P2671The addition of admission lactate to the CREST risk score to determine prognosis in out of hospital cardiac arrest: the C-AREST score

Introduction

There has been an increasing focus on the development of scoring systems for patients admitted following resuscitation from out-of-hospital cardiac arrest (OHCA) to determine both prognosis and short-term management. One such system, the CREST score, has been shown to predict circulatory aetiology death in patients without ST-elevation myocardial infarction, however with an increasing number of OHCAs seen, general scoring systems to predict outcome in OHCA would be helpful.

Aims

We sought to determine whether the addition of an admission lactate ≥8 mmol/l to the existing CREST score was able to better predict in-hospital mortality in patients admitted with OHCA.

Methods and results

We retrospectively analysed the data of 500 patients admitted with an OHCA of presumed cardiac origin to our tertiary cardiac centre between June 2014 and Oct 2018. Mean age was 62.6y (±14.7), 379 (76%) were male and 250 (50%) were Caucasian. 313 (62.6%) were admitted with ST elevation myocardial infarction or equivalent. 48.6% (243/500) of patients died in hospital and of those that survived, 20.2% (52/257) were left with hypoxic brain injury (CPC score 3–4).

When analysed independently, all individual factors other than history of Coronary artery disease (OR 1.47, p=0.084) significantly predicted in-hospital mortality: Admission lactate ≥8 mmol/l (OR 6.78, p<0.0001), non-shockable Rhythm (OR 10.9, p<0.0001), Ejection fraction <30% (OR 5.84, p<0.0001), Shock at presentation (OR 5.49, p<0.0001) and ischaemic Time >25 minutes (OR 12.8, p<0.0001).

When each factor was assigned one point and totalled, both increasing CREST and C-AREST scores were associated with increasing in-hospital mortality: CREST (0–5 points): 4.3%, 30.5%, 41.5%, 85.6%, 95.2%, 100% vs C-AREST (0–6 points): 9.1%, 28.3%, 41.9%, 62.8%, 97.6%, 96.4%, 100%. When analysed with stepwise logistic regression, the addition of admission lactate ≥8 mmol/l to the model improved the prediction of in-hospital mortality: CREST (40.8% of variance explained) vs C-AREST (43.3%), with admission lactate remaining an independently significant predictor (OR 3.67, p=0.002).

Conclusion

We describe a novel modification to the previously described CREST scoring system for OHCA: the C-AREST score. The addition of admission lactate ≥8 mmol/l may have a role in differentiating those in intermediate risk categories (score between 2 and 3) where the predicted in hospital mortality would otherwise vary greatly. Given the relative ease of obtaining admission lactate, this scoring system may further improve stratification of patients who may or may not benefit from invasive management.

Eptifibatide is associated with significant cost savings and similar clinical outcomes to abciximab when used during primary percutaneous coronary intervention for ST-elevation myocardial infarction: An observational cohort study of 3863 patients

INTRODUCTION

Glycoprotein IIb/IIIa inhibitors are recommended by guidelines in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. There are few studies directly comparing these agents. The aim of this study was to assess whether eptifibatide is a safe and cost-effective alternative to abciximab in the treatment of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction.

METHODS

This was an observational cohort study of 3863 patients who received a GPIIb/IIIa inhibitor whilst undergoing primary percutaneous coronary intervention from 2007 to 2014. Patients who did not receive a GPIIb/IIIa inhibitor were excluded. Time to first major adverse cardiac event defined as death, non-fatal myocardial infarction, stroke or target vessel revascularization, and total hospital costs were compared between the groups.

RESULTS

In all, 1741 patients received abciximab with 2122 receiving eptifibatide. Patients who received eptifibatide had higher rates of previous MI/percutaneous coronary intervention and were more likely to undergo a procedure from the radial route. Unadjusted Kaplan-Meier analysis revealed no significant difference in the 1-year event rates between patients given eptifibatide versus abciximab (p = 0.201). Age-adjusted Cox analysis demonstrated no difference in 1-year outcome between abciximab and eptifibatide (hazard ratio: 0.83; 95% confidence interval: 0.73-1.39), which persisted after multivariate adjustment (hazard ratio: 0.92; 95% confidence interval: 0.79-1.56) including the incorporation of a propensity score (hazard ratio: 0.88; 95% confidence interval: 0.71-1.44). Eptifbatide was associated with significant cost savings being 87% cheaper overall compared to abciximab (on average £650 cheaper per patient and saving approximately £950,000).

CONCLUSION

This observational data suggest that eptifibatide is associated with similar outcomes and significant cost savings compared to abciximab when used in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.