Hospital Cardiac Arrest Research Articles

The initiative for medical equity and global health (IMEGH) resuscitation training program: A model for resuscitation training courses in Africa

In high-income countries, outcomes following in hospital cardiac arrest have improved over the last two decades due to the introduction of rapid response teams, cardiac arrest teams, and advanced resuscitation training. However, in low-income countries, such as Rwanda, outcomes are still poor. This is due to multiple factors including lack of adequate resuscitation training, few trainers, and lack of equipment.To address this issue, the Initiative for Medical Equity and Global Health Equity (IMEGH), a training organization founded in 2018 by 5 local anesthesiologists has regularly taught resuscitation courses such as Basic Life Support, Advanced Cardiac Life Support, and Pediatric Advanced Life Support in hospitals throughout Rwanda. The aims of the organization include developing a sustainable model to offer context relevant resuscitation training courses, building a cadre of local instructors to teach on the courses, as well as engaging funding partners to help support the effort. From October 2018 until September 2022, 31 courses were run in 11 hospitals across Rwanda training 1,060 healthcare providers (mainly of non-physician anesthetists, nurses, midwives, and general practitioners). Ongoing challenges include lack of local protocols, inability to tracking resuscitation outcomes, and continued inaccessibility by many healthcare providers. Despite these challenges, the IMEGH program is an example of a successful context-relevant model and has potential to inform the design of resuscitation programs in other similar settings. This article describes the development of the IMEGH program, accomplishments as well as lessons learned, challenges, and next steps for expansion.

Strategi Dalam Meningkatkan Survival Rate Pada Penderita Henti Jantung Di Luar Rumah Sakit Out- Hospital Cardiac Arrest

The incidence of out-hospital cardiac arrest (OHCA) continues to increase. The survival rates of out hospital cardiac arrest decrease by 7-10% every minute. Therefore, Emergency medical services (EMS) as a part of the chain of survival needs to implement paramount strategies in order to increase survival rates. Socialization and discussion to strengthen the strategy has been conducted on December 2023 which involved pre-hospital team of Manambai Abdulkadir hospital (8 nurses, 1 doctor). It was followed by developing action plans. The pre-hospital team has chosen 2 of 10 action plans (rapid dispatch and community CPR) as main strategy to improve survival rates of out-hospital cardiac arrest patients. The Manambai Hospital are recommended to improve their support to develop human resources, medical equipment and funding to EMS team in order to improving survival rates of OHCA patients

Neurological outcome following out of hospital cardiac arrest: Evaluation of performance of existing risk prediction models in a UK cohort.

Out of hospital cardiac arrest (OHCA) is a common problem. Rates of survival are low and a proportion of survivors are left with an unfavourable neurological outcome. Four models have been developed to predict risk of unfavourable outcome at the time of critical care admission - the Cardiac Arrest Hospital Prognosis (CAHP), MIRACLE2, Out of Hospital Cardiac Arrest (OHCA), and Targeted Temperature Management (TTM) models. This evaluation evaluates the performance of these four models in a United Kingdom population and provides comparison to performance of the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score. A retrospective evaluation of the performance of the models was conducted over a 43-month period in 414 adult, non-pregnant patients presenting consecutively following non-traumatic OHCA to the five units in our regional critical care network. Scores were generated for each model for where patients had complete data (CAHP = 347, MIRACLE2 = 375, OHCA = 356, TTM = 385). Cerebral Performance Category (CPC) outcome was calculated for each patient at last documented follow up and an unfavourable outcome defined as CPC ⩾ 3. Performance for discrimination of unfavourable outcome was tested by generating receiver operating characteristic (ROC) curves for each model and comparing the area under the curve (AUC). Best performance for discrimination of unfavourable outcome was demonstrated by the high risk group of the CAHP score with an AUC of 0.87 [95% CI 0.83-0.91], specificity of 97.1% [95% CI 93.8-100] and positive predictive value (PPV) of 96.3% [95% CI 92.2-100]. The high risk group of the MIRACLE2 model, which is significantly easier to calculate, had an AUC of 0.81 [95% CI 0.76-0.86], specificity of 92.3% [95% CI 87.2-97.4] and PPV of 95.2% [95% CI 91.9-98.4]. The CAHP, MIRACLE2, OHCA and TTM scores all perform comparably in a UK population to the original development and validation cohorts. All four scores outperform APACHE-II in a population of patients resuscitated from OHCA. CAHP and TTM perform best but are more complex to calculate than MIRACLE2, which displays inferior performance.

