Letter by Bougouin et al Regarding Article, "Regional Variation in Out-of-Hospital Cardiac Arrest Survival in the United States".

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HomeCirculationVol. 134, No. 19Letter by Bougouin et al Regarding Article, “Regional Variation in Out-of-Hospital Cardiac Arrest Survival in the United States” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Bougouin et al Regarding Article, “Regional Variation in Out-of-Hospital Cardiac Arrest Survival in the United States” Wulfran Bougouin, MD, Eloi Marijon, MD, PhD and Alain Cariou, MD Wulfran BougouinWulfran Bougouin From the Department of Cardiology, European Georges Pompidou Hospital, Paris, France (W.B., E.M.); Paris Descartes University, France (W.B., E.M., A.C.); Paris Cardiovascular Research Center–INSERM U970 (PARCC), France (W.B., E.M., A.C.); Paris Sudden Death Expertise Center, France (W.B., E.M., A.C.); and Medical Intensive Care Unit, Cochin Hospital, Paris, France (A.C.). Search for more papers by this author , Eloi MarijonEloi Marijon From the Department of Cardiology, European Georges Pompidou Hospital, Paris, France (W.B., E.M.); Paris Descartes University, France (W.B., E.M., A.C.); Paris Cardiovascular Research Center–INSERM U970 (PARCC), France (W.B., E.M., A.C.); Paris Sudden Death Expertise Center, France (W.B., E.M., A.C.); and Medical Intensive Care Unit, Cochin Hospital, Paris, France (A.C.). Search for more papers by this author and Alain CariouAlain Cariou From the Department of Cardiology, European Georges Pompidou Hospital, Paris, France (W.B., E.M.); Paris Descartes University, France (W.B., E.M., A.C.); Paris Cardiovascular Research Center–INSERM U970 (PARCC), France (W.B., E.M., A.C.); Paris Sudden Death Expertise Center, France (W.B., E.M., A.C.); and Medical Intensive Care Unit, Cochin Hospital, Paris, France (A.C.). Search for more papers by this author Originally published8 Nov 2016https://doi.org/10.1161/CIRCULATIONAHA.116.023768Circulation. 2016;134:e408–e409To the Editor:We read with great interest the article by Girotra et al.1 The authors reported a marked variation in survival rates after out-of-hospital cardiac arrest (OHCA) across different US counties. Survival rate at discharge was quite heterogeneous and significantly associated with bystander response, especially bystander cardiopulmonary rescusitation and early automated external defibrillator use, which are known to be major links in the chain of survival.2 However, other links matter after OHCA. Recent guidelines have strongly reinforced the crucial importance of multidisciplinary organization of care in the field of OHCA, from collapse recognition (with early identification and basic life support) to postcardiac arrest care (considered as the fifth link in the chain of survival),3 including targeted temperature management and coronary reperfusion.4The authors have stated that data on therapeutic hypothermia or coronary angiography were not collected in CARES (Cardiac Arrest Registry to Enhance Survival) until 2010; thus, they performed a sensitivity analysis restricted to 2010 to 2014 to ascertain the relative impact of these treatments on survival. However, despite its statistical correctness, this approach still does not consider the entire bundle of postcardiac care, including targeted temperature management, coronary reperfusion, hemodynamic management, other aspects of neurocritical care (eg, oxygenation, respiratory management, glycemic control), and neurologic prognostication.4 All of these in-hospital interventions could significantly influence the outcome of resuscitated patients, and a major heterogeneity in their use may be quite likely among hospitals and counties across geographic regions.Consistent with the present study, we previously reported major disparities in survival after sports-related sudden death in France.5 Similar to Girotra and colleagues,1 we identified major differences in immediate cardiopulmonary resuscitation across French districts that were highly correlated with survival. However, to address the potential influence of in-hospital interventions, we also separately reported survival during in-hospital course in all districts, eventually showing a strong association between survival at admission and discharge. We therefore reported comparable in-hospital mortality across districts and demonstrated that survival after OHCA was mainly determined by prehospital factors. To reinforce the results of the present study, we wonder whether the authors could provide data on in-hospital mortality across the different participating counties. Showing a fairly similar in-hospital outcome would reinforce their sensitivity analysis and highlight the key message that heterogeneity in survival after OHCA is mostly because of differences in prehospital care, especially bystander response.Wulfran Bougouin, MDEloi Marijon, MD, PhDAlain Cariou, MDDisclosuresNone.FootnotesCirculation is available at http://circ.ahajournals.org.