Predictors for outcome among cardiac arrest patients: the importance of initial cardiac arrest rhythm versus time to return of spontaneous circulation, a retrospective cohort study

Galectin-3 Predicts Long-Term Risk of Cerebral Disability and Mortality in Out-of-Hospital Cardiac Arrest Survivors

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is associated with high mortality and cerebral disability in survivors. Current models of risk prediction and survival are mainly based on resuscitation duration. We examined the prognostic value of circulating biomarkers in predicting mortality and severe cerebral disability for OHCA survivors, alongside traditional clinical risk indicators.

METHODS

Biomarkers including BNP, troponin I, and galectin-3 were measured at hospital admission in resuscitated OHCA patients. Prognostic significance for mortality and cerebral disability involving circulating biomarkers, resuscitation duration, demographics, and laboratory and clinical characteristics was examined via univariate and multivariate Cox proportional hazards regression models. The incremental prognostic value of the index covariates was examined through model diagnostics, focusing on the Akaike information criterion (AIC) and Harrell's concordance statistic (c-statistic).

RESULTS

In a combinatorial analysis of 144 OHCA survivors (median follow-up 5.7 years (IQR 2.9-6.6)), BNP, galectin-3, arterial pH, and resuscitation time were significant predictors of all-cause death and severe cerebral disability, whereas troponin I levels were not. Multivariate regression, adjusting for BNP, arterial pH, and resuscitation time, identified galectin-3 as an independent predictor of long-term mortality. Multiple linear regression models also confirmed galectin-3 as the strongest predictor of cerebral disability. The incorporation of galectin-3 into models for predicting mortality and cerebral disability enhanced fit and discrimination, demonstrating the incremental value of galectin-3 beyond traditional risk predictors.

CONCLUSIONS

Galectin-3 is a significant, independent long-term risk predictor of cerebral disability and mortality in OHCA survivors. Incorporating galectin-3 into current risk stratification models may enhance early prognostication and guide targeted clinical interventions.

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

BACKGROUND

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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

The relationship between the initial pH and neurological outcome in patients with out-of-hospital cardiac arrest is affected by the status of recovery of spontaneous circulation on hospital arrival

The early prediction of neurological outcomes is useful for out-of-hospital cardiac arrest (OHCA). The initial pH was associated with neurological outcomes, but the values varied among the studies. Patients admitted to our division with OHCA of cardiac origin between January 2015 and December 2022 were retrospectively examined (N = 199). A good neurological outcome was defined as a Glasgow-Pittsburgh cerebral performance category (CPC) of 1-2 at discharge. Patients were divided according to the achievement of recovery of spontaneous circulation (ROSC) on hospital arrival, and the efficacy of pH in predicting good neurological outcomes was compared. In patients with ROSC on hospital arrival (N = 100), the initial pH values for good and poor neurological outcomes were 7.26 ± 0.14 and 7.09 ± 0.18, respectively (p < 0.001). In patients without ROSC on hospital arrival (N = 99), the initial pH values for good and poor neurological outcomes were 7.06 ± 0.23 and 6.92 ± 0.15, respectively (p = 0.007). The pH associated with good neurological outcome was much lower in patients without ROSC than in those with ROSC on hospital arrival (P = 0.003). A higher initial pH is associated with good neurological outcomes in patients with OHCA. However, the pH for a good or poor neurological outcome depends on the ROSC status on hospital arrival.

Serum lactate in refractory out-of-hospital cardiac arrest: Post-hoc analysis of the Prague OHCA study

BACKGROUND

The severity of tissue hypoxia is routinely assessed by serum lactate. We aimed to determine whether early lactate levels predict outcomes in refractory out-of-hospital cardiac arrest (OHCA) treated by conventional and extracorporeal cardiopulmonary resuscitation (ECPR).

METHODS

This study is a post-hoc analysis of a randomized Prague OHCA study (NCT01511666) assessing serum lactate levels in refractory OHCA treated by ECPR (the ECPR group) or conventional resuscitation with prehospital achieved return of spontaneous circulation (the ROSC group). Lactate concentrations measured on admission and every 4 hours (h) during the first 24 h were used to determine their relationship with the neurological outcome (the best Cerebral Performance Category score within 180 days post-cardiac arrest).

RESULTS

In the ECPR group (92 patients, median age 58.5 years, 83% male) 26% attained a favorable neurological outcome. In the ROSC group (82 patients, median age 55 years, 83% male) 59% achieved a favorable neurological outcome. In ECPR patients lactate concentrations could discriminate favorable outcome patients, but not consistently in the ROSC group. On admission, serum lactate >14.0 mmol/L for ECPR (specificity 87.5%, sensitivity 54.4%) and >10.8 mmol/L for the ROSC group (specificity 83%, sensitivity 41.2%) predicted an unfavorable outcome.

CONCLUSION

In refractory OHCA serum lactate concentrations measured anytime during the first 24 h after admission to the hospital were found to correlate with the outcome in patients treated by ECPR but not in patients with prehospital ROSC. A single lactate measurement is not enough for a reliable outcome prediction and cannot be used alone to guide treatment.

Association between bystander intervention and emergency medical services and the return of spontaneous circulation in out-of-hospital cardiac arrests occurring at a train station in the Tokyo metropolitan area: A retrospective cohort study

Aim

The purpose of this study was to stratify patients who achieved return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA) with bystander procedures pre-emergency medical service (EMS) arrival and those who achieved ROSC with procedures post-EMS arrival, compare outcomes at 1-month, and identify factors associated with pre-EMS-arrival-ROSC.

Methods

A retrospective cohort analysis of OHCAs occurring at stations in the Tokyo metropolitan area between 2014 and 2018 was conducted. Subjects were stratified by ROSC phase (categorized as pre- and post-EMS arrival and non-ROSC). Survival at 1-month post-OHCA and the percentage of favourable neurological function in each ROSC phase were analysed. In addition, factors associated with Pre-EMS-arrival-ROSC were identified using multivariable logistic regression analysis. The time of occurrence of OHCA was classified into four-time categories as follows. Rush hour on morning [7:00-9:00], Rush hour on evening [17:00-21:00], Daytime [9:00-17:00], and Night or Early morning [21:00-7:00].

Results

Among the 63,089 OHCA in the dataset, 702 were analysed. At 1-month after OHCA occurrence, Pre-EMS-arrival ROSC had higher survival rates than post-EMS-arrival ROSC (86.8% vs. 54.1%) and CPC1-2 rates (73.6% vs. 38.5%). Pre-EMS-arrival ROSC was associated (adjusted odds ratio [95% confidence interval]) with non-older-adult patients (1.59 [1.05-2.43]), witnessed OHCA (1.82 [1.03-3.31]), evening rush-hour (17:00-21:00; 2.08 [1.05-4.11]), conventional CPR (33.42 [7.82-868.44]), hands-only CPR (17.06 [4.30-436.48]), bystander defibrillation performed once (3.31 [1.59-6.99]).

Conclusions

In an OHCA at a station in Tokyo, ROSC achieved with bystander treatment alone had a better outcome at 1-month compared to ROSC with EMS intervention.

Therapeutic hypothermia in patients after cardiac arrest: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Targeted temperature management (TTM) with therapeutic hypothermia (TH) has been used to improve neurological outcomes in patients after cardiac arrest; however, several trials have reported conflicting results regarding its effectiveness. This systematic review and meta-analysis assessed whether TH was associated with better survival and neurological outcomes after cardiac arrest.

METHOD

We searched online databases for relevant studies published before May 2023. Randomized controlled trials (RCTs) comparing TH and normothermia in post-cardiac-arrest patients were selected. Neurological outcomes and all-cause mortality were assessed as the primary and secondary outcomes, respectively. A subgroup analysis according to initial electrocardiography (ECG) rhythm was performed.

RESULT

Nine RCTs (4058 patients) were included. The neurological prognosis was significantly better in patients with an initial shockable rhythm after cardiac arrest (RR = 0.87, 95% confidence interval [CI] = 0.76-0.99, P = 0.04), especially in those with earlier TH initiation (<120 min) and prolonged TH duration (≥24 h). However, the mortality rate after TH was not lower than that after normothermia (RR = 0.91, 95% CI = 0.79-1.05). In patients with an initial nonshockable rhythm, TH did not provide significantly more neurological or survival benefits (RR = 0.98, 95% CI = 0.93-1.03 and RR = 1.00, 95% CI = 0.95-1.05, respectively).