Pre-hospital ECPR in an Australian metropolitan setting: a single-arm feasibility assessment—The CPR, pre-hospital ECPR and early reperfusion (CHEER3) study

IntroductionSurvival from refractory out of hospital cardiac arrest (OHCA) without timely return of spontaneous circulation (ROSC) utilising conventional advanced cardiac life support (ACLS) therapies is dismal. CHEER3 was a safety and feasibility study of pre-hospital deployed extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) for refractory OHCA in metropolitan Australia.MethodsThis was a single jurisdiction, single-arm feasibility study. Physicians, with pre-existing ECMO expertise, responded to witnessed OHCA, age < 65 yrs, within 30 min driving-time, using an ECMO equipped rapid response vehicle. If pre-hospital ECPR was undertaken, patients were transported to hospital for investigations and therapies including emergent coronary catheterisation, and standard intensive care (ICU) therapy until either cardiac and neurological recovery or palliation occurred. Analyses were descriptive.ResultsFrom February 2020 to May 2023, over 117 days, the team responded to 709 “potential cardiac arrest” emergency calls. 358 were confirmed OHCA. Time from emergency call to scene arrival was 27 min (15–37 min). 10 patients fulfilled the pre-defined inclusion criteria and all were successfully cannulated on scene. Time from emergency call to ECMO initiation was 50 min (35–62 min). Time from decision to ECMO support was 16 min (11–26 min). CPR duration was 46 min (32–62 min). All 10 patients were transferred to hospital for investigations and therapy. 4 patients (40%) survived to hospital discharge neurologically intact (CPC 1/2).ConclusionPre-hospital ECPR was feasible, using an experienced ECMO team from a single-centre. Overall survival was promising in this highly selected group. Further prospective studies are now warranted.

2022: Are We Back to the pre-COVID-19 Pandemic Period in the Management of out-of-Hospital Cardiac Arrest?

Introduction: The COVID-19 pandemic caused a significant strain on the Emergency system, particularly for time-dependent diseases like Out of Hospital Cardiac Arrest (OHCA). Studies have shown an increase in the incidence of OHCA during different waves of the pandemic, but there is limited evidence on how survival rates and rescue efforts have been affected in the post-pandemic period. Methods: We performed a retrospective observational cohort study of all OHCA rescues by AREU (Agenzia Regionale Emergenza Urgenza), in the Lombardy region in March in three different years (2019, 2021 and 2022). We used rescue mission data collected in AREU’s database, where logistic information of patient rescue missions managed by the Lombardy Region’s 112 system is recorded.Results: This study was an epidemiology analysis of OHCA after the pandemic. The results showed no significant changes in the probability of receiving bystander cardiopulmonary resuscitation (22.5% vs 24.0%; p=0.41) and public access defibrillation (3.6 vs 3.2; p=0.50) compared to pre-pandemic period. However, there was a decrease in the probability of ROSC (11.5% vs 6.2%; p&lt;0.01).Conclusion: According to our analysis, there appears to be a return to the pre-pandemic phase with regard to the OHCA network. However, it remains to be pointed out that a careful study of disease networks is essential to understand the resilience of our health system and to understand whether we have returned to a system similar to the pre-pandemic phase after the COVID-19 pandemic.

