577 adult patients aged ≥ 20 years with OHCA due to traffic collisions who were resuscitated by emergency medical service personnel or bystanders and were then transported to medical institutions between 2013 and 2019. Multiple logistic regression analysis was used to assess factors potentially associated with the 1-month survival rate after OHCA. The 1-month survival rate was 1.4% (174/12,577). The proportion of 1-month survival of all OHCAs after a traffic collision origin did not increase significantly (from 1.6% [30/1919] in 2013 to 1.8% [25/1702] in 2019), and the adjusted odds ratio for 1-year increments was 1.04 (95% confidence interval, 0.96-1.12). In multivariate analysis, men who received ventricular fibrillation, pulseless electrical activity, intravenous fluid replacement, or early emergency medical service response and had a traffic collision during daytime had significantly favorable 1-month outcomes. In Japan, the 1-month survival after OHCA of a traffic collision origin was lower than that of a cardiac origin and remains stable.

Low serum cholesterol level as a risk factor for out-of-hospital cardiac arrest: a case-control study

OBJECTIVE

We aimed to identify the association between low serum total cholesterol levels and the risk of out-of-hospital cardiac arrest (OHCA).

METHODS

This case-control study was performed using datasets from the Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance (CAPTURES) project and the Korea National Health and Nutrition Examination Survey (KNHANES). Cases were defined as emergency medical service-treated adult patients who experienced OHCA with a presumed cardiac etiology from the CAPTURES project dataset. Four controls from the KNHANES dataset were matched to each case based on age, sex, and county. Multivariable conditional logistic regression analysis was conducted to evaluate the effect of total cholesterol levels on OHCA.

RESULTS

A total of 607 matched case-control pairs were analyzed. We classified total cholesterol levels into six categories (<148, 148-166.9, 167-189.9, 190-215.9, 216-237.9, and ≥238 mg/dL) according to the distribution of total cholesterol levels in the KNHANES dataset. Subjects with a total cholesterol level of 167-189.9 mg/dL (25th-49th percentile of the KNHANES dataset) were used as the reference group. In both the adjusted models and sensitivity analysis, a total cholesterol level of <148 mg/dL was significantly associated with OHCA (adjusted odds ratio [95% confidence interval], 6.53 [4.47-9.56]).

CONCLUSION

We identified an association between very-low total cholesterol levels and an increased risk of OHCA in a large, community-based population. Future prospective studies are needed to better understand how a low lipid profile is associated with OHCA.

Coronary Revascularization and Out-of-hospital Cardiac Arrest: Past, Present and Future

Cardiologists and the cardiac catheter laboratory have key roles to play in the management of patients after out-of-hospital cardiac arrest (OHCA). Although immediate catheter laboratory activation is the standard of care in cardiogenic shock and ST elevation myocardial infarction, the majority of patients will present without these features and with an uncertain diagnosis. Even in the latter, early assessment and invasive management may be beneficial, but this is counterbalanced by significant resource utilization, potential to cause harm and the possibility that any diagnostic or therapeutic gains are offset by a poor neurological outcome. Past consensus on the management of the OHCA patient without ST elevation or cardiogenic shock is being challenged by emerging results from new trials in this field. Further randomized trials are ongoing, and are expected to deliver robust data from over 4,000 patients, allowing us to further refine the optimal management strategy in this challenging cohort. This article describes the benefits and pitfalls of a strategy of immediate coronary angiography in these patients, examines the recently published COACT and TOMAHAWK trials in detail, and describes a framework with which to approach the patient after resuscitated OHCA, based on the available evidence to date.

Cardiac Arrest in Pigs With 48 hours of Post-Resuscitation Care Induced by 2 Methods of Myocardial Infarction: A Methodological Description

Background

Systematic reviews have disclosed a lack of clinically relevant cardiac arrest animal models. The aim of this study was to develop a cardiac arrest model in pigs encompassing relevant cardiac arrest characteristics and clinically relevant post‐resuscitation care.

Methods and Results

We used 2 methods of myocardial infarction in conjunction with cardiac arrest. One group (n=7) had a continuous coronary occlusion, while another group (n=11) underwent balloon‐deflation during arrest and resuscitation with re‐inflation after return of spontaneous circulation. A sham group was included (n=6). All groups underwent 48 hours of intensive care including 24 hours of targeted temperature management. Pigs underwent invasive hemodynamic monitoring. Left ventricular function was assessed by pressure‐volume measurements. The proportion of pigs with return of spontaneous circulation was 43% in the continuous infarction group and 64% in the deflation‐reinflation group. In the continuous infarction group 29% survived the entire protocol while 55% survived in the deflation‐reinflation group. Both cardiac arrest groups needed vasopressor and inotropic support and pressure‐volume measurements showed cardiac dysfunction. During rewarming, systemic vascular resistance decreased in both cardiac arrest groups. Median [25%;75%] troponin‐I 48 hours after return of spontaneous circulation, was 88 973 ng/L [53 124;99 740] in the continuous infarction group, 19 661 ng/L [10 871;23 209] in the deflation‐reinflation group, and 1973 ng/L [1117;1995] in the sham group.

Conclusions

This article describes a cardiac arrest pig model with myocardial infarction, targeted temperature management, and clinically relevant post‐cardiac arrest care. We demonstrate 2 methods of inducing myocardial ischemia with cardiac arrest resulting in post‐cardiac arrest organ injury including cardiac dysfunction and cerebral injury.

