Cardiac Arrest Rates Research Articles

Critical Care Unit Organizational and Personnel Factors Impact Cardiac Arrest Prevention and Rescue in the Pediatric Cardiac Population.

Patient-level factors related to cardiac arrest in the pediatric cardiac population are well understood but may be unmodifiable. The impact of cardiac ICU organizational and personnel factors on cardiac arrest rates and outcomes remains unknown. We sought to better understand the association between these potentially modifiable organizational and personnel factors on cardiac arrest prevention and rescue. Retrospective analysis of the Pediatric Cardiac Critical Care Consortium registry. Pediatric cardiac ICUs. All cardiac ICU admissions were evaluated for cardiac arrest and survival outcomes. None. Successful prevention was defined as the proportion of admissions with no cardiac arrest (inverse of cardiac arrest incidence). Rescue was the proportion of patients surviving to cardiac ICU discharge after cardiac arrest. Cardiac ICU organizational and personnel factors were captured via site questionnaires. The associations between organizational and personnel factors and prevention/rescue were analyzed using Fine-Gray and multinomial regression, respectively, accounting for clustering within hospitals. We analyzed 54,521 cardiac ICU admissions (29 hospitals) with 1,398 cardiac arrest events (2.5%) between August 1, 2014, and March 5, 2019. For both surgical and medical admissions, lower average daily cardiac ICU occupancy was associated with better cardiac arrest prevention. Better rescue for medical admissions was observed for higher registered nursing hours per patient day and lower proportions of "part time" cardiac ICU physician staff (< 6 service weeks/yr). Increased registered nurse experience was associated with better rescue for surgical admissions. Increased proportion of critical care certified nurses, full-time intensivists with critical care fellowship training, dedicated respiratory therapists, quality/safety resources, and annual cardiac ICU admission volume were not associated with improved prevention or rescue. Our multi-institutional analysis identified cardiac ICU bed occupancy, registered nurse experience, and physician staffing as potentially important factors associated with cardiac arrest prevention and rescue. Recognizing the limitations of measuring these variables cross-sectionally, additional studies are needed to further investigate these organizational and personnel factors, their interrelationships, and how hospitals can modify structure to improve cardiac arrest outcomes.

A Comparison of In-Hospital Outcomes Between the Use of Impella and IABP in Acute Myocardial Infarction Cardiogenic Shock Undergoing Percutaneous Coronary Intervention.

The use of Impella ventricular support systems and intra-aortic balloon pump (IABP) in acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) has increased in recent years and expanded treatment options, although the comparative clinical outcomes and device safety remain unclear. We used the Nationwide Inpatient Sample database (2012-2017) to identify adults who were admitted for AMI complicated by CS and received percutaneous coronary intervention (PCI). The study sample was divided into Impella and IABP groups. Patient characteristics, hospital characteristics, and comorbidities were balanced between groups using propensity-score matching. Regression analysis was utilized to study outcome differences between groups. We identified 51,150 patients, of whom 44,265 (86.54%) received IABP and 6885 (13.46%) received Impella. After propensity matching, compared with the Impella group (n = 1592), the IABP group (n = 8638) had lower rates of sepsis (6.44% vs 12.69%; P=.01), blood transfusion (8.92% vs 14.28%; P=.01), mortality (28.95% vs 49.59%; P<.01), and hospitalization costs ($49,420 vs $68,087; P<.001). The IABP group had similar rates of cardiac arrest (20.32% vs 22.22%; P=.32), in-hospital stroke (1.46% vs 1.59%; P=.37), and length-of-stay (8.56 days vs 8.64 days; P=.26) compared with the Impella group. In patients with CS complicating AMI who underwent PCI, Impella use compared with IABP was associated with higher mortality with no differences in in-hospital stroke and cardiac arrest rates, although study interpretation is limited by retrospective observational design and the potential for remaining confounders. Further prospective research is warranted to elucidate the optimal mechanical circulatory support device in these patients.

Outcomes of Transcatheter Aortic Valve Replacement in Patients Treated With Systemic Steroids.

