Long-term follow-up of cardiac arrest survivors: Protocol of the DESAC (Devenir des survivants d'Arrets Cardiaques) study, a French multicentric prospective cohort

Background

While the short-term prognosis of cardiac arrest patients - nearly 250,000 new cases per year in Europe - has been extensively studied, less is known regarding the mid and long-term outcome of survivors.

Objective

The aim of the DESAC study is to describe mid- and long-term survival rate and functional status of cardiac arrest survivors, and to assess the influence of pre and intra hospital therapeutic strategies on these two outcomes.

Methods

Between Jul 2015 and Oct 2018, adult patients over 18 years who were discharged alive from any intensive care units (public and private hospitals) in the Ile-de-France area (Paris and suburbs, France) after a non-traumatic cardiac arrest were screened for participation in this multicentric study. Survivors were included after they signed (or the proxies) an informed consent before discharge during initial hospitalisation. We calculated that including 600 patients in total would allow an 80% power to demonstrate a 2 years survival rate difference of 10% between patients who did and those who did not receive therapeutic hypothermia after resuscitation. Pre- and in-hospital data related to the circumstances surrounding the event and to the therapeutic interventions (such as cardio-pulmonary resuscitation, defibrillation, emergent coronary revascularization, neuroprotective therapeutics) were collected. After discharge, patients were interviewed at 3 months, 6 months and every year thereafter for a minimum follow-up of 26 months and a maximum follow-up of 48 months. Information on vital status, occurrence of cardiovascular events, medications and a comprehensive assessment of the functional status (qualitive of life as assessed by the Short-Form General Health Survey (SF36) scale, activities of daily living (ADL) scale, neurological Cerebral Performance Categories (CPC) and Overall Performance Categories (OPC) scales, socio-professional activities) were collected at follow-up interviews.

Discussion

The DESAC study should provide important information regarding several dimensions of the mid and long-term prognosis of cardiac arrest survivors and on the benefit (and potentially harm) of early therapeutic strategies.

Differential Effect of Targeted Temperature Management Between 32 °C and 36 °C Following Cardiac Arrest According to Initial Severity of Illness: Insights From Two International Data Sets

BACKGROUND

Recent guidelines have emphasized actively avoiding fever to improve outcomes in patients who are comatose following resuscitation from cardiac arrest (ie, out-of-hospital cardiac arrest). However, whether targeted temperature management between 32 °C and 36 °C (TTM32-36) can improve neurologic outcome in some patients remains debated.

RESEARCH QUESTION

Is there an association between the use of TTM32-36 and outcome according to severity assessed at ICU admission using a previously derived risk score?

STUDY DESIGN AND METHODS

Data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (France) between May 2011 and December 2017 and in the Resuscitation Outcomes Consortium Continuous Chest Compressions (ROC-CCC) trial (United States and Canada) between June 2011 and May 2015 were used for this study. Severity at ICU admission was assessed through a modified version of the Cardiac Arrest Hospital Prognosis (mCAHP) score, divided into tertiles of severity. The study explored associations between TTM32-36 and favorable neurologic status at hospital discharge by using multiple logistic regression as well as in tertiles of severity for each data set.

RESULTS

A total of 2,723 patients were analyzed in the SDEC data set and 4,202 patients in the ROC-CCC data set. A favorable neurologic status at hospital discharge occurred in 728 (27%) patients in the French data set and in 1,239 (29%) patients in the North American data set. Among the French data set, TTM32-36 was independently associated with better neurologic outcome in the tertile of patients with low (adjusted OR, 1.63; 95% CI, 1.15-2.30; P = .006) and high (adjusted OR, 1.94; 95% CI, 1.06-3.54; P = .030) severity according to mCAHP at ICU admission. Similar results were observed in the North American data set (adjusted ORs of 1.36 [95% CI, 1.05-1.75; P = .020] and 2.42 [95% CI, 1.38-4.24; P = .002], respectively). No association was observed between TTM32-36 and outcome in the moderate groups of the two data sets.

INTERPRETATION

TTM32-36 was significantly associated with a better outcome in patients with low and high severity at ICU admission assessed according to the mCAHP score. Further studies are needed to evaluate individualized temperature control following out-of-hospital cardiac arrest.

Organ donation after out-of-hospital cardiac arrest: a population-based study of data from the Paris Sudden Death Expertise Center

BACKGROUND

Organ shortage is a major public health issue, and patients who die after out-of-hospital cardiac arrest (OHCA) could be a valuable source of organs. Here, our objective was to identify factors associated with organ donation after brain death complicating OHCA, in unselected patients entered into a comprehensive real-life registry covering a well-defined geographic area.

