Impact of Social Vulnerability on Cardiac Arrest Mortality in the United States, 2016 to 2020

BACKGROUND

Cardiac arrest is 1 of the leading causes of morbidity and mortality, with an estimated 340 000 out-of-hospital and 292 000 in-hospital cardiac arrest events per year in the United States. Survival rates are lower in certain racial and socioeconomic groups.

METHODS AND RESULTS

We performed a county-level cross-sectional longitudinal study using the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research multiple causes of death data set between 2016 and 2020 among individuals of all ages whose death was attributed to cardiac arrest. The Social Vulnerability Index is a composite measure that includes socioeconomic vulnerability, household composition, disability, individuals from racial and ethnic minority groups status and language, and housing and transportation domains. We examined the impact of social determinants on cardiac arrest mortality stratified by age, race, ethnicity, and sex in the United States. All age-adjusted mortality rate (cardiac arrest AAMRs) are reported as per 100 000. Overall cardiac arrest AAMR during the study period was 95.6. The cardiac arrest AAMR was higher for men compared with women (119.6 versus 89.9) and for the Black population compared with the White population (150.4 versus 92.3). The cardiac arrest AAMR increased from 64.8 in counties in quintile 1 of Social Vulnerability Index to 141 in quintile 5, with an average increase of 13% (95% CI, 9.8%-16.9%) in AAMR per quintile increase.

CONCLUSIONS

Mortality from cardiac arrest varies widely, with a >2-fold difference between the counties with the highest and lowest social vulnerability, highlighting the differential burden of cardiac arrest deaths throughout the United States based on social determinants of health.

Risk Factors for Sudden Cardiac Arrest Among Hispanic or Latino Adults in Southern California: Ventura PRESTO and HCHS/SOL

Background Out-of-hospital sudden cardiac arrest (SCA) is a leading cause of mortality, making prevention of SCA a public health priority. No studies have evaluated predictors of SCA risk among Hispanic or Latino individuals in the United States. Methods and Results In this case-control study, adult SCA cases ages 18-85 (n=1,468) were ascertained in the ongoing Ventura Prediction of Sudden Death in Multi-Ethnic Communities (PRESTO) study (2015-2021) in Ventura County, California. Control subjects were selected from 3033 Hispanic or Latino participants who completed Visit 2 examinations (2014-2017) at the San Diego site of the HCHS/SOL (Hispanic Community Health Survey/Study of Latinos). We used logistic regression to evaluate the association of clinical factors with SCA. Among Hispanic or Latino SCA cases (n=295) and frequency-matched HCHS/SOL controls (n=590) (70.2% men with mean age 63.4 and 61.2 years, respectively), the following clinical variables were associated with SCA in models adjusted for age, sex, and other clinical variables: chronic kidney disease (odds ratio [OR], 7.3 [95% CI, 3.8-14.3]), heavy drinking (OR, 4.5 [95% CI, 2.3-9.0]), stroke (OR, 3.1 [95% CI, 1.2-8.0]), atrial fibrillation (OR, 3.7 [95% CI, 1.7-7.9]), coronary artery disease (OR, 2.9 [95% CI, 1.5-5.9]), heart failure (OR, 2.5 [95% CI, 1.2-5.1]), and diabetes (OR, 1.5 [95% CI, 1.0-2.3]). Conclusions In this first population-based study, to our knowledge, of SCA risk predictors among Hispanic or Latino adults, chronic kidney disease was the strongest risk factor for SCA, and established cardiovascular disease was also important. Early identification and management of chronic kidney disease may reduce SCA risk among Hispanic or Latino individuals, in addition to prevention and treatment of cardiovascular disease.