Chronic steroid therapy is associated with higher vascular complication rates in patients undergoing transcatheter aortic valve replacement (TAVR). The effect of corticosteroids on aortic annular complications has not been directly assessed in this population. A retrospective analysis of 1095 patients undergoing transfemoral TAVR was performed. Patients treated with chronic steroids at the time of the procedure (n = 99) were compared with those who received no steroids (n = 992). The primary outcome included a composite of aortic annular complications, defined as a combination of aortic annular rupture, aortic dissection/perforation, and left ventricular perforation. The primary outcome was significantly higher in the steroid group (4.0% vs 0.5%; P<.01). This finding was primarily driven by higher rates of acute annular rupture in the steroid group (2.0% vs 0.2%; P=.04). Steroid use was associated with higher rates of intraoperative cardiac arrest (5.1% vs 1.5%; P=.03), device capture/retrieval (4.0% vs 0.8%; P=.01), and emergent conversion to open heart surgery (4.0% vs 0.6%; P<.01). There were no differences with respect to in-hospital mortality, stroke, myocardial infarction, need for permanent pacemaker, bleeding complications, minor vascular complications, hospital length of stay, hospital 30-day readmission, or 30-day echocardiographic findings. Additionally, within the steroid group, there were no significant differences between balloon-expandable vs self-expanding TAVR prostheses with respect to composite aortic annular complications. Chronic steroid therapy increases the risk of aortic annular complications in patients undergoing TAVR, with detrimental consequences including intraoperative cardiac arrest and conversion to open heart surgery. Steroid use should be considered in patient selection and determination of procedural technique for TAVR.

Global research trends in cardiac arrest research: a visual analysis of the literature based on CiteSpace.

The high morbidity, high mortality and low survival rate of cardiac arrest (CA) cause a heavy global burden. We aimed to analyze the changes in scientific output related to CA over the past two decades. We analyzed the scientific output related to CA from 2000 to 2020 via the Web of Science. The data were analyzed using CiteSpace software. In total, 28,312 articles relating to CA were identified in the Web of Science. The volume of scientific research output in the field of global CA research was mainly distributed in the Americas, Europe and Asia, covering a wide range. Of the 28,312 articles, the research content of the highly cited literature mainly focused on CA, mild hypothermia treatment, and prognosis of CA patients. Various scientific methods were applied to reveal scientific productivity, collaboration, and research hotspots in the CA research field. Cardiopulmonary resuscitation (CPR), extracorporeal membrane oxygenation (ECMO), survival and target temperature management are research hotspots. Future research on CA will continue to focus on its treatment and prognosis to improve the survival rate of CA patients.

Ketamine for Monitored Anesthesia Care During Transcatheter Aortic Valve Replacement

PurposeTo study the feasibility and outcomes of ketamine as an anesthetic adjunct during monitored anesthesia care (MAC) in transcatheter aortic valve replacement (TAVR). DesignThis was a retrospective study. MethodsData from 155 consecutive TAVR patients at a tertiary care high-volume TAVR medical center were reviewed and analyzed. FindingsAmong the 155 TAVR cases under MAC, intravenous ketamine was administered as an adjunct in 126 patients. The most common ketamine dose was 20 mg. There was no significant difference for postoperative stroke, intraoperative conversion to general anesthesia, postoperative delirium, need for permanent pacemaker implantation, perivalvular leak and length of stay between the ketamine and non-ketamine groups. The ketamine group demonstrated a statistically significant lower 30-day mortality (P = .0381) and intraoperative cardiac arrest (P = .0025) rate when compared to the nonketamine group. ConclusionsOur results demonstrated that employing ketamine as an adjunct during MAC for TAVR is a feasible option.

Evaluation of outcomes after EMS-witnessed traumatic out-of-hospital cardiac arrest caused by traffic collisions

AimThe survival rate of patients with traumatic cardiac arrest is 3% or lower. Cardiac arrest witnessed by emergency medical services (EMS) accounts for approximately 16% of prehospital traumatic cardiac arrests, but the prognosis is unknown. We aimed to compare the 1-month survival rate of cardiac arrest witnessed by EMS with that of cardiac arrest witnessed by bystanders and unwitnessed cardiac arrest in traffic trauma victims; further, the time from injury to cardiac arrest was assessed. MethodsThis analysis used the Utstein Registry in Japan and included data of 3883 patients with traumatic cardiac arrest caused by traffic collisions registered between 2014 and 2019 in Japan. ResultsThe 1-month survival rate was 10.9% in the EMS-witnessed cardiac arrest group; this was significantly higher than that in the bystander-witnessed (7.2%) and unwitnessed (5.6%) cardiac arrest groups (P < 0.01). The median time from injury to cardiac arrest was 18 min (25% quartile: 12, 75% quartile: 26). ConclusionThe 1-month survival rate was significantly higher in the EMS-witnessed cardiac arrest group than in the bystander-witnessed and unwitnessed cardiac arrest groups. It is important to prevent progression to cardiac arrest in trauma patients with intact respiratory function and pulse rate at the time of contact with EMS. A system for early recognition of severe trauma is needed, and a doctor’s car or helicopter can be requested as needed. We believe that early recognition and prompt intervention will improve the prognosis of prehospital traumatic cardiac arrest.

