Women have lower chances than men to be resuscitated and survive out-of-hospital cardiac arrest

Aims

Previous studies on sex differences in out-of-hospital cardiac arrest (OHCA) had limited scope and yielded conflicting results. We aimed to provide a comprehensive overall view on sex differences in care utilization, and outcome of OHCA.

Methods and results

We performed a population-based cohort-study, analysing all emergency medical service (EMS) treated resuscitation attempts in one province of the Netherlands (2006–2012). We calculated odds ratios (ORs) for the association of sex and chance of a resuscitation attempt by EMS, shockable initial rhythm (SIR), and in-hospital treatment using logistic regression analysis. Additionally, we provided an overview of sex differences in overall survival and survival at successive stages of care, in the entire study population and in patients with SIR. We identified 5717 EMS-treated OHCAs (28.0% female). Women with OHCA were less likely than men to receive a resuscitation attempt by a bystander (67.9% vs. 72.7%; P < 0.001), even when OHCA was witnessed (69.2% vs. 73.9%; P < 0.001). Women who were resuscitated had lower odds than men for overall survival to hospital discharge [OR 0.57; 95% confidence interval (CI) 0.48–0.67; 12.5% vs. 20.1%; P < 0.001], survival from OHCA to hospital admission (OR 0.88; 95% CI 0.78–0.99; 33.6% vs. 36.6%; P = 0.033), and survival from hospital admission to discharge (OR 0.49, 95% CI 0.40–0.60; 33.1% vs. 51.7%). This was explained by a lower rate of SIR in women (33.7% vs. 52.7%; P < 0.001). After adjustment for resuscitation parameters, female sex remained independently associated with lower SIR rate.

Conclusion

In case of OHCA, women are less often resuscitated by bystanders than men. When resuscitation is attempted, women have lower survival rates at each successive stage of care. These sex gaps are likely explained by lower rate of SIR in women, which can only partly be explained by resuscitation characteristics.

P2604Clinical features associated with the development of diastolic dysfunction

Background/Introduction

Treatment for heart failure with preserved ejection fraction (HFpEF) is still elusive, which is a serious problem given the fact that it affects approximately 8 million people in Europe. Diastolic dysfunction (DD) is considered a precursor of HFpEF and could serve as a target for prevention. However, it is yet unclear which clinical features are associated with the development of diastolic dysfunction in men and women.

Purpose

To determine which clinical features are associated with the development of diastolic dysfunction in men and women visiting a cardiology outpatient clinic.

Methods

All individuals who visited one of the 13 Cardiology Centers Netherlands locations at least twice between April and 2007 and February 2018 for an echocardiographic evaluation were eligible for inclusion. Participants with incomplete data on diastolic function parameters or diastolic dysfunction at baseline were excluded. Information on age, sex, body mass index (BMI), systolic blood pressure (SBP), blood lipid levels, kidney function, cardiac history, co-morbidities and cardiovascular drug use was obtained for all participants. Diastolic function was scored based on E/e', relative wall thickness (RWT) and left-atrial dimension indexed by body surface area (LAD/BSA). The score allotted zero points for E/e' ≤8, RWT ≤0.41 and LAD/BSA ≤2.3, one point for E/e' between 9–14, RWT >0.42 and LAD/BSA >2.3, and two points for E/e' ≥15. Development of DD was defined as an increase in diastolic function score between the first and second echo. Missing data on determinants (max 26%) was imputed using multiple imputation. A stepwise logistic regression based on AIC was applied to evaluate the association between selected clinical features and DD. All analyses were performed in R.

Results

The study population comprised 1301 patients with a mean age of 56 (± 11) years and 46% were women. The median time between echo appointments was 631 (IQR: 381–1132) days and 549 patients developed DD (42%). After stepwise regression, the final model included age, sex, BMI, SBP, triglycerides and hypertension. DD was less likely to occur in men compared with women (OR=0.62, 95% CI: 0.57–0.67), and more likely in patients with hypertension (OR=1.29, 95% CI: 1.18–1.42) after adjustment. The adjusted risk for DD increased with triglyceride level (OR=1.24, 95% CI: 1.19–1.29), age (OR=1.04 per year, 95% CI: 1.03–1.04), BMI (OR=1.03 per kg/m2, 95% CI: 1.01–1.04) and SBP (OR=1.01 per 1 mmHg, 95% CI: 1.006–1.011) (Figure 1).

