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Tamis-Holland JE, Menon V, Johnson NJ, Kern KB, Lemor A, Mason PJ, Rodgers M, Serrao GW, Yannopoulos D. Cardiac Catheterization Laboratory Management of the Comatose Adult Patient With an Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e274-e295. [PMID: 38112086 DOI: 10.1161/cir.0000000000001199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Out-of-hospital cardiac arrest is a leading cause of death, accounting for ≈50% of all cardiovascular deaths. The prognosis of such individuals is poor, with <10% surviving to hospital discharge. Survival with a favorable neurologic outcome is highest among individuals who present with a witnessed shockable rhythm, received bystander cardiopulmonary resuscitation, achieve return of spontaneous circulation within 15 minutes of arrest, and have evidence of ST-segment elevation on initial ECG after return of spontaneous circulation. The cardiac catheterization laboratory plays an important role in the coordinated Chain of Survival for patients with out-of-hospital cardiac arrest. The catheterization laboratory can be used to provide diagnostic, therapeutic, and resuscitative support after sudden cardiac arrest from many different cardiac causes, but it has a unique importance in the treatment of cardiac arrest resulting from underlying coronary artery disease. Over the past few years, numerous trials have clarified the role of the cardiac catheterization laboratory in the management of resuscitated patients or those with ongoing cardiac arrest. This scientific statement provides an update on the contemporary approach to managing resuscitated patients or those with ongoing cardiac arrest.
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Perman SM, Elmer J, Maciel CB, Uzendu A, May T, Mumma BE, Bartos JA, Rodriguez AJ, Kurz MC, Panchal AR, Rittenberger JC. 2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2024; 149:e254-e273. [PMID: 38108133 DOI: 10.1161/cir.0000000000001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve outcomes. This "2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support" summarizes the most recent published evidence for and recommendations on the use of medications, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation, and seizure management in this population. We discuss the lack of data in recent cardiac arrest literature that limits our ability to evaluate diversity, equity, and inclusion in this population. Last, we consider how the cardiac arrest population may make up an important pool of organ donors for those awaiting organ transplantation.
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Burns B, Marschner I, Eggins R, Buscher H, Morton RL, Bendall J, Keech A, Dennis M. A randomized trial of expedited intra-arrest transfer versus more extended on-scene resuscitation for refractory out of hospital cardiac arrest: Rationale and design of the EVIDENCE trial. Am Heart J 2024; 267:22-32. [PMID: 37871782 DOI: 10.1016/j.ahj.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/11/2023] [Accepted: 10/19/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Refractory Out of Hospital Cardiac Arrest (r-OHCA) is common and the benefit versus harm of intra-arrest transport of patients to hospital is not clear. OBJECTIVE To assess the rate of survival to hospital discharge in adult patients with r-OHCA, initial rhythm pulseless ventricular tachycardia (VT)/ventricular fibrillation (VF) or Pulseless Electrical Activity (PEA) treated with 1 of 2 locally accepted standards of care:1 expedited transport from scene; or2 ongoing advanced life support (ALS) resuscitation on-scene. HYPOTHESIS We hypothesize that expedited transport from scene in r-OHCA improves survival with favorable neurological status/outcome. METHODS/DESIGN Phase III, multi-center, partially blinded, prospective, intention-to-treat, safety and efficacy clinical trial with contemporaneous registry of patient ineligible for the clinical trial. Eligible patients for inclusion are adults with witnessed r-OHCA; estimated age 18 to 70, assumed medical cause with immediate bystander cardiopulmonary resuscitation (CPR); initial rhythm of VF/pulseless VT, or PEA; no return of spontaneous circulation following 3 shocks and/or 15 minutes of professional on-scene resuscitation; with mechanical CPR available. Two hundred patients will be randomized in a 1:1 ratio to either expedited transport from scene or ongoing ALS at the scene of cardiac arrest. SETTING Two urban regions in NSW Australia. OUTCOMES Primary: survival to hospital discharge with cerebral performance category (CPC) 1 or 2. Secondary: safety, survival, prognostic factors, use of ECMO supported CPR and functional assessment at hospital discharge and 4 weeks and 6 months, quality of life, healthcare use and cost-effectiveness. CONCLUSIONS The EVIDENCE trial will determine the potential risks and benefits of an expedited transport from scene of cardiac arrest.
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Affiliation(s)
- Brian Burns
- New South Wales Ambulance, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ian Marschner
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; NHMRC Clinical Trials Centre, The University of Sydney, Sydney Australia
| | - Renee Eggins
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; NHMRC Clinical Trials Centre, The University of Sydney, Sydney Australia
| | - Hergen Buscher
- St. Vincent's Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia
| | - Rachael L Morton
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; NHMRC Clinical Trials Centre, The University of Sydney, Sydney Australia
| | | | - Anthony Keech
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Royal Prince Alfred Hospital, Sydney, Australia
| | - Mark Dennis
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Royal Prince Alfred Hospital, Sydney, Australia.
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Usman M, Qureshi HZ, Zahid K, Bukhari SN. Role of coronary arteries in patients with Acute Coronary Syndrome. Pak J Med Sci 2023; 39:1717-1719. [PMID: 37936760 PMCID: PMC10626102 DOI: 10.12669/pjms.39.6.7173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 06/20/2023] [Accepted: 07/16/2023] [Indexed: 11/09/2023] Open
Abstract
Objective To assess the role of coronary arteries in acute coronary syndrome patients who have survived sudden cardiac arrest. Method A cross-sectional study was conducted in Department of Cardiology at Chaudhary Pervaiz Elahi Institute of Cardiology, Multan from 1st May 2021 to 1st October 2021. A total of 203 patients who were diagnosed with sudden cardiac arrest were included as subjects of the study. Baseline data of all patients including age, sex, body mass index, history of smoking, diabetes and hypertension was noted. Coronary angiography was performed in all patients within five days after admission in hospital due to SCA. Results The average age of patients was 52.61±11.09 years. There were 140 (68.97%) male and 63 (31.03%) female patients. There were 131 (64.53%) patients with STEMI and 72 (35.47%) patients with Non-STEMI. LMCAD were diagnosed in 29 (14.29%) patients, RCA in 88 (43.35%) patients, LAD in 174 (85.71%) Patients and LCX in 41 (20.20%) patients. Conclusion LAD has the most involvement among the coronary arteries (85.71%) in patients with sudden cardiac arrest.
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Affiliation(s)
- Muhammad Usman
- Dr. Muhammad Usman, MBBS, FCPSI, MO, Department of Cardiology, Ch. Pervaiz Elahi Institute of Cardiology Multan, Multan - Pakistan
| | - Hareem Zahra Qureshi
- Dr. Hareem Zahra Qureshi, MBBS, FCPSI, MO, Department of Cardiology, Ch. Pervaiz Elahi Institute of Cardiology Multan, Multan - Pakistan
| | - Kiran Zahid
- Dr. Kiran Zahid, MBBS, FCPSI, WMO, Department of Cardiology, Ch. Pervaiz Elahi Institute of Cardiology Multan, Multan - Pakistan
| | - Syed Naseem Bukhari
- Dr. Syed Naseem Bukhari, MBBS, FCPS, Assistant Professor, Department of Cardiology, Ch. Pervaiz Elahi Institute of Cardiology Multan, Multan - Pakistan
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Sarma D, Jentzer JC. Indications for Cardiac Catheterization and Percutaneous Coronary Intervention in Patients with Resuscitated Out-of-Hospital Cardiac Arrest. Curr Cardiol Rep 2023; 25:1523-1533. [PMID: 37874467 DOI: 10.1007/s11886-023-01980-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE OF REVIEW The role of emergent cardiac catheterization after resuscitated out-of-hospital cardiac arrest (OHCA) has evolved based on recent randomized evidence. This review aims to discuss the latest evidence and current indications for emergent coronary angiography (CAG) and mechanical circulatory support (MCS) use following OHCA. RECENT FINDINGS In contrast to previous observational data, recent RCTs evaluating early CAG in resuscitated OHCA patients without ST elevation have uniformly demonstrated a lack of benefit in terms of survival or neurological outcome. There is currently no randomized evidence supporting MCS use specifically in patients with resuscitated OHCA and cardiogenic shock. Urgent CAG should be considered in all patients with ST elevation, recurrent electrical or hemodynamic instability, those who are awake following resuscitated OHCA, and those receiving extracorporeal cardiopulmonary resuscitation (ECPR). Recent evidence suggests that CAG may be safely delayed in hemodynamically stable patients without ST-segment elevation following resuscitated OHCA.
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Affiliation(s)
- Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine and Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, The Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Heyne S, Macherey S, Meertens MM, Braumann S, Nießen FS, Tichelbäcker T, Baldus S, Adler C, Lee S. Coronary angiography after cardiac arrest without ST-elevation myocardial infarction: a network meta-analysis. Eur Heart J 2023; 44:1040-1054. [PMID: 36300362 DOI: 10.1093/eurheartj/ehac611] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 09/23/2022] [Accepted: 10/11/2022] [Indexed: 12/15/2022] Open
Abstract
AIMS This network meta-analysis aimed to assess the effect of early coronary angiography (CAG) compared with selective CAG (late and no CAG) for patients after out-of-hospital cardiac arrest without ST-elevation myocardial infarction (NSTE-OHCA). METHODS AND RESULTS A systematic literature search was performed using the EMBASE, MEDLINE and Web of Science databases without restrictions on publication date. The last search was performed on 15 July 2022. Randomized controlled trials (RCTs) and non-randomized studies (NRS) comparing the effect of early CAG to selective CAG after NSTE-OHCA on survival and/or neurological outcomes were included. Meta-analyses were performed based on a DerSimonian-Laird random effects model. A total of 18 studies were identified by the literature search. After the exclusion of two studies due to high risk of bias, 16 studies (six RCTs, ten NRS) were included in the final analyses. Meta-analyses showed a statistically significant increase in survival after early CAG compared with selective CAG in the overall analysis [OR: 1.40, 95% confidence interval (CI): (1.12-1.76), P < 0.01, I2 = 68%]. This effect was lost in the subgroup analysis of RCTs [OR: 0.89, 95% CI: (0.73-1.10), P = 0.29, I2 = 0%]. Random effects model network meta-analysis of NRS based on a Bayesian method showed statistically significant increased survival after late compared with early CAG [OR: 4.20, 95% CI: (1.22, 20.91)]. CONCLUSION The previously reported superiority of early CAG after NSTE-OHCA is based on NRS at high risk of selection and survivorship bias. The meta-analysis of RCTs does not support routinely performing early CAG after NSTE-OHCA.