METHODS

We prospectively analyzed consecutive adults with OHCA who were successfully resuscitated, but died in intensive care units in the Paris region in 2011-2018. The primary outcome was organ donation after brain death. Independent risk factors were identified using logistic regression analysis. One-year graft survival was assessed using Cox and log-rank tests.

RESULTS

Of the 3061 included patients, 136 (4.4%) became organ donors after brain death, i.e., 28% of the patients with brain death. An interaction between admission pH and post-resuscitation shock was identified. By multivariate analysis, in patients with post-resuscitation shock, factors associated with organ donation were neurological cause of OHCA (odds ratio [OR], 14.5 [7.6-27.4], P < 0.001), higher pH (OR/0.1 increase, 1.3 [1.1-1.6], P < 0.001); older age was negatively associated with donation (OR/10-year increase, 0.7 [0.6-0.8], P < 0.001). In patients without post-resuscitation shock, the factor associated with donation was neurological cause of OHCA (OR, 6.9 [3.0-15.9], P < 0.001); higher pH (OR/0.1 increase, 0.8 [0.7-1.0], P = 0.04) and OHCA at home (OR, 0.4 [0.2-0.7], P = 0.006) were negatively associated with organ donation. One-year graft survival did not differ according to Utstein characteristics of the donor.

CONCLUSIONS

4% of patients who died in ICU after OHCA led to organ donation. Patients with OHCA constitute a valuable source of donated organs, and special attention should be paid to young patients with OHCA of neurological cause.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study

Aims

Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods and results

We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).

Conclusions

In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

P4167Non-shockable rhythm related sudden cardiac arrest in the community

Introduction

A significant increase in the prevalence of sudden cardiac arrest (SCA) with non-shockable rhythm has been reported, related to asystole and pulseless electrical activity (PEA). Factors associated with non-shockable rhythm and the mode to the return of spontaneous circulation (ROSC) may help for a better understanding.

Purpose

We aimed to describe the frequency, characteristics and outcome of SCA related to non-shockable versus shockable rhythm in the community.

Methods

In this prospective ongoing, multicentre population-based registry (6.7 million inhabitants), data from all SCA over a 5-year period were analyzed. Initial rhythm was obtained from the EMS report and the initial recorded rhythm strip when available. Medical records for each SCA were reviewed by cardiologists to identify underlying aetiology and associated conditions.

Results

Among the 3,028 SCAs admitted alive out of a total of 18,622 out-of-hospital cardiac arrests from May 2011 to May 2016, 2,904 patients had available information regarding initial rhythm at the time of EMS arrival. Among them, 1,314 patients (45.3%) presented with non-shockable rhythm: 1,109 (38.2%) cases with asystole, 197 (6.8%) with PEA and 8 (0.3%) with high degree atrioventricular block.

Cases with non-shockable rhythm were older (60.6 vs. 57.4 years, P<0.001), with greater proportion of females (34.9 vs. 19.2%, P<0.001) and less proportion of family history of coronary artery disease or SCA. Proportion of warning symptoms prior to the SCA was higher among patients with non-shockable rhythm (74.3 vs. 64.9%, P<0.001) but the proportion of chest pain was lower (24.0 vs. 43.3%, P<0.001). Survival rate was much lower in non-shockable rhythm cases (7.2 vs. 42.3%, P<0.001).

Among the 1,314 non-shockable cases eventually admitted alive to hospital, 1,022 (77.8%) did not require external defibrillation prior to ROSC, and a majority (91.7%) received adrenaline during resuscitation. In this subgroup, the main identified cardiac cause was acute coronary syndrome (45.3%), followed by chronic CAD (27.1%), structural non-ischemic heart disease (22.4%), and non-structural heart disease (5.2%).

Conclusions

Initial non-shockable rhythm is encountered in almost half of SCA cases admitted alive; mostly occurs in older patients with higher proportion of females. Over three quarters of these cases did not require external defibrillation prior to ROSC.

P2827Different views of sudden cardiac arrest characteristics according to the assessed population

Background

Survival rate remains extremely low in sudden cardiac arrest (SCA) and death may occur at all stages of its management. We hypothesized that different medical care providers have different visions of the SCA population characteristics.

Purpose

To assess SCA characteristics among four groups: all-comers SCA, resuscitated SCA, SCA admitted alive to intensive care unit (ICU), and SCA admitted to cardiology.

Methods

Data was taken from the Paris Sudden Cardiac Death Expertise Center prospective registry that includes all adults presenting SCA in Paris and suburbs (6.7 millions). We compared SCA characteristics according to the management phase where the population was assessed.