CONCLUSION

Current evidence with a moderate level of certainty suggests that TH has potential neurological benefits for patients with an initial shockable rhythm after cardiac arrest, especially in those with faster TH initiation and longer TH maintenance.

Predictors of neurological outcome after out-of-hospital cardiac arrest: sex-based analysis: do males derive greater benefit from hypothermia management than females?

Background

Previous studies of the effect of sex on after out-of-hospital cardiac arrest (OHCA) outcomes focused on survival to hospital discharge and 1-month survival. Studies on the effect of sex on neurological function after OHCA are still limited. The objective of this study was to identify the predictors of favorable neurological outcome and to examine the association between sex as a biological variable and favorable neurological outcome OHCA.

Methods

Retrospective analyses of clustered data from the Resuscitation Outcomes Consortium multi-center randomized controlled trial (2011–2015). We included adults with non-traumatic OHCA and EMS-attended OHCA. We used multilevel logistic regression to examine the association between sex and favorable neurological outcomes (modified Rankin Scale) and to identify the predictors of favorable neurological outcome.

Results

In total, 22,416 patients were included. Of those, 8109 (36.2%) were females. The multilevel analysis identified the following variables as significant predictors of favorable neurological outcome: younger age, shorter duration of EMS arrival to the scene, arrest in public location, witnessed arrest, bystander CPR, chest compression rate (CCR) of 100–120 compressions per minute, induction of hypothermia, and initial shockable rhythm. Two variables, insertion of an advanced airway and administration of epinephrine, were associated with poor neurological outcome. Our analysis showed that males have higher crude rates of survival with favorable neurological outcome (8.6 vs. 4.9%, p < 0.001). However, the adjusted rate was not significant. Further analyses showed that hypothermia had a significantly greater effect on males than females.

Conclusions

Males had significantly higher crude rates of survival with favorable neurological outcome. However, the adjusted rate was not statistically significant. Males derived significantly greater benefit from hypothermia management than females, but this can possibly be explained by differences in arrest characteristics or in-hospital treatment. In-depth confirmatory studies on the hypothermia effect size by sex are required.

Gender effect in survival after out-of-hospital cardiac arrest: A nationwide, population-based, case-control propensity score matched study based Korean national cardiac arrest registry

Objective

This study aimed to describe the relationship between sex and survival of patients with out-of-hospital cardiac arrest (OHCA) and further investigate the potential impact of female reproductive hormones on survival outcomes, by stratifying the patients into two age groups.

Methods

This retrospective, national population-based observational, case-control study, included Korean OHCA data from January 1, 2009, to December 31, 2016. We used multiple logistic regression with propensity score-matched data. The primary outcome was survival-to-discharge.

Results

Of the 94,160 patients with OHCA included, 34.2% were women. Before propensity score matching (PSM), the survival-to-discharge rate was 5.2% for females and 9.1% for males, in the entire group (OR 0.556, 95% CI [–0.526–0.588], P<0.001). In the reproductive age group (age 18–44 years), the survival-to-discharge rate was 14% for females and 15.6% for males (OR 0.879, 95% CI [0.765–1.012], P = 0,072) and in the post-menopause age group (age ≥ 55 years), the survival-to-discharge rate was 4.1% for females and 7% for males (OR 0.562, 95% CI [0.524–0.603], P<0.001). After PSM (28,577 patients of each sex), the survival-to-discharge rate was 5.4% for females and 5.4% for males (OR, 1.009 [0.938–1.085], P = 0.810). In the reproductive age group, the survival-to-discharge rate was 14.5% for females and 11.5% for males (OR 1.306, 95% CI [1.079–1.580], P = 0.006) and in the post-menopause age group, the survival-to-discharge rate was 4.2% for females and 4.6% for males (OR 0.904, 95% CI [0.828–0.986], P = 0.022). After adjustment for confounders, women of reproductive age were more likely to survive at hospital discharge. However, there was no statistically significant difference in neurological outcome (OR 1.238, 95% CI [0.979–1.566], P = 0.074).

Conclusions

Females of reproductive age had a better chance of survival when matched for confounding factors. Further studies using sex hormones are needed to improve the survival rate of patients with OHCA.

Extracorporeal Life-Support For Out-Of-Hospital Cardiac Arrest: A Nationwide Multicenter Study

BACKGROUND

Despite potential clinical roles of extracorporeal life support (ECLS) for out-of-hospital cardiac arrest (OHCA) compared to that of conventional cardiopulmonary resuscitation (CCPR), use of ECLS for OHCA is not strongly endorsed by current clinical guidelines.

OBJECTIVE

The purpose of this study is to investigate the clinical roles of extracorporeal life support (ECLS) compared with that of conventional cardiopulmonary resuscitation (CCPR) for out-of-hospital cardiac arrest (OHCA) patients.

METHODS

The outcomes of OHCA between 2015 and 2020, enrolled in the Korean Cardiac Arrest Research Consortium (KoCARC), a multicenter OHCA patient registry including 65 participating hospitals throughout the Republic of Korea (ClinicalTrials.gov, number NCT03222999). Differences in clinical features were adjusted by matching the propensity for ECLS. The primary outcome was 30-day neurologically favorable survival with cerebral performance category of 1 or 2. Restricted mean survival time (RMST) was used to compare outcomes between groups.

RESULTS

Of 12,006 patients included, ECLS was applied to 272 patients (2.2%). The frequency of neurologically favorable survival was higher in the ECLS group than the CCPR group (RMST difference, 5.5 days [95% CI, 4.1-7.0 days], p < 0.001). In propensity score-matched 271 pairs, the clinical outcome of ECLS and CCPR did not differ to a statistically significant extent (RMST difference, 0.4 days [95% CI -1.6-2.5 days], p = 0.67). Subgroup analyses revealed that the clinical roles of ECLS was evident in patients with non-shockable rhythm or CPR time≥20 min (RMST difference, 2.7 days [95% CI 0.5-4.8 days], p = 0.015), but not in patients without these features (RMST difference, -3.7days [95% CI -7.6-0.2 days], p = 0.07).

CONCLUSIONS

In this real-world data analysis, ECLS compared to CCPR did not result in better overall clinical outcomes of OHCA. The clinical efficacy of ECLS may be limited to a subgroup of high-risk patients.

Characteristics, prognostic factors, and chronological trends of out-of-hospital cardiac arrests with shockable rhythms in Taiwan - A 7-year observational study

BACKGROUND

The study aimed to explore the characteristics, predictors, and chronological trends of outcomes for adult out-of-hospital cardiac arrests (OHCAs) with shockable rhythms.

METHODS

A 7-year, community-wide observational study using an Utstein-style registry was conducted. Patients who were not transported, those who experienced trauma and those who lacked electronic electrocardiography data were excluded; those with initial shockable rhythms of ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) were included. Outcomes were survival of discharge (SOD) and favorable neurological status (CPC 1-2). The outcome predictors, chronological trends, and their relationship with system interventions were analyzed.

RESULTS

Of the 1544 shockable OHCAs (incidence 12.6%) included, 97.6% had VF and 2.4% had pVT. VF showed better outcomes than pVT. Predictors for both outcomes (SOD; CPC 1-2) were chronological change (adjusted odds ratio [aOR]: 1.133; 1.176), younger age (aOR: 0.973; 0.967), shorter response time (aOR: 0.998; 0.999), shorter scene time (aOR: 0.999; 0.999), witnessed collapse (aOR: 1.668; 1.670), and bystander cardiopulmonary resuscitation (BCPR) (aOR: 1.448; 1.576). Predictors for only SOD were public location (aOR: 1.450) and successful prehospital defibrillation (aOR: 3.374). The use of the supraglottic airway was associated with adverse outcomes. Chronologically with system interventions, BCPR rate, the proportion of shockable OHCA, and improved neurological outcomes increased over time.

