Glasgow-Pittsburgh Cerebral Performance Categories Research Articles

Prognostic value of grey-white matter ratio obtained within two hours after return of spontaneous circulation in out-of-hospital cardiac arrest survivors: A multicenter, observational study

BackgroundGrey-white matter ratio (GWR) measured by head computed tomography (CT) scan is known as a neurological prognostication tool for out-of-hospital cardiac arrest (OHCA) survivors. The prognostic value of GWR obtained early (within two hours after return of spontaneous circulation [ROSC]) remains a matter of debate. MethodsWe conducted a multicenter, retrospective, observational study at five hospitals. We included adult OHCA survivors who underwent head CT within two hours following ROSC. GWR values were measured using head CT. Average GWR values were calculated by the mean of the GWR-basal ganglia and GWR-Cerebrum. We divided the patients into poor or favorable neurological outcome groups defined by Glasgow-Pittsburgh Cerebral Performance Category scores. The predictive accuracy of GWR performance was assessed using the area under the curve (AUC). The sensitivities and specificities for predicting poor outcome were examined. ResultsOf 377 eligible patients, 281 (74.5%) showed poor neurological outcomes at one month after ROSC. Average GWR values of the poor neurological outcome group were significantly lower than those of the favorable neurological outcome. The average GWR value to predict neurological outcome with Youden index was 1.24 with AUC of 0.799. When average GWR values were 1.15 or lower, poor neurological outcomes could be predicted with 100% specificity. ConclusionsGWR values measured by head CT scans early (within two hours after ROSC) demonstrated moderate predictive performance for overall ROSC patients. When limited to the patients with GWR values of 1.15 or lower, poor neurological outcomes could be predicted with high specificity.

Alteration in early resting‑state functional MRI activity in comatose survivors of cardiac arrest: a prospective cohort study

BackgroundThis study aimed to explore the characteristics of abnormal regional resting-state functional magnetic resonance imaging (rs-fMRI) activity in comatose patients in the early period after cardiac arrest (CA), and to investigate their relationships with neurological outcomes. We also explored the correlations between jugular venous oxygen saturation (SjvO2) and rs-fMRI activity in resuscitated comatose patients. We also examined the relationship between the amplitude of the N20-baseline and the rs-fMRI activity within the intracranial conduction pathway of somatosensory evoked potentials (SSEPs).MethodsBetween January 2021 and January 2024, eligible post-resuscitated patients were screened to undergo fMRI examination. The amplitude of low-frequency fluctuation (ALFF), fractional ALFF (fALFF), and regional homogeneity (ReHo) of rs-fMRI blood oxygenation level-dependent (BOLD) signals were used to characterize regional neural activity. Neurological outcomes were evaluated using the Glasgow–Pittsburgh cerebral performance category (CPC) scale at 3 months after CA.ResultsIn total, 20 healthy controls and 31 post-resuscitated patients were enrolled in this study. The rs-fMRI activity of resuscitated patients revealed complex changes, characterized by increased activity in some local brain regions and reduced activity in others compared to healthy controls (P < 0.05). However, the mean ALFF values of the whole brain were significantly greater in CA patients (P = 0.011). Among the clusters of abnormal rs-fMRI activity, the cluster values of ALFF in the left middle temporal gyrus and inferior temporal gyrus and the cluster values of ReHo in the right precentral gyrus, superior frontal gyrus and middle frontal gyrus were strongly correlated with the CPC score (P < 0.001). There was a strong correlation between the mean ALFF and SjvO2 in CA patients (r = 0.910, P < 0.001). The SSEP N20-baseline amplitudes in CA patients were negatively correlated with thalamic rs-fMRI activity (all P < 0.001).ConclusionsThis study revealed that abnormal rs-fMRI BOLD signals in resuscitated patients showed complex changes, characterized by increased activity in some local brain regions and reduced activity in others. Abnormal BOLD signals were associated with neurological outcomes in resuscitated patients. The mean ALFF values of the whole brain were closely related to SjvO2 levels, and changes in the thalamic BOLD signals correlated with the N20-baseline amplitudes of SSEP responses.Trial registrationNCT05966389 (Registered July 27, 2023).

The relationship between the initial pH and neurological outcome in patients with out-of-hospital cardiac arrest is affected by the status of recovery of spontaneous circulation on hospital arrival.