Racial and Ethnic Disparities in Management and Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction

Background The role of race and ethnicity in the outcomes of cardiac arrest (CA) complicating acute myocardial infarction (AMI) is incompletely understood. Methods and Results This was a retrospective cohort study of adult admissions with AMI-CA from the National Inpatient Sample (2012-2017). Self-reported race/ethnicity was classified as White, Black, and others (Hispanic, Asian or Pacific Islander, Native American, Other). Outcomes of interest included in-hospital mortality, coronary angiography, percutaneous coronary intervention, palliative care consultation, do-not-resuscitate status use, hospitalization costs, hospital length of stay, and discharge disposition. Of the 3.5 million admissions with AMI, CA was noted in 182 750 (5.2%), with White, Black, and other races/ethnicities constituting 74.8%, 10.7%, and 14.5%, respectively. Black patients admitted with AMI-CA were more likely to be female, with more comorbidities, higher rates of non-ST-segment-elevation myocardial infarction, and higher neurological and renal failure. Admissions of patients of Black and other races/ethnicities underwent coronary angiography (61.9% versus 70.2% versus 73.1%) and percutaneous coronary intervention (44.6% versus 53.0% versus 58.1%) less frequently compared to patients of white race (p<0.001). Admissions of patients with AMI-CA had significantly higher unadjusted mortality (47.4% and 47.4%) as compared with White patients admitted (40.9%). In adjusted analyses, Black race was associated with lower in-hospital mortality (odds ratio [OR], 0.95; 95% CI, 0.91-0.99; P=0.007) whereas other races had higher in-hospital mortality (OR, 1.11; 95% CI, 1.08-1.15; P<0.001) compared with White race. Admissions of Black patients with AMI-CA had longer length of hospital stay, higher rates of palliative care consultation, less frequent do-not-resuscitate status use, and fewer discharges to home (all P<0.001). Conclusions Racial and ethnic minorities received less frequent guideline-directed procedures and had higher in-hospital mortality and worse outcomes in AMI-CA.

Better Nurse Staffing Is Associated With Survival for Black Patients and Diminishes Racial Disparities in Survival After In-Hospital Cardiac Arrests

BACKGROUND

Racial disparities in survival among patients who had an in-hospital cardiac arrest (IHCA) have been linked to hospital-level factors.

OBJECTIVES

To determine whether nurse staffing is associated with survival disparities after IHCA.

RESEARCH DESIGN

Cross-sectional data from (1) the American Heart Association's Get With the Guidelines-Resuscitation database; (2) the University of Pennsylvania Multi-State Nursing Care and Patient Safety Survey; and (3) The American Hospital Association annual survey. Risk-adjusted logistic regression models, which took account of the hospital and patient characteristics, were used to determine the association of nurse staffing and survival to discharge for black and white patients.

SUBJECTS

A total of 14,132 adult patients aged 18 and older between 2004 and 2010 in 75 hospitals in 4 states.

RESULTS

In models that accounted for hospital and patient characteristics, the odds of survival to discharge was lower for black patients than white patients [odds ratio (OR)=0.70; 95% confidence interval (CI), 0.61-0.82]. A significant interaction was found between race and medical-surgical nurse staffing for survival to discharge, such that each additional patient per nurse lowered the odds of survival for black patients (OR=0.92; 95% CI, 0.87-0.97) more than white patients (OR=0.97; 95% CI, 0.93-1.00).

CONCLUSIONS

Our findings suggest that disparities in IHCA survival between black and white patients may be linked to the level of medical-surgical nurse staffing in the hospitals in which they receive care and that the benefit of being admitted to hospitals with better staffing may be especially pronounced for black patients.

Ambient temperature and risk of cardiovascular events at labor and delivery: A case-crossover study

BACKGROUND

Extreme ambient temperatures are linked to cardiac events in the general population, but this relationship is unclear among pregnant women. We estimated the associations and attributable risk between ambient temperature and the risk of cardiovascular event at labor/delivery, and investigated whether these associations vary by maternal race/ethnicity.