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How to Maintain Safety and Maximize the Efficacy of Cardiopulmonary Resuscitation in COVID-19 Patients: Insights from the Recent Guidelines

Since December 2019, the novel coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has remained a challenge for governments and healthcare systems all around the globe. SARS-CoV-2 infection is associated with increased rates of hospital admissions and significant mortality. The pandemic increased the rate of cardiac arrest and the need for cardiopulmonary resuscitation (CPR). COVID-19, with its pathophysiology and detrimental effects on healthcare, influenced the profile of patients suffering from cardiac arrest, as well as the conditions of performing CPR. To ensure both the safety of medical personnel and the CPR efficacy for patients, resuscitation societies have published modified guidelines addressing the specific reality of the COVID-19 pandemic. In this review, we briefly describe the transmission and pathophysiology of COVID-19, present the challenges of CPR in SARS-CoV-2-infected patients, summarize the current recommendations regarding the algorithms of basic life support (BLS), advanced life support (ALS) and pediatric life support, and discuss other aspects of CPR in COVID-19 patients, which potentially affect the risk-to-benefit ratio of medical procedures and therefore should be considered while formulating further recommendations.

Abstract 11246: Racial Distribution and Regional Comparison in Hospital Outcomes Among Patients with Peripartum Cardiomyopathy in the United States

Introduction: Peripartum cardiomyopathy (PPCM) is a rare entity, first described over two centuries ago, associated with left ventricular systolic dysfunction in the last month of pregnancy and up to 5 months postpartum, in the absence of another identifiable etiology for heart failure. Black women are disproportionately affected by this condition. Our study sought to evaluate the racial distribution of each region and regional differences in-hospital outcomes among patients with PPCM in the United States. Methods: Data were obtained from the nationwide inpatient sample database (NIS) for 2016 and 2017. We included data on all adult females (aged 18 - 49 years) hospitalized with a principal diagnosis of PPCM using ICD-10 codes. Our primary outcome was in-hospital mortality. Secondary outcomes included: length of stay, cardiac arrest, and cardiogenic shock. Multivariable logistic and linear regression models were constructed to evaluate the relationship between PPCM and regional in-hospital clinical outcomes. A p-value &lt;0.05 was considered statistically significant. Results: A total of 3,030 hospitalizations for PPCM were included. Regional distribution for the northeast, midwest, south, and west were 12.0%, 20.8%, 50.0%, and 17.2%, respectively with a mean age of 31 years (CI of 28-34, P &lt; 0.01) across all regions. Inpatient mortality was 0.82% overall. Using northeast as the reference of comparison, there was no statistically significant difference in mortality across the regions. There was white predominant in the midwest and west compare to black predominant in the south and northeast (Table 1). In addition, we found no differences in the average length of stay, rates of cardiac arrest, or cardiogenic shock. Conclusion: There were no regional differences in hospital outcomes among patients admitted with PPCM in the US

Abstract 12639: The Disparities of Gender-Based Out of Hospital Cardiac Arrest Characteristics and Outcomes: Comparing Rural to Urban Vancouver Island

Introduction: The relationship between the “chain of survival” metrics of Out of Hospital Cardiac Arrest (OHCA) and survival rates in rural settings has not been fully examined. In previous studies, low survival rate was attributable to the modifiable prehospital metrics and Return Of Spontaneous Circulation (ROSC). Hypothesis: Gender-based disparities in the modifiable and non-modifiable OHCA characteristics and outcomes are significant between rural and urban settings. Methods: We did a post-hoc analyses of data from the British Columbia cardiac arrest registry, which enrolled all emergency medical system (EMS)-treated OHCAs. All non-EMS-witnessed OHCAs on Vancouver Island from Jan. 2019 to Oct. 2020 were included. The independent variable of interest was rural versus urban settings. Rural areas were defined as all areas outside the urban clusters (population ≥ 1000 and a population density of ≥ 400/km2). Our outcomes were 1. Post resuscitation ROSC, and 2. Survival to hospital discharge. We reported gender-mediated measures and adjusted odds ratios using logistic regression models. Results: We included 1172 OHCA patients, with 23% in rural settings, 33% female, 30% had ROSC, and 23% survived to hospital discharge. The median EMS response time, from 911-call to first EMS arrival, was prolonged [10.5 mins (IQR 7.5-15)] in rural settings compared to urban settings [6.5 mins (IQR 5-9)] (p value&lt;.001). Among females, rural settings were associated with higher odds of bystander CPR compared to males [(OR 1.86; 95% CI 1.04-3.35), (OR 1.42; 95% CI 0.95-2.13)], respectively. After adjusting for all covariates, rural settings were associated with lower odds of ROSC among males compared to females [(OR 0.53; 95% CI 0.31-0.90), (OR 0.70; 95% CI 0.34-1.41)], respectively; however, not associated with survival to hospital discharge. Conclusions: There are significant disparities in the modifiable prehospital OHCA characteristics, and post resuscitation ROSC between rural and urban Vancouver Island. An officially integrated rural CPR community-based program, and innovations focused on gender-based implementation may significantly improve OHCA survival rates and subsequent prognostication.