The early prediction of neurological outcomes is useful for out-of-hospital cardiac arrest (OHCA). The initial pH was associated with neurological outcomes, but the values varied among the studies. Patients admitted to our division with OHCA of cardiac origin between January 2015 and December 2022 were retrospectively examined (N = 199). A good neurological outcome was defined as a Glasgow-Pittsburgh cerebral performance category (CPC) of 1-2 at discharge. Patients were divided according to the achievement of recovery of spontaneous circulation (ROSC) on hospital arrival, and the efficacy of pH in predicting good neurological outcomes was compared. In patients with ROSC on hospital arrival (N = 100), the initial pH values for good and poor neurological outcomes were 7.26 ± 0.14 and 7.09 ± 0.18, respectively (p < 0.001). In patients without ROSC on hospital arrival (N = 99), the initial pH values for good and poor neurological outcomes were 7.06 ± 0.23 and 6.92 ± 0.15, respectively (p = 0.007). The pH associated with good neurological outcome was much lower in patients without ROSC than in those with ROSC on hospital arrival (P = 0.003). A higher initial pH is associated with good neurological outcomes in patients with OHCA. However, the pH for a good or poor neurological outcome depends on the ROSC status on hospital arrival.

The association between blood glucose levels on arrival at the hospital and patient outcomes after out-of-hospital cardiac arrest: A multicenter cohort study

BackgroundThis study aimed to investigate the association between blood glucose levels on arrival at the hospital and 1-month survival and favorable neurological outcomes in patients with OHCA using a large Japanese dataset. MethodsThis study was a secondary analysis of data from the JAAM-OHCA Registry. Adult (≥18 years) patients with witnessed OHCA transported to emergency departments and registered in the database from June 2014 to December 2019 were included in the study. The primary and secondary endpoints were 1-month survival and 1-month favorable neurological outcomes (Glasgow-Pittsburgh Cerebral Performance Category score 1 or 2), respectively. Patients were categorized into the following four groups based on blood glucose levels on arrival at the hospital: <80 mg/dL, 80–179 mg/dL, 180–299 mg/dL, and ≥300 mg/dL. ResultsThis study included 11,387 patients. Survival rates were 1.3%, 3.1%, 7.0%, and 5.7% in the <80 mg/dL, 80–179 mg/dL, 180–299 mg/dL, and ≥ 300 mg/dL blood glucose groups, respectively. The rates of favorable neurological outcomes in each group were 0.4%, 1.5%, 3.3%, and 2.5%, respectively. Multivariable analysis showed that 180–299 mg/dL glucose was significantly associated with 1-month survival and favorable neurological outcomes compared with 80–179 mg/dL glucose (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.34–2.31; p < 0.001 and OR, 1.52; 95 % Cl, 1.02–2.25; p = 0.035, respectively). In this study, blood glucose levels with the best outcomes likely ranged from 200 to 250 mg/dL based on the cubic spline regression model. ConclusionsBlood glucose level of 180–299 mg/dL on arrival at the hospital was significantly associated with 1-month survival and favorable neurological outcomes compared to blood glucose level of 80–179 mg/dL in patients with OHCA.

Abstract 351: Novel Quantitative Imaging Biomarkers From Acute Brain CT Using Artificial Intelligence for Predicting Neurological Prognosis in Cardiac Arrest Patients: A Pilot Study

Background: Effective use of information extracted from medical images has attracted attention for decision support in primary care of patients with cardiac arrest (CA). Hypothesis and Aims: This study aimed to predict the neurological prognosis of patients with cardiac arrest by quantitative imaging biomarkers (QIBs) extracted from acute CT brain images before admission using artificial intelligence. Methods: Eighty-six CA patients (good prognosis; Glasgow-Pittsburgh cerebral performance categories [CPC]=1 or 2 at 90 days after the CA : 32 patients, poor prognosis; CPC=3, 4, or 5 at 90 days after the CA : 54 patients) treated at three hospitals between 2017 and 2019 were retrospectively analyzed. None of the CA patients caused by trauma or brain damage were included in the database. The data were divided into training and test data, and the training data were used to select informative QIBs for classification between the good and poor neurological prognosis in this analysis. Results: Seven CA patients’ data were excluded from the study due to severe metal and bone artifacts broadly spreading on the brain image, and 1170 QIBs were extracted from whole brain and regional brain interest volumes on CT images of each patient. The QIBs were composed of first-order histogram and texture features and informative QIBs for the classification were selected by feature selection algorithms using the training dataset. The feature corresponding to the gray level having a maximum gradient in the image histogram from the brain region of interest on CT images showed the strongest significant difference between the good and poor neurological prognosis of the test data set with p=0.009 and AUC=0.775 (95% CI; 0.590-0.960). Conclusions: We have shown that QIB can be used to predict neurological prognosis in patients with CA. Because this is a pilot study for methodological development and there are limitations in sample size and outcomes, new studies on a larger number of patients are required.

Bayesian network predicted variables for good neurological outcomes in patients with out-of-hospital cardiac arrest.