METHODS

We identified 680 women with singleton deliveries affected by cardiovascular events across 12 US sites (2002-2008). Average daily temperature during the week before, delivery day, and each of the seven days before delivery was estimated for each woman. In a case-crossover analysis, exposures during these hazard periods were compared to two control periods before and after delivery using conditional logistic regression adjusted for other environmental factors.

RESULTS

During the cold season (October-April), 1°C lower during the week prior to delivery was associated with a 4% (95% CI: 1-7%) increased risk of having a labor/delivery affected by cardiovascular events including cardiac arrest and stroke. During the warm season (May-September), 1°C higher during the week prior was associated with a 7% (95% CI: 3-12%) increased risk. These risks translated to 13.4 and 23.9 excess events per 100,000 singleton deliveries during the cold and warm season, respectively. During the warm season, the risks were more pronounced on days closer to delivery and Black women appeared to be more susceptible to the same temperature increase.

CONCLUSION

Small changes in temperature appear to affect the risk of having cardiovascular events at labor/delivery. Black women had a differentially higher warm season risk. These findings merit further investigation.

Race as a predictor of morbidity, mortality, and neurologic events after carotid endarterectomy

OBJECTIVE

Racial disparities in the outcomes of patients undergoing carotid endarterectomy (CEA) have been reported. We sought to examine the contemporary relationship between race and outcomes and to report postdischarge events after CEA.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files were reviewed to identify all CEAs performed from 2005 to 2010 by vascular surgeons. The influence of race on outcomes was examined. Multivariate analysis was performed using variables found to be significant on bivariate analysis. The primary outcomes were stroke and mortality. Secondary outcomes were other 30-day complications, including postdischarge events.

RESULTS

CEA was performed on 29,114 white patients (95.7%) and on 1316 black patients (4.3%); the overall stroke and mortality rates were 1.65% and 0.7%, respectively. The stroke rate was 1.6% for whites and 2.5% blacks (P = .009). The 30-day mortality rate was 0.7% for whites and 1.4% for blacks (P = .002). There was a longer operating time (P < .001) and total length of stay (P < .001), more postoperative pneumonias (P = .049), unplanned intubations (P < .001), ventilator dependence (P < .001), cardiac arrests (P < .001), bleeding requiring transfusions (P = .024), and reoperations within 30 days (P = .021) among black patients. Multivariate logistic regression modeling identified black race as an independent risk factor for 30-day mortality (odds ratio, 1.9; P = .007). Black patients also had a greater proportion of in-hospital deaths than white patients (73.7% vs 43.1%; P = .01). There was no between-group difference in the rate of postdischarge strokes. Thirty-six percent of all strokes occurred after discharge at a mean of 8.3 days, and 54.3% of deaths occurred after discharge at a mean of 11 days.

CONCLUSIONS

Black race is an independent risk factor for 30-day mortality after CEA. A significant proportion of strokes and deaths occur after discharge in both racial groups evaluated.

Racial differences in survival after in-hospital cardiac arrest

CONTEXT

Racial differences in survival have not been previously studied after in-hospital cardiac arrest, an event for which access to care is not likely to influence treatment.

OBJECTIVES

To estimate racial differences in survival for patients with in-hospital cardiac arrests and examine the association of sociodemographic and clinical factors and the admitting hospital with racial differences in survival.

DESIGN, SETTING, AND PATIENTS

Cohort study of 10,011 patients with cardiac arrests due to ventricular fibrillation or pulseless ventricular tachycardia enrolled between January 1, 2000, and February 29, 2008, at 274 hospitals within the National Registry of Cardiopulmonary Resuscitation.

MAIN OUTCOME MEASURES

Survival to hospital discharge; successful resuscitation from initial arrest and postresuscitation survival (secondary outcome measures).