CONCLUSIONS

The incidence of shockable OHCA remained low in Asian community. VF showed better outcomes than pVT. Over time, the incidence of shockable rhythm, BCPR rate and patient outcomes did improve with health system interventions. The number of prehospital defibrillations did not predict outcomes.

Enhancing cardiac arrest survival with extracorporeal cardiopulmonary resuscitation: insights into the process of death

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.

Predictors of Favorable Neurologic Outcomes in a Territory-First Extracorporeal Cardiopulmonary Resuscitation Program

Extracorporeal cardiopulmonary resuscitation (ECPR) is an advanced resuscitation method that has been associated with better outcomes after cardiac arrest compared with conventional cardiopulmonary resuscitation. This is a retrospective analysis of all patients who received ECPR for cardiac arrest in Hong Kong's first ECPR program from 2012 to 2020. The primary outcome was favorable neurologic outcome at 3 months. A new risk prediction model was developed and its performance was compared with published risk scores. One-hundred two patients received ECPR and 19 (18.6%) patients survived with favorable neurologic outcome. Having a shockable rhythm was the strongest predictor of favorable neurologic outcome in multivariate analysis (odds ratio, 9.64; 95% confidence interval [CI], 1.49 to 62.30; P = 0.017). We developed a simple model with three parameters for the prediction of favorable neurologic outcomes - presence of shockable rhythm, mean arterial pressure after extracorporeal membrane oxygenation, and the Acute Physiology And Chronic Health Evaluation IV score, with an area under receiver operating characteristic curve of 0.85 (95% CI, 0.77 to 0.94). In Hong Kong's first ECPR program, 18.6% patients survived with favorable neurologic outcomes, and having a shockable rhythm at presentation was the strongest predictor. Risk scores are useful in predicting important patient outcomes and should be included in clinical decision-making for patients who received ECPR.

Survival and Factors Associated with Survival with Extracorporeal Life Support During Cardiac Arrest: A Systematic Review and Meta-Analysis

The survival rate after cardiac arrest (CA) remains low. The utilization of extracorporeal life support is proposed to improve management. However, this resource-intensive tool is associated with complications and must be used in selected patients. We performed a meta-analysis to determine predictive factors of survival. Among the 81 studies included, involving 9256 patients, survival was 26.2% at discharge and 20.4% with a good neurologic outcome. Meta-regressions identified an association between survival at discharge and lower lactate values, intrahospital CA, and lower cardio pulmonary resuscitation (CPR) duration. After adjustment for age, intrahospital CA, and mean CPR duration, an initial shockable rhythm was the only remaining factor associated with survival to discharge (β = 0.02, 95% CI: 0.007-0.02; p = 0.0004).

Differential Effectiveness of Hypothermic Targeted Temperature Management According to the Severity of Post-Cardiac Arrest Syndrome

International guidelines recommend targeted temperature management (TTM) to improve the neurological outcomes in adult patients with post-cardiac arrest syndrome (PCAS). However, it still remains unclear if the lower temperature setting (hypothermic TTM) or higher temperature setting (normothermic TTM) is superior for TTM. According to the most recent large randomized controlled trial (RCT), hypothermic TTM was not found to be associated with superior neurological outcomes than normothermic TTM in PCAS patients. Even though this represents high-quality evidence obtained from a well-designed large RCT, we believe that we still need to continue investigating the potential benefits of hypothermic TTM. In fact, several studies have indicated that the beneficial effect of hypothermic TTM differs according to the severity of PCAS, suggesting that there may be a subgroup of PCAS patients that is especially likely to benefit from hypothermic TTM. Herein, we summarize the results of major RCTs conducted to evaluate the beneficial effects of hypothermic TTM, review the recent literature suggesting the possibility that the therapeutic effect of hypothermic TTM differs according to the severity of PCAS, and discuss the potential of individualized TTM.

Impact of air temperature on occurrence of bath-related cardiac arrest

The mortality of the bath-related cardiac arrest (BRCA) is extremely high. While air temperature is reported to be associated with the BRCA occurrence, it is unclear whether daily minimum temperatures or the difference between maximum and minimum air temperatures influences BRCA occurrence the most.A retrospective cohort study of adult patients was conducted between January 2015 and February 2020 at Hirosaki University Hospital Emergency Department. The following data were collected: age, sex, day of cardiac arrest event, location of the event, initial cardiac rhythm, presence of return of spontaneous circulation, and overall mortality (status at 1 month after cardiac arrest event). Based on the day of the event and the location in which the event occurred, daily minimum and maximum temperatures were obtained from the Japan Meteorological Agency database.A total of 215 eligible cardiac arrest cases were identified, including 25 cases of BRCA. Comparing BRCA and non-BRCA, initial shockable cardiac rhythm (4.0% vs 44.7%), presence of return of spontaneous circulation (8.0% vs 34.7%), and overall mortality (96.0% vs 71.6%) differed significantly (P < .05 each). Daily minimum and maximum temperatures showed no significant relationships with BRCA or non-BRCA. Daily minimum temperature was a risk factor of BRCA occurrence after adjusting for age and temperature difference (risk ratio, 0.937; 95% confidence interval, 0.882-0.995).Daily minimum temperature represents a potential risk factor for BRCA occurrence.

Circulatory trajectories after out-of-hospital cardiac arrest: a prospective cohort study

BACKGROUND

Circulatory failure frequently occurs after out-of-hospital cardiac arrest (OHCA) and is part of post-cardiac arrest syndrome (PCAS). The aim of this study was to investigate circulatory disturbances in PCAS by assessing the circulatory trajectory during treatment in the intensive care unit (ICU).

METHODS

This was a prospective single-center observational cohort study of patients after OHCA. Circulation was continuously and invasively monitored from the time of admission through the following five days. Every hour, patients were classified into one of three predefined circulatory states, yielding a longitudinal sequence of states for each patient. We used sequence analysis to describe the overall circulatory development and to identify clusters of patients with similar circulatory trajectories. We used ordered logistic regression to identify predictors for cluster membership.

RESULTS

Among 71 patients admitted to the ICU after OHCA during the study period, 50 were included in the study. The overall circulatory development after OHCA was two-phased. Low cardiac output (CO) and high systemic vascular resistance (SVR) characterized the initial phase, whereas high CO and low SVR characterized the later phase. Most patients were stabilized with respect to circulatory state within 72 h after cardiac arrest. We identified four clusters of circulatory trajectories. Initial shockable cardiac rhythm was associated with a favorable circulatory trajectory, whereas low base excess at admission was associated with an unfavorable circulatory trajectory.

CONCLUSION

Circulatory failure after OHCA exhibits time-dependent characteristics. We identified four distinct circulatory trajectories and their characteristics. These findings may guide clinical support for circulatory failure after OHCA.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02648061.

Comparison of Mechanical Support with Impella or Extracorporeal Life Support in Post-Cardiac Arrest Cardiogenic Shock: A Propensity Scoring Matching Analysis

Our aim was to compare the outcomes of Impella with extracorporeal life support (ECLS) in patients with post-cardiac arrest cardiogenic shock (CS) complicating acute myocardial infarction (AMI). This was a retrospective study of patients resuscitated from out of hospital cardiac arrest (OHCA) with post-cardiac arrest CS following AMI (May 2015 to May 2020). Patients were supported either with Impella 2.5/CP or ECLS. Outcomes were compared using propensity score-matched analysis to account for differences in baseline characteristics between groups. 159 patients were included (Impella, n = 105; ECLS, n = 54). Hospital and 12-month survival rates were comparable in the Impella and the ECLS groups (p = 0.16 and p = 0.3, respectively). After adjustment for baseline differences, both groups demonstrated comparable hospital and 12-month survival (p = 0.36 and p = 0.64, respectively). Impella patients had a significantly greater left ventricle ejection-fraction (LVEF) improvement at 96 h (p < 0.01 vs. p = 0.44 in ECLS) and significantly fewer device-associated complications than ECLS patients (15.2% versus 35.2%, p < 0.01 for relevant access site bleeding, 7.6% versus 20.4%, p = 0.04 for limb ischemia needing intervention). In subgroup analyses, Impella was associated with better survival in patients with lower-risk features (lactate < 8.6 mmol/L, time from collapse to return of spontaneous circulation < 28 min, vasoactive score < 46 and Horowitz index > 182). In conclusion, the use of Impella 2.5/CP or ECLS in post-cardiac arrest CS after AMI was associated with comparable adjusted hospital and 12-month survival. Impella patients had a greater LVEF improvement than ECLS patients. Device-related access-site complications occurred more frequently in patients with ECLS than Impella support.