Figure 1

Conclusion(s)

Women and those with hypertension were at higher risk of developing DD compared to their male or normotensive counterparts. Age, triglyceride levels, BMI and SBP were also independently associated with an increased risk for DD. Prevention efforts focussing on life style changed and possibly lipid and blood pressure lowering drugs may reduce the risk of developing DD.

Genetic, clinical and pharmacological determinants of out-of-hospital cardiac arrest: rationale and outline of the AmsteRdam Resuscitation Studies (ARREST) registry

Introduction

Out-of-hospital cardiac arrest (OHCA) is a major public health problem. Recognising the complexity of the underlying causes of OHCA in the community, we aimed to establish the clinical, pharmacological, environmental and genetic factors and their interactions that may cause OHCA.

Methods and analysis

We set up a large-scale prospective community-based registry (AmsteRdam Resuscitation Studies, ARREST) in which we prospectively include all resuscitation attempts from OHCA in a large study region in the Netherlands in collaboration with Emergency Medical Services. Of all OHCA victims since June 2005, we prospectively collect medical history (through hospital and general practitioner), and current and previous medication use (through community pharmacy). In addition, we include DNA samples from OHCA victims with documented ventricular tachycardia/fibrillation during the resuscitation attempt since July 2007. Various study designs are employed to analyse the data of the ARREST registry, including case–control, cohort, case only and case-cross over designs.

Ethics and dissemination

We describe the rationale, outline and potential results of the ARREST registry. The design allows for a stable and reliable collection of multiple determinants of OHCA, while assuring that the patient, lay-caregiver or medical professional is not hindered in any way. Such comprehensive data collection is required to unravel the complex basis of OHCA. Results will be published in peer-reviewed journals and presented at relevant scientific symposia.

Reduced in-hospital survival rates of out-of-hospital cardiac arrest victims with obstructive pulmonary disease

AIM

Out-of-hospital cardiac arrest (OHCA) due to sustained ventricular tachycardia/fibrillation (VT/VF) is common and often lethal. Patient's co-morbidities may determine survival after OHCA, and be instrumental in post-resuscitation care, but are poorly studied. We aimed to study whether patients with obstructive pulmonary disease (OPD) have a lower survival rate after OHCA than non-OPD patients.

METHODS

We performed a community-based cohort study of 1172 patients with non-traumatic OHCA with ECG-documented VT/VF between 2005 and 2008. We compared survival to emergency room (ER), to hospital admission, to hospital discharge, and at 30 days after OHCA, of OPD-patients and non-OPD patients, using logistic regression analysis. We also compared 30-day survival of patients who were admitted to hospital, using multivariate logistic regression analysis.

RESULTS

OPD patients (n=178) and non-OPD patients (n=994) had comparable survival to ER (75% vs. 78%, OR 0.9 [95% CI: 0.6-1.3]) and to hospital admission (56% vs. 57%, OR 1.0 [0.7-1.4]). However, survival to hospital discharge was significantly lower among OPD patients (21% vs. 33%, OR 0.6 [0.4-0.9]). Multivariate regression analysis among patients who were admitted to hospital (OPD: n=100, no OPD: n=561) revealed that OPD was an independent determinant of reduced 30-day survival rate (39% vs. 59%, adjusted OR 0.6 [0.4-1.0, p=0.035]).

CONCLUSION

OPD-patients had lower survival rates after OHCA than non-OPD patients. Survival to ER and to hospital admission was not different between both groups. However, among OHCA victims who survived to hospital admission, OPD was an independent determinant of reduced 30-day survival rate.