RESULTS

Included were 1883 black patients (18.8%) and 8128 white patients (81.2%). Rates of survival to discharge were lower for black patients (25.2%) than for white patients (37.4%) (unadjusted relative rate [RR], 0.73; 95% confidence interval [CI], 0.67-0.79). Unadjusted racial differences narrowed after adjusting for patient characteristics (adjusted RR, 0.81 [95% CI, 0.75-0.88]; P < .001) and diminished further after additional adjustment for hospital site (adjusted RR, 0.89 [95% CI, 0.82-0.96]; P = .002). Lower rates of survival to discharge for blacks reflected lower rates of both successful resuscitation (55.8% vs 67.4% for whites; unadjusted RR, 0.84 [95% CI, 0.81-0.88]) and postresuscitation survival (45.2% vs 55.5% for whites; unadjusted RR, 0.85 [95% CI, 0.79-0.91]). Adjustment for the hospital site at which patients received care explained a substantial portion of the racial differences in successful resuscitation (adjusted RR, 0.92 [95% CI, 0.88-0.96]; P < .001) and eliminated the racial differences in postresuscitation survival (adjusted RR, 0.99 [95% CI, 0.92-1.06]; P = .68).

CONCLUSIONS

Black patients with in-hospital cardiac arrest were significantly less likely to survive to discharge than white patients, with lower rates of survival during both the immediate resuscitation and postresuscitation periods. Much of the racial difference was associated with the hospital center in which black patients received care.

Racial/ethnic differences in bystander CPR in Los Angeles, California

BACKGROUND

Bystander CPR (BCPR) has been demonstrated to improve rates of return of spontaneous circulation, survival to hospital admission, and quality of life in survivors. While previous studies have shown that African Americans are less likely to receive BCPR than Caucasians even after adjusting for variables such as socioeconomic status, BCPR rates in Latinos have not been reported.

OBJECTIVE

To describe BCPR rates in an urban African American and Latino population as compared to Caucasians.

METHODS

A retrospective analysis of the Cardiac Arrest Resuscitation Evaluation in Los Angeles (CARE-LA) database combined with the California Death Statistical Master File (CDSMF). The combined database included location, race/ethnicity/ethnic background, witnessed status, socioeconomic status, and other variables that have previously been associated with differing rates of BCPR.

RESULTS

There were 814 individuals included in the final study group (53% Caucasian, 28% African American, 19% Latino). African Americans and Latinos were younger than the Caucasians, had more events in the home and had a bystander CPR rate of 13% compared to 24% for the Caucasians (OR=0.47 (95%CI: 0.30-0.74) for African Americans and OR=0.48 (95%CI:0.28-0.80) for the Latinos). Bystander CPR was found to be an independent predictor of survival to hospital discharge and, after adjustment, Latino ethnicity was associated with lower rates of bystander CPR (OR 0.45 (95%CI:0.22-0.92)).

CONCLUSION

After adjusting for other variables, Latinos in Los Angeles receive bystander CPR at approximately half the rate of Caucasians.

Mortality and outcomes of elderly patients admitted to the intensive care unit at Cairns Base Hospital, Australia

OBJECTIVE

To determine the survival and outcome of elderly patients admitted to the intensive care unit at Cairns Base Hospital.

METHODS

A retrospective review of patients aged 60 years or over admitted to the ICU (a Level 2 general unit) at Cairns Base Hospital, a regional hospital in Queensland, during 2003-2005. Mortality was determined by review of hospital records, the Queensland register of deaths, and direct patient or family contact in November 2006. Demographic and clinical details were collected, and the EuroQol-5D questionnaire was used to assess current and pre-ICU quality of life.

RESULTS

432 patients aged >or= 60 years had 469 admissions to the ICU during 2003-2005. Long-term outcome was determined for 68%: 201 (46%) were confirmed dead, and 94 (22%) were confirmed alive, while the outcome for 137 (32%) remained unknown. Allowing for an estimated mortality of 39% in the unknown group, the overall estimated mortality was 60%. Mean follow-up time was 2.4 (SD, 0.9) years (range, 11-35 months). As age increased, mortality increased: 37% for the 60-70 years age group; 50% for 70-80 years; 61% for 80-90 years, and 83% for > 90 years. The quality of life of survivors was lower on follow-up than on ICU admission.