Out-of-hospital cardiac arrest outcomes in emergency departments

BACKGROUND

The emergency department (ED) plays an important role in out-hospital-cardiac arrest (OHCA) management. However, ED outcomes are not widely reported. This study aimed to (1) describe OHCA ED outcomes and reasons for ED deaths, and (2) whether these differed between hospitals.

METHODS

Data were obtained from the Victorian Ambulance Cardiac Arrest Registry and 12 hospitals for adult, non-traumatic OHCA cases transported to ED between 2014 and 2016. Multivariable logistic regression was used to examine the association of level of cardiac arrest centre on ED survival in a subset of cases (non-paramedic witnessed OHCA who were unconscious on ED arrival with ROSC).

RESULTS

Of 1547 eligible OHCA cases, 81% (N = 1254) survived ED, varying between 57% to 88% between EDs. Among non-survivors, the majority had either: cessation of resuscitation after presenting with CPR in progress (27%); withdrawal of life-sustaining treatment for non-neurological (n = 65, 22%) or neurological (16%) reasons; or a unsuccessful resuscitation following a rearrested in ED (20%). These causes of ED deaths varied between the different levels of cardiac arrest centres, and in our subset of interest (n = 952) ED survival was associated with transportation to centres with high annual OHCA volumes and with 24-hour cardiac intervention capabilities (AOR = 3.43, 95% CI 1.89-6.21).

CONCLUSION

Our study found wide variation in survival between EDs, which was associated with hospital characteristics. Such data suggests the need for a detailed review of ED deaths, particularly in non-cardiac arrest centres, and potentially the need for monitoring ED survival as a measure of quality.

Premenopausal-aged females have no neurological outcome advantage after out-of-hospital cardiac arrest: A multilevel analysis of North American populations

AIM

We investigated the impact of premenopausal age on neurological function at hospital discharge in patients with out-of-hospital cardiac arrest (OHCA). We hypothesized that premenopausal-aged females (18-47 years of age) with OHCA would have a higher probability of survival with favourable neurological function at hospital discharge compared with males of the same age group, older males, and older females (>53 years of age).

METHODS

Retrospective analyses of data from the Resuscitation Outcomes Consortium multi-center randomized controlled trial (June 2011-May 2015). We included adults with non-traumatic OHCA treated by emergency medical service. We stratified the cohort into four groups by age and sex: premenopausal-aged females (18-47 years of age), older females (≥53 years old), younger males (18-47 years of age), and older male. We used multilevel logistic regression to examine the association between age-sex and favourable neurological outcomes (modified Rankin Scale ≤ 3).

RESULTS

In total, 23,725 patients were included: 1050 (4.5%) premenopausal females; 1930 (8.1%) younger males; 7569 (31.9%) older females; and 13,176 (55.5%) older males. The multilevel analysis showed no difference in neurological outcome between younger males and younger females (OR 0.95, 95% CI 0.69-1.32, p = 0.75). Both older females (OR 0.36, 95% CI 0. 0.26-0.48, p < 0.001) and older males (OR 0.52, 95% CI 0.39-0.69, p < 0.001) had a significantly lower odds of favourable neurological outcome than younger females. Among all groups, older females had the worst outcomes.

CONCLUSIONS

We did not detect an association between premenopausal age and survival with good neurological outcome, suggesting females sex hormones do not impact OHCA outcomes. Our findings are not in line with results from other studies. Studies that rigorously evaluate menopausal status are required to definitively assess the impact of female sex hormones on outcomes.

Effect of arterial oxygen partial pressure inflection point on Venoarterial extracorporeal membrane oxygenation for emergency cardiac support

Background

Temporary circulatory support is a bridge between acute circulatory failure and definitive treatment or recovery. Currently, venoarterial extracorporeal membrane oxygenation (VA-ECMO) is considered to be one of the effective circulatory support methods, although cardiac function monitoring during the treatment still needs further investigation. Inflection point of arterial oxygen partial pressure (IPPaO2) may occur at an early stage in part of patients with a good prognosis after VA-ECMO treatment, and the relationship between time of IPPaO2 (tIPPaO2) and recovery of cardiac function or prognosis remains unclear.

Methods

To investigate this relationship, we retrospectively analyzed the clinical data of 71 patients with different conditions after treatment with VA-ECMO in the emergency center of Jiangsu Province Hospital between May 2015 and July 2020. Spearman’s correlation analysis was used for the correlation between tIPPaO₂ and quantitative data, and ROC curve for the predictive effect of tIPPaO₂ on the 28-day mortality.

Results

Thirty-five patients were admitted because of refractory cardiogenic shock (26 of 35 survived) and the remaining 36 patients due to cardiac arrest (13 of 36 survived). The overall survival rate was 54.9% (39 of 71 survived). Acute physiology and chronic health evaluation II, ECMO time, tIPPaO2, continuous renal replacement therapy time, mechanical ventilation time, and bleeding complications in the survival group were lower than those in the non-survival group, with length of stay, intensive care unit stay, and platelet levels were being higher. The tIPPaO₂ was negatively correlated with ejection fraction, and the shorter tIPPaO2 resulted in a higher 28-day survival probability, higher predictive value for acute myocardial infarction and fulminant myocarditis.

Conclusions

Therefore, tIPPaO2 could be a reliable qualitative indicator of cardiac function in patients treated with VA-ECMO, which can reveal appropriate timing for adjusting VA-ECMO flow or weaning.

Trial registration

ChiCTR1900026105.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00902-5.

Higher 1-year mortality in women admitted to intensive care units after cardiac arrest: A nationwide overview from the Netherlands between 2010 and 2018

PURPOSE

We study sex differences in 1-year mortality of out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) patients admitted to the intensive care unit (ICU).

DATA

A retrospective cohort analysis of OHCA and IHCA patients registered in the NICE registry in the Netherlands. The primary and secondary outcomes were 1-year and hospital mortality, respectively.

RESULTS

We included 19,440 OHCA patients (5977 women, 30.7%) and 13,461 IHCA patients (4889 women, 36.3%). For OHCA, 1-year mortality was 63.9% in women and 52.6% in men (Hazard Ratio [HR] 1.28, 95% Confidence Interval [95% CI] 1.23-1.34). For IHCA, 1-year mortality was 60.0% in women and 57.0% in men (HR 1.09, 95% CI 1.04-1.14). In OHCA, hospital mortality was 57.4% in women and 46.5% in men (Odds Ratio [OR] 1.42, 95% CI 1.33-1.52). In IHCA, hospital mortality was 52.0% in women and 48.2% in men (OR 1.11, 95% CI 1.03-1.20).

CONCLUSION

Women admitted to the ICU after cardiac arrest have a higher mortality rate than men. After left-truncation, we found that this sex difference persisted for OHCA. For IHCA we found that the effect of sex was mainly present in the initial phase after the cardiac arrest.

Early Impella Support in Postcardiac Arrest Cardiogenic Shock Complicating Acute Myocardial Infarction Improves Short- and Long-Term Survival

OBJECTIVES

Early mechanical circulatory support with Impella may improve survival outcomes in the setting of postcardiac arrest cardiogenic shock after out-of-hospital cardiac arrest complicating acute myocardial infarction. However, the optimal timing to initiate mechanical circulatory support in this particular setting remains unclear. Therefore, we aimed to compare survival outcomes of patients supported with Impella 2.5 before percutaneous coronary intervention (pre-PCI) with those supported after percutaneous coronary intervention (post-PCI).

DESIGN

Retrospective single-center study between September 2014 and December 2019 admitted to the Cardiac Arrest Center in Marburg, Germany.