Out-of-hospital cardiac arrest (OHCA) is linked to a poor prognosis and remains a public health concern. Several studies have predicted good neurological outcomes of OHCA. In this study, we used the Bayesian network to identify variables closely associated with good neurological survival outcomes in patients with OHCA. This was a retrospective observational study using the Japan Association for Acute Medicine OHCA registry. Fifteen explanatory variables were used, and the outcome was one-month survival with Glasgow-Pittsburgh cerebral performance category (CPC) 1-2. The 2014-2018 dataset was used as training data. The variables selected were identified and a sensitivity analysis was performed. The 2019 dataset was used for the validation analysis. Four variables were identified, including the motor response component of the Glasgow Coma Scale (GCS M), initial rhythm, age, and absence of epinephrine. Estimated probabilities were increased in the following order: GCS M score: 2-6; epinephrine: non-administered; initial rhythm: spontaneous rhythm and shockable; and age: <58 and 59-70 years. The validation showed a sensitivity of 75.4% and a specificity of 95.4%. We identified GCS M score of 2-6, initial rhythm (spontaneous rhythm and shockable), younger age, and absence of epinephrine as variables associated with one-month survival with CPC 1-2. These variables may help clinicians in the decision-making process while treating patients with OHCA.

Impact of time-to-compression on out-of-hospital cardiac arrest survival outcomes: A national registry study

ObjectiveWe aimed to quantify the association of no-flow interval in out-of-hospital cardiac arrests (OHCA) with the odds of neurologically favorable survival and survival to hospital discharge/ 30th day. Our secondary aim was to explore futility thresholds to guide clinical decisions, such as prehospital termination of resuscitation. MethodsAll OHCAs from 2012 to 2017 in Singapore were extracted. We examined the association between no-flow interval (continuous variable) and survival outcomes using univariate and multivariable logistic regressions. The primary outcome was survival with favorable cerebral performance (Glasgow-Pittsburgh Cerebral Performance Categories 1/2), the secondary outcome was survival to hospital discharge/ 30th day if not discharged. To determine futility thresholds, we plotted the adjusted probability of good neurological outcomes to no-flow interval. Results12,771 OHCAs were analyzed. The per-minute adjusted OR when no-flow interval was incorporated as a continuous variable in the multivariable model was: good neurological function– aOR 0.98 (95%CI: 0.97–0.98); survival to discharge– aOR 0.98 (95%CI: 0.98–0.99). Taking the 1% futility of survival line gave a no-flow interval cutoff of 12 mins (NPV 99%, sensitivity 85% and specificity 42%) overall and 7.5 mins for witnessed arrests. ConclusionWe demonstrated that prolonged no-flow interval had a significant effect on lower odds of favorable neurological outcomes, with medical futility occurring when no-flow interval was >12 mins (>7.5 mins for witnessed arrest). Our study adds to the literature of the importance of early CPR and EMS response and provided a threshold beyond traditional ‘down-times’, which could aid clinical decisions in TOR or OHCA management.

難治性院外心原性心停止に対する初期心電図によるpercutaneous cardiopulmonary support導入時間の検討(Analysis of the percutaneous cardiopulmonary support implementation time for refractory out–of–hospital cardiogenic cardiac arrest by initial electrocardiogram)

要旨【目的】治療抵抗性心停止に対する経皮的心肺補助（以下，PCPS）の転帰良好な因子として，初期心電図がショック適応心リズム（以下，ショックリズム）と心停止（以下，CA）からPCPS開始までの時間（以下，CA to PCPS）が短いことが挙げられる。しかし，近年ではショック非適応心リズム（以下，非ショックリズム）でも転帰良好な症例が報告されており，院外心原性心停止における初期心電図別のCA to PCPSと1か月後の転帰良好について検討した。【対象】これは単施設，後方視的研究であり，2000年1月から2017年3月に院外心原性心停止症例に対してPCPSを導入した219例（平均58歳，男性193例）を対象とした。【結果】ショックリズム群（167例）と非ショックリズム群（52例）において，転帰良好率は31% vs 10%（p＝0.003）であり，CA to PCPSの中央値は44.0分 vs 35.0分（p＝0.014）であった。さらにCA to PCPSを5分ごとに区切り転帰良好率を検討すると，ショックリズム群では36～40分で59%であったが，41～45分では33%まで低下しており，非ショックリズム群では40分以降に転帰良好は存在しなかった。【結語】心停止から40分以内のPCPS導入がより転帰良好になると考えられたが，非ショックリズム群ではさらに短縮する必要がある。

Impact of bystander cardiopulmonary resuscitation on neurological outcomes in patients undergoing veno-arterial extracorporeal membrane oxygenation