Diffusely Invasive Mucormycosis of the Small Bowel in a Patient with Microbiologic Cultures and Tissue Biopsies Negative for Fungal Organisms

Abstract Introduction/Objective Invasive mucormycosis can be a swiftly fatal medical emergency occurring in patients with uncontrolled diabetes. This angioinvasive fungus causes tissue necrosis, hemorrhage, and thrombosis and often develops in the sinonasal cavities where it can extend directly to the CNS or spread systemically to visceral sites like the GI tract. Here, we describe a patient whose small bowel resection shortly before death, revealed diffusely invasive mucormycosis despite that blood and body fluid cultures and tissue biopsies were negative for fungal organisms. Methods/Case Report Our patient is a 39 year old male with a history of uncontrolled diabetes, brought to our hospital in cardiac arrest and found to have fentanyl in his system. His labs showed severe metabolic and electrolyte derangements including diabetic ketoacidosis. His blood cultures revealed bacteremia but no fungal growth, and he was placed on antibiotics for sepsis. The patient developed compartment syndrome of his bilateral forearms, which were amputated and showed necrotic skeletal muscle but no fungal infection. The patient also developed facial necrosis concerning for mucormycosis, but nasal endoscopic and facial skin biopsies were negative for mucor. However, his abdominal CT showed diffuse mural thickening of his small bowel concerning for bowel ischemia, which prompted an exploratory laparotomy that revealed large segments of necrotic jejunum and ileum. While peritoneal fluids collected during the surgery yielded no fungal growth on culture, resected segments of necrotic small bowel showed massive presence of mucor with broad, pauci-septate, ribbon-like hyphae branching at right angles. Small bowel and mesenteric vessels showed angioinvasion by mucor with vasculitis and fibrin thrombi causing ischemic enteritis. Mucor was also noted diffusely invading small bowel muscularis propria, adventitia, and mesenteric fat, and small bowel also showed ulceration, hemorrhage, and transmural and mesenteric fat necrosis. Unfortunately, a few days after his surgery, the patient expired from multi-organ failure and septic shock before he could receive anti-fungal therapy for mucormycosis. Results (if a Case Study enter NA) NA Conclusion Mucormycosis is a rapidly growing, angioinvasive, and potentially lethal fungal infection that must be promptly recognized. This report documents an unusual case of invasive mucormycosis of the small bowel that went undetected in a severely ill patient whose blood and peritoneal cultures and tissue biopsies were all negative for fungal organisms.

Epidemiology and outcomes of out of hospital cardiac arrest in Saudi Arabia: Findings from the Saudi Out of Hospital cardiac Arrest Registry (SOHAR)

AimThe Saudi Out-of-Hospital Cardiac Arrest Registry (SOHAR) is the first out-of-hospital cardiac arrest (OHCA) registry in Saudi Arabia. This study aimed to describe the epidemiology and outcomes of OHCA in Saudi Arabia. MethodsThe SOHAR is a prospective data collection system. Data were collected monthly from defined regions, and registry measured variables were adopted from the Utstein recommendations. ResultsDuring the period from 01/01/2019 to 31/12/2022, 3671 patients were included in the registry. The mean age was 62 years, and 6.5% (240) of patients were under the age of 18 years. The most common cause of OHCA was medical 3439 (93.6%). A total of 641 (17.4%) and 129 (3.9%) had presumed cardiac and respiratory causes. Additionally, most OHCA in Saudi Arabia (3034, 82.6%) occurred at home. Prehospital Return Of Spontaneous Circulation (ROSC) was achieved in 275 (7.4%) cases, and 491 (13.3%) patients were pronounced dead upon arrival at the hospital. Survival to hospital discharge was achieved in 107 (2.9%) of the cases, and good neurological outcomes, defined as a Cerebral Performance Category (CPC) of 1–3, occurred in < 0.5% of patients. ConclusionThe Saudi out-of-hospital ROSC was 7.4%. The survival to hospital discharge rate was 2.9%, and less than 1% of patients were discharged with good neurological outcomes. Further research and the continuation of registry data collection is highly recommended. Additionally, a national-level out-of-hospital cardiac arrest system is recommended to ensure the standardization of medical care provided to patients with OHCA.