PATIENTS

Out of 2,105 patients resuscitated from out-of-hospital cardiac arrest due to acute myocardial infarction with postcardiac arrest cardiogenic shock between September 2014 and December 2019 and admitted to our regional cardiac arrest center, 81 consecutive patients receiving Impella 2.5 during admission coronary angiogram were identified.

OUTCOMES/MEASUREMENTS

Survival outcomes were compared between those with Impella support pre-PCI to those with support post-PCI.

MAIN RESULTS

A total of 81 consecutive patients with infarct-related postcardiac arrest shock supported with Impella 2.5 during admission coronary angiogram were included. All patients were in profound cardiogenic shock requiring catecholamines at admission. Overall survival to discharge and at 6 months was 40.7% and 38.3%, respectively. Patients in the pre-PCI group had a higher survival to discharge and at 6 months as compared to patients of the post-PCI group (54.3% vs 30.4%; p = 0.04 and 51.4% vs 28.2%; p = 0.04, respectively). Furthermore, the patients in the early support group demonstrated a greater functional recovery of the left ventricle and a better restoration of the end-organ function when Impella support was initiated prior to percutaneous coronary intervention.

CONCLUSIONS

Our results suggest that the early initiation of mechanical circulatory support with Impella 2.5 prior to percutaneous coronary intervention is associated with improved hospital and 6-month survival in patients with postcardiac arrest cardiogenic shock complicating acute myocardial infarction.

Comparison of Mortality Risk Models in Patients with Postcardiac Arrest Cardiogenic Shock and Percutaneous Mechanical Circulatory Support

Background

Although scoring systems are widely used to predict outcomes in postcardiac arrest cardiogenic shock (CS) after out-of-hospital cardiac arrest (OHCA) complicating acute myocardial infarction (AMI), data concerning the accuracy of these scores to predict mortality of patients treated with Impella in this setting are lacking. Thus, we aimed to evaluate as well as to compare the prognostic accuracy of acute physiology and chronic health II (APACHE II), simplified acute physiology score II (SAPS II), sepsis-related organ failure assessment (SOFA), the intra-aortic balloon pump (IABP), CardShock, the prediction of cardiogenic shock outcome for AMI patients salvaged by VA-ECMO (ENCOURAGE), and the survival after venoarterial extracorporeal membrane oxygenation (SAVE) score in patients with OHCA refractory CS due to an AMI treated with Impella 2.5 or CP.

Methods

Retrospective study of 65 consecutive Impella 2.5 and 32 CP patients treated in our cardiac arrest center from September 2015 until June 2020.

Results

Overall survival to discharge was 44.3%. The expected mortality according to scores was SOFA 70%, SAPS II 90%, IABP shock 55%, CardShock 80%, APACHE II 85%, ENCOURAGE 50%, and SAVE score 70% in the 2.5 group; SOFA 70%, SAPS II 85%, IABP shock 55%, CardShock 80%, APACHE II 85%, ENCOURAGE 75%, and SAVE score 70% in the CP group. The ENCOURAGE score was the most effective predictive model of mortality outcome presenting a moderate area under the curve (AUC) of 0.79, followed by the CardShock, APACHE II, IABP, and SAPS score. These derived an AUC between 0.71 and 0.78. The SOFA and the SAVE scores failed to predict the outcome in this particular setting of refractory CS after OHCA due to an AMI.

Conclusion

The available intensive care and newly developed CS scores offered only a moderate prognostic accuracy for outcomes in OHCA patients with refractory CS due to an AMI treated with Impella. A new score is needed in order to guide the therapy in these patients.

Effect of gender on out-of-hospital cardiac arrest survival: a registry-based study

OBJECTIVE

The aim of the study was to compare outcomes after out-of-hospital cardiac arrest (OHCA) between comparable female and male OHCA cohorts in a large nationwide registry.

METHODS

This was a national multicentre retrospective, case-control propensity score-matched study based on French National Cardiac Arrest Registry data from 1 July 2011 to 21 September 2017. Female and male survival rates at D30 were compared.

RESULTS

At baseline 66 395 OHCA victims were included, of which 34.3% were women. At hospital admission, survival was 18.2% for female patients and 20.2% for male patients [odds ratio (OR), 1.138 (1.092-1.185)]; at 30 days, survival was 4.3 and 5.9%, respectively [OR, 1.290 (1.191-1.500)]. After matching (14 051 patients within each group), female patients received less advanced life support by mobile medical team (MMT), they also had a longer no-flow duration and shorter resuscitation effort by MMT than male patients. However, 15.3% of female patients vs. 9.1% of male patients were alive at hospital admission [OR, 0.557 (0.517-0.599)] and 3.2 vs. 2.6% at D30 [OR, 0.801 (0.697-0.921)], with no statistically significant difference in neurological outcome [OR, 0.966 (0.664-1.407)].

CONCLUSIONS

In this large nationwide matched OHCA study, female patients had a better chance of survival with no significant difference in neurological outcome. We also noticed that female patients received delayed care with a shorter resuscitation effort compared to men; these complex issues warrant further specific investigation. Encouraging bystanders to act as quickly as possible and medical teams to care for female patients in the same way as male patients should increase survival rates.

Out-of-hospital cardiac arrest treated by emergency medical service teams during COVID-19 pandemic: A retrospective cohort study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a challenge for medical personnel, especially in the current COVID-19 pandemic, where medical personnel should perform resuscitation wearing full personal protective equipment. This study aims were to assess the characteristics and outcomes of adults who suffered an OHCA in the COVID-19 pandemic treated by emergency medical service (EMS) teams.

METHODS

All EMS-attended OHCA adults over than 18 years in the Polish EMS registry were analyzed. The retrospective EMS database was conducted. EMS interventions performed between March 1, and April 30, 2020 were retrospectively screened.

RESULTS

In the study period EMS operated 527 times for OHCA cases. The average age of patients with OHCA was 67.8 years. Statistically significantly more frequently men were involved (64.3%). 298 (56.6%) of all OHCA patients had resuscitation attempted by EMS providers. Among resuscitated patients, 73.8% were cardiac etiology. 9.4% of patients had return of spontaneous circulation, 27.2% of patients were admitted to hospital with ongoing chest compression. In the case of 63.4% cardiopulmonary resuscitation was ineffective and death was determined.

CONCLUSIONS

The present study found that OHCA incidence rate in the Masovian population (central region of Poland) in March-April 2020 period was 12.2/100,000 adult inhabitants. Return of spontaneous circulation in EMS was observed only in 9.4% of resuscitated patients. The presence of shockable rhythms was associated with better prognosis. The prehospital mortality, even though it was high, did not differ from those reported by other studies.

Rationale and methods of the Advanced R2Eperfusion STrategies for Refractory Cardiac Arrest (ARREST) trial

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.

Establishment of an extracorporeal cardio-pulmonary resuscitation program in Berlin - outcomes of 254 patients with refractory circulatory arrest

Objective

Optimal management of out of hospital circulatory arrest (OHCA) remains challenging, in particular in patients who do not develop rapid return of spontaneous circulation (ROSC). Extracorporeal cardiopulmonary resuscitation (eCPR) can be a life-saving bridging procedure. However its requirements and feasibility of implementation in patients with OHCA, appropriate inclusion criteria and achievable outcomes remain poorly defined.

Design

Prospective cohort study.

Setting

Tertiary referral university hospital center.

Patients

Here we report on characteristics, course and outcomes on the first consecutive 254 patients admitted between August 2014 and December 2017.

Intervention

eCPR program for OHCA.

Mesurements and main results

A structured clinical pathway was designed and implemented as 24/7 eCPR service at the Charité in Berlin. In total, 254 patients were transferred with ongoing CPR, including automated chest compression, of which 30 showed or developed ROSC after admission. Following hospital admission predefined in- and exclusion criteria for eCPR were checked; in the remaining 224, 126 were considered as eligible for eCPR.

State of the art postresuscitation therapy was applied and prognostication of neurological outcome was performed according to a standardized protocol.