The prevalence of bacteremia in out of hospital cardiac arrest patients presenting to the emergency department of a tertiary care hospital

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) remains one of the most common causes of death. There is a scarcity of evidence concerning the prevalence of bacteraemia in cardiac arrest patients presenting to the Emergency Department (ED). We aimed to determine the prevalence of bacteraemia in OHCA patients presenting to the ED, as well as study the association between bacteraemia and in-hospital mortality in OHCA patients. In addition, the association between antibiotic use during resuscitation and in-hospital mortality was examined.

METHODS AND RESULTS

This was a study of 200 adult OHCA patients who presented to the ED between 2015 and 2019. Bacteraemia was confirmed if at least one of the blood culture bottles grew a non-skin flora pathogen or if two blood culture bottles grew a skin flora pathogen from two different sites. The prevalence of bacteraemia was 46.5%. Gram positive bacteria, specifically Staphylococcus species, were the most common pathogens isolated from the bacteremic group. 42 patients survived to hospital admission. The multivariate analysis revealed that there was no association between bacteraemia and hospital mortality in OHCA patients (OR = 1.3, 95% CI= 0.2-9.2) with a p-value of .8. There was no association between antibiotic administration during resuscitation and hospital mortality (OR = 0.6, 95% CI= 0.1 - 3.8) with a p-value of .6.

CONCLUSION

In our study, the prevalence of bacteraemia among OHCA patients presenting to the ED was found to be 46.5%. Bacteremic and non-bacteremic OHCA patients had similar initial baseline characteristics and laboratory parameters except for higher serum creatinine and BUN in the bacteremic group. In OHCA patients who survived their ED stay there was no association between hospital mortality and bacteraemia or antibiotic administration during resuscitation. There is a need for randomised controlled trials with a strong patient oriented primary outcome to better understand the association between in-hospital mortality and bacteraemia or antibiotic administration in OHCA patients.KEY MESSAGESWe aimed to determine the prevalence of bacteraemia in OHCA patients presenting to the Emergency Department. In our study, we found that 46.5% of patients presenting to our ED with OHCA were bacteremic.Bacteremic and non-bacteremic OHCA patients had similar initial baseline characteristics and laboratory parameters except for higher serum creatinine and BUN in the bacteremic group.We found no association between bacteraemia and hospital mortality. There was no association between antibiotic administration during resuscitation and hospital mortality.There is a need for randomised controlled trials with a strong patient oriented primary outcome to better understand the association between in-hospital mortality and bacteraemia or antibiotic administration in OHCA patients.

Comparison of Circadian Variation for In-Hospital Versus Out-of-Hospital Sudden Cardiac Arrest Survivors

Several studies have reported circadian periodicity of sudden cardiac arrest (SCA). It remains unclear to what extent this circadian rhythm is influenced by variation in patients' activities. One way to elucidate this is to compare patients with out-of-hospital cardiac arrests (OHCAs) with those with in-hospital cardiac arrests (IHCAs). We therefore examined the presence of a circadian pattern of SCA in a large cohort of OHCA and IHCA survivors. A total of 1,433 consecutive survivors of SCA in the Pittsburgh area from 2002 to 2012 were included. Patient demographics, including clinical histories and details of SCA, were collected. The distribution of SCA throughout the day was tested for differences using the chi-square test. Of the 1,224 patients analyzed, 706 had IHCA and 518 OHCA. We observed a nadir of SCA in the nighttime hours between 12 a.m. and 6 a.m. in both IHCA and OHCA groups (p <0.001), although this pattern was more blunted in the IHCA group. Patients who had an SCA in the nighttime window had more co-morbidities (p = 0.01). The circadian pattern was noted to be absent in patients with higher co-morbidity burden in IHCA only. In conclusion, the typical pattern of nighttime nadir in SCA is observed in patients with both OHCA and IHCA but is blunted in the hospital and especially in sicker patients. This suggests a common mechanistic pathway of SCA transcending differences in physical activities of patients and a difference in how co-morbidities interact with the timing of SCA in the inpatient setting.

Long-term outcome of myocardial scarring and deformation with cardiovascular magnetic resonance in out of hospital cardiac arrest survivors

AIMS

Cardiovascular magnetic resonance (CMR) is increasingly recognized as a diagnostic and prognostic tool in out of hospital cardiac arrest (OHCA) survivors. After assessing CMR findings early after ventricular fibrillation (VF) OHCA, we sought to explore the long-term outcome of myocardial scarring and deformation.

METHODS AND RESULTS

We included 121 consecutive VF OHCA survivors (82% male, median 62 years) undergoing CMR within 2 weeks from cardiac arrest. Late gadolinium-enhancement (LGE) was quantified using the full width at half maximum method and tissue tracking analysis software was used to assess myocardial deformation. LGE was found in 71% of patients (median LGE mass 6.2% of the left ventricle, LV), mainly with an ischaemic pattern. Myocardial deformation was overall impaired and showed a significant correlation with LGE presence and extent (P < 0.001). A composite end-point of all-cause mortality and appropriate ICD discharge/anti-tachycardia pacing was met in 24% of patients. Patients meeting the end-point had significantly greater LGE extent (8.6% of LV myocardium vs. 4.1%, P = 0.02), while there was no difference with regards to myocardial deformation. Survival rate was significantly lower in patients with LGE (P = 0.05) and LGE mass >4.4% of the LV identified a group of patients at higher risk of adverse events (P = 0.005).