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Affiliation(s)
- Sebastian Heyne
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 62, 50937 Cologne, Germany
| | - Sascha Macherey
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 62, 50937 Cologne, Germany
| | - Max M Meertens
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 62, 50937 Cologne, Germany
| | - Simon Braumann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 62, 50937 Cologne, Germany
| | - Franz S Nießen
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 62, 50937 Cologne, Germany
| | - Tobias Tichelbäcker
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 62, 50937 Cologne, Germany
| | - Stephan Baldus
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 62, 50937 Cologne, Germany
| | - Christoph Adler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 62, 50937 Cologne, Germany
| | - Samuel Lee
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 62, 50937 Cologne, Germany
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Tseng LM, Chuang CY, Chua SK, Tseng VS. Identification of Coronary Culprit Lesion in ST Elevation Myocardial Infarction by Using Deep Learning. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE 2022; 11:70-79. [PMID: 36654772 PMCID: PMC9842227 DOI: 10.1109/jtehm.2022.3227204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 07/08/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Early revascularization of the occluded coronary artery in patients with ST elevation myocardial infarction (STEMI) has been demonstrated to decrease mortality and morbidity. Currently, physicians rely on features of electrocardiograms (ECGs) to identify the most likely location of coronary arteries related to an infarct. We sought to predict these culprit arteries more accurately by using deep learning. METHODS A deep learning model with a convolutional neural network (CNN) that incorporated ECG signals was trained on 384 patients with STEMI who underwent primary percutaneous coronary intervention (PCI) at a medical center. The performances of various signal preprocessing methods (short-time Fourier transform [STFT] and continuous wavelet transform [CWT]) with different lengths of input ECG signals were compared. The sensitivity and specificity for predicting each infarct-related artery and the overall accuracy were evaluated. RESULTS ECG signal preprocessing with STFT achieved fair overall prediction accuracy (79.3%). The sensitivity and specificity for predicting the left anterior descending artery (LAD) as the culprit vessel were 85.7% and 88.4%, respectively. The sensitivity and specificity for predicting the left circumflex artery (LCX) were 37% and 99%, respectively, and the sensitivity and specificity for predicting the right coronary artery (RCA) were 88.4% and 82.4%, respectively. Using CWT (Morlet wavelet) for signal preprocessing resulted in better overall accuracy (83.7%) compared with STFT preprocessing. The sensitivity and specificity were 93.46% and 80.39% for LAD, 56% and 99.7% for LCX, and 85.9% and 92.9% for RCA, respectively. CONCLUSION Our study demonstrated that deep learning with a CNN could facilitate the identification of the culprit coronary artery in patients with STEMI. Preprocessing ECG signals with CWT was demonstrated to be superior to doing so with STFT.
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Affiliation(s)
- Li-Ming Tseng
- Department of Emergency MedicineShin Kong Wu Ho-Su Memorial HospitalTaipei11101Taiwan
- Department of Computer ScienceNational Yang Ming Chiao Tung UniversityHsinchu30010Taiwan
- School of Medicine, College of MedicineFu Jen Catholic UniversityNew Taipei24205Taiwan
| | - Cheng-Yen Chuang
- Division of CardiologyDepartment of Internal MedicineShin Kong Wu Ho-Su Memorial HospitalTaipei11101Taiwan
| | - Su-Kiat Chua
- Division of CardiologyDepartment of Internal MedicineShin Kong Wu Ho-Su Memorial HospitalTaipei11101Taiwan
- School of Medicine, College of MedicineFu Jen Catholic UniversityNew Taipei24205Taiwan
| | - Vincent S. Tseng
- Department of Computer ScienceNational Yang Ming Chiao Tung UniversityHsinchu30010Taiwan
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8
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Zheng WC, Noaman S, Batchelor RJ, Hanson L, Bloom JE, Al-Mukhtar O, Haji K, D'Elia N, Ho FCS, Kaye D, Shaw J, Yang Y, French C, Stub D, Cox N, Chan W. Evaluation of factors associated with selection for coronary angiography and in-hospital mortality among patients presenting with out-of-hospital cardiac arrest without ST-segment elevation. Catheter Cardiovasc Interv 2022; 100:1159-1170. [PMID: 36273421 PMCID: PMC10092555 DOI: 10.1002/ccd.30442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/02/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Clinical factors favouring coronary angiography (CA) selection and variables associated with in-hospital mortality among patients presenting with out-of-hospital cardiac arrest (OHCA) without ST-segment elevation (STE) remain unclear. METHODS We evaluated clinical characteristics associated with CA selection and in-hospital mortality in patients with OHCA, shockable rhythm and no STE. RESULTS Between 2014 and 2018, 118 patients with OHCA and shockable rhythm without STE (mean age 59; males 75%) were stratified by whether CA was performed. Of 86 (73%) patients undergoing CA, 30 (35%) received percutaneous coronary intervention (PCI). CA patients had shorter return of spontaneous circulation (ROSC) time (17 vs. 25 min) and were more frequently between 50 and 60 years (29% vs. 6.5%), with initial Glasgow Coma Scale (GCS) score >8 (24% vs. 6%) (all p < 0.05). In-hospital mortality was 33% (n = 39) for overall cohort (CA 27% vs. no-CA 50%, p = 0.02). Compared to late CA, early CA ( ≤ 2 h) was not associated with lower in-hospital mortality (32% vs. 34%, p = 0.82). Predictors of in-hospital mortality included longer defibrillation time (odds ratio 3.07, 95% confidence interval 1.44-6.53 per 5-min increase), lower pH (2.02, 1.33-3.09 per 0.1 decrease), hypoalbuminemia (2.02, 1.03-3.95 per 5 g/L decrease), and baseline renal dysfunction (1.33, 1.02-1.72 per 10 ml/min/1.73 m2 decrease), while PCI to lesion (0.11, 0.01-0.79) and bystander defibrillation (0.06, 0.004-0.80) were protective factors (all p < 0.05). CONCLUSIONS Among patients with OHCA and shockable rhythm without STE, younger age, shorter time to ROSC and GCS >8 were associated with CA selection, while less effective resuscitation, greater burden of comorbidities and absence of treatable coronary lesion were key adverse prognostic predictors.
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Affiliation(s)
- Wayne C Zheng
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Department of Medicine, Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Riley J Batchelor
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Laura Hanson
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Jason E Bloom
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Clinical Research Domain, The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Omar Al-Mukhtar
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Kawa Haji
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Nicholas D'Elia
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Clinical Research Domain, The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Felicia C S Ho
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - David Kaye
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Clinical Research Domain, The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - James Shaw
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Yang Yang
- Intensive Care Unit, Western Health, Melbourne, Victoria, Australia
| | - Craig French
- Department of Medicine, Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Intensive Care Unit, Western Health, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Department of Medicine, Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Department of Medicine, Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Clinical Research Domain, The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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9
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Gottula AL, Shaw CR, Gorder KL, Lane BH, Latessa J, Qi M, Koshoffer A, Al-Araji R, Young W, Bonomo J, Langabeer JR, Yannopoulos D, Henry TD, Hsu CH, Benoit JL. Eligibility of out-of-hospital cardiac arrest patients for extracorporeal cardiopulmonary resuscitation in the United States: A geographic information system model. Resuscitation 2022; 180:111-120. [PMID: 36183812 DOI: 10.1016/j.resuscitation.2022.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/10/2022] [Accepted: 09/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recent evidence suggest that extracorporeal cardiopulmonary resuscitation (ECPR) may improve survival rates for nontraumatic out-of-hospital cardiac arrest (OHCA). Eligibility criteria for ECPR are often based on patient age, clinical variables, and facility capabilities. Expanding access to ECPR across the U.S. requires a better understanding of how these factors interact with transport time to ECPR centers. METHODS We constructed a Geographic Information System (GIS) model to estimate the number of ECPR candidates in the U.S. We utilized a Resuscitation Outcome Consortium (ROC) database to model time-dependent rates of ECPR eligibility and the Cardiac Arrest Registry to Enhance Survival (CARES) registry to determine the total number of OHCA patients who meet pre-specified ECPR criteria within designated transportation times. The combined model was used to estimate the total number of ECPR candidates. RESULTS There were 588,203 OHCA patients in the CARES registry from 2013 to 2020. After applying clinical eligibility criteria, 22,104 (3.76%) OHCA patients were deemed eligible for ECPR. The rate of ROSC increased with longer resuscitation time, which resulted in fewer ECPR candidates. The proportion of OHCA patients eligible for ECPR increased with older age cutoffs. Only 1.68% (9,889/588,203) of OHCA patients in the U.S. were eligible for ECPR based on a 45-minute transportation time to an ECMO-ready center model. CONCLUSIONS Less than 2% of OHCA patients are eligible for ECPR in the U.S. GIS models can identify the impact of clinical criteria, transportation time, and hospital capabilities on ECPR eligibility to inform future implementation strategies.
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Affiliation(s)
- Adam L Gottula
- Department of Emergency Medicine, University of Michigan, United States; Department of Anesthesiology, University of Michigan, United States; Max Harry Weil Institute for Critical Care Research and Innovation, United States.
| | - Christopher R Shaw
- Department of Medicine Division of Pulmonary and Critical Care, Oregon Health and Science University, United States
| | - Kari L Gorder
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, United States.
| | - Bennett H Lane
- Department of Emergency Medicine, University of Cincinnati, United States.
| | - Jennifer Latessa
- Department of Planning, The University of Cincinnati, United States.
| | - Man Qi
- Department of Geography and Geographic Information System, The University of Cincinnati, United States.
| | - Amy Koshoffer
- University of Cincinnati Libraries, The University of Cincinnati, United States.
| | - Rabab Al-Araji
- Department of Emergency Medicine, Emory University, United States; The Cardiac Arrest Registry to Enhance Survival, United States.
| | - Wesley Young
- College of Medicine, The University of Cincinnati, United States
| | - Jordan Bonomo
- Department of Emergency Medicine, University of Cincinnati, United States; Department of Neurosurgery, University of Cincinnati, United States.
| | - James R Langabeer
- Department of Emergency, Medicine McGovern School of Medicine, The University of Texas Health Center, United States; UT School of Public Health, The University of Texas Health Center, United States; School of Biomedical Informatics, The University of Texas Health Center, United States.
| | | | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, United States.
| | - Cindy H Hsu
- Department of Emergency Medicine, University of Michigan, United States; Max Harry Weil Institute for Critical Care Research and Innovation, United States; Department of Surgery, University of Michigan, United States.
| | - Justin L Benoit
- Department of Emergency Medicine, University of Cincinnati, United States.
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10
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Alves N, Mota M, Cunha M, Ribeiro JM. Impact of emergent coronary angiography after out-of-the-hospital cardiac arrest without ST-segment elevation - a systematic review and meta-analysis. Int J Cardiol 2022; 364:1-8. [PMID: 35660557 DOI: 10.1016/j.ijcard.2022.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 05/15/2022] [Accepted: 06/01/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Coronary artery disease is a leading cause of out-of-the-hospital cardiac arrest (OHCA). However, there is no consensus on whether OHCA patients without ST-segment elevation (STE) benefit from emergent (ie < 2 h) coronary angiography (CAG). Our aim was to assess the impact of emergent CAG in no-STE OHCA patients. METHODS We performed a systematic review and meta-analysis by searching the MEDLINE, Cochrane, Scopus, CINAHL and JBI databases for randomized controlled trials (RCTs) comparing emergent CAG versus standard of care (ie CAG >2 h after OHCA or not performed) in no-STE OHCA patients of presumed cardiac aetiology. The primary outcome was short term survival. Secondary outcomes included survival with good neurological outcome, mid-term survival, left ventricle ejection fraction (LVEF), acute kidney injury (AKI) and renal replacement therapy (RRT), ventricular arrhythmias and major bleeding during hospital stay. RESULTS Seven RCTs met the inclusion and exclusion criteria and were included; one was included only in the analysis of mid-term survival and another in the LVEF analysis. Five studies (1278 patients, 643 with early CAG and 635 with no early CAG) were included in the analysis of the primary endpoint. The groups were balanced for all baseline characteristics but previous PCI, which was more frequent in the standard of care groups. There were no significant differences between groups for short-term survival (57 vs 61%; OR0.85, 95% CI0.68-1.07; I2 = 0%). There were also no differences for any of the secondary endpoints. CONCLUSION Routine emergent CAG did not improve survival in comatose survivors of OHCA with shockable rhythm and no-STE.