Impact of the COVID-19 pandemic on Canadian emergency medical system management of out-of-hospital cardiac arrest: A retrospective cohort study

AimWe sought to describe the impact of the COVID-19 pandemic on the care provided by Canadian emergency medical system (EMS) clinicians to patients suffering out of hospital cardiac arrest (OHCA), and whether any observed changes persisted beyond the initial phase of the pandemic. MethodsWe analysed cases of adult, non-traumatic, OHCA from the Canadian Resuscitation Outcome Consortium (CanROC) registry who were treated between January 27th, 2018, and December 31st, 2021. We used adjusted regression models and interrupted time series analysis to examine the impact of the COVID-19 pandemic (January 27th, 2020 – December 31st, 2021)on the care provided to patients with OHCA by EMS clinicians. ResultsThere were 12,947 cases of OHCA recorded in the CanROC registry in the pre-COVID-19 period and 17,488 during the COVID-19 period. We observed a reduction in the cumulative number of defibrillations provided by EMS (aRR 0.91, 95% CI 0.89 – 0.93, p < 0.01), a reduction in the odds of attempts at intubation (aOR 0.33, 95% CI 0.31 – 0.34, p < 0.01), higher rates of supraglottic airway use (aOR 1.23, 95% CI 1.16–1.30, p < 0.01), a reduction in vascular access (aOR for intravenous access 0.84, 95% CI 0.79 – 0.89, p < 0.01; aOR for intraosseous access 0.89, 95% CI 0.82 – 0.96, p < 0.01), a reduction in the odds of epinephrine administration (aOR 0.89, 95% CI 0.85 – 0.94, p < 0.01), and higher odds of resuscitation termination on scene (aOR 1.38, 95% CI 1.31 – 1.46, p < 0.01). Delays to initiation of chest compressions (2 min. vs. 3 min., p < 0.01), intubation (16 min. vs. 19 min., p = 0.01), and epinephrine administration (11 min. vs. 13 min., p < 0.01) were observed, whilst supraglottic airways were inserted earlier (11 min. vs. 10 min., p < 0.01). ConclusionThe COVID-19 pandemic was associated with substantial changes in EMS management of OHCA. EMS leaders should consider these findings to optimise current OHCA management and prepare for future pandemics.

Association between distance to nearest automated external defibrillator and socioeconomic deprivation in Great Britain

Abstract Background Disparities in socioeconomic status manifest in death from out of hospital cardiac arrest (OHCA). Inequalities in access to automated external defibrillators (AED) due to socioeconomically determined location of AEDs may be associated with OHCA survival. Purpose To investigate distances between nearest AED location and postcode by socioeconomic deprivation for the population of Great Britain (GB). Methods AED location data for 2022 were drawn from the British Heart Foundation The Circuit registry. All 1,677,466 unit postcodes in Great Britain were linked to the Index of Deprivation for the corresponding Lower Layer Super Output Area using the 2019 Ministry of Housing Communities and Local Government tool. The median distance by road from the centre of each postcode to the nearest AED was calculated using geographic information systems. The proportion available 24/7 was also reported. Multilevel linear mixed regression models fit by country and adjusted for urban/rural status and clustering to calculate predicted marginal mean distances to the nearest active AED, and nearest AED accessible 24/7 by deprivation decile. Results 78,425 unique AED locations were included in the analysis (Table 1). The median distance to nearest AED was 762.1m (IQR 410.8 - 1221.0) in GB; 742.7m (407.2 - 1340.7) in Scotland, 738.8m (422.6 - 1223.5) in England, and 511.5m (282.9 - 937.3) in Wales. For 24/7 access AEDs, median distances were greater: 964.0m (524.7 - 1667.5), 994.1m (538.5 – 1832.3), 990.8m (544.9 - 1683.3), and 569.7m (316.8 - 1033.4), respectively. Overall, there was little evidence of a trend in nearest AED distance by deprivation (fig 1). In Scotland the nearest AED was, on average, 108m further away in the most compared with the least deprived areas. In England, the nearest AED was closer to postcodes in the least deprived areas of England (predicted mean 20m) and Wales (predicted mean 95m). In England, AEDs with 24/7 access were further from postcodes with increasing deprivation (predicted mean 99m further than least deprived areas). In Scotland, nearest 24/7 access AEDs were 317m further away in the most deprived areas, and 62m closer in Wales, but with no evidence of a linear trend. At a typical walking speed (1.31m/sec), on average in GB it would take 17 minutes to retrieve an AED and 21 minutes out of hours. In England and Scotland out of hours, those in the most deprived areas would be delayed access to an AED by 2.5 and 8 minutes respectively compared the least deprived. Conclusions Overall, the median distance to nearest AED across postcodes in GB is at odds with the likelihood of successful resuscitation. Graded social inequalities were not observed in AED access across GB. However, substantive differences were observed in 24/7 AED access between most and least deprived areas of England and Scotland. Greater and more equitable access to AEDs has the potential to save lives and improve outcomes for people with OHCA.