BackgroundVeno-arterial extracorporeal membrane oxygenation (V-A ECMO) requires a large amount of economic and human resources. The presence of bystander cardiopulmonary resuscitation (CPR) was focused on selecting appropriate V-A ECMO candidates.ResultThis study retrospectively enrolled 39 patients with V-A ECMO due to out-of-hospital cardiac arrest (CA) between January 2010 and March 2019. The introduction criteria of V-A ECMO included the following: (1) < 75 years old, (2) CA on arrival, (3) < 40 min from CA to hospital arrival, (4) shockable rhythm, and (5) good activity of daily living (ADL). The prescribed introduction criteria were not met by 14 patients, but they were introduced to V-A ECMO at the discretion of their attending physicians and were also included in the analysis. Neurological prognosis at discharge was defined using The Glasgow-Pittsburgh Cerebral Performance and Overall Performance Categories of Brain Function (CPC). Patients were divided into good or poor neurological prognosis (CPC ≤ 2 or ≥ 3) groups (8 vs. 31 patients). The good prognosis group had a significantly larger number of patients who received bystander CPR (p = 0.04). The mean CPC at discharge was compared based on the combination with the presence of bystander CPR and all five original criteria. Patients who received bystander CPR and met all original five criteria showed significantly better CPC than patients who did not receive bystander CPR and did not meet some of the original five criteria (p = 0.046).ConclusionConsidering the presence of bystander CPR help in selecting the appropriate candidate of V-A ECMO among out-of-hospital CA cases.

Effects of cardiopulmonary resuscitation instructions on the outcomes of out-of-hospital cardiac arrest: An analysis of the JAAM-OHCA registry.

To determine whether dispatcher-provided cardiopulmonary resuscitation (CPR) instructions improve the outcomes of out-of-hospital cardiac arrest (OHCA). Cases registered in the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest (JAAM-OHCA) Registry between June 2014 and December 2019 were included. Cases in which the dispatcher provided CPR instructions to the bystander were included in the "Instructions" group", and cases without CPR instructions were included in the "No Instructions" group. The primary outcome was the proportion of patients with a favorable neurological outcome, defined as a Glasgow-Pittsburgh cerebral performance category scale of 1 to 2 at 1 month after OHCA. Overall, 51,199 patients with OHCA were registered in the JAAM-OHCA Registry during the study period. Of these, 33,745 were eligible for the study, with 16,509 in the Instructions group and 17,236 in the No Instructions group. The proportion of patients with a favorable neurological outcome at 1 month after OHCA was inferior in the Instructions group than in the No Instructions group (2.3% versus 3.0%, p < 0.001). After adjustment for patient background characteristics, no association was found between CPR instructions provided by a dispatcher and favorable neurological outcomes at 1 month after OHCA (adjusted odds ratio, 1.000; 95% confidence interval, 0.869-1.151, p = 0.996). The present study found no clear clinical benefit of dispatcher-provided CPR instructions on the neurological outcomes of cases with OHCA.

The impact of different targeted temperatures on out-of-hospital cardiac arrest outcomes in patients receiving extracorporeal membrane oxygenation: a nationwide cohort study

BackgroundTargeted temperature management (TTM) is recommended in the management of out-of-hospital cardiac arrest (OHCA) when coma persists after the return of spontaneous circulation. In the setting of extracorporeal membrane oxygenation (ECMO) for OHCA patients, TTM is associated with good neurological outcomes and is recommended in the Extracorporeal Life Support Organization guidelines. However, the optimal targeted temperature for these patients has not yet been adequately investigated. This study aimed to compare the impact of different targeted temperatures on the outcomes in OHCA patients receiving ECMO.MethodsThis was a retrospective analysis of data from the Japanese Association for Acute Medicine (JAAM)-OHCA Registry, a multicentre nationwide prospective database in Japan in which 103 institutions providing emergency care participated. OHCA patients aged ≥ 18 years who required ECMO with TTM between June 2014 and December 2019 were included in our analysis. The primary outcome was 30-day survival with favourable neurological outcomes, defined as a Glasgow–Pittsburgh cerebral performance category score of 1 or 2. Patients were divided into two groups according to their targeted temperature: normothermic TTM (n-TTM) (35–36 °C) and hypothermic TTM (h-TTM) (32–34 °C). We compared the outcomes between the two targeted temperature groups using multivariable logistic regression and inverse probability weighting (IPW).ResultsA total of 890 adult OHCA patients who received ECMO and TTM were eligible for our analysis. Of these patients, 249 (28%) and 641 (72%) were treated with n-TTM and h-TTM, respectively. The proportions of patients with 30-day favourable neurological outcomes were 16.5% (41/249) and 15.9% (102/641), in the n-TTM and h-TTM groups, respectively. No difference in neurological outcomes was observed in the multiple regression analysis [adjusted odds ratio 0.91, 95% confidence interval (CI) 0.58–1.43], and the result was constant in the IPW (odds ratio 1.01, 95% CI 0.67–1.54).ConclusionNo difference was observed between n-TTM and h-TTM in OHCA patients receiving TTM with ECMO. The current understanding that changes to the targeted temperature have little impact on the outcome of patients may remain true regardless of ECMO use.