CONCLUSIONS

Elderly patients admitted to the ICU have high mortality. As age increases, mortality increases. Elderly survivors can expect a lower quality of life after an ICU admission, although on average the difference is not great.

Explaining racial disparities in incidence of and survival from out-of-hospital cardiac arrest

A prospective observational study of 4,653 consecutive cases of out-of-hospital cardiac arrest (OOHCA) occurring in New York City from April 1, 2002, to March 31, 2003, was used to assess racial/ethnic differences in the incidence of OOHCA and 30-day survival after hospital discharge among OOHCA patients. The age-adjusted incidence of OOHCA per 10,000 adults was higher among Blacks than among persons in other racial/ethnic groups, and age-adjusted survival from OOHCA was higher among Whites compared with other groups. In analyses restricted to 3,891 patients for whom complete data on all variables were available, the age-adjusted relative odds of survival from OOHCA among Blacks were 0.4 (95% confidence interval: 0.2, 0.7) as compared with Whites. A full multivariable model accounting for demographic factors, prior functional status, initial cardiac rhythm, and characteristics of the OOHCA event explained approximately 41 percent of the lower age-adjusted survival among Blacks. The lower prevalence of ventricular fibrillation as the initial cardiac rhythm among Blacks relative to Whites was the primary contributor. A combination of factors probably accounts for racial/ethnic disparities in OOHCA survival. Previously hypothesized factors such as delays in emergency medical service response or differences in the likelihood of receipt of cardiopulmonary resuscitation did not appear to be substantial contributors to these racial/ethnic disparities.

Shocking a community into action: a social marketing approach to cardiac arrests

Social marketing techniques have enhanced the success of programs designed to improve the health outcomes of individuals or communities when adopting new health behaviors. Current research suggests, however, that behavior change models, when added to social marketing techniques, could result in even greater success in changing health behaviors and health outcomes. This retrospective analysis of the results of a Public Access Defibrillation (PAD) Trial, designed to improve a community's response to cardiac arrest, tests this proposition. Data from one of the 24 participating PAD Trial sites were analyzed and interpreted from a social marketing and behavior change model perspective, to assess the success in changing a community's response to cardiac arrest victims in 61 residential buildings that participated in the PAD Trial in New York City (NYC). The findings suggest that to improve the success of community-based, emergency response systems to cardiac arrest victims, health programs must first assess the community's awareness of the health problem and their willingness to change behaviors before designing and implementing social marketing programs for health behavior change.

Racial disparities in cardiac care: geography matters

Racial disparities in health care have been well-documented, although the reasons for many of these disparities remain obscure. An intriguing possibility is that geographic factors--the places where certain groups live or obtain health care--contribute to racial disparities, especially in the use of new medical technologies. This Issue Brief examines racial disparities in the use of life-saving cardiac procedures and mortality after cardiac arrest, and considers how geographic differences in health care affect these disparities.

Racial disparity in cardiac procedures and mortality among long-term survivors of cardiac arrest

BACKGROUND

It is unknown whether white and black Medicare beneficiaries have different rates of cardiac procedure utilization or long-term survival after cardiac arrest.

METHODS AND RESULTS

A total of 5948 elderly Medicare beneficiaries (5429 white and 519 black) were identified who survived to hospital discharge between 1990 and 1999 after admission for cardiac arrest. Demographic, socioeconomic, and clinical information about these patients was obtained from Medicare administrative files, the US census, and the American Hospital Association's annual institutional survey. A Cox proportional hazard model that included demographic and clinical predictors indicated a hazard ratio for mortality of 1.30 (95% CI 1.09 to 1.55) for blacks aged 66 to 74 years compared with whites of the same age. The addition of cardiac procedures to this model lowered the hazard ratio for blacks to 1.23 (95% CI 1.03 to 1.46). In analyses stratified by race, implantable cardioverter-defibrillators (ICDs) had a mortality hazard ratio of 0.53 (95% CI 0.45 to 0.62) for white patients and 0.50 (95% CI 0.27 to 0.91) for black patients. Logistic regression models that compared procedure rates between races indicated odds ratios for blacks aged 66 to 74 years of 0.58 (95% CI 0.36 to 0.94) to receive an ICD and 0.50 (95% CI 0.34 to 0.75) to receive either revascularization or an ICD.