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Affiliation(s)
- Nuno Alves
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Politécnico de Viseu, Escola Superior de Saúde, Viseu, Portugal; UICISA:E, ESEnfC, Coimbra / SIGMA - Phi Xi Chapter, ESEnfC, Coimbra, Portugal
- CIEC -, UM, Braga, Portugal
| | - Mauro Mota
- Politécnico de Viseu, Escola Superior de Saúde, Viseu, Portugal; Unidade de Investigação em Ciências da Saúde: Enfermagem (UICISA:E)
- Unidade Local de Saúde da Guarda, Portugal
| | - Madelena Cunha
- Politécnico de Viseu, Escola Superior de Saúde, Viseu, Portugal; Serviço de Cardiologia, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
| | - Joana Maria Ribeiro
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Serviço de Cardiologia, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal.
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11
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Mørk SR, Bøtker MT, Christensen S, Tang M, Terkelsen CJ. Survival and neurological outcome after out-of-hospital cardiac arrest treated with and without mechanical circulatory support. Resusc Plus 2022; 10:100230. [PMID: 35434669 PMCID: PMC9010695 DOI: 10.1016/j.resplu.2022.100230] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/09/2022] [Accepted: 03/18/2022] [Indexed: 11/18/2022] Open
Abstract
Aim The aim of this study was to describe the survival and neurological outcome in patients with OHCA treated with and without mechanical circulatory support (MCS). Methods This was a retrospective observational cohort study on patients with OHCA admitted to Aarhus University Hospital, Denmark, between January 2015 and December 2019. Kaplan-Meier estimates were used to evaluate 30-day and 30–180-day survival. Cox regression analysis was used to assess the association between covariates and one-year mortality. Results Among 1,015 patients admitted, 698 achieved return of spontaneous circulation (ROSC) before admission, 101 patients with refractory OHCA received mechanical circulatory support (MCS) and the remaining 216 patients with refractory OHCA did not receive MCS treatment. Survival to hospital discharge was 47% (478/1015). Good neurological outcome defined as Cerebral Performance Categories 1–2 were seen among 92% (438/478) of the patients discharged from hospital. Median low-flow was 15 [8–22] minutes in the ROSC group and 105 [94–123] minutes in the MCS group. Mortality rates were high within the first 30 days, however; 30–180-day survival in patients discharged remained constant over time in both patients with ROSC on admission and patients admitted with MCS. Advanced age > 70 years (hazard ratio (HR) 1.98, 95% confidence interval (CI) 1.11–3.49), pulseless electrical activity (HR 2.39, 95% CI 1.25–4.60) and asystole HR 2.70, 95% CI 1.25–5.95) as initial rhythms were associated with one-year mortality in patients with ROSC. Conclusions Short-term survival rates were high among patients with ROSC and patients receiving MCS. Among patients who survived to day 30, landmark analyses showed comparable 180-day survival in the two groups despite long low-flow times in the MCS group. Advanced age and initial non-shockable rhythms were independent predictors of one-year mortality in patients with ROSC on admission.
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Affiliation(s)
- Sivagowry Rasalingam Mørk
- Department of Cardiology, Aarhus University Hospital, Denmark
- Aarhus University, Aarhus, Denmark
- Corresponding author at: Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark.
| | - Morten Thingemann Bøtker
- Aarhus University, Aarhus, Denmark
- Research and Development, Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Steffen Christensen
- Aarhus University, Aarhus, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | - Mariann Tang
- Aarhus University, Aarhus, Denmark
- Department of Thoracic and Vascular Surgery, Aarhus University Hospital, Denmark
| | - Christian Juhl Terkelsen
- Department of Cardiology, Aarhus University Hospital, Denmark
- Aarhus University, Aarhus, Denmark
- The Danish Heart Foundation, Denmark
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12
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Huebinger R, Thomas J, Abella BS, Waller-Delarosa J, Al-Araji R, Witkov R, Villa N, Nikonowicz P, Renbarger T, Panczyk M, Bobrow B. Impact of post-arrest care variation on hospital performance after out-of-hospital cardiac arrest. Resusc Plus 2022; 10:100231. [PMID: 35434670 PMCID: PMC9005946 DOI: 10.1016/j.resplu.2022.100231] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background Large variation exists for out-of-hospital-cardiac-arrest (OHCA) prehospital care, but less is known about variations in post-arrest care. We sought to evaluate variation in post-arrest care in Texas as well as factors associated with higher performing hospitals. Methods We analyzed data in Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES), including all adult, non-traumatic OHCAs from 1/1/2014 through 12/31/ 2020 that survived to hospital admission. We first evaluated variability in provisions of post-arrest care and outcomes. We then stratified hospitals into quartiles based on their rate of survival and evaluated the association between improving quartiles and care. Lastly, we evaluated for outliers in post-arrest care and outcomes using a mixed-effect regression model. Results We analyzed 7,842 OHCAs admitted to 146 hospitals. We identified large variations in post-arrest care, including targeted temperature management (TTM) (IQR 7.0-51.1%), left heart catheterization (LHC) (IQ 0-25%), and percutaneous coronary intervention (PCI) (IQR 0-10.3%). Higher performing hospital quartiles were associated with higher rates of TTM (aOR 1.42, 95% CI 1.36-1.49), LHC (aOR 2.07, 95% CI 1.92-2.23), and PCI (aOR 2.02, 95% CI 1.81-2.25); but lower rates of bystander CPR (aOR 0.90, 95% CI 0.87-0.94). We identified numerous performance outlier hospitals; 39 for TTM, 34 for PCI, 9 for survival to discharge, and 24 for survival with good neurologic function. Conclusions Post-arrest care varied widely across Texas hospitals. Hospitals with higher rates of survival to discharge had increased rates of TTM, LHC, and PCI but not bystander CPR.
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Affiliation(s)
- Ryan Huebinger
- Texas Emergency Medicine Research Center, McGovern Medical School, Houston, TX, United States
- McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, TX, United States
| | - Jordan Thomas
- McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, United States
| | - Benjamin S. Abella
- University of Pennsylvania Department of Emergency Medicine, Philadelphia, PA, United States
| | - John Waller-Delarosa
- Texas Emergency Medicine Research Center, McGovern Medical School, Houston, TX, United States
- McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, TX, United States
| | - Rabab Al-Araji
- Emory University Rollins School of Public Health, Atlanta, GA, United States
| | - Richard Witkov
- Texas Emergency Medicine Research Center, McGovern Medical School, Houston, TX, United States
- McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, TX, United States
| | - Normandy Villa
- Texas Emergency Medicine Research Center, McGovern Medical School, Houston, TX, United States
- McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, TX, United States
| | - Peter Nikonowicz
- Texas Emergency Medicine Research Center, McGovern Medical School, Houston, TX, United States
| | - Taylor Renbarger
- McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, TX, United States
| | - Micah Panczyk
- Texas Emergency Medicine Research Center, McGovern Medical School, Houston, TX, United States
- McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, TX, United States
| | - Bentley Bobrow
- Texas Emergency Medicine Research Center, McGovern Medical School, Houston, TX, United States
- McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, TX, United States
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13
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Huebinger R, Abella BS, Chavez S, Luber S, Al-Araji R, Panczyk M, Waller-Delarosa J, Villa N, Bobrow B. Socioeconomic Status and Post-Arrest Care after Out-of-Hospital Cardiac Arrest in Texas. Resuscitation 2022; 176:107-116. [DOI: 10.1016/j.resuscitation.2022.03.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/17/2022] [Accepted: 03/25/2022] [Indexed: 02/09/2023]
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14
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Aufderheide TP, Kalra R, Kosmopoulos M, Bartos JA, Yannopoulos D. Enhancing cardiac arrest survival with extracorporeal cardiopulmonary resuscitation: insights into the process of death. Ann N Y Acad Sci 2022; 1507:37-48. [PMID: 33609316 PMCID: PMC8377067 DOI: 10.1111/nyas.14580] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/30/2021] [Accepted: 02/02/2021] [Indexed: 01/03/2023]
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging method of cardiopulmonary resuscitation to improve outcomes from cardiac arrest. This approach targets patients with out-of-hospital cardiac arrest previously unresponsive and refractory to standard treatment, combining approximately 1 h of standard CPR followed by venoarterial extracorporeal membrane oxygenation (VA-ECMO) and coronary artery revascularization. Despite its relatively new emergence for the treatment of cardiac arrest, the approach is grounded in a vast body of preclinical and clinical data that demonstrate significantly improved survival and neurological outcomes despite unprecedented, prolonged periods of CPR. In this review, we detail the principles behind VA-ECMO-facilitated resuscitation, contemporary clinical approaches with outcomes, and address the emerging new understanding of the process of death and capability for neurological recovery.
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Affiliation(s)
- Tom P. Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Rajat Kalra
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Jason A. Bartos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
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15
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Yeo JW, Ng ZHC, Goh AXC, Gao JF, Liu N, Lam SWS, Chia YW, Perkins GD, Ong MEH, Ho AFW. Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 11:e023806. [PMID: 34927456 PMCID: PMC9075197 DOI: 10.1161/jaha.121.023806] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background The role of cardiac arrest centers (CACs) in out‐of‐hospital cardiac arrest care systems is continuously evolving. Interpretation of existing literature is limited by heterogeneity in CAC characteristics and types of patients transported to CACs. This study assesses the impact of CACs on survival in out‐of‐hospital cardiac arrest according to varying definitions of CAC and prespecified subgroups. Methods and Results Electronic databases were searched from inception to March 9, 2021 for relevant studies. Centers were considered CACs if self‐declared by study authors and capable of relevant interventions. Main outcomes were survival and neurologically favorable survival at hospital discharge or 30 days. Meta‐analyses were performed for adjusted odds ratio (aOR) and crude odds ratios. Thirty‐six studies were analyzed. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR, 1.85 [95% CI, 1.52–2.26]), even when including high‐volume centers (aOR, 1.50 [95% CI, 1.18–1.91]) or including improved‐care centers (aOR, 2.13 [95% CI, 1.75–2.59]) as CACs. Survival significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59–2.32]), even when including high‐volume centers (aOR, 1.74 [95% CI, 1.38–2.18]) or when including improved‐care centers (aOR, 1.97 [95% CI, 1.71–2.26]) as CACs. The treatment effect was more pronounced among patients with shockable rhythm (P=0.006) and without prehospital return of spontaneous circulation (P=0.005). Conclusions were robust to sensitivity analyses, with no publication bias detected. Conclusions Care at CACs was associated with improved survival and neurological outcomes for patients with nontraumatic out‐of‐hospital cardiac arrest regardless of varying CAC definitions. Patients with shockable rhythms and those without prehospital return of spontaneous circulation benefited more from CACs. Evidence for bypassing hospitals or interhospital transfer remains inconclusive.