CONCLUSIONS

We found a high prevalence of LGE, early after OHCA, and an overall impaired myocardial deformation. On long-term follow-up both LGE presence and extent showed a significant association with recurrent adverse events, while LV ejection fraction and myocardial deformation did not identify patients with an unfavourable outcome.

2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families

This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.

Out-of-hospital cardiac arrest in patients treated for ST-elevation acute myocardial infarction: Incidence, clinical features, and prognosis based on population-level data from Hungary

Aim

Out-of-hospital cardiac arrest (OHCA) is a severe complication of myocardial infarction. Literature data on the incidence of OHCA are inconsistent, and population-level data are incomplete.

Methods

Based on the Hungarian Myocardial Infarction Registry, the incidence of OHCA and its 30-day and 1-year mortality, as well as the significance of factors influencing the course of the disease in 28,083 ST-elevation myocardial infarction patients, were investigated using multivariable regression models.

Results

Of the 28,083 STEMI patients, 1535 (5.5%) had OHCA, which was more likely to occur in men. The long-term incidence of OHCA did not change significantly; no significant seasonality was found either. However, the daily distribution of cases showed that most OHCA patients were admitted to the hospital around 8 p.m. The occurrence of OHCA significantly worsened patients' prognoses; both 30-day and 1-year mortalities were considerably higher in the OHCA group than in the control group (46% vs 11.6%, 53.2% vs 18.7%, p < 0.001). This difference accumulated in the first few months; conditional survival after six months was no worse in those who had OHCA. Compared to those without OHCA, cardiogenic shock was more common at the time of hospitalisation (18.4% vs 2.2%) in the OHCA group. The highest risk of death was caused by the co-occurrence of OHCA and cardiogenic shock, which led to an eight times greater hazard of death (HR: 8.41, 95% CI: 7.37–9.60, p < 0.001).

Conclusion

Multivariable analysis confirmed the independent prognostic significance of age, catheter intervention during the index hospitalisation, OHCA, and cardiogenic shock.

Strategies on locations of public access defibrillator: A systematic review

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a critical condition with poor outcomes. Although the survival rate increases in those who undergo defibrillation, the utility of on-time defibrillation among bystanders remained low. An evaluation of the deployment strategy for public access defibrillators (PADs) is necessary to increase their use and accessibility. This study was to conduct a systematic review for deployment strategies of PADs.

METHODS

Two authors independently searched for articles published before October 2019 from PubMed, Embase, Web of Science, and Cochrane Library. An independent librarian provided the search strategy and assisted the literature research. We included articles that were focused on the main topic, but excluded those which were missing results or that used an unclear definition. The qualitative outcomes were the utility and OHCA coverage of PADs. We performed a qualitative analysis across the studies, but a quantitative analysis was not available due to the studies' heterogeneity in design and variety of outcomes.

RESULTS

We eventually included 15 studies. Three strategies were presented: guidelines-based, grid-based, and landmark-based. The guidelines-based deployment was common fit for OHCA events. The grid-based method increased the use of bystander defibrillation 3-fold, and 30-day survival doubled. The top 3 landmarks in the landmark-based strategy were offices (18.6%), schools (13.3%), and sports facilities (12.9%). Utility of PADs might increase if we optimize PAD location by mathematical modeling and evaluation feedback.

CONCLUSION

Three deployment strategies were presented. Although the optimal method could not be fully identified, a more efficient PAD deployment could benefit the population in terms of OHCA coverage and survival among patients with OHCA.

Predictors of recognition of out of hospital cardiac arrest by emergency medical services call handlers in England: a mixed methods diagnostic accuracy study

BACKGROUND

The aim of this study was to identify key indicator symptoms and patient factors associated with correct out of hospital cardiac arrest (OHCA) dispatch allocation. In previous studies, from 3% to 62% of OHCAs are not recognised by Emergency Medical Service call handlers, resulting in delayed arrival at scene.

METHODS

Retrospective, mixed methods study including all suspected or confirmed OHCA patients transferred to one acute hospital from its associated regional Emergency Medical Service in England from 1/7/2013 to 30/6/2014. Emergency Medical Service and hospital data, including voice recordings of EMS calls, were analysed to identify predictors of recognition of OHCA by call handlers. Logistic regression was used to explore the role of the most frequently occurring (key) indicator symptoms and characteristics in predicting a correct dispatch for patients with OHCA.

RESULTS

A total of 39,136 dispatches were made which resulted in transfer to the hospital within the study period, including 184 patients with OHCA. The use of the term 'Unconscious' plus one or more of symptoms 'Not breathing/Ineffective breathing/Noisy breathing' occurred in 79.8% of all OHCAs, but only 72.8% of OHCAs were correctly dispatched as such. 'Not breathing' was associated with recognition of OHCA by call handlers (Odds Ratio (OR) 3.76). The presence of key indicator symptoms 'Breathing' (OR 0.29), 'Reduced or fluctuating level of consciousness' (OR 0.24), abnormal pulse/heart rate (OR 0.26) and the characteristic 'Female patient' (OR 0.40) were associated with lack of recognition of OHCA by call handlers (p-values < 0.05).