CONCLUSIONS

There is racial disparity in long-term mortality among elderly cardiac arrest survivors. Both black and white patients benefited from ICD implantation, but blacks were less likely to undergo this potentially life-saving procedure. Lower rates of cardiac procedures may explain in part the lower survival rates among black patients.

Outcome of "out of hospital" cardiopulmonary arrest in children admitted to the emergency room

BACKGROUND

The outcome of cardiopulmonary arrest in children is poor, with many survivors suffering from severe neurological defects. There are few data on the survival rate following cardiopulmonary arrest in children who arrived at the emergency room without a palpable pulse.

OBJECTIVE

To determine the survival rate and epidemiology of cardiopulmonary arrest in children who arrived without a palpable pulse at a pediatric ER in southern Israel.

METHODS

We retrospectively reviewed the medical records of all patients with cardiopulmonary arrest who arrived at the ER of the Soroka University Medical Center during the period January 1995 to June 1997.

RESULTS

The study group included 35 patients. Resuscitation efforts were attempted on 20, but the remaining 15 showed signs of death and were not resuscitated. None of the patients survived, although one patient survived the resuscitation but succumbed a few hours later. The statistics show that more cardiopulmonary arrests occurred among Bedouins than among Jews (32 vs. 3, P < 0.0001).

CONCLUSIONS

The probability of survival from cardiopulmonary arrest in children who arrive at the emergency room without palpable pulse is extremely low. Bedouin children have a much higher risk of suffering from out-of-hospital cardiopulmonary arrest than Jewish children.

A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest

STUDY OBJECTIVES

To perform a population-based study addressing the demography, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest (PCPA).

METHODS

Prospective, population-based study of all children (17 years of age or younger) in a large urban municipality who were treated by EMS personnel for apneic, pulseless conditions. Data were collected prospectively for 3(1/2) years using a comprehensive data collection tool and on-line computerized database. Each child received standard pediatric advanced cardiac life support.

RESULTS

During the 3(1/2)-year period, 300 children presented with PCPA (annual incidence of 19. 7/100,000 at risk). Of these, 60% (n=181) were male (P =.0003), and 54% (n=161) were patients 12 months of age or younger (152,500 at risk). Compared with the population at risk (32% black patients, 36% Hispanic patients, 26% white patients), a disproportionate number of arrests occurred in black children (51.6% versus 26.6% in Hispanics, and 17% in white children; P <.0001). Over 60% of all cases (n=181) occurred in the home with family members present, and yet those family members initiated basic CPR in only 31 (17%) of such cases. Only 33 (11%) of the total 300 PCPA cases had a return of spontaneous circulation, and 5 of the 6 discharged survivors had significant neurologic sequelae. Only 1 factor, endotracheal intubation, was correlated positively with return of spontaneous circulation (P =.032).

CONCLUSION

This population-based study underscores the need to investigate new therapeutic interventions for PCPA, as well as innovative strategies for improving the frequency of basic CPR for children.

