Higher Incidence Of Cardiac Arrest Research Articles

Abstract 18865: Cardiac Arrest on Weekends Are More Fatal Than Weekdays - A Study From National Database

Introduction: The overall survival of cardiac arrest patients is very poor. There is a higher incidence of cardiac arrest on weekends especially on Saturdays as per national statistics. Also, hospitals experience reduced staffing on the weekends. We examined the outcomes of cardiac arrests on weekends compared to weekdays. Hypothesis: There is no difference in mortality in cardiac arrests which happen over the weekday compared to over the weekend. Methods: This retrospective cohort study used a national inpatient sample database to identify patients from 2016 to 2019 presenting with cardiac arrest on weekdays vs on weekends. SAS 9.3 was used for data analysis. The data were weighted to generate national estimates of the entire US hospitalized population. Results: Out of 57,300 patients who presented with cardiac arrest during the study period, 41,410 were on weekdays (72.2%; mean age 65.9; 56.2% males) and 15,890 were on weekends (27.8%, mean age 65.2; 56.7% males). Inhospital mortality was less on weekdays than on weekends (72.4% vs 76.2%). The younger age group (18-40 years) had a higher share of of cardiac arrest on weekends when compared to weekdays (8.2% vs 7.1%). Weekday admissions had a higher rate of prior MI (8.9% vs 7.6%) and a higher rate of comorbities including DM (39.4% vs 36%), CHF (32.2% vs 28.9%), Renal Failure (29.5% vs 26.6%), CAD (34.8% vs 31.7%). Weekend admissions had a higher rate of smoking history (16.9% vs 15.1%). All p values <0.001. Conclusions: Cardiac arrest on weekends has a higher mortality rate compared to weekdays. We found a higher burden of comorbidities on patients with weekday cardiac arrest.

Facilitating cardiopulmonary resuscitation training in high-risk areas of England: A study protocol

IntroductionBystanders’ interventions improve chances of survival from out-of-hospital cardiac arrest (OHCA) before Emergency Medical Services arrive. Some areas in England are of concern. These high-risk areas have a higher incidence of cardiac arrest combined with lower-than-average bystander CPR rates and are characterised by higher proportions of minority ethnic group residents and deprivation.Collaborating with people from the Black African and Caribbean and South Asian minority communities in deprived areas of England, we aim to develop and evaluate the implementation of theoretically informed intervention(s) to address factors contributing to lower bystander intervention rates. MethodsThe study is a collaborative realist enquiry, informed by the Theoretical Domains Framework and associated Behaviour Change Wheel. It consists of 1) a realist evidence synthesis to produce initial program theories developed from primary workshop data and published evidence. It will include identifying factors contributing to the issue and potential interventions to address them; 2) theoretically informed intervention development, using the initial program theories and behaviour change theory and 3) a realist mixed methods implementation evaluation with embedded feasibility.Public involvement (PPI) as study team and public advisory group members is key to this study.We will conduct realist evidence synthesis, qualitative and statistical analyses appropriate to the various methods used. DisseminationWe will develop a dissemination plan and materials targeted to members of the public in high-risk areas as well as academic outputs. We will hold an event for participating community groups and stakeholders to share findings and seek advice on next steps. Study registrationISRCTN90350842. Registration date 28.03.2023. The study was registered after its start date.

The impact of aorto-uni-iliac graft configuration on outcomes of endovascular repair for ruptured abdominal aortic aneurysms