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Affiliation(s)
- Jun Wei Yeo
- Yong Loo Lin School of Medicine National University of Singapore Singapore
| | - Zi Hui Celeste Ng
- Yong Loo Lin School of Medicine National University of Singapore Singapore
| | | | | | - Nan Liu
- Centre for Quantitative Medicine Duke-NUS Medical SchoolNational University of Singapore Singapore
| | - Shao Wei Sean Lam
- Health Services Research Centre SingHealth Duke-NUS Academic Medical Centre Singapore
| | - Yew Woon Chia
- Department of Cardiology Tan Tock Seng Hospital Singapore
| | - Gavin D Perkins
- Warwick Medical School University of Warwick Coventry United Kingdom
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine Singapore General Hospital Singapore.,Health Services & Systems Research Duke-NUS Medical School Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine Singapore General Hospital Singapore.,Pre-Hospital and Emergency Research Centre Health Services and Systems Research Duke-NUS Medical School Singapore
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16
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Youn CS, Yi H, Kim YJ, Song H, Kim N, Kim WY. Early Identification of Resuscitated Patients with a Significant Coronary Disease in Out-of-Hospital Cardiac Arrest Survivors without ST-Segment Elevation. J Clin Med 2021; 10:jcm10235688. [PMID: 34884390 PMCID: PMC8658463 DOI: 10.3390/jcm10235688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/27/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
This study aimed to develop a machine learning (ML)-based model for identifying patients who had a significant coronary artery disease among out-of-hospital cardiac arrest (OHCA) survivors without ST-segment elevation (STE). This multicenter observational study used data from the Korean Hypothermia Network prospective registry (KORHN-PRO) gathered between October 2015 and December 2018. We used information available before targeted temperature management (TTM) as predictor variables, and the primary outcome was a significant coronary artery lesion in coronary angiography (CAG). Among 1373 OHCA patients treated with TTM, 331 patients without STE who underwent CAG were enrolled. Among them, 127 patients (38.4%) had a significant coronary artery lesion. Four ML algorithms, namely regularized logistic regression (RLR), random forest classifier (RF), CatBoost classifier (CBC), and voting classifier (VC), were used with data collected before CAG. The VC model showed the highest accuracy for predicting significant lesions (area under the curve of 0.751). Eight variables (older age, male, initial shockable rhythm, shorter total collapse duration, higher glucose and creatinine, and lower pH and lactate) were significant to ML models. These results showed that ML models may be useful in developing early predictive tools for identifying high-risk patients with a significant stenosis in CAG.
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Affiliation(s)
- Chun-Song Youn
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (C.-S.Y.); (H.S.)
| | - Hahn Yi
- Asan Medical Center, Asan Institute for Life Sciences, Seoul 05505, Korea;
| | - Youn-Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea;
| | - Hwan Song
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (C.-S.Y.); (H.S.)
| | - Namkug Kim
- Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
- Correspondence: (N.K.); (W.-Y.K.)
| | - Won-Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea;
- Correspondence: (N.K.); (W.-Y.K.)
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17
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Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, Zideman D, Bhanji F, Andersen LW, Avis SR, Aziz K, Bendall JC, Berry DC, Borra V, Böttiger BW, Bradley R, Bray JE, Breckwoldt J, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Cheng A, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Davis PG, de Almeida MF, de Caen AR, de Paiva EF, Deakin CD, Djärv T, Douma MJ, Drennan IR, Duff JP, Eastwood KJ, El-Naggar W, Epstein JL, Escalante R, Fabres JG, Fawke J, Finn JC, Foglia EE, Folke F, Freeman K, Gilfoyle E, Goolsby CA, Grove A, Guinsburg R, Hatanaka T, Hazinski MF, Heriot GS, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hung KKC, Hsu CH, Ikeyama T, Isayama T, Kapadia VS, Kawakami MD, Kim HS, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lockey AS, Malta Hansen C, Markenson D, Matsuyama T, McKinlay CJD, Mehrabian A, Merchant RM, Meyran D, Morley PT, Morrison LJ, Nation KJ, Nemeth M, Neumar RW, Nicholson T, Niermeyer S, Nikolaou N, Nishiyama C, O'Neil BJ, Orkin AM, Osemeke O, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reynolds JC, Ristagno G, Roehr CC, Sakamoto T, Sandroni C, Sawyer T, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Smyth MA, Soll RF, Sugiura T, Taylor-Phillips S, Trevisanuto D, Vaillancourt C, Wang TL, Weiner GM, Welsford M, Wigginton J, Wyllie JP, Yeung J, Nolan JP, Berg KM. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group. Resuscitation 2021; 169:229-311. [PMID: 34933747 PMCID: PMC8581280 DOI: 10.1016/j.resuscitation.2021.10.040] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.
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18
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Abusnina W, Al-Abdouh A, Latif A, Alkhouli M, Alraies MC, Daggubati R, Alasnag M, Kerrigan J, Paul TK. Timing of coronary angiography in patients following out-of-hospital cardiac arrest without ST-segment elevation: A systematic review and Meta-analysis of randomized trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:92-98. [PMID: 34844869 DOI: 10.1016/j.carrev.2021.11.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Out-of-hospital cardiac arrest (OHCA) has a poor prognosis. The timing and role of early coronary angiography (CAG) in OHCA patients without ST elevation remains unclear. OBJECTIVE We performed a meta-analysis of randomized controlled trials (RCTs) that compared early CAG to delayed CAG in OHCA patients without ST elevation. METHODS We searched PubMed, Cochrane, and ClinicalTrials.gov databases (from inception to September 2021) for studies comparing early CAG to delayed CAG in OHCA patients without ST elevation. We used a random-effect model to calculate relative ratio (RR) with 95% confidence interval (CI). The primary outcome was all-cause mortality at 30 days. Secondary outcomes included neurological status with cerebral performance category ≤2 (CPC) and the rate of percutaneous coronary intervention (PCI) following CAG. RESULTS A total of 6 RCTs including 1822 patients, of whom 895 underwent early CAG, and 927 underwent delayed CAG, were included in this meta-analysis. There was no statistically significant difference between the 2 groups in terms of 30-day all-cause mortality (Relative risk [RR] 1.06; 95%CI 0.94-1.20; P = 0.32; I2 = 13%), neurological status (CPC ≤2) (RR 1.01; 95%CI 0.90-1.13; P = 0.85, I2 = 37%), and rates of PCI following CAG (RR 1.08; 95%CI 0.84-1.39; P = 0.56; I2 = 49%). CONCLUSION In patients suffering OHCA without ST-elevation, early CAG is not associated with reduced 30-day mortality when compared to patients who underwent delayed CAG. Given our meta-analysis results including multiple trials that have not shown a benefit, it is likely that updated guidelines will not support early angiography in patients suffering OHCA without ST-elevation.
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Affiliation(s)
- Waiel Abusnina
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, USA
| | - Ahmad Al-Abdouh
- Division of Hospital Medicine, University of Kentucky, Lexington, KY, USA
| | - Azka Latif
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, USA
| | | | - M Chadi Alraies
- Wayne State University, Detroit Medical Center, Heart Hospital, Detroit, MI, USA
| | | | | | - Jimmy Kerrigan
- Department of Medical Education, University of Tennessee at Nashville, Nashville, TN, USA
| | - Timir K Paul
- Department of Medical Education, University of Tennessee at Nashville, Nashville, TN, USA.
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19
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Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, Zideman D, Bhanji F, Andersen LW, Avis SR, Aziz K, Bendall JC, Berry DC, Borra V, Böttiger BW, Bradley R, Bray JE, Breckwoldt J, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Cheng A, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Davis PG, de Almeida MF, de Caen AR, de Paiva EF, Deakin CD, Djärv T, Douma MJ, Drennan IR, Duff JP, Eastwood KJ, El-Naggar W, Epstein JL, Escalante R, Fabres JG, Fawke J, Finn JC, Foglia EE, Folke F, Freeman K, Gilfoyle E, Goolsby CA, Grove A, Guinsburg R, Hatanaka T, Hazinski MF, Heriot GS, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hung KKC, Hsu CH, Ikeyama T, Isayama T, Kapadia VS, Kawakami MD, Kim HS, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lockey AS, Malta Hansen C, Markenson D, Matsuyama T, McKinlay CJD, Mehrabian A, Merchant RM, Meyran D, Morley PT, Morrison LJ, Nation KJ, Nemeth M, Neumar RW, Nicholson T, Niermeyer S, Nikolaou N, Nishiyama C, O'Neil BJ, Orkin AM, Osemeke O, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reynolds JC, Ristagno G, Roehr CC, Sakamoto T, Sandroni C, Sawyer T, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Smyth MA, Soll RF, Sugiura T, Taylor-Phillips S, Trevisanuto D, Vaillancourt C, Wang TL, Weiner GM, Welsford M, Wigginton J, Wyllie JP, Yeung J, Nolan JP, Berg KM. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group. Circulation 2021; 145:e645-e721. [PMID: 34813356 DOI: 10.1161/cir.0000000000001017] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.
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20
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Elliott A, Dahyia G, Kalra R, Alexy T, Bartos J, Kosmopoulos M, Yannopoulos D. Extracorporeal Life Support for Cardiac Arrest and Cardiogenic Shock. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The rising incidence and recognition of cardiogenic shock has led to an increase in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). As clinical experience with this therapy has increased, there has also been a rapid growth in the body of observational and randomized data describing the clinical and logistical considerations required to institute a VA-ECMO program with successful clinical outcomes. The aim of this review is to summarize this contemporary data in the context of four key themes that pertain to VA-ECMO programs: the principles of patient selection; basic hemodynamic and technical principles underlying VA-ECMO; contraindications to VA-ECMO therapy; and common complications and intensive care considerations that are encountered in the setting of VA-ECMO therapy.
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Affiliation(s)
- Andrea Elliott
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Garima Dahyia
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Rajat Kalra
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Tamas Alexy
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Jason Bartos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Marinos Kosmopoulos
- Department of Medicine, Division of Cardiology, Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN
| | - Demetri Yannopoulos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
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Predictive Model of Good Clinical Outcomes in Patients Undergoing Coronary Angiography after Out-of-Hospital Cardiac Arrest: A Prospective, Multicenter Observational Study Conducted by the Korean Cardiac Arrest Research Consortium. J Clin Med 2021; 10:jcm10163695. [PMID: 34441996 PMCID: PMC8396842 DOI: 10.3390/jcm10163695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 12/03/2022] Open
Abstract
This observational study aimed to develop novel nomograms that predict the benefits of coronary angiography (CAG) after resuscitating patients with out-of-hospital cardiac arrest (OHCA) regardless of the electrocardiography findings and to perform an external validation of these models. Data were extracted from a prospective, multicenter registry of resuscitated patients with OHCA (October 2015–June 2018). New nomograms were developed based on variables associated with survival discharge and neurologic outcomes; their analysis included 723 and 709 patients, respectively. Patient age (p < 0.001), prehospital defibrillation by emergency medical technicians (EMTs) (p = 0.003), prehospital return of spontaneous circulation (ROSC) (p = 0.02), and time from collapse to ROSC (p < 0.001) were associated with survival discharge. Patient age (p < 0.001), prehospital defibrillation by EMTs (p < 0.001), and time from collapse to ROSC (p < 0.001) were associated with neurologic outcomes. The new nomogram had a good predictive performance, with an area under the curve (AUC) of 0.8832 (95% confidence interval (CI): 0.8358–0.9305) for survival discharge and an AUC of 0.9048 (95% CI: 0.8627–0.9469) for neurologic outcomes. Novel nomograms that predict survival discharge and good neurological outcomes after CAG in patients with OHCA were developed and validated; they can be quickly and easily applied to identify patients who will benefit from CAG.