The Brugada syndrome in a Chinese population

Sudden cardiac death has been reported in patients with a unique electrocardiographic (ECG) abnormality showing right bundle branch block and ST segment elevation in the precordial leads. This syndrome was first described by Brugada and Brugada and has not been previously described in a Chinese population. We report here the first three cases in Singapore. The first patient was a 49-year-old man who presented with syncope, associated with generalized convulsions. The second patient was a 25-year-old man who complained of palpitations but no syncope. The third patient was a 77-year-old man who presented with recurrent episodes of syncope and collapsed with ventricular fibrillation. All patients had no past cardiac or drug history of note. The neurological examination and investigations were normal. All three patients showed a unique right bundle branch block pattern with ST segment elevation in leads V1-3. The echocardiogram and 24-h ambulatory ECG monitoring, were normal. Single vessel disease was present in the third patient. Electrophysiological studies performed in all three patients were able to induce ventricular fibrillation. The patient with resuscitated cardiac death underwent an implantable cardioverter defibrillator implantation. The importance of this syndrome is that the recognition of the unique ECG pattern enables early identification and treatment of these patients.

Race and survival after out-of-hospital cardiac arrest in a suburban community

STUDY OBJECTIVE

To determine whether race, when controlled for income, is an independent predictor of survival to hospital discharge after out-of-hospital cardiac arrest (OHCA).

METHODS

Prospective OHCA data were collected over 4 years (1991-1994) from a convenience sample of OHCA patients transported to nine hospitals in three suburban counties. Race was determined from hospital and vital statistics records. The average household income was identified from ZIP codes and used as a marker of socioeconomic status. Demographic data and known predictors of survival were compared between blacks and whites. A logistic regression analysis was used to assess the association between race, income, and survival.

RESULTS

Of the 1,690 patients, 223 (13%) were blacks and 1,467 (87%) were whites. Average household income was less for blacks than for whites ($40,225 versus $46,193; P < .001), but both populations were affluent by national standards (national percentile ranks were 73% and 88%, respectively). The populations were no different in percentage of witnessed arrests (57% versus 61%; P = .465). Blacks were younger (mean +/- SD, 62 +/- 16 versus 68 +/- 15 years; P < .001); less frequently received bystander CPR (11% versus 20%; P = .002); less often had ventricular tachycardia or ventricular fibrillation (37% versus 50%; P < .001); and had a shorter advanced life support call-response interval (median, 4 versus 6 minutes; P < .001). The odds ratio for survival (white/black) was .931 (95% confidence interval, .446 to 1.945).

CONCLUSION

Race was not found to predict adverse OHCA outcomes in this affluent population.

Effect of race on survival following in-hospital cardiopulmonary resuscitation

BACKGROUND

Race has been shown to be a significant predictive factor in a number of treatment decisions and outcomes, including survival following out-of-hospital cardiopulmonary resuscitation (CPR). The goal of this study was to determine whether race is associated with the rate of survival to discharge following in-hospital CPR.

METHODS

Consecutive adult patients undergoing attempted CPR at three teaching hospitals were identified. Demographic, clinical, and laboratory data from the time of admission, information about the resuscitation attempt, and the outcome of CPR were recorded for each patient. The characteristics of black and non-black patients were compared. Logistic regression was used to determine whether race was a significant independent predictor of CPR outcome.

RESULTS

A total of 656 patients were identified. Black patients had a higher mean severity of illness as measured by the Acute Physiology and Chronic Health Evaluation (APACHE) III score, were more likely to have an initial rhythm of electromechanical dissociation or asystole, were less likely to have an admitting diagnosis of myocardial infarction or a history of coronary artery disease, and had a higher serum creatinine level, lower serum albumin value, and lower 24-hour urine output for the first 24 hours. There was no difference between black and nonblack patients regarding the rate of survival of the resuscitative effort itself. However, black patients were significantly less likely than nonblack patients to survive to discharge following resuscitation (Mantel-Haenszel odds ratio, 0.31; 95% confidence interval, 0.15 to 0.68). This relationship persisted after adjusting for potential confounders such as age, sex, initial cardiac rhythm, diagnosis of pneumonia, serum creatinine level, hospital, and APACHE III score.

CONCLUSIONS

Black race is significantly associated with a lower rate of survival to discharge following in-hospital CPR. Further work is needed to explore this association in other settings; to examine the effect of other possible confounding variables, such as tobacco use, socioeconomic status, and marital status; and to further study the determinants of physician decision-making about resuscitation.