IntroductionEndovascular aneurysm repair has improved outcomes for ruptured abdominal aortic aneurysms (rAAA) compared with open repair. We examined the impact of aorto-uni-iliac (AUI) vs standard bifurcated endograft configuration on outcomes in rAAA. MethodsPatients 18 years or older in the Vascular Quality Initiative database who underwent endovascular aneurysm repair for rAAA from January 2011 to April 2020 were included. Patient characteristics were analyzed by graft configuration: AUI or standard bifurcated. Primary and secondary outcomes included 30-day mortality, postoperative major adverse events (myocardial infarction, stroke, heart failure, mesenteric ischemia, lower extremity embolization, dialysis requirement, reoperation, pneumonia, or reintubation), and 1-year mortality. A subset propensity-score matched cohort was also analyzed. ResultsWe included 2717 patients: 151 had AUI and 2566 had standard bifurcated repair. There was no significant difference between the groups in terms of age, major medical comorbidities, anatomic aortic neck characteristics, or rates of conversion to open repair. Patients who underwent AUI were more commonly female (30% vs 22%, P = .011) and had a history of congestive heart failure (19% vs 12%, P = .013). Perioperatively, patients who underwent AUI had a significantly higher incidence of cardiac arrest (15% vs 7%, P < .001), greater intraoperative blood loss (1.3 L vs 0.6 L, P < .001), longer operative duration (218 minutes vs 138 minutes, P < .0001), higher incidence of major adverse events (46.3% vs 33.3%, P = .001), and prolonged intensive care unit (7 vs 4.7 days, P = .0006) and overall hospital length of stay (11.4 vs 8.1 days, P = .0003). Kaplan-Meier survival analyses demonstrated significant differences in 30-day (31.1% vs 20.2%, log-rank P = .001) and 1-year mortality (41.7% vs 27.7%, log-rank P = .001). The propensity-score matched cohort demonstrated similar results. ConclusionsThe AUI configuration for rAAA appears to be implemented in a sicker cohort of patients and is associated with worse perioperative and 1-year outcomes compared with a bifurcated graft configuration, which was also seen on propensity-matched analysis. Standard bifurcated graft configuration may be the preferred approach in the management of rAAA unless AUI configuration is mandated by patient anatomy or other extenuating circumstances.

Perioperative administration of methylprednisolone was associated with postoperative pulmonary complications in elderly patients undergoing hip fracture surgery.

Postoperative pulmonary complications (PPCs) seriously affect the postoperative prognosis of elderly patients underwent hip fracture surgery. Although methylprednisolone is increasingly used, the association between perioperative methylprednisolone and PPCs is still controversial. The study aims to determine whether perioperative administration of methylprednisolone is associated with PPCs in elderlypatients during hip fracture surgery. In this retrospective cohort study, records of 584 patients (≥ 65years) who underwent hip fracture surgery between January 2013 and October 2020 were extracted. Univariate and multivariate regression analysis were performed to identify the risk factors for PPCs. To further explore the association between administration of methylprednisolone and PPCs, 53 patients received methylprednisolone and 53 patients without methylprednisolone were matched for the confounding factors using propensity score matching (PSM) analysis. The odds ratios (OR) and 95% confidence intervals (CI) for the above variables were analyzed. The incidence of PPCs during postoperative hospitalization was 6.83% (38/556) among the elderly patients following hip fracture surgery. Patients with PPCs had higher postoperative mortality rate, longer hospital stay, more hospitalization cost, and higher incidence of cardiac arrest (all P < 0.05). Multivariate logistic regression analysis showed that age, hypertension, hypoglycemia, hypoproteinemia and perioperative methylprednisolone were independent risk factors for PPCs. Moreover, administration of methylprednisolone was significantly correlated with PPCs both before PSM adjustment (OR = 3.25; 95% CI, 1.67 to 6.33; P = 0.001) and after PSM adjustment (OR = 6.68; 95% CI, 1.40 to 31.82; P = 0.017). Perioperative administration of methylprednisolone is a risk factor for PPCs in elderly patients undergoing hip fracture surgery.

Barriers and facilitators to delivering bystander cardiopulmonary resuscitation in deprived communities: a systematic review.

There is a higher incidence of cardiac arrest in economically deprived areas; however, data show that bystander cardiopulmonary resuscitation (CPR) in those areas is lower. This results in lower survival rates, placing those communities at a double disadvantage. This systematic review explored the barriers and facilitators to engaging with bystander CPR in deprived communities. Studies were eligible for inclusion if they addressed any barrier or facilitator to performing bystander CPR or being trained in CPR or training others. Studies had to either be set in a deprived area or examine a deprived population. Selected studies were published between January 2000 and December 2017 and reported on primary research. No language limitations were applied. Searches were conducted in the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PsycINFO, PubMed, and Web of Science Core Collection. Unpublished 'grey' literature was also searched as well as the reference lists of any relevant studies. The systematic review highlighted several main factors acting as barriers or facilitators to engaging with bystander CPR in deprived communities: (1) the willingness to learn or perform CPR, (2) the confidence to perform CPR, and (3) self-reported likelihood of performing CPR. The review also revealed additional barriers to engaging with CPR which are specific to - or more acute for - individuals from socioeconomically deprived backgrounds or areas. We found little evidence suggesting that the willingness to perform or learn bystander CPR is lower in deprived communities compared to the general population. However, the confidence to perform CPR in deprived communities was affected by some measures of socioeconomic status. The results also crucially highlighted other barriers more acute in deprived communities: the risk to personal safety in administering CPR; the fear of legal consequences; and the lack of community cohesion and other cultural barriers.