CONCLUSIONS

There is a small proportion of calls in which cardiac arrest indicators are described but the call is not dispatched as such. Stricter adherence to dispatch protocols may improve call handlers' OHCA recognition. The existing dispatch protocol would not be improved by the addition of further terms as this would be at the expense of dispatch specificity.

2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families

This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.

Can We Predict Good Survival Outcomes by Classifying Initial and Re-Arrest Rhythm Change Patterns in Out-of-Hospital Cardiac Arrest Settings?

Objective

The purpose of this study was to investigate whether a change in prehospital arrest rhythms could allow medical personnel to predict survival outcomes in patients who achieved a return of spontaneous circulation (ROSC) in the setting of out-of-hospital cardiac arrest (OHCA).

Methods

The design of this study was retrospective, multi-regional, observational, and cross-sectional with a determining period between August 2015 and July 2016. Cardiac arrest rhythms were defined as a shockable rhythm (S), which refers to ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), and non-shockable rhythm (NS), which refers to pulseless electrical activity or asystole. Survival to admission, survival to discharge, and good cerebral performance category (CPC) (CPC 1 or 2) were defined as good survival outcomes.

Results

A total of 163 subjects were classified into four groups according to the rhythm change pattern: NS→NS (98), S→S (27), S→NS (23), and NS→S (15). NS→NS pattern was used as the reference in logistic regression analysis. In the case of survival to hospital admission, the odds ratio (OR) (95% CI) of the S→S pattern was the highest [12.63 (3.56-44.85), p: <0.001 by no correction] and [7.29 (1.96-27.10), p = 0.003 with adjusting]. In the case of survival to hospital discharge, the OR (95% CI) of the S→S pattern was the highest [37.14 (11.71-117.78), p: <0.001 by no correction] and [13.85 (3.69-51.97), p: <0.001 with adjusting]. In the case of good CPC (CPC 1 or 2) at discharge, the OR (95% CI) of the S→S pattern was the highest [96 (19.14-481.60), p: <0.001 by no correction] and [149.69 (19.51-1148.48), p: <0.001 with adjusting].

Conclusions

The S→S group showed the highest correlation with survival to hospital admission, survival to hospital discharge, and good CPC (CPC 1 or 2) at discharge compared to the NS→NS group. Verifying changes in initial cardiac arrest rhythm and prehospital re-arrest (RA) rhythm patterns after prehospital ROSC can help us predict good survival outcomes in the OHCA setting.

QTc interval in survivors of out of hospital cardiac arrest

BACKGROUND

QTc interval (QTc) prolongation is seen on the post-arrest electrocardiogram (ECG) of many out of hospital cardiac arrest (OHCA) survivors. It remains unclear whether this is a transient phenomenon or a manifestation of an underlying arrhythmic substrate. This observational study assessed the trend of QTc in an unselected group of patients presenting with OHCA. We sought to identify any relationship between QTc, gender and aetiology of arrest. We observed whether targeted temperature management (TTM) is associated with malignant arrhythmia.

METHOD

We analysed 60 patients presenting with OHCA to the Bristol Heart Institute during a 20-month period. We measured QTc on admission and assessed for persistence, development and resolution of prolongation at up to 5 time points post-OHCA. Aetiology of arrest was divided into coronary, non-coronary or primary arrhythmic to investigate for patterns in QTc behaviour.

RESULTS

81.7% (49/60) of arrests were attributed to an acute coronary event. 55% (33/60) had QTc prolongation on admission, of which 79% resolved. There were no significant differences in QTc behaviour by aetiology. One patient presenting with a normal QTc, developed prolongation during admission and received a genetic diagnosis of Long QT Syndrome. TTM was employed in 57/60, with no increased incidence of malignant arrhythmia.

CONCLUSIONS

Prolonged QTc on admission does not imply a primary arrhythmic aetiology and resolves in the majority pre-discharge. However, an initial normal QTc post-OHCA does not preclude a diagnosis of Long QT syndrome, highlighting the importance of thorough investigations in these patients. TTM appears safe from a cardiac perspective.

Outcome prediction of out-of-hospital cardiac arrest with presumed cardiac aetiology using an advanced machine learning technique

BACKGROUND

Outcome prediction for patients with out-of-hospital cardiac arrest (OHCA) has the possibility to detect patients who could have been potentially saved. Advanced machine learning techniques have recently been developed and employed for clinical studies. In this study, we aimed to establish a prognostication model for OHCA with presumed cardiac aetiology using an advanced machine learning technique.

METHODS AND RESULTS

Cohort data from a prospective multi-centre cohort study for OHCA patients transported by an ambulance in the Kanto area of Japan between January 2012 and March 2013 (SOS-KANTO 2012 study) were analysed in this study. Of 16,452 patients, data for OHCA patients aged ≥18 years with presumed cardiac aetiology were retrieved, and were divided into two groups (training set: n = 5718, between January 1, 2012 and December 12, 2012; test set: n = 1608, between January 1, 2013 and March 31, 2013). Of 421 variables observed during prehospital and emergency department settings, 35 prehospital variables, or 35 prehospital and 18 in-hospital variables, were used for outcome prediction of 1-year survival using a random forest method. In validation using the test set, prognostication models trained with 35 variables, or 53 variables for 1-year survival showed area under the receiver operating characteristics curve (AUC) values of 0.943 (95% CI [0.930, 0.955]) and 0.958 (95% CI [0.948, 0.969]), respectively.