Demographics of cardiac arrest: association with residence in a low-income area

OBJECTIVE

To report cardiac arrest demographics and assess whether arrest rate is associated with differences in intracity regional population densities, incomes, or race distributions.

METHODS

One-year retrospective review of out-of-hospital cardiac arrests in a city with a two-tier emergency medical service (EMS) system. Associations of population density, median income, and race data with age- and gender-adjusted cardiac arrest rates for seven city regions and groupings of high- and low-income census tracts were made.

RESULTS

Median income, but not race or population density, was associated with sex- and age-adjusted intracity regional cardiac arrest rates (p = 0.034). This association of cardiac arrest rate with income status was magnified when the 20 lowest and the 20 highest income census tracts were compared. Cardiac arrest victims in these two income groups did not differ in regard to rate of witnessed arrest, bystander-administered CPR, or previous cardiac disease. Rates of survival to hospital discharge were not significantly different between the two groups.

CONCLUSION

The association of lower income with cardiac arrest suggests that cardiac health promotion and EMS intervention measures, including CPR instruction, should be targeted to lower-income neighborhoods. These findings may help explain previous studies suggesting a racial or population density association with cardiac arrest rates.

Racial differences in the incidence of cardiac arrest and subsequent survival. The CPR Chicago Project

BACKGROUND

Differences between blacks and whites have been reported in the incidence of several forms of cardiovascular disease, including hypertension and stroke. We examined racial differences in the incidence of cardiac arrest in a large urban population and in subsequent survival.

METHODS

We collected data on all nontraumatic, out-of-hospital cardiac arrests in Chicago from January 1, 1987, through December 31, 1988, and compared the incidence and survival rates for blacks and whites. We examined the association between survival and race and seven other known risk factors by logistic-regression analysis. We computed incidence rates by coupling our data with U.S. Census population data.

RESULTS

Our study population comprised 6451 patients: 3207 whites, 2910 blacks, and 334 persons of other races. The incidence of cardiac arrest was significantly higher for blacks than for whites in every age group. The survival rate after cardiac arrest was 2.6 percent in whites, as compared with 0.8 percent in blacks (P < 0.001). Blacks were significantly less likely to have a witnessed cardiac arrest, bystander-initiated cardiopulmonary resuscitation, or a "favorable" initial rhythm or to be admitted to the hospital. When they were admitted, blacks were half as likely to survive. The association between race and survival persisted even when other recognized risk factors were taken into account. We did not find important differences between blacks and whites in the response times of the emergency medical services.

CONCLUSIONS

The black community in our study was at higher risk for cardiac arrest and subsequent death than the white community, even after we controlled for other variables.

Out-of-hospital cardiac arrest: racial differences in outcome in Seattle

OBJECTIVES

Out-of-hospital sudden cardiac arrest is a key area in which to study the dual problem of the poorer health status of minority populations and their poorer access to the health care system. We proposed to examine the relationship between race (Black/White) and survival.

METHODS

We determined the incidence and outcome of cardiac arrests in Seattle for which medical assistance was requested.

RESULTS

Over a 26-month period, the age-adjusted incidence of out-of-hospital cardiac arrest was twice as great in Blacks than in Whites (3.4 vs 1.6 per 1000 aged 20 and over). The initial resuscitation rate was markedly poorer in the Black victims (17.1% vs 40.7%), and rates of survival to hospital discharge were also lower in Blacks (9.4% vs 17.1%). Both effective initial resuscitation and survival were significantly related to White race following adjustment for other covariates.

CONCLUSION

The differences in outcomes were not fully explained by features of the collapse or relevant service factors. Possible explanations include delays in instituting therapy, less bystander-initiated cardiopulmonary resuscitation, poorer levels of health, and differences in the underlying cardiac disorders.