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.

High venous to arterial CO2 gap is related to cardiovascular death in cardiogenic shock

Abstract Funding Acknowledgements Type of funding sources: None. Background Venous to arterial CO2 gap (CO2gap) is calculated by subtracting partial pressure of arterial CO2 to central venous partial pressure of CO2 (ScvCO2). This marker has been studied in septic shock and indicates hypoperfusion when exceeds 6mmHg. Its kinetics and applicability in cardiogenic shock (CS) are unclear, being mixed/central venous saturation and lactate more commonly used. Purpose The objective of the study is to describe CO2gap kinetics in patients with CS. Secondary objective is to analyze if CO2gap is as marker of prognosis in CS. Methods Prospective observational study that included patients admitted for CS in the Acute Cardiovascular Care Unit of a tertiary hospital. Gasometric samples were obtained at admission, 6, 12, 24 and 48 hours from the onset of shock. In-hospital mortality was registered. Results We included 40 patients with CS during 1 year. Most patients were male (80%), average age was 68 years. There was a high incidence of cardiac arrest (58%), most frequent cause of CS was STEMI (45%), in-hospital mortality was 45%, most cases from non-cardiovascular causes (61%). Refractory shock was frequent (28%). Average lactate peak was 6.02 mmol / L. CO2gap kinetics consisted in a peak at admission (8.8mmHg), a valley 6h (7.7mmHg), new peak at 12h (8.5mmHg) and progressive decrease at at 24 (6.8mmHg) and 48h (5.7 mmHg). Significantly, higher CO2gap values at admission (10.97mmHg vs 8.16mmHg, p = 0.007) was predictor of cardiovascular mortality. Lactate values at 6, 12 and 48 hours were also predictors of cardiovascular mortality, as well as ScvO2 at admission. Conclusions Patients with CS present with high CO2gap values during first hours of admission. The kinetics of this marker consists in two peaks at admission and 12 hours from CS onset, a valley at 6 hours and a progressive decrease at 24 and 48 hours. Its determination at admission is associated with cardiovascular mortality. We suggest the potential benefit of combining this marker, along with lactate and ScvO2 values, to guide management of patients with CS. Abstract Figure. CO2 gap and cardiovascular mortality

Use of Impella 5.0 with Axillary Approach as a Bridge to Decision in Advanced Decompensated Heart Failure

Cardiogenic shock is a spectrum and short term mechanical circulatory support devices such as VA ECMO and Impella 5.0 have been increasingly utilized as a salvage and bridge therapy. The objective of this study is to evaluate the use of these temporary support devices in patients with refractory cardiogenic shock. Retrospective review of all patients with an Impella 5.0 or EC-Pella between January 2018 to September 2019. A total of 39 patients were placed on Impella 5.0 and 17 of those received EC-Pella. Overall, patients were predominantly INTERMACS profile 1 (43%) or 2 (57%). Average age was 57 and length of stay was 28 days. Common indications included progressive decline on inotropic support, as an exit to wean from VA ECMO, and to evaluate right sided heart function to bridge to a durable LVAD. Overall survival of these patients is 74% (n= 29). Of the 39 Impella patients, 46% (n= 18) received a durable LVAD, 15% (n= 6) received OHT, 21% (n= 8) were a bridge to recovery, and 18% (n= 7) expired. The survival to discharge for patients with an LVAD was 84% (n=15), 100% for OHT (n= 6). Of the 10 total patients that expired, 3 patients died of RV failure post LVAD, and 7 died from lack of end-organ recovery..The survival to discharge rate was 90% for Impella patients that never required ECMO support during their admission. Alternatively, in the EC-Pella population, the survival to discharge was 53%. Axillary Impella 5.0 approach can be successfully used with excellent survival to discharge. With concomitant VA ECMO use the survival rate decreases, however, the patients were more acute with higher incidence of cardiac arrest, post cardiotomy shock, and increasing utilization of hemodialysis. This data needs to be validated prospectively through further data collection.