Eighteen patients survived, with a good neurological outcome (cerebral performance category (CPC) 1 or 2) in 15 patients. Compared to non-survivors survivors had significantly shorter time between collaps and start of eCPR (58 min (IQR 12–85) vs. 90 min (IQR 74–114), p = 0.01), lower lactate levels on admission (95 mg/dL (IQR 44–130) vs. 143 mg/dL (IQR 111–178), p <  0.05), and less severe acidosis on admission (pH 7.2 (IQR 7.15–7.4) vs. 7.0 (IQR6.9–7.2), p <  0.05). Binary logistic regression analysis identified latency to eCPR and low pH as independent predictors for mortality.

Conclusion

An eCPR program can be life-saving for a subset of individuals with refractory circulatory arrest, with time to initiation of eCPR being a main determinant of survival.

Comparison of in-hospital and out-of-hospital cardiac arrest patients receiving targeted temperature management: A matched case-control study

BACKGROUND

Evidences that support the use of targeted temperature management (TTM) for in-hospital cardiac arrest (IHCA) are lacking. We aimed to investigate the hypothesis that TTM benefits for patients with IHCA are similar to those with out-of-hospital cardiac arrest (OHCA) and to determine the independent predictors of resuscitation outcomes in patients with cardiac arrest receiving subsequent TTM.

METHODS

This is a retrospective, matched, case-control study (ratio 1:1) including 93 patients with IHCA treated with TTM after the return of spontaneous circulation, who were admitted to Partners HealthCare system in Boston from January 2011 to December 2018. Controls were defined as the same number of patients with OHCA, matched for age, Charlson score, and sex. Survival and neurological outcomes upon discharge were the primary outcome measures.

RESULTS

Patients with IHCA were more likely to have experienced a witnessed arrest and receive bystander cardiopulmonary resuscitation, a larger total dosage of epinephrine, and extracorporeal membrane oxygenation. The time duration for ROSC was shorter in patients with IHCA than in those with OHCA. The IHCA group was more likely associated with mild thrombocytopenia during TTM than the OHCA group. Survival after discharge and favorable neurological outcomes did not differ between the two groups. Among all patients who had cardiac arrest treated with TTM, the initial shockable rhythm, time to ROSC, and medical history of heart failure were independent outcome predictors for survival to hospital discharge. The only factor to predict favorable neurological outcomes at discharge was initial shockable rhythm.

CONCLUSION

The beneficial effects of TTM in eligible patients with IHCA were similar with those with OHCA. Initial shockable rhythm was the only independent predictor of both survival and favorable neurological outcomes at discharge in all cardiac arrest survivors receiving TTM.

N-terminal pro-B-type natriuretic peptide as a prognostic indicator for 30-day mortality following out-of-hospital cardiac arrest: a prospective observational study

BACKGROUND

Early risk stratification applying cardiac biomarkers may prove useful in sudden cardiac arrest patients. We investigated the prognostic utility of early-on levels of high sensitivity cardiac troponin-T (hs-cTnT), copeptin and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with out-of-hospital cardiac arrest (OHCA).

METHODS

We conducted a prospective observational unicenter study, including patients with OHCA of assumed cardiac origin from the southwestern part of Norway from 2007 until 2010. Blood samples for later measurements were drawn during cardiopulmonary resuscitation or at hospital admission.

RESULTS

A total of 114 patients were included, 37 patients with asystole and 77 patients with VF as first recorded heart rhythm. Forty-four patients (38.6%) survived 30-day follow-up. Neither hs-cTnT (p = 0.49), nor copeptin (p = 0.39) differed between non-survivors and survivors, whereas NT-proBNP was higher in non-survivors (p <  0.001) and significantly associated with 30-days all-cause mortality in univariate analysis, with a hazard ratio (HR) for patients in the highest compared to the lowest quartile of 4.6 (95% confidence interval (CI), 2.1-10.1), p <  0.001. This association was no longer significant in multivariable analysis applying continuous values, [HR 0.96, (95% CI, 0.64-1.43), p = 0.84]. Similar results were obtained by dividing the population by survival at hospital admission, excluding non-return of spontaneous circulation (ROSC) patients on scene [HR 0.93 (95% CI, 0.50-1.73), P = 0.83]. We also noted that NT-proBNP was significantly higher in asystole- as compared to VF-patients, p <  0.001.

CONCLUSIONS

Early-on levels of hs-cTnT, copeptin and NT-proBNP did not provide independent prognostic information following OHCA. Prediction was unaffected by excluding on-scene non-ROSC patients in the multivariable analysis.

TRIAL REGISTRATION

ClinicalTrials. gov, NCT02886273 .

Neurological outcome in patients after successful resuscitation in out-of-hospital settings

Neurological outcome is an important determinant of death in admitted survivors after out-of-hospital cardiac arrest (OHCA). Studies demonstrated several significant pre-hospital predictors of ischemic brain injury (time to resuscitation, time of resuscitation, and cause of OHCA). Our aim was to evaluate the relationship between post-resuscitation clinical parameters and neurological outcome in OHCA patients, when all recommended therapeutic strategies, including hypothermia, were on board. We retrospectively included consecutive 110 patients, admitted to the medical ICU after successful resuscitation due to OHCA. Neurological outcome was defined by cerebral performance category (CPC) scale I-V. CPC categories I-II defined good neurological outcome and CPC categories III-V severe ischemic brain injury. Therapeutic measures were aimed to achieve optimal circulation and oxygenation, early percutaneous coronary interventions (PCI) in acute coronary syndromes (ACS), and therapeutic hypothermia to improve survival and neurological outcome of OHCA patients. We observed good neurological outcome in 37.2% and severe ischemic brain injury in 62.7% of patients. Severe ischemic brain injury was associated significantly with known pre-hospital data (older age, cause of OHCA, and longer resuscitations), but also with increased admission lactate, in-hospital complications (involuntary muscular contractions/seizures, heart failure, cardiogenic shock, acute kidney injury, and mortality), and inotropic and vasopressor support. Good neurological outcome was associated with early PCI, dual antiplatelet therapy, and better survival. We conclude that in OHCA patients, post-resuscitation early PCI and dual antiplatelet therapy in ACS were significantly associated with good neurological outcome, but severe ischemic brain injury was associated with several in-hospital complications and the need for vasopressor and inotropic support.

Impact of Transport Time and Cardiac Arrest Centers on the Neurological Outcome After Out-of-Hospital Cardiac Arrest: A Retrospective Cohort Study

Background

Should all out‐of‐hospital cardiac arrest (OHCA) patients be directly transported to cardiac arrest centers (CACs) remains under debate. Our study evaluated the impacts of different transport time and destination hospital on the outcomes of OHCA patients.

Methods and Results

Data were collected from 6655 OHCA patients recorded in the regional prospective OHCA registry database of Taoyuan City, Taiwan, between January 2012 and December 2016. Patients were matched on propensity score, which left 5156 patients, 2578 each in the CAC and non‐CAC groups. Transport time was dichotomized into <8 and ≥8 minutes. The relations between the transport time to CACs and good neurological outcome at discharge and survival to discharge were investigated. Of the 5156 patients, 4215 (81.7%) presented with nonshockable rhythms and 941 (18.3%) presented with shockable rhythms. Regardless of transport time, transportation to a CAC increased the likelihoods of survival to discharge (<8 minutes: adjusted odds ratio [aOR], 1.95; 95% CI, 1.11–3.41; ≥8 minutes: aOR, 1.92; 95% CI, 1.25–2.94) and good neurological outcome at discharge (<8 minutes: aOR, 2.70; 95% CI, 1.40–5.22; ≥8 minutes: aOR, 2.20; 95% CI, 1.29–3.75) in OHCA patients with shockable rhythms but not in patients with nonshockable rhythms.

Conclusions

OHCA patients with shockable rhythms transported to CACs demonstrated higher probabilities of survival to discharge and a good neurological outcome at discharge. Direct ambulance delivery to CACs should thus be considered, particularly when OHCA patients present with shockable rhythms.

Predicting factors for long-term survival in patients with out-of-hospital cardiac arrest - A propensity score-matched analysis

Background

Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death worldwide, with acute coronary syndromes accounting for most of the cases. While the benefit of early revascularization has been clearly demonstrated in patients with ST-segment-elevation myocardial infarction (STEMI), diagnostic pathways remain unclear in the absence of STEMI. We aimed to characterize OHCA patients presenting to 2 tertiary cardiology centers and identify predicting factors associated with survival.