Validation the clinical value of good outcome following attempted resuscitation scores in Chinese populations in predicting the prognosis of in-hospital cardiac arrest

To verify the clinical value of the good outcome following attempted resuscitation (GO-FAR) score in predicting the neurological status of patients with in-hospital cardiac arrest (IHCA) in the Chinese population. The clinical data of patients with IHCA who were admitted to the Zigong Fourth People's Hospital from January 1 to December 31, 2020 were retrospectively analyzed. Used Glasgow-Pittsburgh cerebral performance category (CPC) score 1 point as the end point, the subjects were divided into 4 groups according to the score: ≤ 0 group, 1-8 group, 9-20 group and ≥ 21 group. Taken the group which GO-FAR score ≤ 0 as the reference group, the odds ratio (OR) of the other three groups compared with this group was calculated. The receiver operator characteristic curve (ROC curve) was performed to evaluate the predictive value of the GO-FAR score in favorable neurological outcome. A calibration curve was drawn for the Hosmer-Lemeshow test to analyze the degree of calibration of the GO-FAR score for predicting good neurological outcome. A total of 230 IHCA patients were enrolled in the study, including 130 males, aged 74 (65, 81) years old, and 23 case (10.0%) had good neurological prognosis. There were statistically significant differences in GO-FAR-related variables, including age, a normal neurological function on admitted, acute stroke, metastatic cancer, septicemia, medical noncardiac admission, hepatic insufficiency, hypotension, renal insufficiency or dialysis, respiratory insufficiency, pneumonia, etc (all P < 0.05). Taken the GO-FAR score ≤ 0 group as the reference group, the OR values of good neurological prognosis in the GO-FAR score 1-8 group were 0.54 [95% confidence interval (95%CI) was 0.17-1.53, P = 0.250], 9-20 group were 0.17 (95%CI was 0.02-0.67, P = 0.009) and ≥ 21 group were 0.25 (95%CI was 0.05-0.85, P = 0.025). The area under the ROC curve (AUC) of the GO-FAR score for predicting favorable neurological outcome in IHCA patients was 0.653 (95%CI was 0.529-0.777, P = 0.015) and there was no significant difference in Hosmer-Lemeshow test (P = 0.311). All these suggested that there was no significant difference between the predicted value and the actual value. GO-FAR score can be applied to predict neurological prognosis of IHCA patients in Chinese population. It can help clinicians to predict the prognosis of cardio-pulmonary resuscitation (CPR) and propose critical recommendations in treatment for these patients or their families.

A Study on the Outcome of Targeted Temperature Management Comparing Cardiac Arrest Patients Who Received Bystander Cardiopulmonary Resuscitation With Those Who Did Not, Using the Nationwide TIMECARD Multicenter Registry.

Background and PurposeTargeted temperature management (TTM) is associated with decreased mortality and improved neurological function after cardiac arrest. Additionally, studies have shown that bystander cardiopulmonary resuscitation (BCPR) doubled the survival of patients with out-of-hospital cardiac arrest (OHCA) compared to patients who received no BPCR (no-BCPR). However, the outcome benefits of BCPR on patients who received TTM are not fully understood. Therefore, this study aimed to investigate the outcome differences between BCPR and no-BCPR in patients who received TTM after cardiac arrest.MethodsThe Taiwan Network of Targeted Temperature Management for Cardiac Arrest (TIMECARD) multicenter registry established a study cohort and a database for patients receiving TTM between January 2013 and September 2019. A total of 580 patients were enrolled and divided into 376 and 204 patients in the BCPR and no-BCPR groups, respectively.ResultsCompared to the no-BCPR group, the BCPR group had a better hospital discharge and survival rate (42.25 vs. 31.86%, P = 0.0305). The BCPR group also had a better neurological outcome at hospital discharge. It had a higher average GCS score (11.3 vs. 8.31, P < 0.0001) and a lower average Glasgow–Pittsburgh cerebral performance category (CPC) scale score (2.14 vs. 2.98, P < 0.0001). After undertaking a multiple logistic regression analysis, it was found that BCPR was a significant positive predictor for in-hospital survival (OR = 0.66, 95% CI: 0.45–0.97, P = 0.0363).ConclusionsThis study demonstrated that BCPR had a positive survival and neurological impact on the return of spontaneous circulation (ROSC) in patients receiving TTM after cardiac arrest.