Epilepsy is a risk factor for sudden cardiac arrest in the general population

BACKGROUND

People with epilepsy are at increased risk for sudden death. The most prevalent cause of sudden death in the general population is sudden cardiac arrest (SCA) due to ventricular fibrillation (VF). SCA may contribute to the increased incidence of sudden death in people with epilepsy. We assessed whether the risk for SCA is increased in epilepsy by determining the risk for SCA among people with active epilepsy in a community-based study.

METHODS AND RESULTS

This investigation was part of the Amsterdam Resuscitation Studies (ARREST) in the Netherlands. It was designed to assess SCA risk in the general population. All SCA cases in the study area were identified and matched to controls (by age, sex, and SCA date). A diagnosis of active epilepsy was ascertained in all cases and controls. Relative risk for SCA was estimated by calculating the adjusted odds ratios using conditional logistic regression (adjustment was made for known risk factors for SCA). We identified 1019 cases of SCA with ECG-documented VF, and matched them to 2834 controls. There were 12 people with active epilepsy among cases and 12 among controls. Epilepsy was associated with a three-fold increased risk for SCA (adjusted OR 2.9 [95%CI 1.1-8.0.], p=0.034). The risk for SCA in epilepsy was particularly increased in young and females.

CONCLUSION

Epilepsy in the general population seems to be associated with an increased risk for SCA.

Implantable cardioverter-defibrillators have reduced the incidence of resuscitation for out-of-hospital cardiac arrest caused by lethal arrhythmias

BACKGROUND

Over the last decades, a gradual decrease in ventricular fibrillation (VF) as initial recorded rhythm during resuscitation for out-of-hospital cardiac arrest (OHCA) has been noted. We sought to establish the contribution of implantable cardioverter-defibrillator (ICD) therapy to this decline.

METHODS AND RESULTS

Using a prospective database of all OHCA resuscitation in the province North Holland in the Netherlands (Amsterdam Resuscitation Studies [ARREST]), we collected data on all patients in whom resuscitation for OHCA was attempted in 2005-2008. VF OHCA incidence (per 100 000 inhabitants per year) was compared with VF OHCA incidence data during 1995-1997, collected in a similar way. We also collected ICD interrogations of all ICD patients from North Holland and identified all appropriate ICD shocks in 2005-2008; we calculated the number of prevented VF OHCA episodes, considering that only part of the appropriate shocks would result in avoided resuscitation. VF OHCA incidence decreased from 21.1/100 000 in 1995-1997 to 17.4/100 000 in 2005-2008 (P<0.001). Non-VF OHCA increased from 12.2/100 000 to 19.4/100 000 (P<0.001). VF as presenting rhythm declined from 63% to 47%. In 2005-2008, 1972 ICD patients received 977 shocks. Of these shocks, 339 were caused by a life-threatening arrhythmia. We estimate that these 339 shocks have prevented 81 (minimum, 39; maximum, 152) cases of VF OHCA, corresponding with 33% (minimum, 16%; maximum, 63%) of the observed decline in VF OHCA incidence.

CONCLUSIONS

The incidence of VF OHCA decreased over the last 10 years in North Holland. ICD therapy explained a decrease of 1.2/100 000 inhabitants per year, corresponding with 33% of the observed decline in VF OHCA.

Incidence, causes, and outcomes of out-of-hospital cardiac arrest in children. A comprehensive, prospective, population-based study in the Netherlands

OBJECTIVES

This study sought to determine comprehensively the incidence of pediatric out-of-hospital cardiac arrest (OHCA) and its contribution to total pediatric mortality, the causes of pediatric OHCA, and the outcome of resuscitation of pediatric OHCA patients.

BACKGROUND

There is a paucity of complete studies on incidence, causes, and outcomes of pediatric OHCA.

METHODS

In this prospective, population-based study, OHCA victims younger than age 21 years in 1 province of the Netherlands were registered through both emergency medical services and coroners over a period of 4.3 years. Death certificate data on total pediatric mortality, survival status, and neurological outcome at hospital discharge also were obtained.