Abstract 12494: The Disparities of Gender-Based Out of Hospital Cardiac Arrest Characteristics and Outcomes: Comparing Rural to Urban Vancouver Island

Introduction: The relationship between the “chain of survival” metrics of Out of Hospital Cardiac Arrest (OHCA) and survival rates in rural settings has not been fully examined. In previous studies, low survival rate was attributable to the modifiable prehospital metrics and Return Of Spontaneous Circulation (ROSC). We sought to examine the association of the modifiable and non-modifiable OHCA characteristics and patient outcomes with rural settings. Methods: We did a post-hoc analyses of data from the British Columbia cardiac arrest registry, which enrolled all emergency medical system (EMS)-treated OHCAs. All non-EMS-witnessed OHCAs on Vancouver Island from Jan. 2019 to Oct. 2020 were included. The independent variable of interest was rural versus urban settings. Rural areas were defined as all areas outside the urban clusters (population ≥ 1000 and a population density of ≥ 400/km2). Our outcomes were 1. Post resuscitation ROSC, and 2. Survival to hospital discharge. We reported gender-mediated measures and adjusted odds ratios using logistic regression models. Results: We included 1172 OHCA patients, with 23% in rural settings, 33% Female, 30% had ROSC, and 23% survived to hospital discharge. The median EMS response time, from 911-call to first EMS arrival, was prolonged [10.5 mins (IQR 7.5-15)] in rural settings compared to urban settings [6.5 mins (IQR 5-9)] (p value&lt;.001) . Among females, rural settings were associated with higher odds of bystander CPR compared to males [(OR 1.86; 95% CI 1.04-3.35), (OR 1.42; 95% CI 0.95-2.13)], respectively. After adjusting for all covariates, rural settings were associated with lower odds of ROSC among males compared to females [(OR 0.53; 95% CI 0.31-0.90), (OR 0.70; 95% CI 0.34-1.41)], respectively; however, not associated with survival to hospital discharge. Conclusions: There are significant disparities in the modifiable prehospital OHCA characteristics, and post resuscitation ROSC between rural and urban Vancouver Island. An officially integrated rural CPR community-based program, and innovations focused on gender-based implementation may significantly improve OHCA survival rates and subsequent prognostication.

Abstract 9878: Higher Rates of Cardiac Arrest with Lower Inpatient Mortality Following Hospitalizations for ST-Elevation Myocardial Infarction Among Young Cannabis Users (18-44 Years): A Nationwide Propensity-Matched Analysis

Introduction: Given the rising use of unmonitored cannabis use in the young population and scarcity of data on the subject, we aimed to compare the outcomes of ST-elevation myocardial infarction (STEMI) admissions in patients with vs without cannabis use disorder (CUD+ vs. CUD-). Methods: The National Inpatient Sample (October2015-2017) was queried to identify STEMI admissions in young patients with CUD vs without CUD using relevant ICD-10 codes. Propensity-matched cohorts were obtained adjusting for sociodemographic, hospital characteristics, cardiovascular/extracardiac comorbidities. Primary endpoints were in-hospital mortality and complications, whereas secondary endpoints were discharge disposition, mean length of stay (LOS) and hospital cost. Results: Matched cohorts, STEMI-CUD+ (n=940) and STEMI-CUD- (n=940) were comparable in terms of age, sex, race and rate of non-elective admissions (Table 1) . The rates of hypertension (52.1% vs. 46.3%) and hyperlipidemia (39.9% vs 34.6%) were higher in the STEMI-CUD+ cohort (p&lt;0.05) with comparable rates of other risk factors (diabetes mellitus, smoking, and obesity). Post-STEMI MACCE was significantly higher (23.9% vs. 19.1%, p=0.012) including cardiac arrest (from ventricular tachyarrhythmias, 14.4% vs 10.6%, p=0.015), though with lower all-cause mortality (2.7% vs 4.8%, p=0.015) compared to CUD- cohort. Although complication rates of cardiogenic shock (9.6% vs 8.5%), arrhythmias (22.3% vs 19.7%), and stroke (3.7% vs. 2.7%) were higher in the CUD+ cohort, the statistical significance was not achieved. Conclusions: This nationwide multicenter analysis demonstrated that CUD+ cohort among young STEMI admissions had higher rates of hypertension, hyperlipidemia and MACCE including cardiac arrest without translating into higher inpatient mortality compared to CUD- cohort. Future large-scale prospective studies are invited to investigate and confirm these findings.