Maternal cardiac arrest in the Netherlands: A nationwide surveillance study

BackgroundMaternal cardiac arrest is a complex and demanding clinical situation requiring a well-attuned team effort of healthcare workers of multiple disciplines. A recent report on maternal cardiac arrest in the United Kingdom reported a rise in incidence over a span of 10 years, while maternal mortality increased in the United States between 2000 and 2014. However, reported causes of maternal cardiac arrest differed between both countries. Objective(s)To determine the incidence, causes and management of maternal cardiac arrest in the Netherlands and compare incidence with previous estimates in the Netherlands and the United Kingdom. Study designUsing the Netherlands Obstetric Surveillance System, all Dutch cases of maternal cardiac arrest during a three-year period (2013–2016) were prospectively collected. Complete casefile copies were obtained for analysis. Main outcome measures were incidence of maternal cardiac arrest and cardiac arrest in pregnancy, use of perimortem caesarean section if appropriate and maternal death. ResultsThe monthly card return rate was 97%; 18 women with cardiac arrest during pregnancy and 20 postpartum met the inclusion criteria. Incidence of maternal cardiac arrest was 7.6 per 100,000 pregnancies and 3.6 per 100,000 pregnancies excluding postpartum maternal cardiac arrest. Main causes were pulmonary embolism (n = 9), major obstetric hemorrhage (n = 7) and amniotic fluid embolism (n = 6). Aortocaval compression relief and perimortem caesarean section were performed in 9/14 (29%) and 11/14 (79%) respectively in pregnancies 20 weeks gestational age onwards. Twenty-two women died, representing a case fatality rate of 58% (95% CI 42–72%). Conclusion(s)There is a higher incidence of cardiac arrest in pregnancy compared to both previous estimates in the Netherlands and recently established figures in the United Kingdom. Main causes of maternal cardiac arrest are potentially preventable and/or treatable complications of pregnancy. Insufficient use of critical elements of obstetric resuscitation identifies the need for enhanced obstetric emergency training for obstetric and non-obstetric first responders.

Abstract 268: Patients &gt;65 Years of Age With Acute Myocardial Infarction Are Less Likely to Undergo Percutaneous Coronary Intervention and Have a Higher In-hospital Mortality

Background: Studies have shown that patients &gt;65 years of age with ST-elevation myocardial infarction are less likely to undergo a percutaneous coronary intervention (PCI) and are more likely to have a delayed door-to-balloon time above 90 minutes despite proven efficacy in these population. We investigated current outcomes and therapeutic approach in a large unselected population of patients. Methods: In a retrospective study, using the 2014 Nationwide Inpatient Sample (NIS), we analyzed patients &gt;65 years of age presenting with acute myocardial infarction (AMI). We performed univariate analysis of age, sex, race, hospital location, hospital teaching status, insurance type, hospital bed size, Charlson Comorbidity Index and other relevant comorbidities and we included variables with p&lt;0.2 in the multivariate logistic regression model. Results: A total of 115,042 patients with AMI were identified. Patients &gt;65 years of age (54%) had mean age of 78+/_0.04, vs 55 +/_ 0.04, p&lt;0001 and a higher percentage of them were female (45% vs 30%, p&lt;0.001). Patients &gt;65 years of age were were more likely to have hypertension (78% vs 69%, p&lt;0.001), chronic kidney disease (26% vs 9%, p&lt;0.001), heart failure (0.8% vs 0.5%, p&lt;0.001) and diabetes mellites (32% vs 29%, p&lt;0.001). Patients &gt;65 years of age were less likely to receive a PCI including angioplasty (OR=0.66, 95%CI =0.46-0.94, p&lt;0.02) and stent placement (OR=0.64, 95%CI =0.62-0.67, p&lt;0.001). They also had less timely stent implantation (stent within 48 hours: OR=0.66, 95%CI =0.63-0.68, p&lt;0.001). There was no difference in utilization of thrombolysis and CABG surgeries. Patients &gt;65 years of age with AMI had higher incidence of cardiac arrest (OR=1.21, 95%CI =1.06-1.37, p=0.004) as well as higher in-hospital mortality (OR=2.32, 95%CI =2.11-2.56, p&lt;0.001). There was no difference in implantation of cardioverter-defibrillator. Patients &gt;65 years of age were more likely to have shock (OR=1.28, 95%CI = 1.06-1.54, p-=0.009), heart failure (OR=1.62, 95%CI = 1.54-1.71, p&lt;0.001), and were more likely to require mechanical ventilation (OR=0.15, 95%CI = 1.07-1.25, p&lt;0.001). The use of short-term mechanical circulatory support was similar in patients &gt;65 years of age. Despite increased length of stay in patients &gt;65 years of age (Coef. =0.56, 95% CI= 0.45-0.66, p&lt;0.001), the total charges were smaller (Coef. = -3231$, 95% CI=- 5237$ - -1224$, p=0.002). Conclusion: Patients &gt;65 years of age and AMI had worse outcomes and were treated with a different therapeutic approach. They were less likely to be treated with a PCI and receive a timely intervention, which might explain lower total charges. Yet, they had a higher incidence of cardiac arrest and in-hospital mortality as well as higher incidence of shock, heart failure exacerbations and required higher utilization of mechanical ventilation, which could have contributed to the increased length of stay.