CONCLUSIONS

The advanced machine learning technique showed favourable prediction capability for 1-year survival of OHCA with presumed cardiac aetiology. These models can be useful for detecting patients who could have been potentially saved.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in non-traumatic out-of-hospital cardiac arrest: evaluation of an educational programme

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a critical incident with a high mortality rate. Augmentation of the circulation during cardiopulmonary resuscitation (CPR) might be beneficial. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) redistribute cardiac output to the organs proximal to the occlusion. Preclinical data support that patients in non-traumatic cardiac arrest might benefit from REBOA in the thoracic level during CPR. This study describes a training programme to implement the REBOA procedure to a prehospital working team, in preparation to a planned clinical study.

METHODS

We developed a team-based REBOA training programme involving the physicians and paramedics working on the National Air Ambulance helicopter base in Trondheim, Norway. The programme consists of a four-step approach to educate, train and implement the REBOA procedure in a simulated prehospital setting. An objective structured assessment of prehospital REBOA application scoring chart and a special designed simulation mannequin was made for this study.

RESULTS

Seven physicians and 3 paramedics participated. The time needed to perform the REBOA procedure was 8.5 (6.3-12.7) min. The corresponding time from arrival at scene to balloon inflation was 12.0 (8.8-15) min. The total objective assessment scores of the candidates' competency was 41.8 (39-43.5) points out of 48. The advanced cardiovascular life support (ACLS) remained at standard quality, regardless of the simultaneous REBOA procedure.

CONCLUSION

This four-step approach to educate, train and implement the REBOA procedure to a prehospital working team ensures adequate competence in a simulated OHCA setting. The use of a structured training programme and objective assessment of skills is recommended before utilising the procedure in a clinical setting. In a simulated setting, the procedure does not add significant time to the prehospital resuscitation time nor does the procedure interfere with the quality of the ACLS.

TRIAL REGISTRATION NUMBER

NCT03534011.

Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study

OBJECTIVE

To assess the association between stress related disorders and subsequent risk of cardiovascular disease.

DESIGN

Population based, sibling controlled cohort study.

SETTING

Population of Sweden.

PARTICIPANTS

136 637 patients in the Swedish National Patient Register with stress related disorders, including post-traumatic stress disorder (PTSD), acute stress reaction, adjustment disorder, and other stress reactions, from 1987 to 2013; 171 314 unaffected full siblings of these patients; and 1 366 370 matched unexposed people from the general population.

MAIN OUTCOME MEASURES

Primary diagnosis of incident cardiovascular disease—any or specific subtypes (ischaemic heart disease, cerebrovascular disease, emboli/thrombosis, hypertensive diseases, heart failure, arrhythmia/conduction disorder, and fatal cardiovascular disease)—and 16 individual diagnoses of cardiovascular disease. Hazard ratios for cardiovascular disease were derived from Cox models, after controlling for multiple confounders.

RESULTS

During up to 27 years of follow-up, the crude incidence rate of any cardiovascular disease was 10.5, 8.4, and 6.9 per 1000 person years among exposed patients, their unaffected full siblings, and the matched unexposed individuals, respectively. In sibling based comparisons, the hazard ratio for any cardiovascular disease was 1.64 (95% confidence interval 1.45 to 1.84), with the highest subtype specific hazard ratio observed for heart failure (6.95, 1.88 to 25.68), during the first year after the diagnosis of any stress related disorder. Beyond one year, the hazard ratios became lower (overall 1.29, 1.24 to 1.34), ranging from 1.12 (1.04 to 1.21) for arrhythmia to 2.02 (1.45 to 2.82) for artery thrombosis/embolus. Stress related disorders were more strongly associated with early onset cardiovascular diseases (hazard ratio 1.40 (1.32 to 1.49) for attained age <50) than later onset ones (1.24 (1.18 to 1.30) for attained age ≥50; P for difference=0.002). Except for fatal cardiovascular diseases, these associations were not modified by the presence of psychiatric comorbidity. Analyses within the population matched cohort yielded similar results (hazard ratio 1.71 (1.59 to 1.83) for any cardiovascular disease during the first year of follow-up and 1.36 (1.33 to 1.39) thereafter).

CONCLUSION

Stress related disorders are robustly associated with multiple types of cardiovascular disease, independently of familial background, history of somatic/psychiatric diseases, and psychiatric comorbidity.

A prediction model for good neurological outcome in successfully resuscitated out-of-hospital cardiac arrest patients

BACKGROUND

In the initial hours after out-of-hospital cardiac arrest (OHCA), it remains difficult to estimate whether the degree of post-ischemic brain damage will be compatible with long-term good neurological outcome. We aimed to construct prognostic models able to predict good neurological outcome of OHCA patients within 48 h after CCU admission using variables that are bedside available.

METHODS

Based on prospectively gathered data, a retrospective data analysis was performed on 107 successfully resuscitated OHCA patients with a presumed cardiac cause of arrest. Targeted temperature management at 33 °C was initiated at CCU admission. Prediction models for good neurological outcome (CPC1-2) at 180 days post-CA were constructed at hour 1, 12, 24 and 48 after CCU admission. Following multiple imputation, variables were selected using the elastic-net method. Each imputed dataset was divided into training and validation sets (80% and 20% of patients, respectively). Logistic regression was fitted on training sets and prediction performance was evaluated on validation sets using misclassification rates.