Abstract 10276: Impact of Time-to-Compression on Out-of-Hospital Cardiac Arrest Survival Outcomes: A National Registry Study

Introduction: Time To first Compression (TTC) in out-of-hospital cardiac arrests (OHCA) is thought to be an important predictor of survival outcomes. Guidelines such as the Journal of American College of Cardiology Scientific Expert Panel recommend that extracorporeal membrane oxygenation (ECMO) should not be used on OHCA patients with TTC &gt; 10 minutes. However, there is no literature validating this exclusion criterion on OHCA survival and neurological outcomes. This study aimed to evaluate the difference in neurological outcomes and survival to discharge of patients with CPR administered after 10 minutes, compared to within 10 minutes. Methodology: Data of OHCAs from 2012-2017 in Singapore were extracted from our national OHCA registry. We compared patients who received CPR within 10 minutes versus those who received CPR after 10 minutes. Primary outcomes were favorable cerebral performance (Glasgow-Pittsburgh Cerebral Performance Categories 1 and 2), and secondary were survival to hospital discharge or 30-day-survival. Results: There were 12,771 OHCAs analyzed, with 5,704 patients with TTC &lt;/=10 minutes and 7,067 with TTC &gt;10 minutes. Fewer patients survived to hospital discharge/30 th day with TTC &gt; 10 minutes (aOR 0.43, 95%CI: 0.32-0.58) and survival with good neurological outcomes was lower (aOR 0.51; 95%CI: 0.41-0.62). Other significant predictors of good neurological outcomes included age (aOR 0.98, 95%CI: 0.98 - 0.99), witnessed arrest (aOR 2.39, 95%CI: 1.69-3.40), bystander AED (aOR 1.55, 95%CI: 1.12-2.26), and presence of shockable rhythm (aOR 8.76, 95%CI: 7.12-10.78). A cut-off of 17.5 minutes (aOR 0.43, 95%CI:0.28-0.65) resulted in &lt;1% (127 out of 12,771) chance of survival with good neurological function based on the medical definition of Futility (specificity 0.84 sensitivity 0.84 ROC 0.91). Conclusion: Our study showed that there is a significant difference in survival and favourable neurological outcomes when TTC was &gt;10 minutes. However, more data-driven cut-off timings/criteria should be considered instead of the arbitrary 10 minutes for eligibility of ECMO therapy.

Habitual exercise provides better prognosis for cardiac arrest with coronary artery disease

Abstract Background Although regular physical activity has beneficial cardiovascular effects, exercise can trigger sudden cardiac arrest (SCA). Coronary artery disease (CAD) was identified as the most common cause of an exercise-related out-of-hospital cardiac arrest (OHCA). Regular exercise has been reported to reduce the risk of plaque rupture in animal studies and basic research. Therefore, we compared the coronary artery findings in CAD-OHCA patients with and without habitual exercise. There have been few reports on whether regular exercise changes the prognosis in OHCA due to CAD (CAD-OHCA). We investigated the association between the better clinical outcome and the regular exercise in patients with CAD-OHCA. Methods This is a single-center retrospective analysis from 2006 to 2019. The consecutive 397 patients with OHCA due to myocardial ischemia underwent coronary angiography (CAG). After excluding 73 patients with vasospastic angina, the remaining 324 patients with CAD were enrolled in this study. We divided these patients into two groups according to whether they were habitually exercising (Exercise group: N=37) or not/unknown (Non-Exercise group: N=287). Clinical outcome was a 30-day survival with minimal neurologic impairment represented by a Glasgow-Pittsburgh Cerebral Performance Categories Scale value 1 or 2. Results The patients in the Exercise Group were significantly younger (exercise vs. non-exercise, 57±12 vs. 64±12 years; P&amp;lt;0.01) than those in the non-exercise group. The Exercise group had a lower incidence of diabetes mellitus (22% vs. 42%; P=0.02) and a higher incidence of dyslipidemia (81% vs. 62%; P=0.02) than the non-exercise group. The time from collapse to cardiopulmonary resuscitation (1.4±4.0 vs. 3.0±4.8min) and from collapse to return of spontaneous circulation (11.9±10.0 vs. 28.0±25.3min) were shorter in Exercise group (all p&amp;lt;0.05). The ST-segment elevation was recorded on electrocardiography in fewer of the Exercise group (22% vs. 63%; P&amp;lt;0.01). The finding of culprit lesion in the coronary arteries on arrival resulted significant differences between the 2groups (good collateral and/or TIMI3 flow: 62% vs. 25%, the plaque rupture and/or thrombus: 22% vs. 73%) (all p&amp;lt;0.01) (Figure 1). Kaplan-Meier curve showed Exercise group has better neurological outcome at 30days compared than Non-Exercise (95% vs 51%; P&amp;lt;0.001, log-rank test) (Figure 2). Multivariable Cox proportional hazards models revealed that a habitual exercise was one of the predictors of a good neurological outcome (HR 0.21, 95% CI 0.05–0.92; P=0.039). Conclusions The patients with habitual exercise had less plaque rupture, less coronary thrombosis than non-exercise. The patients with regular exercise had better clinical outcomes than non-exercise after CAD-OHCA. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Tokyo Metropolitan Goverment Figure 1. Findings of the culprit lesion in coronar arteriesFigure 2. Kaplan-Meier analysis

Machine Learning Models for Survival and Neurological Outcome Prediction of Out-of-Hospital Cardiac Arrest Patients.