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22
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Kosmopoulos M, Bartos JA. Coronary angiography after cardiac arrest: Toward a nuanced approach. Resuscitation 2021; 167:422-424. [PMID: 34314777 DOI: 10.1016/j.resuscitation.2021.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 07/08/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Marinos Kosmopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States.
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Adabag S, Zimmerman P, Lexcen D, Cheng A. Predictors of Sudden Cardiac Arrest Among Patients With Post-Myocardial Infarction Ejection Fraction Greater Than 35. J Am Heart Assoc 2021; 10:e020993. [PMID: 34259015 PMCID: PMC8483475 DOI: 10.1161/jaha.121.020993] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Sudden cardiac arrest (SCA) risk increases after myocardial infarction (MI) in patients with a reduced ejection fraction (EF). However, the risk factors for SCA among patients with a post‐MI EF >35% remain poorly understood. Methods and Results Using the Optum de‐identified electronic health record data set from 2008 to 2017, we identified patients with an incident MI diagnosis and troponin elevation who had a post‐MI EF >35% and underwent coronary angiography. Primary outcome was SCA within 1 year post‐MI. The database was divided into derivation (70%) and validation (30%) cohorts by random selection. Cox proportional hazard regression was used to generate and validate a risk prediction model. Among 31 286 patients with an MI (median age 64.1; 39% female; 87% White), 499 experienced SCA within 1 year post‐MI (estimated probability 1.8%). Lack of revascularization at MI, post‐MI EF <50%, Black race, renal failure, chronic obstructive pulmonary disease, antiarrhythmic therapy, and absence of beta blocker therapy were independent predictors of SCA. A multivariable model consisting of these variables predicted SCA risk (C‐statistic 0.73). Based on this model, the estimated annual probability of SCA was 4.4% (95% CI, 3.9–4.9) in the highest quartile of risk versus 0.6% (95% CI, 0.4–0.8) in the lowest quartile. Conclusions Patients with a post‐MI EF >35% have a substantial annual risk of SCA. A risk model consisting of acute coronary revascularization, EF, race, renal failure, chronic obstructive pulmonary disease, antiarrhythmic therapy, and beta blocker therapy can identify patients with higher risk of SCA, who may benefit from further risk stratification and closer monitoring.
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Affiliation(s)
- Selçuk Adabag
- Division of Cardiology Minneapolis VA Health Care System Minneapolis MN.,Department of Medicine University of Minnesota Minneapolis MN
| | | | - Daniel Lexcen
- Cardiac Rhythm Heart FailureMedtronic, Inc. Minneapolis MN
| | - Alan Cheng
- Cardiac Rhythm Heart FailureMedtronic, Inc. Minneapolis MN
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24
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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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25
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Garcheva V, Akin M, Adel J, Sanchez Martinez C, Bauersachs J, Schäfer A. High rate of critical coronary stenosis in comatose patients with Non-ST-elevation out-of-hospital cardiac arrest (NSTE-OHCA) undergoing therapeutic hypothermia-Experience from the HAnnover COoling REgistry (HACORE). PLoS One 2021; 16:e0251178. [PMID: 33945587 PMCID: PMC8096113 DOI: 10.1371/journal.pone.0251178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/22/2021] [Indexed: 11/30/2022] Open
Abstract
Background Myocardial infarction is the most frequent cause for out-of-hospital cardiac arrest (OHCA) in adults. Patients with ST-segment elevations (STE) following return of spontaneous circulation (ROSC) are regularly admitted to the catheterisation laboratory for urgent coronary angiography. Whether patients without obvious STE (NSTE) should receive coronary angiography as part of a standardised diagnostic work-up following OHCA is still debated. Methods We analysed a cohort of 517 subsequent OHCA patients admitted at our institution who received a standardised diagnostic work-up including coronary angiography and therapeutic hypothermia. Patients were 63±14 years old, 76% were male. Overall, 180 (35%) had ST-elevation in the post-ROSC ECG, 317 (61%) had shockable rhythm (ventricular fibrillation or tachycardia) at first ECG. ROSC was achieved after 26±21 minutes. Results Critical coronary stenosis requiring PCI was present in 83% of shockable and 87% of non-shockable STE-OHCA and in 48% of shockable and 22% of non-shockable NSTE-OHCA patients. In-hospital survival was 61% in shockable and 55% in non-shockable STE-OHCA and 60% in shockable and 28% in non-shockable NSTE-OHCA. Conclusion Standardised admission diagnostics in OHCA patients undergoing therapeutic hypothermia with a strict admission protocol incorporating ECG and coronary catheterisation shows a high rate of relevant coronary stenosis in STE-OHCA irrespective of the initial rhythm and in NSTE-OHCA with initial shockable rhythm. Based on the unfavourable outcome and low PCI rate observed in NSTE-OHCA patients with a primary non-shockable ECG rhythm it might be reasonable to restrict routine early coronary angiography to patients with primary shockable rhythms and/or ST-segment elevations after ROSC.
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Affiliation(s)
- Vera Garcheva
- Department of Cardiology and Angiology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Muharrem Akin
- Department of Cardiology and Angiology, Medizinische Hochschule Hannover, Hannover, Germany
| | - John Adel
- Department of Cardiology and Angiology, Medizinische Hochschule Hannover, Hannover, Germany
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Medizinische Hochschule Hannover, Hannover, Germany
- * E-mail:
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26
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Lemkes JS, Spoormans EM, Demirkiran A, Leutscher S, Janssens GN, van der Hoeven NW, Jewbali LSD, Dubois EA, Meuwissen M, Rijpstra TA, Bosker HA, Blans MJ, Bleeker GB, Baak R, Vlachojannis GJ, Eikemans BJW, van der Harst P, van der Horst ICC, Voskuil M, van der Heijden JJ, Beishuizen A, Stoel M, Camaro C, van der Hoeven H, Henriques JP, Vlaar APJ, Vink MA, van den Bogaard B, Heestermans TACM, de Ruijter W, Delnoij TSR, Crijns HJGM, Jessurun GAJ, Oemrawsingh PV, Gosselink MTM, Plomp K, Magro M, Elbers PWG, van de Ven PM, van Loon RB, van Royen N. The effect of immediate coronary angiography after cardiac arrest without ST-segment elevation on left ventricular function. A sub-study of the COACT randomised trial. Resuscitation 2021; 164:93-100. [PMID: 33932485 DOI: 10.1016/j.resuscitation.2021.04.020] [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: 01/22/2021] [Revised: 04/09/2021] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The effect of immediate coronary angiography and percutaneous coronary intervention (PCI) in patients who are successfully resuscitated after cardiac arrest in the absence of ST-segment elevation myocardial infarction (STEMI) on left ventricular function is currently unknown. METHODS This prespecified sub-study of a multicentre trial evaluated 552 patients, successfully resuscitated from out-of-hospital cardiac arrest without signs of STEMI. Patients were randomized to either undergo immediate coronary angiography or delayed coronary angiography, after neurologic recovery. All patients underwent PCI if indicated. The main outcomes of this analysis were left ventricular ejection fraction and end-diastolic and systolic volumes assessed by cardiac magnetic resonance imaging or echocardiography. RESULTS Data on left ventricular function was available for 397 patients. The mean (± standard deviation) left ventricular ejection fraction was 45.2% (±12.8) in the immediate angiography group and 48.4% (±13.2) in the delayed angiography group (mean difference: -3.19; 95% confidence interval [CI], -6.75 to 0.37). Median left ventricular end-diastolic volume was 177 ml in the immediate angiography group compared to 169 ml in the delayed angiography group (ratio of geometric means: 1.06; 95% CI, 0.95-1.19). In addition, mean left ventricular end-systolic volume was 90 ml in the immediate angiography group compared to 78 ml in the delayed angiography group (ratio of geometric means: 1.13; 95% CI 0.97-1.32). CONCLUSION In patients successfully resuscitated after out-of-hospital cardiac arrest and without signs of STEMI, immediate coronary angiography was not found to improve left ventricular dimensions or function compared with a delayed angiography strategy. CLINICAL TRIAL REGISTRATION Netherlands Trial Register number, NTR4973.
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Affiliation(s)
- Jorrit S Lemkes
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands.
| | - Eva M Spoormans
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Ahmet Demirkiran
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Sophie Leutscher
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Gladys N Janssens
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Nina W van der Hoeven
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Lucia S D Jewbali
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Eric A Dubois
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands; Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Tom A Rijpstra
- Department of Intensive Care Medicine, Amphia Hospital, Breda, The Netherlands
| | - Hans A Bosker
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Michiel J Blans
- Department of Intensive Care Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Gabe B Bleeker
- Department of Cardiology, HAGA Hospital, Den Haag, The Netherlands
| | - Rémon Baak
- Department of Intensive Care Medicine, HAGA Hospital, Den Haag, The Netherlands
| | - Georgios J Vlachojannis
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, University Medical Centre Utrecht, The Netherlands
| | - Bob J W Eikemans
- Department of Intensive Care Medicine, Maasstad Hospital, Rotterdam, The Netherlands
| | - Pim van der Harst
- University of Groningen, University Medical Centre Groningen, Department of Cardiology, Groningen, The Netherlands; Department of Cardiology, University Medical Centre Utrecht, The Netherlands
| | - Iwan C C van der Horst
- University of Groningen, University Medical Centre Groningen, Department of Intensive Care Medicine, Groningen, The Netherlands; Department of Intensive Care Medicine, Maastricht University Medical Centre, University Maastricht, Maastricht, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Centre Utrecht, The Netherlands
| | | | - Albertus Beishuizen
- Department of Intensive Care Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Martin Stoel
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Cyril Camaro
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Hans van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - José P Henriques
- Department of Cardiology, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
| | - Maarten A Vink
- Department of Cardiology, OLVG, Amsterdam, The Netherlands
| | | | | | - Wouter de Ruijter
- Department of Intensive care medicine, Noord West Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Thijs S R Delnoij
- Department of Intensive Care Medicine, Maastricht University Medical Centre, University Maastricht, Maastricht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | | | - Koos Plomp
- Department of Cardiology, Ter Gooi Hospital, Blaricum, The Netherlands
| | - Michael Magro
- Department of Cardiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Ramon B van Loon
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands; Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Nikolaou NI, Netherton S, Welsford M, Drennan IR, Nation K, Belley-Cote E, Torabi N, Morrison LJ. A systematic review and meta-analysis of the effect of routine early angiography in patients with return of spontaneous circulation after Out-of-Hospital Cardiac Arrest. Resuscitation 2021; 163:28-48. [PMID: 33838169 DOI: 10.1016/j.resuscitation.2021.03.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/09/2021] [Accepted: 03/20/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Early coronary angiography (CAG) has been reported in individual studies and systematic reviews to significantly improve outcomes of patients with return of spontaneous circulation (ROSC) after cardiac arrest (CA). METHODS We undertook a systematic review and meta-analysis to evaluate the impact of early CAG on key clinical outcomes in comatose patients after ROSC following out-of-hospital CA of presumed cardiac origin. We searched the PubMED, EMBASE, CINAHL, ERIC and Cochrane Central Register of Controlled Trials databases from 1990 until April 2020. Eligible studies compared patients undergoing early CAG to patients with late or no CAG. When randomized controlled trials (RCTs) existed for a specific outcome, we used their results to estimate the effect of the intervention. In the absence of randomized data, we used observational data. We excluded studies at high risk of bias according to the Robins-I tool from the meta-analysis. The GRADE system was used to assess certainty of evidence at an outcome level. RESULTS Of 3738 citations screened, 3 randomized trials and 41 observational studies were eligible for inclusion. Evidence certainty across all outcomes for the RCTs was assessed as low. Randomized data showed no benefit from early as opposed to late CAG across all critical outcomes of survival and survival with favourable neurologic outcome for undifferentiated patients and for patient subgroups without ST-segment-elevation on post ROSC ECG and shockable initial rhythm. CONCLUSION These results do not support routine early CAG in undifferentiated comatose patients and patients without STE on post ROSC ECG after OHCA. REVIEW REGISTRATION PROSPERO - CRD42020160152.
