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.

Care management and 90-day mortality in patients hospitalized for myocardial infarction and COVID-19 in France

Background

Concomitant COVID-19 in patients with myocardial infarction (MI) may lead to difficulties in acute care management and may impair prognosis. To date, studies have involved a limited number of patients.

Purpose

To estimate and compare the characteristics, care management and 90-day outcomes of patients hospitalized for MI who didn’t have Covid-19, with those having concomitant hospital diagnosis of Covid-19 from the French National Health Data System, an exhaustive and nationwide database.

Methods

All patients hospitalised for MI in France between 30 December 2019 and 4 October 2020 were included. Patients with a previous hospitalization with Covid-19 were excluded (n = 135). Patients’ characteristics were compared according to Covid-19 status. 90-day mortality rates and follow-up outcomes were estimated and adjusted on age, sex and comorbidities.

Results

Among the 55,389 patients hospitalized for MI, 329 had concomitant Covid-19 (21% asymptomatic). MI patients with concomitant Covid-19 were more comorbid than patients without Covid-19. They had longer hospital stays, more admissions to resuscitation unit, underwent less percutaneous coronary intervention, and discharged more often to rehabilitation units than patients without Covid-19. The in-hospital and 90-day-out-of hospital mortality rates of MI patients with Covid-19 were 11.9% and 6.2%, respectively, compared to 3.5% and 2.8% in MI patients without Covid-19. The risk of in-hospital and out-of-hospital death remained increased after adjustment on comorbidities (OR_ajin-hosp = 3.31[2.32;4.72], OR_{ajout-of-hosp} = 1.79 [1.02;3.15]).

Conclusions

The prognosis of patients hospitalized for MI who had concomitant Covid-19 was impaired in the short term but also in the medium term. These results underline the need of an urgent protection of the population at cardiovascular risk from Covid-19, as well as a systematized and rapid management despite the pandemic context, and then a close follow-up of these patients.

One year of Covid-19: French nationwide study of hospitalisation, 90-day readmission and mortality rates from myocardial infarction

Background

Studies reported a decrease in hospital admissions for myocardial infarction (MI) in early 2020 due to Covid19 crisis, but these were restricted to the early weeks of the pandemic.

Purpose

To describe patient characteristics, in-hospital management and 90-day mortality of MI patients throughout the year 2020, in particular during periods of lockdowns.

Methods

All patients hospitalised for MI in France from 2017 to 2020 were selected from the national hospital discharge database. Incidence rate ratios were computed to analyze time trends in MI admissions and mortality rates and stratified by type of MI, sex, age, and period of admission. Characteristics and management of patients in 2020 were described and compared to 2017-19 (OR adjusted on temporality, sex, age)

Results

In 2020, 94,747 patients were hospitalized for MI corresponding to a 6% decrease in MI admissions compared to 2017-19. This decrease was more significant during the first lockdown (−24%, P < 0.0001), in particular in week 13 (−40%) than during the second lockdown (−8%). Decreases in MI admissions were more pronounced and longer for NSTEMI, older people and for women. An increase in the rate of STEMI admissions was observed between the two 2020 lockdowns (+4%, P = 0.0005). Admission to a resuscitation unit and complications rates did not differ between 2017-19 and 2020. In early 2020, there was also a decrease in 90-days readmission. In 2020, the in-hospital and 90-days-out-of hospital mortality rates were 5.5% and 3.8%, compared to 5.7% and 3.6% in reference years. Globally and after adjustment, mortality rates did not differ in 2020 vs. 2017-19 (IRR_in-hosp = 1.03[0.98;1.08], P = 0.19 - IRR_out-hosp = 1.04[0.97;1.27], P = 0.21).

Conclusions

This nationwide study showed significant decrease in MI hospitalization during 2020, in particular during the first lockdown, with a slight STEMI increase during the summer. However, these trends were not associated with more cardiac complications or mortality.

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).