The BE-ALIVE score: predicting 30-day mortality in patients presenting with acute coronary syndromes and cardiogenic shock

Abstract Aims The aim of this study was to create and validate a simple scoring system for predicting 30-day mortality in patients presenting with acute coronary syndromes (ACS) and any sign of shock at their moment of admission. Methods and results 2407 consecutive patients presenting to Harefield Hospital with clinical features of cardiogenic shock, from January 2011 to December 2020, were studied to build the training set. 30-day mortality was 17.2%. A scoring algorithm was built using binary logistic regression of variables available on admission and then converted to an additive risk score. The resultant scoring system is the BE-ALIVE score, which incorporates the following factors: Base Excess (1 point for &amp;lt; -2 mmols/L), Age (&amp;lt;65 years: 0 points, 65-74: 1 point, 75-84: 2 points, ³85: 3 points), Lactate (&amp;lt;2 mmols/L: 0 points, 2 - 4.9: 1 point, 5 - 9.9: 3 points, ³10: 6 points), Intubated (2 points), Left Ventricular function (mildly impaired or better: -1 point, moderately impaired: 1 point, severely impaired: 3 points) and External / out of hospital cardiac arrest (1 point). The scoring system was validated using a testing set of 515 patients presenting to Harefield hospital. The validation metrics were excellent with an AUC of 0.9, Brier score of 0.06 versus a naïve classifier of 0.15, Spiegelhalter’s z-statistic probability of 0.267 and a calibration slope of 1.08. Conclusion The BE-ALIVE score is a simple and accurate scoring system to predict 30-day mortality in patients presenting with ACS and shock.

Reduction in acute coronary events without excess out of hospital cardiac arrest during the COVID-19 lockdown of 2020 in new South Wales, Australia

Abstract Background The COVID-19 pandemic has seen a significant reduction in reported ACS cases, raising concerns of avoidance behaviour contributing to increased OHCA incidence; exploring this phenomenon can help identify potential mediating factors for these changes and better understand its impact on cardiovascular health. Purpose Australia's successful COVID-19 lockdown provides a unique opportunity to study whether it affected the incidence of ACS and OHCAs, shedding light on the impact of pandemic-related behavioural modifications on cardiovascular health. Method Using data from the NSW Government database for ACS and NSW Ambulance dispatch data for OHCA, along with climate, traffic, and air quality data, we estimated the excess number of cases using an interrupted time-series analysis that adjusted for seasonal variations, day of the week and temperature. As a sensitivity analysis, we also conducted a two-stage time series analysis for the excess OHCA. Results During COVID-19’s first lockdown period (15th March to 1st July 2020), there were reductions in both ACS (-1259 [95% CI -1530, -989]) and OHCA (-69[-235, -92]) (Fig1). In this period there was a clear changes in anthropogenic activities with reductions in traffic (5670±1380 in 2020 versus 9150±1220 in 2018 and 8640±2370 in 2019) and flights (207±169 versus 884±152 and 902±103).These reductions were accompanied with improvement in PM2.5 (5.1±2.1μg/m3 versus 9.0±3.2 in 2018 and 8.2±3.2 in 2019), PM10 (13.3±5.4μg/m3 versus 20.9±8.6 and 17.7±6.0), and NO2 (7.4±2.7 ppb versus 8.4±3.3 and 9.0±2.8) (Fig2). Conclusion During the first COVID-19 lockdown in NSW, there was a significant reduction in the number of ACS cases without any associated excess in OHCA. This may be caused, at least partly, by the improved air quality from the behavioural changes.Excess ACS (STEMI &amp; NSTEMI) and OHCAChanges in Traffic and Flights Activitie