Methods

We retrospectively analyzed 519 patients after OHCA from February 2003 to December 2017 at 2 centers in Munich, Germany. Patients undergoing immediate coronary angiography (CAG) were compared to those without. Multivariate regression analysis and inverse probability treatment weighting (IPTW) were performed to identify predictors for improved outcome in a matched population.

Results

Immediate CAG was performed in 385 (74.1%) patients after OHCA with presumed cardiac cause of arrest. As a result of multivariate analysis after propensity score matching, we found that immediate CAG, return of spontaneous circulation (ROSC) at admission, witnessed arrest and former smoking were associated with improved 30-days-survival [(OR, 0.46; 95% CI, 0.26–0.84), (OR, 0.21; 95% CI, 0.10–0.45), (OR, 0.50; 95% CI, 0.26–0.97), (OR, 0.43; 95% CI, 0.23–0.81)], and 1-year-survival [(OR, 0.39; 95% CI, 0.19–0.82), (OR, 0.29; 95% CI, 0.12–0.7), (OR, 0.43; 95% CI, 0.2–1.00), (OR, 0.3; 95% CI, 0.14–0.63)].

Conclusions

In our study, immediate CAG, ROSC at admission, witnessed arrest and former smoking were independent predictors of survival in cardiac arrest survivors. Improvement in prehospital management including bystander CPR and best practice post-resuscitation care with optimized triage of patients to an early invasive strategy may help ameliorate overall outcome of this critically-ill patient population.

Gender differences in cognitive outcome after cardiac arrest: A retrospective cohort study

Introduction: Recent studies have suggested gender disparities in neurologic outcome after cardiac arrest (CA). However, the relation between gender and cognitive outcome has been rarely examined. Here we investigated whether sex is associated with cognitive outcome after CA events.Methods: A retrospective analysis was conducted using data collected at our institution from January 2006 to May 2017. Patients were included if they had a documented CA and were able to participate in structured neuropsychological testing. Cognitive status was assessed at about 2.1 month after CA and included tests of attention as well as short and long-term memory. Gender was used as the main predictor of outcome and was studied in relation to age, depressive mood, therapeutic hypothermia (TH), and other potential confounders.Results: Males were more likely to show favorable cognitive outcome in both univariate and multivariate analyses. Women were more likely to exhibit depressive mood. Patients who underwent TH (31% of the patients) did not show any gender differences in benefits from the treatment. Among males and females, no significant differences between age groups could be observed.Conclusions: Male sex was associated with favorable cognitive outcome after CA which could not be attributed to baseline characteristics.

Predicting survival in out-of-hospital cardiac arrest patients undergoing targeted temperature management: The Polish Hypothermia Registry Risk Score

BACKGROUND

Prompt reperfusion and post-resuscitation care, including targeted temperature management (TTM), improve survival in out-of-hospital cardiac arrest (OHCA) patients. To predict inhospital mortality in OHCA patients treated with TTM, the Polish Hypothermia Registry Risk Score (PHR-RS) was developed. The use of dedicated risk stratification tools may support treatment decisions.

METHODS

Three hundred seventy-six OHCA patients who underwent TTM between 2012 and 2016 were retrospectively analysed and whose data were collected in the Polish Hypothermia Registry. A multivariate logistic regression model identified a set of predictors of in-hospital mortality that were used to develop a dedicated risk prediction model, which was tested for accuracy.

RESULTS

The mean age of the studied population was 59.2 ± 12.9 years. 80% of patients were male, 73.8% had shockable rhythms, and mean time from cardiac arrest (CA) to cardiopulmonary resuscitation (CPR) was 7.2 ± 8.6 min. The inputs for PHR-RS were patient age and score according to the Mild Therapeutic Hypothermia (MTH) Scale. Criteria for the MTH score consisted of time from CA to CPR above 10 min, time from CA to the return of spontaneous circulation above 20 min, in-hospital CA, unwitnessed CA, and non-shockable rhythm, each counted as 1 point. The predictive value of PHR-RS was expressed as an area under the curve of 0.74.

CONCLUSIONS

PHR-RS is one of the simplest and easiest models to use and enables a reliable prediction of in-hospital mortality in OHCA patients treated with TTM.

A systematic literature review and meta-analysis of the effectiveness of extracorporeal-CPR versus conventional-CPR for adult patients in cardiac arrest

Introduction

The probability of surviving a cardiac arrest remains low. International resuscitation guidelines state that extracorporeal cardiopulmonary resuscitation (ECPR) may have a role in selected patients suffering refractory cardiac arrest. Identifying these patients is challenging. This project systematically reviewed the evidence comparing the outcomes of ECPR over conventional-CPR (CCPR), before examining resuscitation-specific parameters to assess which patients might benefit from ECPR.

Method

Literature searches of studies comparing ECPR to CCPR and the clinical parameters of survivors of ECPR were performed. The primary outcome examined was survival at hospital discharge or 30 days. A secondary analysis examined the resuscitation parameters that may be associated with survival in patients who receive ECPR (no-flow and low-flow intervals, bystander-CPR, initial shockable cardiac rhythm, and witnessed cardiac arrest).

Results

Seventeen of 948 examined studies were included. ECPR demonstrated improved survival (OR 0.40 (0.27-0.60)) and a better neurological outcome (OR 0.10 (0.04-0.27)) over CCPR during literature review and meta-analysis. Characteristics that were associated with improved survival in patients receiving ECPR included an initial shockable rhythm and a shorter low-flow time. Shorter no-flow, the presence of bystander-CPR and witnessed arrests were not characteristics that were associated with improved survival following meta-analysis, although the quality of input data was low. All data were non-randomised, and hence the potential for bias is high.

Conclusion

ECPR is a sophisticated treatment option which may improve outcomes in a selected patient population in refractory cardiac arrest. Further comparative research is needed clarify the role of this potential resuscitative therapy.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

The lactate clearance calculated using serum lactate level 6 h after is an important prognostic predictor after extracorporeal cardiopulmonary resuscitation: a single-center retrospective observational study

Background

Serum lactate level can predict clinical outcomes in some critical cases. In the clinical setting, we noted that patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) and with poor serum lactate improvement often do not recover from cardiopulmonary arrest. Therefore, we investigated the association between lactate clearance and in-hospital mortality in cardiac arrest patients undergoing ECPR.

Methods

Serum lactate levels were measured on admission and every hour after starting ECPR. Lactate clearance [(lactate at first measurement − lactate 6 h after)/lactate at first measurement × 100] was calculated 6 h after first serum lactate measurement. All patients who underwent ECPR were registered retrospectively using opt-out in our outpatient’s segment.

Result

In this retrospective study, 64 cases were evaluated, and they were classified into two groups according to lactate clearance: high-clearance group, > 65%; low-clearance group, ≤ 65%. Surviving discharge rate of high-clearance group (12 cases, 63%) is significantly higher than that of low-clearance group (11 cases, 24%) (p < 0.01). Considering other confounders, lactate clearance was an independent predictor for in-hospital mortality (odds ratio, 7.10; 95% confidence interval, 1.71–29.5; p < 0.01). Both net reclassification improvement (0.64, p < 0.01) and integrated reclassification improvement (0.12, p < 0.01) show that adding lactate clearance on established risk factors improved the predictability of in-hospital mortality.

Conclusion

In our study, lactate clearance calculated through arterial blood gas analysis 6 h after ECPR was one of the most important predictors of in-hospital mortality in patients treated with ECPR after cardiac arrest.

Early prognosis and predictor analysis for positive coronary angiography after out-of-hospital cardiac arrest (OHCA)

BACKGROUND

Key predictors of survival after OHCA have been described in the literature. Current guidelines recommend emergency angiography in patients without an obvious extra-cardiac cause of arrest. However, the value of this strategy is debated. Moreover, diagnosis of acute coronary ischaemia after OHCA remains challenging, especially in patients without ST-segment elevation.