Background Out-of-hospital cardiac arrest (OHCA) is a major health problem worldwide, and neurologic injury remains the leading cause of morbidity and mortality among survivors of OHCA. The purpose of this study was to investigate whether a machine learning algorithm could detect complex dependencies between clinical variables in emergency departments in OHCA survivors and perform reliable predictions of favorable neurologic outcomes. Methods This study included adults (≥18 years of age) with a sustained return of spontaneous circulation after successful resuscitation from OHCA between 1 January 2004 and 31 December 2014. We applied three machine learning algorithms, including logistic regression (LR), support vector machine (SVM), and extreme gradient boosting (XGB). The primary outcome was a favorable neurological outcome at hospital discharge, defined as a Glasgow-Pittsburgh cerebral performance category of 1 to 2. The secondary outcome was a 30-day survival rate and survival-to-discharge rate. Results The final analysis included 1071 participants from the study period. For neurologic outcome prediction, the area under the receiver operating curve (AUC) was 0.819, 0.771, and 0.956 in LR, SVM, and XGB, respectively. The sensitivity and specificity were 0.875 and 0.751 in LR, 0.687 and 0.793 in SVM, and 0.875 and 0.904 in XGB. The AUC was 0.766 and 0.732 in LR, 0.749 and 0.725 in SVM, and 0.866 and 0.831 in XGB, for survival-to-discharge and 30-day survival, respectively. Conclusions Prognostic models trained with ML technique showed appropriate calibration and high discrimination for survival and neurologic outcome of OHCA without using prehospital data, with XGB exhibiting the best performance.

Changes of regional saturation of cerebral oxygenation and neuron specific enolase in patients after cardiopulmonary resuscitation

To observe the changes of regional saturation of cerebral oxygenation (rScO2) and blood neuron specific enolase (NSE) in patients after cardiopulmonary resuscitation (CPR), and to explore its value in evaluating the prognosis of patients' neurological function. From January 2012 to December 2020, 97 patients with return of spontaneous circulation (ROSC) after cardiac arrest (CA) treated in the intensive care unit (ICU) of the Second Affiliated Hospital of Soochow University were selected. According to the prognosis, the patients were divided into two groups: good neurological function group [Glasgow-Pittsburgh Cerebral Performance Categories (CPC) 1-2, 20 cases] and neurological dysfunction group (CPC classification 3-5, 77 cases). The clinical data of gender, age, the number of patients with defibrillable rhythm, time of ROSC, the number of CA patients outside the hospital, acute physiology and chronic health evaluation II (APACHE II), Glasgow coma scale (GCS), global non-response scale (FOUR), body temperature, mean arterial pressure (MAP), blood lactic acid (Lac) and GCS at discharge, as well as the length of ICU stay, rScO2 and blood NSE were collected. The differences of rScO2 and NSE between the two groups were compared; and the receiver operator characteristic curve (ROC curve) was drawn to evaluate the value of rScO2 and NSE alone or in combination in predicting the prognosis of patients with ROSC after CA. The rScO2 of good neurological function group was significantly higher than that of neurological dysfunction group at 1, 3, 6, 12, 24 and 48 hours (all P < 0.05). At 24 hours after admission, the rScO2 on the left and right sides of good neurological function group was significantly higher than that in neurological dysfunction group [left: 0.65 (0.59, 0.76) vs. 0.55 (0.44, 0.67), right: 0.62 (0.61, 0.73) vs. 0.50 (0.30, 0.69), both P < 0.05], and NSE was significantly lower than that in the neurological dysfunction group [ng/L: 21.42 (15.38, 29.69) vs. 45.82 (24.05, 291.26), P < 0.05]. ROC curve analysis showed that both rScO2 and NSE alone and combined detection had a certain value in predicting the prognosis of neurological function in patients with ROSC after CA, and the area under the ROC curve (AUC) detected by the combination was the largest, which was higher than the AUC predicted by rScO2 or NSE (0.904 vs. 0.884, 0.792). When the cut-off value of combination was 0.83, the sensitivity and specificity were 75.7% and 100% respectively. Monitoring rScO2 and NSE can predict the prognosis of neurological function after CPR, especially the combined evaluation of the two indexes, which can greatly improve the accuracy of diagnosis.