RESULTS

The prediction model at hour 24 predicted good neurological outcome with the lowest misclassification rate (21.5%), using a cut-off probability of 0.55 (sensitivity = 75%; specificity = 82%). This model contained sex, age, diabetes status, initial rhythm, percutaneous coronary intervention, presence of a BIS 0 value, mean BIS value and lactate as predictive variables for good neurological outcome.

DISCUSSION

This study shows that good neurological outcome after OHCA can be reasonably predicted as early as 24 h following ICU admission using parameters that are bedside available. These prediction models could identify patients who would benefit the most from intensive care.

Renal Function and Outcome of Out-of-Hospital Cardiac Arrest - Multicenter Prospective Study (SOS-KANTO 2012 Study)

BACKGROUND

Renal dysfunction is associated with increased cardiovascular-related mortality, but its impact on outcome of out-of-hospital cardiac arrest (OHCA) remains unclear. We assessed whether post-OHCA outcome correlated with renal function early after OHCA. Methods and Results: Of the 16,452 registered patients in the SOS-KANTO 2012 Study, 5,112 cardiogenic OHCA adults with creatinine measurement (mean age, 72 years; male, 64%) were examined. First-obtained creatinine was used to assess eGFR. Associations between eGFR groups, ≥60 (n=997), 45-59 (n=1,311), 30-44 (n=1,441), and <30 mL/min/1.73 m²(n=1,363), and 3-month survival and neurological outcomes were examined. Favorable neurological outcome was defined as cerebral performance categories 1 or 2. Survival rate (15.1%, 9.7%, 3.9%, and 2.9%; P<0.001) and proportion of favorable neurological outcome (12.3%, 7.4%, 2.6%, and 2.2%; P<0.001) were determined for eGFR groups ≥60, 45-59, 30-44, and <30 mL/min/1.73 m², respectively. The survival rate decreased with eGFR (<60 mL/min/1.73 m²), and survival adjusted OR were 0.74 (95% CI: 0.54-1.03), 0.42 (95% CI: 0.28-0.62), and 0.43 (95% CI: 0.28-0.68) for eGFR 45-59, 30-44, and <30 mL/min/1.73 m², respectively. The adjusted OR for favorable neurological outcome also decreased with eGFR: 0.74 (95% CI: 0.52-1.06), 0.40 (95% CI: 0.25-0.64), and 0.48 (95% CI: 0.29-0.81), respectively.

CONCLUSIONS

An independent and graded association was observed between decreased eGFR and 3-month survival and proportion of favorable neurological outcome in cardiogenic OHCA patients.

Current Status of Knowledge about Cardiopulmonary Resuscitation among the University Students in the Northern Region of Saudi Arabia

Background

Sudden cardiac arrest is a major public health problem in the world. Immediate initiation of high-quality cardiopulmonary resuscitation (CPR) significantly increased patient survival rate. Therefore, it is very important to train young people and increase public awareness of CPR for the long-term benefit of the community.

Objective

We aimed at estimating the level of knowledge and attitude towards cardiopulmonary resuscitation (CPR) among the university students in the northern region of Saudi Arabia.

Methodology

A cross-sectional, prospective study was conducted among the students of four northern region universities of Saudi Arabia (Jouf, Hail, Northern Borders, and Tabuk) between March and November 2017. A self-administered questionnaire was prepared in both Arabic and English languages and distributed to all the participants. All the data were collected and analyzed by using SPSS version 21.

Results

A total of 947 students from four universities completed the questionnaire: Jouf (57%), Hail (15%), Northern Borders (13%), and Tabuk (15%). Although 72% of students have previous knowledge about CPR, 49% of them lack knowledge about a medical emergency. Moreover, 59% failed to answer regarding CPR where only 41% wrote the ABC steps in the correct sequence. However, 67% of the participants had very poor knowledge, 89% of participants desired to receive additional CPR training course, and 49% of the students thought that CPR training should be a mandatory graduation requirement for all universities. There were no significant differences between male and female students. Students from medicine-related colleges have significantly (p < 0.001) more knowledge and scored better compared with non-medicine-related colleges. Tabuk University scored better compared to the others, but the overall knowledge and attitude scored were low.

Conclusions

Overall knowledge about CPR among the university students was not satisfactory; however, attitude towards CRP training was very positive. Our results suggested that there is a need for improvement of CPR education among Saudi university students, which will help to reduce the cardiac arrest mortality rate among the community.

Singapore Defibrillation Guidelines 2016

The most common initial rhythm in a sudden cardiac arrest is ventricular fibrillation or pulseless ventricular tachycardia. This is potentially treatable with defibrillation, especially if provided early. However, any delay in defibrillation will result in a decline in survival. Defibrillation requires coordination with the cardiopulmonary resuscitation component for effective resuscitation. These two components, which form the key links in the chain of survival, have to be brought to the cardiac victim in a timely fashion. An effective chain of survival is needed in both the institution and community settings.

Epidemiology and chronobiology of out-of-hospital cardiac arrest in a subpopulation of southern Poland: A two-year observation

BACKGROUND

Although recent studies indicate temporal variations in the incidence of out-of-hospital cardiac arrest (OHCA), the Polish experience in this research is scarce to date. We evaluated the epidemiology of OHCA and circadian, weekly and seasonal variations of OHCA frequency among the adult population of the Opole district, Poland.