OBJECTIVES

The primary objective was to identify qualitative variables associated with an increased chance of 30-d survival after OHCA. The secondary objective was to identify predictors of 30-d survival among patients with ischaemic cardiomyopathy and patients without ST-segment elevation. Afterwards, we sought to identify parameters associated with acute coronary ischaemia and positive coronary angiography in patients without ST-segment elevation.

METHODS

Retrospective single-centre study including 123 patients resuscitated from OHCA. Baseline characteristics, resuscitation settings and angiographic findings were analysed.

RESULTS

The predictors of 30-d survival after OHCA included witnessed cardiac arrest, haemodynamic instability and coronary angiography. Convertible cardiac rhythm, history of coronary disease and presence of at least two cardiovascular risk factors were associated with acute coronary ischaemia. Predictors for a positive angiography in patients without ST-segment elevation included history of coronary disease, gender, diabetes, dyslipidaemia and presence of at least two cardiovascular risk factors (all p < .05).

CONCLUSIONS

We identified qualitative predictors of 30-day survival after OHCA. Our findings suggest that the recognition of acute coronary ischaemia after OHCA might be improved. The identification of risk criteria may help to select the best candidates for emergency angiography.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for emergency cardiac support

PURPOSE

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may provide benefit to patients in refractory cardiac arrest and cardiogenic shock. We aim to summarize our center's 6-year experience with resuscitative VA-ECMO.

MATERIALS AND METHODS

A retrospective medical record review (April 2009 to 2015) was performed on consecutive non-cardiotomy patients who were managed with VA-ECMO due to refractory in- or out-of-hospital cardiac (IHCA/OHCA) arrest (E-CPR) or refractory cardiogenic shock (E-CS) with or without preceding cardiac arrest. Our primary outcome was survival to hospital discharge and good neurological status (Cerebral Performance Category 1-2).

RESULTS

There were a total of 22 patients who met inclusion criteria of whom 9 received E-CPR (8 IHCA, 1 OHCA) and 13 received E-CS. The median age for E-CPR patients was 52 [IQR 45, 58] years, and 54 [IQR 38, 64] years for E-CS patients. Cardiac arrest duration was 70.33 (SD 39.56) min for the E-CPR patients, and 24.67 (SD 26.73) min for the 9 patients treated with E-CS who had previously arrested. Initial cardiac arrest rhythms were pulseless electrical activity (39%), ventricular fibrillation (33%), or ventricular tachycardia (28%). A total of 18/22 patients were successfully weaned from VA-ECMO (78%); 16 patients survived to hospital discharge (73%) with 15 in good neurological condition.

CONCLUSION

The initiation of VA-ECMO at our center for treatment of refractory cardiac arrest and cardiogenic shock yielded a high proportion of survivors and favorable neurological outcomes.

Increased cardiac arrest survival and bystander intervention in enclosed pedestrian walkway systems

BACKGROUND

Cities worldwide have underground or above-ground enclosed walkway systems for pedestrian travel, representing unique environments for studying out-of-hospital cardiac arrests (OHCAs). The characteristics and outcomes of OHCAs that occur in such systems are unknown.

OBJECTIVE

To determine whether OHCAs occurring in enclosed pedestrian walkway systems have differing demographics, prehospital intervention, and survival outcomes compared to the encompassing city, by examining the PATH walkway system in Toronto.

METHODS

We identified all atraumatic, public-location OHCAs in Toronto from April 2006 to March 2016. Exclusion criteria were obvious death, existing DNR, and EMS-witnessed OHCAs. OHCAs were classified into mutually exclusive location groups: Toronto, Downtown, and PATH-accessible. PATH-accessible OHCAs were those that occurred within the PATH system between the first basement and third floor. We analyzed demographic, prehospital intervention, and survival data using t-tests and chi-squared tests.

RESULTS

We identified 2172 OHCAs: 1752 Toronto, 371 Downtown, and 49 PATH-accessible. Compared to Toronto, a significantly higher proportion of PATH-accessible OHCAs was bystander-witnessed (62.6% vs 83.7%, p=0.003), had bystander CPR (56.6% vs 73.5%, p=0.019), bystander AED use (11.0% vs 42.6%, p<0.001), shockable initial rhythm (45.5% vs 72.9%, p<0.001), and overall survival (18.5% vs 33.3%, p=0.009). Similar significant differences were observed when compared to Downtown.

CONCLUSIONS

This study suggests that OHCAs in enclosed pedestrian walkway systems are uniquely different from other public settings. Bystander resuscitation efforts are significantly more frequent and survival rates are significantly higher. Urban planners in similar infrastructure systems worldwide should consider these findings when determining AED placement and public engagement strategies.

Early predictors of poor outcome after out-of-hospital cardiac arrest

Background

Early identification of predictors for a poor long-term outcome in patients who survive the initial phase of out-of-hospital cardiac arrest (OHCA) may facilitate future clinical research, the process of care and information provided to relatives. The aim of this study was to determine the association between variables available from the patient’s history and status at intensive care admission with outcome in unconscious survivors of OHCA.

Methods

Using the cohort of the Target Temperature Management trial, we performed a post hoc analysis of 933 unconscious patients with OHCA of presumed cardiac cause who had a complete 6-month follow-up. Outcomes were survival and neurological function as defined by the Cerebral Performance Category (CPC) scale at 6 months after OHCA. After multiple imputations to compensate for missing data, backward stepwise multivariable logistic regression was applied to identify factors independently predictive of a poor outcome (CPC 3–5). On the basis of these factors, a risk score for poor outcome was constructed.

Results

We identified ten independent predictors of a poor outcome: older age, cardiac arrest occurring at home, initial rhythm other than ventricular fibrillation/tachycardia, longer duration of no flow, longer duration of low flow, administration of adrenaline, bilateral absence of corneal and pupillary reflexes, Glasgow Coma Scale motor response 1, lower pH and a partial pressure of carbon dioxide in arterial blood value lower than 4.5 kPa at hospital admission. A risk score based on the impact of each of these variables in the model yielded a median (range) AUC of 0.842 (0.840–0.845) and good calibration. Internal validation of the score using bootstrapping yielded a median (range) AUC corrected for optimism of 0.818 (0.816–0.821).

Conclusions

Among variables available at admission to intensive care, we identified ten independent predictors of a poor outcome at 6 months for initial survivors of OHCA. They reflected pre-hospital circumstances (six variables) and patient status on hospital admission (four variables). By using a simple and easy-to-use risk scoring system based on these variables, patients at high risk for a poor outcome after OHCA may be identified early.

Factors modifying performance of a novel citizen text message alert system in improving survival of out-of-hospital cardiac arrest

AIMS

Recently we found that the text message alert system increases survival of sudden out-of-hospital cardiac arrest. The aim of the present study is to explore the contribution of the system to survival specifically in resuscitation settings with prolonged delay of start of resuscitation.

METHODS AND RESULTS

Data were used from consecutive patients resuscitated for out-of-hospital cardiac arrest during a two-year period in the Dutch province Limburg. Survival of 291 cases with out-of-hospital cardiac arrest where one or more volunteers attended (Scenario 2) was compared with survival of 131 cases with out-of-hospital cardiac arrest where no volunteers attended and only standard care was given (Scenario 1). Multivariable logistic regression models including terms for interaction between scenario and the covariate coding for resuscitation setting were used to test for effect modification. The highest impact on survival of the alert system was observed in cases of (a) witnessed arrests (odds ratio=2.25; 95% confidence interval: 1.27-4.00; p=0.005); (b) arrests that occurred in the home (odds ratio=2.28; 95% confidence interval: 1.21-4.28; p=0.011); (c) arrival of the ambulance with a delay of 7-10 min (odds ratio=2.63; 95% confidence interval: 1.09-6.35; p=0.032); and (d) arrests at evening/night (odds ratio=3.07; 95% confidence interval: 1.34-7.03; p=0.008). Due to the low sample size, p-values from tests for interaction were non-significant.

CONCLUSION

The contribution of the alert system to survival is most substantial in cases of witnessed arrest, in the home situation, at slightly delayed arrival of the first ambulance and during the evening/night.