Mechanical circulatory support for refractory out-of-hospital cardiac arrest: a Danish nationwide multicenter study

BackgroundMechanical circulatory support (MCS) with either extracorporeal membrane oxygenation or Impella has shown potential as a salvage therapy for patients with refractory out-of-hospital cardiac arrest (OHCA). The objective of this study was to describe the gradual implementation, survival and adherence to the national consensus with respect to use of MCS for OHCA in Denmark, and to identify factors associated with outcome.MethodsThis retrospective, observational cohort study included patients receiving MCS for OHCA at all tertiary cardiac arrest centers (n = 4) in Denmark between July 2011 and December 2020. Logistic regression and Kaplan–Meier survival analysis were used to determine association with outcome. Outcome was presented as survival to hospital discharge with good neurological outcome, 30-day survival and predictors of 30-day mortality.ResultsA total of 259 patients were included in the study. Thirty-day survival was 26%. Sixty-five (25%) survived to hospital discharge and a good neurological outcome (Glasgow–Pittsburgh Cerebral Performance Categories 1–2) was observed in 94% of these patients. Strict adherence to the national consensus showed a 30-day survival rate of 30% compared with 22% in patients violating one or more criteria. Adding criteria to the national consensus such as signs of life during cardiopulmonary resuscitation (CPR), pre-hospital low-flow < 100 min, pH > 6.8 and lactate < 15 mmol/L increased the survival rate to 48%, but would exclude 58% of the survivors from the current cohort. Logistic regression identified asystole (RR 1.36, 95% CI 1.18–1.57), pulseless electrical activity (RR 1.20, 95% CI 1.03–1.41), initial pH < 6.8 (RR 1.28, 95% CI 1.12–1.46) and lactate levels > 15 mmol/L (RR 1.16, 95% CI 1.16–1.53) as factors associated with increased risk of 30-day mortality. Patients presenting signs of life during CPR had reduced risk of 30-day mortality (RR 0.63, 95% CI 0.52–0.76).ConclusionsA high survival rate with a good neurological outcome was observed in this Danish population of patients treated with MCS for OHCA. Stringent patient selection for MCS may produce higher survival rates but potentially withholds life-saving treatment in a significant proportion of survivors.

Implementation of Venoarterial Extracorporeal Membrane Oxygenation in Nonintubated Patients.

BackgroundAlthough extracorporeal membrane oxygenation (ECMO) is generally performed percutaneously, the technology is deployed under sedation and necessitates endotracheal intubation. However, in some patients, the use of venoarterial (VA) ECMO without intubation may be beneficial. Herein, we describe our experiences with VA ECMO performed without prior endotracheal intubation.MethodsA total of 783 patients treated with VA ECMO at a single center between January 2013 and July 2018 were reviewed retrospectively. We included patients who underwent successful VA ECMO implementation without prior endotracheal intubation, and excluded those who were younger than 18 years, had ongoing cardiopulmonary resuscitation status, and had poor quality of the vessels needed for percutaneous cannulation. The primary study outcome was in-hospital survival.ResultsIn total, 50 patients were included in this study, 94% of whom showed cardiogenic shock. The mean age of the study participants was 56.3±14.5 years. The median VA ECMO support time was 7 days (range, 2–13 days). Twenty-one patients (42%) did not receive ventilator care during the VA ECMO support period, while 29 patients (58%) progressed to intubation after VA ECMO implementation. The rates of survival at discharge and weaning success were 82% (n=41) and 92% (n=46), respectively, and 80% (n=40) of patients presented good Glasgow–Pittsburgh Cerebral Performance Categories scores at discharge.ConclusionEven in patients with cardiogenic shock, percutaneous VA ECMO can be introduced safely without prior endotracheal intubation by an experienced care team. The application of nonintubated VA ECMO might be a feasible strategy in selected cases.

Is two-dimensional echocardiography better than electrocardiography for predicting patient outcomes after cardiac arrest?

BackgroundCoronary artery stenosis increases hospital mortality and leads to poor neurological recovery in cardiac arrest (CA) patients. However, electrocardiography (ECG) cannot fully predict the presence of coronary artery stenosis in CA patients. Hence, we aimed to determine whether regional wall motion abnormality (RWMA), as observed by two-dimensional echocardiography (2DE), predicted patient survival outcomes with greater accuracy than did ST segment elevation (STE) on ECG in CA patients who underwent coronary angiography (CAG) after return of spontaneous circulation.MethodsThis was a retrospective observational study of adult patients with CA of presumed cardiac etiology who underwent CAG at a single tertiary care hospital. We investigated whether RWMA observed on 2DE predicted patient outcomes more accurately than did STE observed on ECG. The primary outcome was incidence of hospital mortality. The secondary outcomes were Glasgow-Pittsburgh Cerebral Performance Category scores measured 6 months after discharge and significant coronary artery stenosis on CAG.ResultsAmong the 145 patients, 36 (24.8%) experienced in-hospital death. In multivariable analysis of survival outcomes, only total arrest time (P=0.011) and STE (P=0.035) were significant. The odds ratio (OR) and 95% confidence interval (CI), which were obtained by adjusting the total arrest time for survival outcomes, were significant only for STE (OR, 0.40; 95% CI, 0.17–0.94). The presence of RWMA was not a significant factor.ConclusionsWhile STE predicted survival outcomes in adult CA patients, RWMA did not. The decision to perform CAG after CA should include ECG under existing guidelines. The use of RWMA has limited benefits in treatment of this population.