RESULTS

With a total mortality of 923 during the study period and 233 victims of OHCA (including 221 who died and 12 who survived), OHCA caused 24% (221 of 923) of total pediatric mortality. Natural causes of OHCA amounted to 115 (49%) cases, with cardiac causes being most prevalent (n = 90, 39%). The incidence of pediatric OHCA was 9.0 per 100,000 pediatric person-years (95% confidence interval: 7.8 to 10.3), whereas the incidence of pediatric OHCA from cardiac causes was 3.2 (95% confidence interval: 2.5 to 3.9). Of 51 resuscitated patients, 12 (24%) survived; among survivors, 10 (83%) had a neurologically intact outcome.

CONCLUSIONS

Out-of-hospital cardiac arrest accounts for a significant proportion of pediatric mortality, and cardiac causes are the most prevalent causes of OHCA. The vast majority of OHCA survivors have a neurologically intact outcome.

Survival and health care costs until hospital discharge of patients treated with onsite, dispatched or without automated external defibrillator

BACKGROUND

This study aimed to determine whether automated external defibrillator (AED) use during resuscitation is associated with lower in-hospital health care costs.

METHODS

For this observational prospective study, we included all treated out-of-hospital cardiac arrests of suspected cardiac cause. Clinical, survival and cost data were collected from July 2005 until March 2008. Cost data were based on hospital transport, duration of admission in hospital wards, diagnostics and interventions. We divided the study population in three groups based on AED use: (1) onsite AED, (2) dispatched AED, (3) no AED. The endpoint was survival to discharge. P<0.05 is indicated by *.

RESULTS

Of the 2126 included patients, 136 were treated with an onsite AED, 365 with a dispatched AED and 1625 without AED. Overall (95% confidence interval [CI]) survival rate was 43% (35-51%), 16% (13-20%) and 14% (12-16%), respectively*. Per 100 survivors, the mean duration admitted at intensive care unit [ICU] were 267 (166-374), 495 (344-658), and 537 (450-609) days, respectively*; total duration of hospital admission was 2188 (1800-2594), 3132 (2573-3797), and 2765 (2519-3050) days, respectively*. Mean costs per survivor for hospital stay were euro9233 (euro7351-euro11,280), euro14,194 (euro11,656-euro17,254), and euro13,693 (euro12,226-euro15,166), respectively*; total health care costs were euro29,575 (euro24,695-euro34,183), euro34,533 (euro29,832-euro39,487) and euro31,772 (euro29,217-euro34,385), respectively. For both survivors and non-survivors, total costs per patient were euro14,727 (euro11,957-euro18,324), euro7703 (euro6141-euro9366) and euro6580 (euro5875-euro7238), respectively*.

CONCLUSIONS

Onsite AED use was associated with higher survival rates. Surviving patients of the onsite AED group had lower total costs, mainly due to the shorter ICU stay.

[First cracks in smoking ban in catering establishments]

The first exemption to the comprehensive ban on smoking in public places in the Netherlands was made on 14 May 2009. The exemption was based on a technicality in the wording of the law, and could potentially lead to further exemptions to the smoking ban being made. The authors argue that focusing solely on the wording is a sidetrack in the main discussion. Furthermore, they argue that the smoking ban only bans smoking in public places and that the individual's right to perform actions potentially hazardous to their own health should not be limited, as long as it puts no-one else at risk. That is exactly what smoking in public places does. They also argue that other legislative measures comparable to the smoking ban are already in effect. In conclusion, the ban on smoking in public places does not remove the right to smoke, but serves to create a healthier social environment for everyone.

Third-Order Nonlinear Optical Figure of Merits for Conjugated TTF−Quinone Molecules

We have revealed a substantial enhancement of third-order optical figure of merits by the synthesis of a compact molecule possessing the tetrathiafulvalene (TTF) group with two backside C=O groups. Addition of the saturated methylene chain substantially suppresses the third-order optical figure of merits and even local optical hyperpolarizabilities at lambda = 532 nm. Another TTF-derivative molecule possessing ethylenic and acetylenic chains demonstrates large hyperpolarizabilities; however, generally, the figure of merit factor decreases due to the increasing optical losses as a consequence of enhanced linear absorption. At the same time, both of the chromophores have a large nonlinear optical response. General approaches for search and design of the third-order optical materials with improved properties are given.