Targeted Temperature Management and Multimodality Monitoring of Comatose Patients After Cardiac Arrest.

Out-of-hospital cardiac arrest (CA) remains a leading cause of sudden morbidity and mortality; however, outcomes have continued to improve in the era of targeted temperature management (TTM). In this review, we highlight the clinical use of TTM, and provide an updated summary of multimodality monitoring possible in a modern ICU. TTM is neuroprotective for survivors of CA by inhibiting multiple pathophysiologic processes caused by anoxic brain injury, with a final common pathway of neuronal death. Current guidelines recommend the use of TTM for out-of-hospital CA survivors who present with a shockable rhythm. Further studies are being completed to determine the optimal timing, depth and duration of hypothermia to optimize patient outcomes. Although a multidisciplinary approach is necessary in the CA population, neurologists and neurointensivists are central in selecting TTM candidates and guiding patient care and prognostic evaluation. Established prognostic tools include clinal exam, SSEP, EEG and MR imaging, while functional MRI and invasive monitoring is not validated to improve outcomes in CA or aid in prognosis. We recommend that an evidence-based TTM and prognostication algorithm be locally implemented, based on each institution's resources and limitations. Given the high incidence of CA and difficulty in predicting outcomes, further study is urgently needed to determine the utility of more recent multimodality devices and studies.

Analysis of Screening Electrocardiogram for the Subcutaneous Defibrillator in Adults with Congenital Heart Disease.

Candidates for the subcutaneous implantable cardioverter-defibrillator (S-ICD) are screened using an electrocardiogram (S-ECG) tool to measure appropriate detection. We sought to define the S-ICD candidacy of congenital heart disease patients using the S-ECG tool. We also analyzed the reliability of the (S-ECG) tool between measurers in this population. Patients above the age of 12 and with a diagnosis associated with either a higher incidence of cardiac arrest or vascular access challenges were asked to undergo screening. S-ECGs were then analyzed by a pediatric electrophysiologist, an S-ICD device engineer, and an S-ICD clinical representative for candidacy. Results were compared for interobserver variability and S-ECGs were analyzed by t test to determine variables that differ among passing and failing leads. Thirty-one patients underwent screening. Two of the 31 (6.5%) patients failed S-ICD screening. Analysis of the screening leads demonstrated the highest passing rates using lead III at a 5mm/mV amplitude setting with 71 and 62% pass rate in the supine and standing positions, respectively. Interobserver analysis correlated well among the three measurers. There was a higher amplitude difference between QRS and T waves among passing versus failing S-ECG. Congenital heart disease patients have acceptable passage rates utilizing the S-ECG algorithm. Interobserver measurements were well correlated and these data suggest that the proximal coil to device (lead III) vector would be best utilized in this patient population. A larger difference between QRS and T wave amplitudes was associated with a higher S-ECG passing rate.

Early Experience of Medical Alert System in a Rural Training Hospital: a Pilot Study.

BackgroundMedical emergency teams (METs) have shown their merit in preventing unexpected cardiac arrest. However, it might be impractical for small- or medium-sized hospitals to operate an MET due to limited manpower and resources. In this study, we sought to evaluate the feasibility of a medical alert system (MAS) that alerts all doctors involved in patient care of patient deterioration via text message using smart-phones.MethodsThe MAS was test-operated from July 2015 to September 2015, in five general wards with a high incidence of cardiac arrest. The number of cardiac arrests was compared to that of 2014. The indication for activation of MAS was decided by the intensive care unit committee of the institution, which examined previous reports on MET.ResultsDuring the three-month study period, 2,322 patients were admitted to the participating wards. In all, MAS activation occurred in 9 patients (0.39%). After activation, 7 patients were admitted to the intensive care unit. Two patients (0.09%) experienced cardiac arrest. Of 13,129 patients admitted to the ward in 2014, there were 50 cases (0.38%) of cardiac arrest (p = 0.009).ConclusionsIt is feasible to use MAS to prevent unexpected cardiac arrest in a general ward.