Results

Of 18,622 out-of-hospital cardiac arrests occurring between 2011 and 2016, 15,207 fulfilled SCA criteria and had known resuscitation status. Among them, 9,721 SCA (63.9%) underwent resuscitation, leading to 3,349 SCA (22.0%) admitted to ICU, then 735 (4.8%) admitted to Cardiology. Mean age was highest in the global population (70.7yrs), and decreased progressively throughout the phases to 57.0yrs in cardiology (P<0.001). Ratio of male victims and rates of witnessed SCA and bystanders' cardiopulmonary resuscitation and automated external defibrillator use increased gradually (all P<0.001). No flow duration decreased by a third (9.1min overall to 3.0min in cardiology, P<0.001). The rate of shockable initial rhythm increased drastically, from 19.5% overall to 26.8% in resuscitated patients, 48.9% in ICU-admitted SCA, and 89.4% in cardiology-admitted (Table).

Sudden cardiac arrests characteristics Entire SCA population SCA with attempted resuscitation SCA admitted to ICU SCA admitted to Cardiology P value n=15,207 n=9,721 n=3349 n=735 Age (years ± SD) 70.7±16.9 65.8±16.1 59.7±15.7 57.0±14.5 <0.001 Male sex, n (%) 9,353 (61.6) 6607 (68.0) 2395 (71.5) 599 (81.5) <0.001 Home location, n (%) 12,297 (81.1) 7075 (73.0) 1906 (56.9) 269 (36.6) <0.001 Bystander, n (%) 10,546 (71.2) 7545 (78.7) 3037 (90.7) 715 (97.3) <0.001 Bystander CPR, n (%) 5,684 (39.1) 4504 (47.7) 2120 (63.5) 583 (81.2) <0.001 Public AED use, n (%) 155 (1.0) 142 (1.5) 116 (3.5) 51 (6.9) <0.001 No flow, (min ± SD) 9.1±12.5 7.5±10.4 5.3±6.6 3.0±3.8 <0.001 EMS call-to-arrival delay, (min ± SD) 10.2±5.8 10.1±5.7 10.1±6.1 9.6±6.4 0.068 Initial Shockable rhythm, n (%) 2,643 (19.5) 2529 (26.8) 1635 (48.9) 657 (89.4) <0.001 SCA: sudden cardiac arrest; AED: automated external defibrillator; CPR: cardiopulmonary resuscitation; EMS: emergency medical service; ICU: intensive care unit.

Conclusion

Characteristics of SCA change considerably according to the assessed population, leading to different views on SCA reality. Keeping in mind the SCA population considered is paramount for a non-biased view of SCA.

Mathematical model for evaluating the Krebs cycle flux with non-constant glutamate-pool size by 13C-NMR spectroscopy. Evidence for the existence of two types of Krebs cycles in cells

A practical method using matrix operations is proposed for studying the isotopic transformation of glutamate, or any other metabolite isotopomers, in the Krebs cycle. Two mathematical models were constructed for evaluating the Krebs cycle flux where the enrichment of [2-13C]acetyl-CoA is not 100% and the total glutamate concentration remains constant or varies during incubation. A comparative study of [1-13C]glucose metabolism was subsequently carried out using Saccharomyces cerevisiae cells from two different strains (ATCC-9763 and NCYC-239) by 13C-NMR spectroscopy and biochemical techniques. The results show that there are two types of Krebs cycles in cells. The first is represented by the ATCC cells which contain a small amount of 2-oxoglutarate dehydrogenase and hence the flux in the Krebs cycle is negligible. With [1-13C]glucose as a carbon source, the 13C-NMR spectra of glutamate exhibit the C2 and C4 resonances that are almost equivalent and much greater than that of the C3. Labeled metabolites derived from [1-13C]glucose enter the Krebs cycle at two points: oxaloacetate and citrate. The second cell type is represented by NCYC-239. The C2 and C3 areas are equivalent and smaller than the C4 resonance. The results suggest that labeled metabolites enter the Krebs cycle only at the citrate level via acetyl-CoA, 2-oxoglutarate dehydrogenase is present but pyruvate carboxylase is virtually absent or inactivated. When both are incubated with glucose, the total concentration of glutamate was found to decrease with the incubation time. The fraction of glutamate in isotopic exchange with the Krebs cycle in NCYC-239 cells is about 2.6% and the reduction in glutamate concentration is about 0.5%/min. Using our model, with a variable glutamate pool size, good agreement between the theoretical and experimental data is obtained.