METHODS

The retrospective analysis of 815 OHCA cases with presumed cardiac etiology was made based on dispatch cards from the Emergency Medical Center in Opole registered during a 2 year period (2006-2007).

RESULTS

The incidence of OHCA in the studied population was 1.56/1000 inhabitants per year. Mean age of the group was 69.2 ± 14.2 years, with the majority of men (63%), younger than women (66.1 vs. 74 years, p = 0.0001). The OHCA occurrence increased with age reaching a peak between 71 and 75 years. The incidence of OHCA stayed at stable low levels between 22:00 and 4:59 and started to increase at 5:00, with trimodal peaks: 8:00-10:59, 14:00-15:59 and 18.00-21.59. The lowest number of OHCA occurred from 00:00 to 5:59, the highest from 6:00 to 11:59 (13% vs. 32.4%, p < 0.001). The day with the lowest occurrence of OHCA was Friday, the highest Saturday (10.9% vs. 16%, p = 0.01). Summer was the season of the lowest incidence of OHCA, while winter - the highest (22.6% vs. 26%, p = 0.04). These seasons were the warmest and the coldest one, respectively (average temperature 18.5°C vs. 0°C, p < 0.001).

CONCLUSIONS

Circadian and less marked, weekly variability in OHCA occurrence were confirmed. Existing seasonal differences may be affected by temperature. This is the first Polish analysis of a large subpopulation, which also includes seasonal temperature data.

Out-of-hospital cardiac arrest: current concepts

Out-of-hospital cardiac arrest (OHCA) is a leading cause of global mortality. Regional variations in reporting frameworks and survival mean the exact burden of OHCA to public health is unknown. Nevertheless, overall prognosis and neurological outcome are relatively poor following OHCA and have remained almost static for the past three decades. In this Series paper, we explore the aetiology of OHCA. Coronary artery disease remains the predominant cause, but there is a diverse range of other potential cardiac and non-cardiac causes to be aware of. Additionally, we describe how investigators and key stakeholders in resuscitation science have formulated specific Utstein data element domains in an attempt to standardise the definitions and outcomes reported in OHCA research so that management pathways can be improved. Finally, we identify the predictors of survival after OHCA and what primary and secondary prevention strategies can be instigated to mitigate the devastating sequelae of this growing public health issue.

Prognostic value of T-wave morphology parameters in coronary artery disease in current treatment era

BACKGROUND

The prognostic value of T-wave morphology parameters in coronary artery disease in the current treatment era is not well established.

METHODS

The Innovation to reduce Cardiovascular Complications of Diabetes at the Intersection (ARTEMIS) study included 1,946 patients with angiographically verified coronary artery disease (CAD). The study patients underwent thorough examinations including 12-lead digital electrocardiogram (ECG) at baseline.

RESULTS

During a follow-up period of 73 ± 22 months, a total of 201 (10.3%) patients died. Of the study patients, 95 (4.9%) experienced cardiac death (CD) consisting of 44 (2.3%) sudden cardiac deaths (SCD) and 51 (2.6%) nonsudden cardiac deaths (NSCD), and 106 (5.4%) patients experienced noncardiac death (NCD). T-wave morphology dispersion (TMD), T-wave area dispersion (TWAD), and total cosine R-to-T (TCRT) had a significant association with CD even after adjustment with relevant clinical risk markers in the Cox regression analysis (multivariate HRs: 1.015, 95% CI 1.007-1.023, p = .0003; 0.474, 95% CI 0.305-0.737, p = .0009; 0.598, 95% CI 0.412-0.866, p = .006, respectively). When including these parameters to the clinical risk model for CD, the C-index increased from 0.810 to 0.823 improving the discrimination significantly (integrated discrimination index [IDI] = 0.0118, 95% CI 0.0028-0.0208, p = .01). These parameters were more closely associated with NSCD (multivariate p-values from .016 to .001) than with SCD (univariate/multivariate p-values for TMD .015/.197 and for TCRT .012/.43).

CONCLUSION

T-wave morphology parameters describing repolarization heterogeneity improve the predictive power of the clinical risk model for CD in patients with CAD in the current treatment era.

Sudden cardiac death and antipsychotics. Part 1: Risk factors and mechanisms

Mortality from causes other than suicide is higher than expected in schizophrenia. Cardiovascular causes are most common, accounting for the majority of the 5% of sudden and unexpected deaths. Most cases have no clear explanation on post-mortem examination (‘sudden unexplained deaths’) and are thought to result from fatal arrhythmias. Prospective studies show that people with prolongation of the QT interval beyond 500 ms are at increased risk of serious arrhythmias such as ventricular tachycardia and torsade de pointes. In about 1 in 10 cases, the torsade is fatal. Most antipsychotics prolong the QTc interval in overdose but some prolong it even at therapeutic doses. Droperidol, sertindole and ziprasidone extend the QT interval by an average of 15–35 ms; quetiapine, haloperidol and olanzapine by 5 ms, to 15 ms. There is only an approximate relationship between QT prolongation and risk of sudden death, and the risk related to antipsychotics is thought to increase in people with pre-existing cardiac disease, those taking multiple QT-acting drugs and those taking antipsychotics at high dose for long periods. There is little evidence of an association with route of administration. More data are required to clarify to what extent people with mental health difficulties who die suddenly have pre-existing cardiac disease.