Association of Freestanding Children's Hospitals With Outcomes in Children With Critical Illness.

Little is known about the relationship between freestanding children's hospitals and outcomes in children with critical illness. The purpose of this study was to evaluate the association of freestanding children's hospitals with outcomes in children with critical illness. Propensity score matching was performed to adjust for potential confounding variables between patients cared for in freestanding or nonfreestanding children's hospitals. We tested the sensitivity of our findings by repeating the primary analyses using inverse probability of treatment weighting method and regression adjustment using the propensity score. Retrospective study from an existing national database, Virtual PICU Systems (LLC) database. Patients less than 18 years old admitted to one of the participating PICUs in the Virtual PICU Systems, LLC database were included (2009-2014). None. A total of 538,967 patients from 140 centers were included. Of these, 323,319 patients were treated in 60 freestanding hospitals. In contrast, 215,648 patients were cared for in 80 nonfreestanding hospitals. By propensity matching, 134,656 patients were matched 1:1 in the two groups (67,328 in each group). Prior to matching, patients in the freestanding hospitals were younger, had greater comorbidities, had higher severity of illness scores, had higher incidence of cardiac arrest, had higher resource utilization, and had higher proportion of patients undergoing complex procedures such as cardiac surgery. Before matching, the outcomes including mortality were worse among the patients cared for in the freestanding hospitals (freestanding vs nonfreestanding, 2.5% vs 2.3%; p < 0.001). After matching, the majority of the study outcomes were better in freestanding hospitals (freestanding vs nonfreestanding, mortality: 2.1% vs 2.8%, p < 0.001; standardized mortality ratio: 0.77 [0.73-0.82] vs 0.99 [0.87-0.96], p < 0.001; reintubation: 3.4% vs 3.8%, p < 0.001; good neurologic outcome: 97.7% vs 97.1%, p = 0.001). In this large observational study, we demonstrated that ICU care provided in freestanding children's hospitals is associated with improved risk-adjusted survival chances compared to nonfreestanding children's hospitals. However, the clinical significance of this change in mortality should be interpreted with caution. It is also possible that the hospital structure may be a surrogate of other factors that may bias the results.

Épidémiologie de l’arrêt cardio-respiratoire : données France–États-Unis

Epidemiological data on the incidence, the survival and the prognostic factors of cardiac arrest (CA) are often heterogeneous. However, recent advances in methodology and research have improved the knowledge on that topic. The generation of registries in United States and France, in particular, improved significantly the characterization and the transatlantic comparability of provided data. The main information of these registries confirmed the high incidence of cardiac arrest and highlighted an overall survival better than previous published. The assessment of characteristics of patients and pre- and in-hospital interventions supports the consistent influence of identified prognostic factors in United States and France as well. Advantages of these registries rely on the development of large database and quality of information. However, some data are limited by volunteering collection, incompletion and/or restriction on defined communities, avoiding any generalization. Nevertheless, these collections of data represent an outstanding resource for descriptive and analytic interpretation of outcome in cardiac arrest setting. They also represent a necessary source for origin of randomized clinical trials, representing solely the high level of evidence for application of management strategy.

Risk factor paradox in the occurrence of cardiac arrest in acute coronary syndrome patients.

ObjectiveTo compare patients without previously diagnosed cardiovascular risk factors) and patients with one or more risk factors admitted with acute coronary syndrome.MethodsThis was a retrospective analysis of patients admitted with first episode of acute coronary syndrome without previous heart disease, who were included in a national acute coronary syndrome registry. The patients were divided according to the number of risk factors, as follows: 0 risk factor (G0), 1 or 2 risk factors (G1 - 2) and 3 or more risk factors (G ≥ 3). Comparative analysis was performed between the three groups, and independent predictors of cardiac arrest and death were studied.ResultsA total of 5,518 patients were studied, of which 72.2% were male and the mean age was 64 ± 14 years. G0 had a greater incidence of ST-segment elevation myocardial infarction, with the left anterior descending artery being the most frequently involved vessel, and a lower prevalence of multivessel disease. Even though G0 had a lower Killip class (96% in Killip I; p < 0.001) and higher ejection fraction (G0 56 ± 10% versus G1 - 2 and G ≥ 3 53 ± 12%; p = 0.024) on admission, there was a significant higher incidence of cardiac arrest. Multivariate analysis identified the absence of risk factors as an independent predictor of cardiac arrest (OR 2.78; p = 0.019). Hospital mortality was slightly higher in G0, although this difference was not significant. By Cox regression analysis, the number of risk factors was found not to be associated with mortality. Predictors of death at 1 year follow up included age (OR 1.05; p < 0.001), ST-segment elevation myocardial infarction (OR 1.94; p = 0.003) and ejection fraction < 50% (OR 2.34; p < 0.001).ConclusionEven though the group without risk factors was composed of younger patients with fewer comorbidities, better left ventricular function and less extensive coronary disease, the absence of risk factors was an independent predictor of cardiac arrest.