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Affiliation(s)
- Nikolaos I Nikolaou
- Department of Cardiology and Cardiac Intensive Care, Konstantopouleio General Hopsital, Athens, Greece.
| | | | | | - Ian R Drennan
- Sunnybrook Research Institute, Sunnybrook Health Science Centre, Canada
| | | | - Emilie Belley-Cote
- Division of Cardiology, Department of Medicine, McMaster University, Canada
| | | | - Laurie J Morrison
- Rescu, Emergency Department, St Michael's Hospital, Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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28
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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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Chiu WT, Lin KC, Tsai MS, Hsu CH, Wang CH, Kuo LK, Chien YS, Wu CH, Lai CH, Huang WC, Wang CH, Wang TL, Hsu HH, Lin JJ, Hwang JJ, Ng CJ, Choi WM, Huang CH. Post-cardiac arrest care and targeted temperature management: A consensus of scientific statement from the Taiwan Society of Emergency & Critical Care Medicine, Taiwan Society of Critical Care Medicine and Taiwan Society of Emergency Medicine. J Formos Med Assoc 2021; 120:569-587. [PMID: 32829996 DOI: 10.1016/j.jfma.2020.07.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 06/07/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Post-cardiac arrest care is critically important in bringing cardiac arrest patients to functional recovery after the detrimental event. More high quality studies are published and evidence is accumulated for the post-cardiac arrest care in the recent years. It is still a challenge for the clinicians to integrate these scientific data into the real clinical practice for such a complicated intensive care involving many different disciplines. METHODS With the cooperation of the experienced experts from all disciplines relevant to post-cardiac arrest care, the consensus of the scientific statement was generated and supported by three major scientific groups for emergency and critical care in post-cardiac arrest care. RESULTS High quality post-cardiac arrest care, including targeted temperature management, early evaluation of possible acute coronary event and intensive care for hemodynamic and respiratory care are inevitably needed to get full recovery for cardiac arrest. Management of these critical issues were reviewed and proposed in the consensus CONCLUSION: The goal of the statement is to provide help for the clinical physician to achieve better quality and evidence-based care in post-cardiac arrest period.
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Affiliation(s)
- Wei-Ting Chiu
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan, ROC
| | - Kun-Chang Lin
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Chih-Hsin Hsu
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital Dou Liou Branch, College of Medicine, National Cheng Kung University, Taiwan
| | - Chen-Hsu Wang
- Attending Physician, Coronary Care Unit, Cardiovascular Center, Cathay General Hospital, Taipei, Taiwan
| | - Li-Kuo Kuo
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei Branch, Taiwan; Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | - Yu-San Chien
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei Branch, Taiwan
| | - Cheng-Hsueh Wu
- Department of Critical Care Medicine, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Hung Lai
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Chih-Hsien Wang
- Cardiovascular Surgery, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Tzong-Luen Wang
- Chang Bing Show Chwang Memorial Hospital, Changhua, Taiwan; School of Medicine and Law, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Hsin-Hui Hsu
- Department of Critical Care Medicine, Changhua Christian Hospital, Taiwan
| | - Jen-Jyh Lin
- Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan; Department of Respiratory Therapy, China Medical University, Taichung, Taiwan, ROC
| | - Juey-Jen Hwang
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taiwan
| | - Chip-Jin Ng
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Wai-Mau Choi
- Department of Emergency Medicine, Hsinchu MacKay Memorial Hospital, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan; Cardiovascular Division, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taiwan.
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Miraglia D, Ramzy M. Double external defibrillation for shock-refractory ventricular fibrillation cardiac arrest: A step towards standardization. Am J Emerg Med 2020; 41:73-79. [PMID: 33387933 DOI: 10.1016/j.ajem.2020.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 11/16/2022] Open
Abstract
Double (or dual) external defibrillation (DED) has increasingly been used in the last few years by a number of emergency medical services (EMS) as a last resort to terminate ventricular fibrillation and pulseless ventricular tachycardia in adult patients who remain refractory to standard defibrillation. However, no randomized controlled trials comparing DED with standard defibrillation focusing on patient-oriented outcomes as the primary objective have been published to date. Selection criteria, procedure techniques, and protocol are not clearly defined and vary across observational studies. The terms and/or nomenclature used to describe DED are confusing and vary throughout the literature. Despite increased use of DED, many questions remain as to which patients will derive the most benefit from DED, when to implement DED, and the optimal form of delivering DED. The present paper provides a brief overview of the background, procedure techniques, pad placement, and factors affecting how DED is delivered. A further objective of this paper is to offer a proposal for a uniform nomenclature and a standardized protocol in the form of a flowchart for EMS agencies to guide further clinical trials and best practices. This paper should not only help give background on novel definitions and clarify nomenclature for this practice, but more importantly should help institutions lay the groundwork for performing EMS-based large trials to further investigate the effectiveness of DED.
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Affiliation(s)
- Dennis Miraglia
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States.
| | - Mark Ramzy
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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31
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Yannopoulos D, Kalra R, Kosmopoulos M, Walser E, Bartos JA, Murray TA, Connett JE, Aufderheide TP. Rationale and methods of the Advanced R 2Eperfusion STrategies for Refractory Cardiac Arrest (ARREST) trial. Am Heart J 2020; 229:29-39. [PMID: 32911433 DOI: 10.1016/j.ahj.2020.07.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 07/08/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation has emerged as a prominent therapy for patients with refractory cardiac arrest. However, the optimal time of initiation remains unknown. AIM The aim was to assess the rate of survival to hospital discharge in adult patients with refractory ventricular fibrillation/pulseless ventricular tachycardia out-of-hospital cardiac arrest treated with 1 of 2 local standards of care: (1) early venoarterial extracorporeal membrane oxygenation-facilitated resuscitation for circulatory support and percutaneous coronary intervention, when needed, or (2) standard advanced cardiac life support resuscitation. DESIGN Phase II, single-center, partially blinded, prospective, intention-to-treat, safety and efficacy clinical trial. POPULATION Adults (aged 18-75), initial out-of-hospital cardiac arrest rhythm of ventricular fibrillation/pulseless ventricular tachycardia, no ROSC following 3 shocks, body morphology to accommodate a Lund University Cardiac Arrest System automated cardiopulmonary resuscitation device, and transfer time of <30 minutes. SETTING Hospital-based. OUTCOMES Primary: survival to hospital discharge. Secondary: safety, survival, and functional assessment at hospital discharge and 3 and 6 months, and cost. SAMPLE SIZE Assuming success rates of 12% versus 37% in the 2 arms and 90% power, a type 1 error rate of .05, and a 15% rate of withdrawal prior to hospital discharge, the required sample size is N = 174 evaluated patients. CONCLUSIONS The ARREST trial will generate safety/effectiveness data and comparative costs associated with extracorporeal cardiopulmonary resuscitation, informing broader implementation and a definitive Phase III clinical trial.
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Affiliation(s)
- Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota, Medical School, Cardiovascular Division, Minneapolis, MN.
| | - Rajat Kalra
- Center for Resuscitation Medicine, University of Minnesota, Medical School, Cardiovascular Division, Minneapolis, MN
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota, Medical School, Cardiovascular Division, Minneapolis, MN
| | - Emily Walser
- Center for Resuscitation Medicine, University of Minnesota, Medical School, Cardiovascular Division, Minneapolis, MN
| | - Jason A Bartos
- Center for Resuscitation Medicine, University of Minnesota, Medical School, Cardiovascular Division, Minneapolis, MN
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - John E Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
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Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Yang MC, Meng-Jun W, Xiao-Yan X, Peng KL, Peng YG, Wang RR. Coronary angiography or not after cardiac arrest without ST segment elevation: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e22197. [PMID: 33031262 PMCID: PMC7544299 DOI: 10.1097/md.0000000000022197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE This meta-analysis aimed to review the available evidence and evaluate the necessity of immediate coronary angiography (CAG) to obtain positive outcomes for out-of-hospital cardiac arrest (OHCA) patients without ST segment elevation. DATA SOURCES Web of Science, PubMed, Embase, Chinese National Knowledge Infrastructure, Wanfang, and SinoMed databases. STUDY SELECTION We included observational and case-control studies of outcomes among individuals without ST segment elevation experiencing OHCA who had immediate, delayed, or no CAG. DATA EXTRACTION We extracted study details, as well as patient characteristics and outcomes. DATA SYNTHESIS Six studies (n = 2665) investigating mortality until discharge demonstrated a significant increase in survival benefit with early CAG (odds ratio [OR] = 1.78; 95%CI = 1.51-2.11; I = 81%; P < .0001). Seven studies (n = 2909) showed a significant preservation of neurological functions with early CAG at discharge (OR = 1.66; 95%CI = 1.37-2.02; P < .00001). Four studies (n = 1357) investigating survival outcomes with middle-term follow-up revealed no significant benefit with early CAG (OR = 1.21; 95%CI = 0.93-1.57; I = 66%; P = .15). CONCLUSIONS Our meta-analysis demonstrates that there may be significant benefits in performing immediate CAG on patients who experience OHCA without ST segment elevation.