Abstract 12159: Impact of Ischemic Heart Disease on Cardiac Resynchronization Therapy - Analysis From National Inpatient Sample

Introduction: Comparative outcomes of hospitalizations for Cardiac Resynchronization Therapy (CRT) implantation procedures with and without coexisting Ischemic Heart Diseases (IHD) have not been studied at national level databases. We attempted to assess outcomes and baseline characteristics in these hospitalizations based on the National Inpatient Sample (NIS). Hypothesis: Ischemic heart disease worsens inpatient outcomes in patients undergoing CRT implantation. Methods: We conducted a retrospective analysis of hospitalizations for CRT implantation from the National Inpatient Sample (NIS) between 2013 and 2014. ICD-9 Billing codes were used to identify the target population. The primary outcomes were inpatient mortality, and hospital length and cost of stay. Results: A total of 11057 cases were identified. IHD was listed as any diagnosis in 66% of these hospitalizations. The mean age was 72.5 and 66.9 years for CRT implantation with and without IHD, respectively. Hospitalizations without IHD were more likely to be female (44% vs. 25%; p=0.01). Patients in the CRT with IHD group had a higher comorbidity burden with a higher proportion of hypertension, chronic kidney disease, anemia, peripheral artery disease, and congestive heart failure (Table 1). Inpatient mortality was similar between both groups (OR 1.17, CI 0.75-1.81). The IHD cohort had higher rates of cardiac arrest (OR 1.30, CI 1.05-1.62), acute kidney injury (OR 1.21, CI 1.08-1.35), longer length and a higher cost of stay (Table 1). Conclusions: IHD is associated with higher costs, longer length of stay, and higher rates of cardiac arrest. However, the in-hospital mortality was not different between the two groups. Higher incidence of cardiac arrest in patients with CRT and IHD underlines the importance of ICD with CRT. The clinical implication is that the threshold of selecting a CRT-D device in patients eligible for CRT therapy should be lower in patients with IHD vis-à-vis patients without IHD.

Cardiogenic shock complicating non-ST-segment elevation myocardial infarction: An 18-year study

To evaluate the epidemiology and outcomes of non-ST-segment-elevation myocardial infarction-cardiogenic shock (NSTEMI-CS) in the United States. Adult (>18 years) NSTEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011 and 2012-2017). Outcomes of interest included temporal trends of prevalence and in-hospital mortality, use of cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay. In over 7.3 million NSTEMI admissions, CS was noted in 189,155 (2.6%). NSTEMI-CS increased from 1.5% in 2000 to 3.6% in 2017 (adjusted odds ratio 2.03 [95% confidence interval 1.97-2.09]; P < .001). Rates of non-cardiac organ failure and cardiac arrest increased during the study period. Between 2000 and 2017, coronary angiography (43.9%-63.9%), early coronary angiography (13.6%-25.6%), percutaneous coronary intervention (14.8%-31.6%), and coronary artery bypass grafting use (19.0%-25.8%) increased (P < .001). Over the study period, the use of intra-aortic balloon pump remained stable (28.6%-28.8%), and both percutaneous left ventricular assist devices (0%-9.1%) and extra-corporeal membrane oxygenation (0.1%-1.6%) increased (all P < .001). In hospital mortality decreased from 50.2% in 2000 to 32.3% in 2017 (adjusted odds ratio 0.27 [95% confidence interval 0.25-0.29]; P < .001). During the 18-year period, hospital lengths of stay decreased, and hospitalization costs increased. In the United States, prevalence of CS in NSTEMI has increased 2-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and percutaneous coronary intervention increased during the study period.

Racial differences in outcomes and utilization after cardiac arrest in the USA: A longitudinal study comparing different geographical regions in the USA from 2006–2018