Abstract 18364: Barriers to Community CPR Training in High-risk Neighborhoods- Lessons Learned From the Hands-only CPR Program

Background: Improving the performance of bystander CPR in high-risk communities is essential for decreasing disparities in cardiac arrest survival. In this study, we identified the barriers to community CPR training in high-risk neighborhoods as part of the multi-centered trial of the Hands-Only™ CPR Program - a novel intervention targeting neighborhoods with high incidence of cardiac arrest and low bystander CPR rates. Methods: The Hands-Only CPR program was implemented in high-risk neighborhoods in Tampa, FL, Columbus, OH and Chicago, IL. Participants underwent group-based Hands-Only CPR training (1 hour) with a CPR Anytime kit, which includes a DVD and manikin. A $10 gift card incentive was offered to participants who used the kits to train family and friends and returned data at 2 weeks. Study coordinators identified barriers and facilitators to recruitment, training and follow-up. Results: In 20 weeks, 815 participants were recruited (Tampa, n=580; Columbus, n=165; Chicago, n=70). Participant demographics differed by site. Participants in Columbus and Chicago were predominantly Black (81% and 88%, respectively) whereas in Tampa they were White (42%) and Hispanic (38%). Annual income was &lt; $30,000 for 45% of participants. Recruitment was challenging even with participants receiving a $10 incentive, CPR Anytime kit, and meal with training. This may be related to CPR training being a low priority compared to other needs (i.e work, child care, neighborhood safety). Communication challenges with the community was cited as another barrier leading to low return response rate of 11%. Highest response rates occurred in Columbus (33%) where community liaisons lived in the neighborhood and interacted with residents daily. Participants did feel comfortable training others using the CPR Anytime kits (P&lt;0.001) The average number of family and friends trained was 4.1 (range: 1 to 15) individuals per respondent. Conclusion: The Hands-Only CPR program facilitates training in high-risk neighborhoods and minority populations through a train the trainer model. The biggest challenges faced by the sites were recruiting participants and response rates on family and friends trained. Future research will need to assess methods to improve outreach to this population.

Resuscitation of the patient with the functionally univentricular heart.

Neonates and infants with functional single ventricle anatomy face nearly certain early mortality without cardiac transplantation or successive palliation through a pathway of staged interventions. Patients with single ventricle variants typically have multiple hospitalizations and high incidence of cardiac arrest. Few studies have directly addressed the physiology, pharmacology, techniques or outcomes of resuscitation of this high-risk group. The unique challenge posed by resuscitation of this patient group was recently recognized within the 2010 International Liaison Committee on Resuscitation consensus statement, where, for the first time, two worksheets were devoted exclusively to the resuscitation of the single ventricle patient before and after S1P and those patients with bidirectional Glenn/hemi-Fontan and Fontan physiology. This article will review the consensus on science, treatment recommendations, and areas of uncertainty in the resuscitation of the infants and children with single ventricle physiology during each stage of surgical repair.