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Affiliation(s)
- Meng-Chang Yang
- Department of Anesthesiology, West China Hospital, Sichuan University
- Department of Anesthesiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital
| | - Wu Meng-Jun
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's and Children's Central Hospital, Chengdu, Sichuan, P.R. China
| | - Xu Xiao-Yan
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's and Children's Central Hospital, Chengdu, Sichuan, P.R. China
| | | | - Yong G. Peng
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Ru-Rong Wang
- Department of Anesthesiology, West China Hospital, Sichuan University
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Singer B, Reynolds JC, Davies GE, Wrigley F, Whitbread M, Faulkner M, O'Brien B, Proudfoot AG, Mathur A, Evens T, Field J, Monk V, Finney SJ. Sub30: Protocol for the Sub30 feasibility study of a pre-hospital Extracorporeal membrane oxygenation (ECMO) capable advanced resuscitation team at achieving blood flow within 30 min in patients with refractory out-of-hospital cardiac arrest. Resusc Plus 2020; 4:100029. [PMID: 33403364 PMCID: PMC7543759 DOI: 10.1016/j.resplu.2020.100029] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/12/2020] [Accepted: 09/15/2020] [Indexed: 10/29/2022] Open
Abstract
Background Out-of-hospital cardiac arrest carries a poor prognosis with survival less than 10% in many patient cohorts. Survival is inversely associated with duration of resuscitation as external chest compressions do not provide sufficient blood flow to prevent irreversible organ damage during a prolonged resuscitation. Extracorporeal membrane oxygenation (ECMO) instituted during cardiac arrest can provide normal physiological blood flows and is termed Extracorporeal Cardio-Pulmonary Resuscitation (ECPR). ECPR may improve survival when used with in-hospital cardiac arrests. This possible survival benefit has not been replicated in trials of out-of-hospital cardiac arrests, possibly because of the additional time it takes to transport the patient to hospital and initiate ECPR. Pre-hospital ECPR may shorten the time between cardiac arrest and physiological blood flows, potentially improving survival. It may also mitigate some of the neurological injury that many survivors suffer. Methods Sub30 is a prospective six patient feasibility study. The primary aim is to test whether it is possible to institute ECPR within 30 min of collapse in adult patients with refractory out of hospital cardiac arrest (OHCA). The secondary aims are to gather preliminary data on clinical outcomes, resource utilisation, and health economics associated with rapid ECPR delivery in order to plan any subsequent clinical investigation or clinical service. On study days a dedicated fast-response vehicle with ECPR capability will be tasked to out-of-hospital cardiac arrests in an area of London served by Barts Heart Centre. If patients suffer a cardiac arrest refractory to standard advanced resuscitation and meet eligibility criteria, ECPR will be started in the pre-hospital environment. Discussion Delivering pre-hospital ECPR within 30 min of an out-of-hospital cardiac arrest presents significant ethical, clinical, governance and logistical challenges. Prior to conducting an efficacy study of ECPR the feasibility of timely and safe application must be demonstrated first. Extensive planning, multiple high-fidelity multiagency simulations and a unique collaboration between pre-hospital and in-hospital institutions will allow us to test the feasibility of this intervention in London. The study has been reviewed, refined and endorsed by the International ECMO Network (ECMONet). Trial registration Clinicaltrials. gov NCT03700125, prospectively registered October 9, 2018.
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Affiliation(s)
- Ben Singer
- St Bartholomew's Hospital, London, UK.,London's Air Ambulance, UK
| | | | | | | | | | | | | | | | | | | | - Jane Field
- Barts Cardiovascular Clinical Trials Unit, London, UK
| | - Vivienne Monk
- Barts Cardiovascular Clinical Trials Unit, London, UK
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Sharma A, Miranda DF, Rodin H, Bart BA, Smith SW, Shroff GR. Do not disregard the initial 12 lead ECG after out-of-hospital cardiac arrest: It predicts angiographic culprit despite metabolic abnormalities. Resusc Plus 2020; 4:100032. [PMID: 34223310 PMCID: PMC8244459 DOI: 10.1016/j.resplu.2020.100032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/19/2020] [Accepted: 09/18/2020] [Indexed: 01/14/2023] Open
Abstract
Objectives The initial 12 lead electrocardiogram (ECG) following return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), is often disregarded by clinicians in ability to predict acute thrombotic coronary occlusion (ATCO) due to markedly abnormal metabolic milieu (AMM). We sought to evaluate the accuracy of initial vs. follow-up ECG prior to invasive coronary angiography (ICA) to predict ATCO following resuscitated OHCA. Methods We included OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA). AMM was defined as one of: pH < 7.1, lactate >2 mmol/L, serum potassium <2.8 or >6.0 mEq/L. Two ECGs A (initial) and B (follow-up) following ROSC but prior to ICA were adjudicated by 2 experienced readers using expanded ECG criteria to predict angiographic ATCO on ICA. Results 152 consecutive patients (mean age 58 years, 75% male) met inclusion criteria, 77% had AMM. Among those with both ECGs (n = 102), overall accuracy, sensitivity, specificity, positive predictive value, negative predictive value for correctly predicting angiographic ATCO for ECG A was 72%, 63%, 81%, 61%, 83% and for ECG B was 71%, 50%, 91%, 73%, 80% respectively. Predictive accuracy for angiographic ATCO was similar between ECG A [odds ratio (OR) 7.31, CI 2.87–18.62, p < 0.0001) and ECG B [OR 10.67; CI 3.6–31.61, p < 0.0001], and consistent in AMM. Conclusions In OHCA, despite AMM, the initial post ROSC ECG retains a statistically significant, and similar accuracy as the follow-up ECG to predict angiographic ATCO using expanded criteria.
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Affiliation(s)
- Amit Sharma
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC, Minneapolis, MN, USA.,Regions Hospital, St. Paul, MN, USA
| | - David F Miranda
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC, Minneapolis, MN, USA.,CentraCare Heart and Vascular Center, St. Cloud, MN, USA
| | - Holly Rodin
- Analytic Center of Excellence, Hennepin Healthcare System, HCMC, Minneapolis, MN, USA
| | - Bradley A Bart
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, USA.,Veterans Affairs Medical Center, Minneapolis, MN, USA
| | - Stephen W Smith
- Emergency Department, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, USA
| | - Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, USA
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Miraglia D, Miguel LA, Alonso W. Double Defibrillation for Refractory In- and Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Emerg Med 2020; 59:521-541. [DOI: 10.1016/j.jemermed.2020.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/12/2020] [Accepted: 06/01/2020] [Indexed: 02/07/2023]
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Krishnamoorthy P, Sharma SK, Kini AS. Stable Significant Coronary Artery Disease: An Innocent Bystander in Sudden Cardiac Death? Circ Cardiovasc Interv 2020; 13:e009888. [PMID: 32895008 DOI: 10.1161/circinterventions.120.009888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Parasuram Krishnamoorthy
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Samin K Sharma
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Annapoorna S Kini
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY
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Gutierrez A, Ash J, Akdemir B, Alexy T, Cogswell R, Chen J, Adabag S. Nonsustained ventricular tachycardia in heart failure with preserved ejection fraction. Pacing Clin Electrophysiol 2020; 43:1126-1131. [PMID: 32809234 DOI: 10.1111/pace.14043] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 08/09/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ventricular tachycardia (VT) is a common arrhythmia in heart failure with reduced ejection fraction but its incidence, predictors, and significance have not been determined in heart failure with preserved ejection fraction (HFpEF). METHODS We performed a retrospective review of arrhythmias in two cohorts of patients with an HFpEF diagnosis. Patients in cohort 1 (n = 40) underwent routine arrhythmia surveillance with a 14-day ambulatory electrocardiogram (ECG) monitor. Patients in cohort 2 (n = 85) had cardiac pacemakers and underwent routine device interrogations. RESULTS In cohort 1, 13 patients (32.5%) had one or more episodes of nonsustained VT (NSVT) on ambulatory ECG. In cohort 2, 38 patients (44.7%) had NSVT on cardiac pacemaker interrogations. During a median (interquartile range) follow-up of 3.0 (1.6 to 5.1) years, 15 (12%) patients died (20% of patients with NSVT versus 6.8% of those without NSVT; P = .03). In logistic regression analysis, NSVT was associated with a 3.4-fold higher odds of death (95% confidence interval 1.08 to 10.53; P = .04) in HFpEF. CONCLUSIONS In conclusion, patients with HFpEF have a relatively high, and possibly underappreciated, burden of NSVT, which confers a higher risk of mortality. The frequent episodes of NSVT in these patients may provide insight into the mechanism of sudden cardiac death in HFpEF.
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Affiliation(s)
- Alejandra Gutierrez
- Division of Cardiovascular Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Jerry Ash
- Division of Cardiovascular Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Baris Akdemir
- Division of Cardiovascular Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Tamas Alexy
- Division of Cardiovascular Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Rebecca Cogswell
- Division of Cardiovascular Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Jane Chen
- Division of Cardiovascular Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Selcuk Adabag
- Division of Cardiology, Minneapolis VA Health Care System, Minneapolis, Minnesota
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Spoormans EM, Lemkes JS, Janssens GN, van der Hoeven NW, Bonnes JL, van Royen N. The role of coronary angiography in out-of-hospital cardiac arrest patients in the absence of ST-segment elevation: A literature review. Neth Heart J 2020; 28:108-114. [PMID: 32780340 PMCID: PMC7419423 DOI: 10.1007/s12471-020-01460-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) is a major cause of death. Although the aetiology of cardiac arrest can be diverse, the most common cause is ischaemic heart disease. Coronary angiography and percutaneous coronary intervention, if indicated, has been associated with improved long-term survival for patients with initial shockable rhythm. However, in patients without ST-segment elevation on the post-resuscitation electrocardiogram, the optimal timing of performing this invasive procedure is uncertain. One important challenge that clinicians face is to appropriately select patients that will benefit from immediate coronary angiography, yet avoid unnecessary delay of intensive care support and targeted temperature management. Observational studies have reported contradictory results and until recently, randomised trials were lacking. The Coronary Angiography after Cardiac Arrest without ST-segment elevation (COACT) was the first randomised trial that provided comparative information between coronary angiography treatment strategies. This literature review will provide the current knowledge and gaps in the literature regarding optimal care for patients successfully resuscitated from OHCA in the absence of ST-segment elevation and will primarily focus on the role and timing of coronary angiography in this high-risk patient population.
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Affiliation(s)
- E M Spoormans
- Department of Cardiology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - J S Lemkes
- Department of Cardiology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands.
| | - G N Janssens
- Department of Cardiology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - N W van der Hoeven
- Department of Cardiology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - J L Bonnes
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - N van Royen
- Department of Cardiology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
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Miraglia D, Miguel LA, Alonso W. Extracorporeal cardiopulmonary resuscitation for in- and out-of-hospital cardiac arrest: systematic review and meta-analysis of propensity score-matched cohort studies. J Am Coll Emerg Physicians Open 2020; 1:342-361. [PMID: 33000057 PMCID: PMC7493557 DOI: 10.1002/emp2.12091] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/25/2020] [Accepted: 04/15/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION In this systematic review and meta-analysis of propensity score-matched cohort studies, we quantitatively summarize whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) used as extracorporeal cardiopulmonary resuscitation (ECPR), compared with conventional cardiopulmonary resuscitation (CCPR), is associated with improved rates of 30-day and long-term favorable neurological outcomes and survival in patients resuscitated from in- and out-of-hospital cardiac arrest. METHODS We searched MEDLINE via PubMed, Embase, Scopus, and Google Scholar for eligible studies on January 14, 2019. All searches were limited to studies published between January 2000 and January 2019. Two investigators independently evaluated the quality (or certainty) of evidence according to GRADE guidelines. Pooled results are presented as relative risks (RRs) with 95% confidence intervals (CIs). RESULTS Six cohort studies using propensity score-matched analysis were included, totaling 1108 matched patients. Pooled analyses showed that ECPR was likely associated with improved 30-day and long-term favorable neurological outcome in adults compared to CCPR for in- and out-of-hospital cardiac arrest (RR = 2.02, 95% CI = 1.29-3.16; I2 = 20%, P = 0.002; very low-quality evidence) and (RR = 2.86, 95% CI = 1.64-5.01; I2 = 0%, P = 0.0002; moderate-quality evidence), respectively. When we analyzed in- and out-of-hospital cardiac arrest separately, ECPR was likely associated with improved 30-day favorable neurological outcome compared to CCPR for in-hospital cardiac arrest (RR = 2.18, 95% CI = 1.24-3.81; I2 = 9%, P = 0.006; very low-quality evidence), but not for out-of-hospital cardiac arrest (RR = 2.61, 95% CI = 0.56-12.20; I2 = 59%, P = 0.22; very low-quality evidence). ECPR was also likely associated with improved long-term favorable neurological outcome compared to CCPR for in-hospital cardiac arrest (RR = 2.50, 95% CI = 1.33-4.71; I2 = 0%, P = 0.005; moderate-quality evidence) and out-of-hospital cardiac arrest (RR = 4.64, 95% CI = 1.41-15.25; I2 = 0%, P = 0.01; moderate-quality evidence). CONCLUSIONS Our analysis suggests that VA-ECMO used as ECPR may improve long-term favorable neurological outcomes and survival when compared to the best standard of care in a selected patient population. Therefore, it is imperative for well-designed randomized clinical trials to obtain a higher level of scientific evidence to ensure optimal outcomes for cardiac arrest patients.