AimHealthcare disparities can affect access and quality of care among many in the United States (US). In addition to race, we sought to assess if geography affected rates of cardiac arrest, and the subsequent outcomes. MethodsUsing the National Inpatient Sample database from 2006–2018, we assessed rates of cardiac arrest (out of hospital that survived to admission and in-hospital) and cardiac catheterization, and length of stay (LOS) in four regions: Northeast (NE), South (SO) West (W) and Midwest (MW). ResultsCardiac arrest increased from 27,611 (2006) to 43,333 (2018). The proportion of African American (AA) patients experiencing cardiac arrest significantly increased from 11.9% to 18.8%. The mortality decreased from 65.4% to 60.8% in all patients and 70.2% to 61.4% in AA. Mortality in AA remained higher than non-AA (OR, 1.09 [1.08–1.11], p < 0.001). When regions were compared for mortality, MW had a lower risk than NE 0.94[0.92–9.96]; SO 1.05[1.04–1.07] and W 1.11[1.09–1.13] were higher compared to NE. LOS decreased slightly from 9.0 days to 8.7 in all patients. LOS for AA was longer than non-AA (11.3 vs 8.6 days) with the NE having the longest LOS. AA were less likely to receive cardiac catheterization than non-AA (9.5% vs 15%) with the largest racial gap in the MW region. ConclusionThe proportion of AA with cardiac arrests increased over the study period. Mortality and LOS improved significantly in AA from 2006 to 2018 but remain significantly higher than non-AA patients. Future research should identify contributors to these concerning trends.

Reducing ICU Utilization, Length of Stay, and Cost by Optimizing the Clinical Use of Continuous Monitoring System Technology in the Hospital

BackgroundContinuous monitoring system technology (CMST) aids in earlier detection of deterioration of hospitalized patients, but whether improved outcomes are sustainable is unknown. MethodsThis interrupted time series evaluation explored whether optimized clinical use of CMST was associated with sustained improvement in intensive care unit (ICU) utilization, hospital length of stay, cardiac arrest rates, code blue events, mortality, and cost across multiple adult acute care units. ResultsA total of 20,320 patients in the postoptimized use cohort compared with 16,781 patients in the preoptimized use cohort had a significantly reduced ICU transfer rate (1.73% vs 2.25%, P = .026) corresponding to 367.11 ICU days saved over a 2-year period, generating an estimated cost savings of more than $2.3 million. Among patients who transferred to the ICU, hospital length of stay was decreased (8.37 vs 9.64 days, P = .004). Cardiac arrest, code blue, and mortality rates did not differ significantly. ConclusionOpportunities exist to promote optimized adoption and use of CMST at acute care facilities to sustainably improve clinical outcomes and reduce cost.

Clinical outcomes in COVID-19 patients with in-hospital cardiac arrest – an insight from multi-centre data

Abstract Background In general, rates of in-hospital cardiac arrest are reportedly 9 to 10 arrests per 1000 admissions, with survival rates of approximately 20–25%. Data regarding clinical characteristics and outcomes in patients with COVID-19 who received in-hospital CPR (cardiopulmonary resuscitation) are limited. This information can help guide end-of-life care conversations between families and health care workers based on real-world experience. Purpose To observe the outcomes (survival to discharged alive from the hospital) in critically sick COVID-19 patients who experienced in-hospital cardiac arrest. Methods This is a multi-centre institutional review board (IRB) approved retrospective study. The RT-PCR confirmed adult COVID-19 patients consecutively admitted from March 1st to April 30, 2020, were included. Data were extracted manually using the hospital's electronic medical record. The final date of follow-up to monitor clinical outcomes was January 2021. Results A total of 721 patients were admitted to the hospital. Of these, only 64 (8.87%) patients had “no CPR” orders.Cardiac arrest occurred in 141 (19.5%) patients. The mean duration of beginning of resuscitation was less than a minute and the mean duration of CPR was 19 minutes. The median age was 65 years; 62.4% were male. The most common co-morbidities were hypertension (66%) and diabetes mellitus (56%). The initial rhythm was non-shockable in 93.7% of patients [asystole in 48.4% and Pulseless Electrical Activity (PEA) in 45.3% of patients]. Only six (4.2%) patients had pulseless ventricular tachycardia and three (2.1%) patients had ventricular fibrillation. A total of eight patients (5.6%) survived and were discharged from the hospital; six (4.25%) had non-shockable and two (0.82%) had shockable initial rhythms. The median age of those who survived was 60 years (Figure 1). Conclusions Our study showed that critically sick patients with COVID-19 have a high rate of cardiac arrest and poor outcomes in those who received CPR. A non-shockable initial rhythm indicates that non-cardiac reasons might be playing a major role. These include acute respiratory insufficiency, severe sepsis, or multiorgan failure. These data should inform end-of-life care discussions between providers and patients' families. Funding Acknowledgement Type of funding sources: None.