Thrombolysis as a Therapeutic Modality in Cardiac Arrest

Introduction

In recent years, thrombolysis has emerged as a potentially promising treatment for cardiac arrest. Patients with cardiac arrests from myocardial infarction or pulmonary embolism, as well as out-of-hospital cardiac arrests, were reported to have improvement in both survival and neurologic outcome after being treated with thrombolysis. This paper aims to review the available literature on the use of thrombolysis in cardiac arrest.

Method

Study of papers from PubMed literature search for all articles with terms related to thrombolysis and cardiac arrest in title or abstract.

Results

Thrombolytics are thought to act by lysing both macroscopic clots and microthrombi, particularly in the cerebral microcirculation, thus alleviating or reversing post-arrest cerebral no-reflow. Their use in cardiac arrest has been restrained by concerns over their safety after cardiopulmonary resuscitation, in particular bleeding-related complications, although these concerns seem to have been misplaced.

Conclusions

Thrombolysis for cardiac arrest is likely to be most efficacious in a pre-hospital environment, and future research should be directed to this setting.

Outcome and Prognostic Factors of Patients in Out-Of-Hospital Cardiac Arrests Presenting with Non-Shockable Rhythm in Hong Kong

Objective

To obtain the recent local epidemiological data and evaluate factors associated with outcomes of adult patients in non-traumatic non-shockable out-of-hospital-cardiac-arrest (OHCA) in Hong Kong.

Methods

It was a cross-sectional study lasting for nine months (from July 2009 to March 2010) in two emergency departments (ED) which served a population of 1.1 million. All non-traumatic OHCA patients aged equal or greater than 18 years presented with non-shockable cardiac rhythms to ED without postmortem changes were included. The pre-hospital factors, managements and outcomes were recorded in a standardised data entry form at the time of patient consultation. Logistic regression was used to evaluate the relationship between survival to admission (STA) and various prognostic factors.

Results

A total of 348 patients fulfilled the inclusion criteria. The mean age was 75.9 years old. Overall, there were 61 patients (17.5%) with restoration of spontaneous circulation and 58 patients (16.7%) had STA. The survival to hospital discharge (STD) rate was 0.86% (3 patients). Factors independently associated with better prognosis in terms of STA were initial pulseless electrical activity arrest (PEA) rhythm in ED (OR=4.72, 95% CI 2.30-9.69), witnessed arrest (OR=8.00, 95% CI 3.38-18.96) and non-cardiac cause of arrest (OR=2.17, 95% CI 1.00-4.67).

Conclusion

STA for adults presenting with non-traumatic non-shockable OHCA in our centre is 16.7%. Witnessed non-shockable OHCA patients presenting with initial PEA arrest rhythm and with a presumed non-cardiac in etiology are significantly associated with higher STA rate.

Basic cardiopulmonary life support (BCLS) for cardiopulmonary resuscitation by trained paramedics and medics outside the hospital

The cardiopulmonary resuscitation guideline of Basic Cardiopulmonary Life Support (BCLS) for management of adult victims with cardiopulmonary arrest outside the hospital provides an algorithmic stepwise approach for optimal outcome of the victims by trained medics and paramedics. This guideline has been developed considering the need to have a universally acceptable practice guideline for India and keeping in mind the infrastructural limitations of some areas of the country. This guideline is based on evidence elicited in the international and national literature. In the absence of data from Indian population, the excerpts have been taken from international data, discussed with Indian experts and thereafter modified to make them practically applicable across India. The optimal outcome for a victim with cardiopulmonary arrest would depend on core links of early recognition and activation; early high-quality cardiopulmonary resuscitation, early defibrillation and early transfer to medical facility. These links are elaborated in a stepwise manner in the BCLS algorithm. The BCLS also emphasise on quality check for various steps of resuscitation.

Thermoregulate, autoregulate and ventilate: brain-directed critical care for pediatric cardiac arrest

PURPOSE OF REVIEW

Cardiac arrest in childhood is associated with a high risk for mortality and poor long-term functional outcome. This review discusses the current evidence for neuroprotective therapies and goals for postarrest care in the context of the pathophysiology of hypoxic-ischemic injury, modalities for neurologic prognostication in these children and potential future monitoring paradigms for maximizing cerebral perfusion in the postarrest period.

RECENT FINDINGS

The recent publication of the in-hospital and out-of-hospital Therapeutic Hypothermia After Cardiac Arrest trials demonstrated a lack of statistically significant benefit for the use of postarrest therapeutic hypothermia. As a result, targeted normothermic temperature management has become standard of care. Continuous electroencephalographic monitoring during the acute postarrest period provides useful additional data for neurologic prognostication, in addition to its value for detection of seizures. Ongoing research into noninvasive monitoring of cerebrovascular autoregulation has the potential to individualize blood pressure goals in the postarrest period, maximizing cerebral perfusion in these patients.

SUMMARY

Therapeutic strategies after cardiac arrest seek to maximize cerebral perfusion while mitigating the effects of secondary brain injury and loss of autoregulation. Future research into new monitoring strategies and better long-term outcome measures may allow more precise targeting of therapies to these goals.