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Affiliation(s)
- Dennis Miraglia
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
| | - Lourdes A Miguel
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
| | - Wilfredo Alonso
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
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Miraglia D, Miguel LA. Prehospital Double Defibrillation for Refractory Ventricular Fibrillation: A Scoping Review Protocol. J Innov Card Rhythm Manag 2020; 11:4129-4133. [PMID: 32596028 PMCID: PMC7313623 DOI: 10.19102/icrm.2020.110603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 01/06/2020] [Indexed: 11/06/2022] Open
Abstract
Double defibrillation (DD) has been proposed as an alternative treatment for patients with refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) out-of-hospital cardiac arrest (OHCA) nonresponsive to the best current standard of care. Treatment results are promising, but the efficacy and safety of the procedure remain unclear. Currently, there is a paucity of evidence in the literature on DD suggesting the optimal strategy for treating this challenging patient population. Thus, we aim to perform a scoping review to explore the current literature addressing resuscitative parameters, survival rates, and neurological outcomes in refractory VF/pVT OHCA patients treated with DD as well as to identify gaps in the literature that may require further research. Here, we discuss the anticipated study protocol.
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Affiliation(s)
- Dennis Miraglia
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, Puerto Rico
| | - Lourdes A Miguel
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, Puerto Rico
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Lotfi A, Klein LW, Hira RS, Mallidi J, Mehran R, Messenger JC, Pinto DS, Mooney MR, Rab T, Yannopoulos D, van Diepen S. SCAI expert consensus statement on out of hospital cardiac arrest. Catheter Cardiovasc Interv 2020; 96:844-861. [PMID: 32406999 DOI: 10.1002/ccd.28990] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Amir Lotfi
- Division of Cardiology, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Lloyd W Klein
- Division of Cardiology, University of California, San Francisco, California, USA
| | - Ravi S Hira
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Jaya Mallidi
- Santa Rosa Memorial Hospital, St. Joseph Cardiology Medical Group, Santa Rosa, California, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York, USA
| | - John C Messenger
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Duane S Pinto
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Michael R Mooney
- Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Tanveer Rab
- Division of Cardiology, Emory University, Atlanta, Georgia, USA
| | - Demetri Yannopoulos
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, University of Alberta, Edmonton, Canada
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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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Sharma A, Sonny A, Panaich S, Walia A, Ramakrishna H. Analysis of the 2019 American Heart Association (AHA) Focused Update on Advanced Cardiovascular Life Support. J Cardiothorac Vasc Anesth 2020; 35:1516-1523. [PMID: 32576411 DOI: 10.1053/j.jvca.2020.05.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Archit Sharma
- Department of Anesthesia, University of Iowa, Iowa City, IA
| | - Abraham Sonny
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Sidakpal Panaich
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa, Iowa City, IA
| | - Anureet Walia
- Department of Anesthesia, University of Iowa, Iowa City, IA
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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May T, Skinner K, Unger B, Mooney M, Patel N, Dupont A, McPherson J, McMullan P, Nielsen N, Seder DB, Kern KB. Coronary Angiography and Intervention in Women Resuscitated From Sudden Cardiac Death. J Am Heart Assoc 2020; 9:e015629. [PMID: 32208830 PMCID: PMC7428608 DOI: 10.1161/jaha.119.015629] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Coronary artery disease is the primary etiology for sudden cardiac arrest in adults, but potential differences in the incidence and utility of invasive coronary testing between resuscitated men and women have not been extensively evaluated. Our aim was to characterize angiographic similarities and differences between men and women after cardiac arrest. Methods and Results Data from the International Cardiac Arrest Registry–Cardiology database included patients resuscitated from out‐of‐hospital cardiac arrest of presumed cardiac origin, admitted to 7 academic cardiology/resuscitation centers during 2006 to 2017. Demographics, clinical factors, and angiographic findings of subjects were evaluated in relationship to sex and multivariable logistic regression models created to predict both angiography and outcome. Among 966 subjects, including 277 (29%) women and 689 (71%) men, fewer women had prior coronary artery disease and more had prior congestive heart failure (P=0.05). Women were less likely to have ST‐segment–elevation myocardial infarction (32% versus 39%, P=0.04). Among those with ST‐segment–elevation myocardial infarctions, identification and distribution of culprit arteries was similar between women and men, and there were no differences in treatment or outcome. In patients without ST‐segment elevation post‐arrest, women were overall less likely to undergo coronary angiography (51% versus 61%, P<0.02), have a culprit vessel identified (29% versus 45%, P=0.03), and had fewer culprits acutely occluded (17% versus 28%, P=0.03). Women were also less often re‐vascularized (44% versus 52%, P<0.03). Conclusions Among cardiac arrest survivors, women are less likely to undergo angiography or percutaneous coronary intervention than men. Sex disparities for invasive therapies in post‐cardiac arrest care need continued attention.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Karl B Kern
- Sarver Heart Center University of Arizona Tucson AZ
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Sudden cardiac death risk prediction in heart failure with preserved ejection fraction. Heart Rhythm 2020; 17:358-364. [DOI: 10.1016/j.hrthm.2019.12.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Indexed: 11/23/2022]
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Akin M, Sieweke JT, Zauner F, Garcheva V, Tongers J, Napp LC, Friedrich L, Treptau J, Bahntje MU, Flierl U, Sedding DG, Bauersachs J, Schäfer A. Mortality in Patients With Out-of-Hospital Cardiac Arrest Undergoing a Standardized Protocol Including Therapeutic Hypothermia and Routine Coronary Angiography: Experience From the HACORE Registry. JACC Cardiovasc Interv 2019; 11:1811-1820. [PMID: 30236353 DOI: 10.1016/j.jcin.2018.06.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 06/07/2018] [Accepted: 06/13/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES This study sought to analyze the impact of mandatory therapeutic hypothermia and cardiac catheterization in the absence of overt noncardiac cause of arrest as part of the Hannover Cardiac Resuscitation Algorithm before intensive care admission. BACKGROUND Despite advanced therapies, out-of-hospital cardiac arrest (OHCA) is still associated with high mortality rates. Recently, the TTM (Target Temperature Management 33°C Versus 36°C After Out-of-Hospital Cardiac Arrest)-trial caused severe uncertainty about the efficacy of and need for therapeutic hypothermia. Furthermore, the role of early coronary angiography in OHCA survivors without ST-segment elevation remains undetermined. METHODS In the HACORE (HAnnover Cooling REgistry) we investigated 233 consecutive patients (median age 64 [interquartile range: 53 to 74] years) with OHCA admitted to our institution between January 2011 and December 2015 who were treated according to the algorithm. RESULTS A total of 73% had ventricular fibrillation as primary rhythm. Return of spontaneous circulation was achieved after 20 (interquartile range: 10 to 30) min. Immediate percutaneous coronary angiography was performed in 96% and coronary angioplasty in 59% of all cases. ST-segment elevation was present in 47%. Critical coronary stenosis requiring percutaneous coronary intervention was present in 67% of patients with and 52% of patients without ST-segment elevation. Overall 30-day intrahospital mortality in this real-world registry was 37%. Patients in our local registry who matched the inclusion/exclusion criteria of the TTM-trial (n = 145) had a markedly lower 30-day mortality (27%) compared with the published trial (44%). CONCLUSIONS Standardized treatment of patients with OHCA following a strict protocol incorporating computed tomography, cardiac catheterization and revascularization, liberal use of active hemodynamic support in presence of shock, and mandatory therapeutic hypothermia results in mortality rates lower than previously reported.
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Affiliation(s)
- Muharrem Akin
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Jan-Thorben Sieweke
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Florian Zauner
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Vera Garcheva
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Jörn Tongers
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - L Christian Napp
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lars Friedrich
- Department of Anaesthesiology, Hannover Medical School, Hannover, Germany
| | - Jens Treptau
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Max-Udo Bahntje
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Ulrike Flierl
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Daniel G Sedding
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Johann Bauersachs
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Andreas Schäfer
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.
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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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Barbarawi M, Zayed Y, Kheiri B, Barbarawi O, Al-Abdouh A, Dhillon H, Rizk F, Bachuwa G, Alkotob ML. Optimal timing of coronary intervention in patients resuscitated from cardiac arrest without ST-segment elevation myocardial infarction (NSTEMI): A systematic review and meta-analysis. Resuscitation 2019; 144:137-144. [DOI: 10.1016/j.resuscitation.2019.06.279] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/11/2019] [Accepted: 06/19/2019] [Indexed: 02/08/2023]
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Lee HY, Lee BK, Lee DH, Youn CS, Ryoo SM, Kim SJ, Kim WY, Jeung KW, Min YI. Turn-to-Shockable Rhythm Has Comparable Neurologic Outcomes to Initial Shockable Rhythm in Out-of-Hospital Cardiac Arrest Patients Who Underwent Targeted Temperature Management. Ther Hypothermia Temp Manag 2019; 10:220-228. [PMID: 31411544 DOI: 10.1089/ther.2019.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Shockable rhythm in out-of-hospital cardiac arrest (OHCA) implies better outcome and underlying coronary stenosis. We investigated the neurologic outcome and coronary lesions between initial shockable rhythm and turn-to-shockable rhythm. This multicenter, retrospective observational study included adult nontraumatic OHCA survivors with any shockable rhythm during cardiopulmonary resuscitation (CPR) who underwent targeted temperature management between January 2010 and December 2016. Patients were divided into two groups according to the first monitored rhythm: initial shockable rhythm or turn-to-shockable rhythm. The primary outcome was good neurologic outcome at discharge based on cerebral performance categories, and the secondary outcomes were survival discharge, recurrent arrest, and coronary lesions. The two groups were matched in a 1:1 ratio using propensity score (PS). Of 426 patients, 137 and 289 patients were divided into the turn-to-shockable and initial shockable rhythm groups, respectively. Overall, 224 (52.6%) patients had good neurologic outcomes. The turn-to-shockable rhythm group had less patients with good neurologic outcome (57/137 vs. 167/289; p = 0.002) and less culprit lesions in the left anterior descending and left circumflex arteries. However, survival discharge and recurrent arrest were not different between the two groups, and the turn-to-shockable rhythm had no independent association with neurologic outcome (odds ratio, 1.874; 95% confidence interval, 0.909-3.863). In the PS-matched cohort, the turn-to-shockable rhythm group had similar good neurologic outcome (47/100 vs. 35/100, p = 0.083). Survival discharge, recurrent arrest, and coronary culprit lesions were not different between the two groups. In this PS-matched study, OHCA with any shockable rhythm during CPR had similar neurologic outcome and coronary culprit lesions, irrespective of the first monitored rhythm.
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Affiliation(s)
- Hyoung Youn Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Su Jin Kim
- Department of Emergency Medicine, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Yong Il Min
- Department of Emergency Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
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