National prevalence and outcomes of coronary chronic total occlusion revascularization in patients with congestive heart failure

Abstract Background There is limited data on the prevalence and outcomes of coronary artery chronic total occlusion (CTO) revascularization in patients with congestive heart failure. Purpose Our goal is to study the prevalence and outcomes of CTO revascularization in terms of in-hospital mortality, re-admission rate, and complications in patients stratified by their heart failure status. Methods Patients with CTO who underwent percutaneous coronary intervention (PCI) were included for the years 2010 - 2018 from the national readmission database. We compared the national trends, prevalence and outcomes of CTO revascularization in patients with no heart failure, heart failure with preserved ejection fraction (HFpEF), and heart failure with reduced ejection fraction (HFrEF) using one-way ANOVA and logistic regression. Results A total of 166,244 (69±11 years, 26% women) patients with coronary CTO who underwent PCI were identified. Of these, 131,664 (79%) patients had no clinical diagnosis of HF, while 26,612 (16%) patients had HFpEF, and 7,968 (5%) patients had HFrEF. Majority of patients with HFpEF and HFrEF had a moderate to high Elixhauser comorbidity score, while those with no HF had mostly low to moderate score (p&amp;lt;0.001). We observed a steady decrease in annual CTO revascularization from a total of 24,708 in 2010 to 13,505 in 2018. However, the percentage of CTO revascularization in patients with HFrEF has increased during this period from 2% in 2010 to 8% in 2018. Interestingly, patients with HFpEF had higher rates of cardiac arrest (Odds Ratio (OR) 2.2; 95% Confidence Interval (CI) 1.8–2.7, p&amp;lt;0.001), ventricular tachycardia/fibrillation (OR 3.7; 95% CI 3.4–4.0, p&amp;lt;0.001), use of mechanical support (OR 5.5; 95% CI 4.9–6.2, p&amp;lt;0.001), and death during admission (OR 2.2; 95% CI 1.8–2.7, p&amp;lt;0.001) than those with no HF and with HFrEF. Similarly, patients with HFpEF had higher rates of intensive care unit admission (9%), than those with HFrEF (5%), and no HF (2%) (p&amp;lt;0.001). Readmission rates were similar across all three groups (0.5–0.7%, p=0.06). The median cost of hospitalization was significantly higher in the HFpEF group compared to the other groups ($98,366, p&amp;lt;0.001). Conclusion In this cohort of patients, we observed an overall annual decline in CTO revascularization over the 8-year study period. Despite this decline, we observed an increase in CTO revascularization in patient with HFrEF. Interestingly, patients with HFpEF had elevated in hospital mortality and higher rates of cardiac arrest, ventricular arrhythmias, mechanical circulatory support, and admission to the cardiac care unit than those with no HF, or those with HFrEF. Despite their persevered ejection fraction, our findings suggest that CTO revascularization in with patients with HFpEF carry a significant risk, thus risks versus benefits in this group of patients should be weighed considerably before attempting revascularization. Funding Acknowledgement Type of funding sources: None.

CARDIOVASCULAR OUTCOMES OF ACUTE CORONARY SYNDROMES IN INDIGENOUS COMPARED WITH NON-INDIGENOUS PATIENTS IN NORTHERN SASKATCHEWAN

<h3>BACKGROUND</h3> Indigenous compared with non-Indigenous patients have historically been known to have higher cardiovascular risk. With improved care delivery of acute myocardial infarction, we sought to compare contemporary profiles between indigenous versus non-Indigenous patients presenting with acute coronary syndromes (ACS) to a single PCI cardiac center in Saskatchewan. <h3>METHODS AND RESULTS</h3> We prospectively evaluated consecutive ACS admissions (no exclusion criteria applied) from March 15, 2019 to March 30, 2021 at the Royal University Hospital, Saskatoon. Categorized by self-reported Indigenous and non-Indigenous status, we describe presenting demographics, treatment patterns, unadjusted all-cause mortality and all-cause rehospitalization. Continuous variables are presented as medians (25th, 75th percentiles), categorical values as frequencies (%). Of the 1950 ACS admissions, 260 (13.3%) were Indigenous. Indigenous compared with non-Indigenous patients were younger, more likely female, have a history of heart failure and a significant burden of both traditional and non-traditional cardiovascular risk factors. Both groups were revascularized comparably with PCI. Indigenous compared with non-Indigenous patients were however more likely to present with higher levels of NTproBNP and higher incident rates of cardiogenic shock and/or cardiac arrest, with a greater severity of left ventricular systolic dysfunction (Table 1). While in-hospital mortality is comparable between the two groups, Indigenous compared with non-Indigenous have significantly higher unadjusted 1-year mortality (11.9% vs. 8.0%, p=0.039). <h3>CONCLUSION</h3> Indigenous compared with non-Indigenous patients hospitalized with an acute coronary syndrome have a significantly greater burden of premorbid cardiovascular risk and present with greater clinical acuity. While the in-hospital outcomes are comparable, likely due to established pre-hospital/in-hospital ACS processes of care, the higher one-year mortality suggest that the higher residual risk in Indigenous patients is likely driven by the greater burden of modifiable traditional and non-traditional risk factors in this patient population.