324: Women in the intensive unit care of cardiology: morbidity and mortality study

The aim of this observational study that includes 800 consecutive patients admitted in our unit intensive care of cardiology (UIC) is the evaluation of the cardiac pathology in women, and the morbidity and mortality of them compared to men. The women represent 25% of patients, they were older (mean age 66 ±5 years versus 56±7 years in men, p=0.05), and we observed more diabetes 48.6% vs 38%, p=0.003. The diagnostic of acute coronary syndrome without ST elevation were relieved in 43% of women vs 24% in men, p=0.03. STEMI were more frequent in men (24% vs 32%), the auriculo ventricular block were more frequent in women 16.8% vs 5%, p=0.002. We observed in women patient a higher incidence of cardiac arrest resuscitated (2.5% vs 1.7% p=0.05) and cardiac shock 3.2% vs 0.7%, p=0.004. Insides a better left ventricular ejection fraction (47±15% vs 40±14%, p=0.03), they presented more hemodynamic complication (6% versus 2.8% in men, p<0.01) and more rhythmic complication (8% versus 4.5% in men, p<0.01) Angiographic Coronarography were performed in 61% of women compared to 77% in men. A coronary revascularization by percutaneous transluminal coronary angioplasty were performed in 9% of women vs 11.5% in men, and only 9.6% of women beneficed of chirurgical revascularization versus 14.3% of men, p=0.004 Finaly, we observed more mortality in our study in women patients (3.2% vs 1.8%, p=0.002). The predictive factors of mortality were the level of the CRP (odds ratios and 95 percent confidence intervals =7.6, 1.1–14.3, p=0.013) and the female gender (OR at 3.8, CI at 95% a =1.2–5.4, p=0.0013) and the LVEF (OR at 1.4, CI aT 95% =1.1–7.8, p=0.012), but only the female gender was in independent predictive factor of mortality in IUC of cardiology using multiple logistic regression to estimate the adjusted odds raio (OR adjusted a 1.7, CI at 95% =1.11–5.4, P= 0.002). The women presented only the quart of the patients admitted in the intensive unit care of cardiology, but this population have a higher level of morbidity, hospital complication. More, the female gender in an independent predictive factor of mortality.

Abstract 258: Incidence and Predictors of Cardiac Arrest in Cerebrovascular Diseases

Background and purpose: Large scale studies of cardiac arrest in hospitalized patients with cerebrovascular accident (CVA) are lacking. We sought to describe the incidence, demographics and hospital characteristics of cardiac arrest in CVA. Additionally, we aimed to indentify predictors of cardiac arrest in patients with CVA. Methods: We analyzed the data from the Nationwide Inpatient Sample (NIS) of Healthcare Cost and Utilization Project for years 2005-2009. NIS is a discharge level 20% stratified sample of all non-federal hospitals in the US. We used International Classification of Diseases-9 (ICD-9) codes to select cases of CVA. Comparisons were made by using χ2 and student-t tests. Multivariate logistic regression was used to identify independent predictors of cardiac arrest. Results: We included 672,161 cases of CVA [ischemic stroke: 58.2%, transient ischemic attack (TIA):28.2%, intracerebral hemorrhage (ICH): 9.7%, and subarachnoid hemorrhage (SAH): 3.9%] in our analysis. Of these, 3,154 (0.467%) also had cardiac arrest. Compared to ischemic stroke (0.413%), incidence of cardiac arrest was higher in ICH (1.221%) and SAH (2.523%) and was lower in TIA (0.038%). Patients with cardiac arrest were younger (mean age±SD: 67.8±16.4 vs. 70.5±15.7 years, p&lt;0.001) and were less likely of female gender (51.8% vs. 55.7%, p&lt;0.001). There was a significant difference in the incidence of cardiac arrest between various ethnic groups (Caucasian: 0.415% vs. African-American: 0.563% vs. Hispanic: 0.633% vs. Asian/Pacific Islander: 0.722%, p&lt;0.001). Compared to the rest, patients in lowest income quartile had higher incidence of cardiac arrest (0.526% vs. 0.437%, p&lt;0.001). Significant differences based on the hospital characteristics were as follows: 1. Bedsize: small (0.349%) vs. medium (0.443%) vs. large (0.498%), p&lt;0.001; 2. Location: rural (0.354%) vs. urban (0.485%), p&lt;0.001; 3. Academic status: teaching (0.553%) vs. non-teaching (0.403%), p&lt;0.001; and 4. Region: northeast (0.399%) vs. midwest (0.403%) vs. south (0.489%) vs. west (0.553%), p&lt;0.001. In multivariate analysis, factors associated with cardiac arrest are shown in the table. Conclusion: This is one of the largest studies to describe the predictors of cardiac arrest in CVA. The patients with ICH and SAH are at significantly higher risk of cardiac arrest. The association of hospital characteristics and the incidence of cardiac arrest warrants further exploration into the contributing factors. The patients with higher risk profile as per the predictor model should warrant closer monitoring.