SEPSIS PREDICTS HIGHER MORTALITY AND CARDIOPULMONARY COMPLICATIONS IN PERIPARTUM CARDIOMYOPATHY-RELATED HOSPITALIZATIONS: A NATIONWIDE ANALYSIS

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Sepsis-induced cardiomyopathy has been increasingly recognized; however, the prevalence and impact of sepsis in peripartum cardiomyopathy (PPCM) patients need further exploration. We aimed to assess the burden and outcomes of PPCM-related hospitalization with vs. without sepsis in this population-based study in the United States. METHODS: We queried the National Inpatient Sample (2015October-2017) to access PPCM with vs. without sepsis using relevant ICD-10 codes. We compared baseline demographics and comorbidities between the groups (sepsis+ vs. sepsis-). The primary outcomes included all-cause mortality, cardiac arrest including ventricular tachyarrhythmias, cardiogenic shock, respiratory failure, mechanical ventilation/respiratory intubation, and secondary outcomes included patient disposition, length of stay, and hospital charges. A two-tailed p-value<0.05 was considered for statistical significance. RESULTS: Of the 10,275 PPCM admissions, 460 were related to sepsis (0.04%). The PPCM-sepsis+ cohort often consisted of younger (30 [24-36]), white (47.1% vs 39%, p<0.001) patients admitted non-electively (90.2% vs 87.7%, p=0.109) compared to the PPCM-sepsis- cohort. The PPCM-sepsis+ cohort more frequently comprised of Medicaid enrollees (52.2% vs 51.9%, p<0.001), patients in middle income quartile (27.2% vs 26.0%, p=0.007), admissions to large bedsized hospitals (64.1% vs 62%, p=0.588) compared to PPCM-sepsis - cohort. The PPCM-sepsis+ cohort was often associated with congestive heart failure (55.4% vs 48.2%, p=0.003), coagulopathy (10.9% vs 6.4%, p<0.001), chronic kidney disease (15.2% vs 5.9%, p<0.001), anemias (27.2% vs 20.8%, p<0.001), pulmonary circulation disorder (3.3% vs 1.7%, p=0.012), and psychoses (4.3% vs 1.9%, p<0.001) compared to PPCM-sepsis- cohort. PPCM-sepsis+ cohort showed lower frequency of hypertension (40.2% vs 59.9%, p<0.001), obesity (16.3% vs 26.3%, p<0.001), chronic pulmonary disease (8.7% vs 14.9%, p<0.001) and valvular heart disease (7.6% vs 13.0%, p<0.001) compared to sepsis- cohort. The PPCM-sepsis+ cohort had significantly higher frequency and odds of all-cause mortality (7.6% vs 1.2%, aOR 7.59, 95% CI 4.35-13.23; p<0.001) along with higher rates of cardiac arrest (5.4% vs 3.0%, p0.003), cardiogenic shock (8.7% vs 5.2%, p<0.001), respiratory failure (56.5% vs 19.8%, p<0.001), mechanical ventilation/respiratory intubation (28.3% vs 10.9%, p<0.001) compared to the PPCM-sepsis- cohort. The PPCM-sepsis+ cohort were less often discharged routinely (63.0% vs. 81.5%, p<0.001), experienced prolonged hospital stay (5 vs 3 days) and higher hospital charges (60,752$ vs 30,554$) as compared to PPCM-sepsis- cohort (p<0.001). CONCLUSIONS: The frequency of sepsis in PPCM-related admissions remains low. However, concomitant sepsis predicted nearly seven times higher all-cause mortality and alarmingly higher rates of cardiopulmonary complications in PPCM. Preventive screening measures and timely management of sepsis in PPCM could prevent worse outcomes. CLINICAL IMPLICATIONS: Sepsis in PPCM patients leads to significantly higher mortality and morbidity which needs to be further assessed with larger prospective studies. Enforcement of screening protocols in PPCM could help curtail worse outcomes and healthcare expenditure. DISCLOSURES: No relevant relationships by Charu Agarwal, source=Web Response No relevant relationships by Rupak Desai, source=Web Response No relevant relationships by Zainab Gandhi, source=Web Response No relevant relationships by Geethu Jnaneswaran, source=Web Response No relevant relationships by Gaurav Mudgal, source=Web Response No relevant relationships by Athul Raj Raju, source=Web Response No relevant relationships by Bisharah Rizvi, source=Web Response No relevant relationships by Rutul Shah, source=Web Response No relevant relationships by Vivek Joseph Varughese, source=Web Response