Early versus deferred coronary angiography in patients with out-of-hospital cardiac arrest - a systematic review and meta-analysis

Abstract Background The role of early coronary angiography (CAG) compared with deferred CAG on mortality and neurological outcomes in patients presenting with out of hospital cardiac arrest (OHCA) and no ST-elevation myocardial infarction (STEMI) pattern on electrocardiogram (ECG) remains disputed. Purpose The aim of this meta-analysis was to evaluate the impact of early versus deferred CAG on mortality and neurological outcomes in patients with OHCA and no STEMI. Methods OVID MEDLINE, EMBASE, Web of Science and Cochrane Library Register were searched from inception until July 18, 2022. Randomized clinical trials (RCTs) of patients with OHCA without STEMI that compared early CAG with deferred CAG were included. The primary endpoint was 30-day mortality. Secondary endpoints included mortality at discharge or 30-days, favorable neurology at 30-days, major bleeding, renal failure and recurrent cardiac arrest. A random-effects model was used with effect sizes presented as odds ratios (ORs). Results Of the 7,998 citations, a total of 5 trials randomizing 1524 patients to either early CAG or deferred CAG were included. There were 404 (26.5%) females. All studies were deemed to have at least a moderate risk of bias. Meta-analysis showed no significant difference in 30-day mortality with early versus deferred CAG (OR 1.17, CI 0.91 – 1.49 I2 = 27%) (figure 1). There was no observed difference in favorable neurological outcome at 30 days (OR 0.88, CI 0.52 – 1.49, I2 = 63%), major bleeding (OR 0.94, CI 0.33 – 2.68, I2 = 39%), renal failure (OR 1.14, CI 0.77 – 1.69, I2 = 0%), and recurrent cardiac arrest (OR 1.39, CI 0.79 – 2.43, I2 = 0%) when comparing early and deferred CAG (figure 2). Conclusions In this study, early CAG was not associated with improved survival and neurological outcomes among patients with OHCA without STEMI. This meta-analysis does not support routinely performing early CAG in this select patient cohort. Future studies are needed to identify a subgroup of patients who may benefit from an early CAG strategy in this high-risk population.Figure 1Primary OutcomeFigure 2Secondary Outcomes

Does the type of mechanical chest compressor affect resuscitation outcome of out of hospital cardiac arrest patients? A propensity-score based comparison of three devices

Abstract Background Mechanical cardiopulmonary resuscitation (CPR) devices are currently recommended when high-quality CPR could not be provided and only if used by trained rescuers. Guidelines are against their routinely use since clinical trials results are controversial, and solid evidence of improved survival are missing. Moreover, many studies compared these devices to very high-quality manual CPR, hardly replicable in a pre-hospital emergency setting. Nowadays, different machines are available but literature is poor in direct comparison studies. Purpose To assess whether the type of mechanical chest compressor could affect the probability of return of spontaneous circulation (ROSC) and of 30-days mortality after an out-of-hospital cardiac arrest (OHCA) as compared to manual standard CPR. Methods Data were prospectively collected from our Utstein-based cardiac arrest registry. We considered all OHCAs from January 1, 2015 to December 31, 2022 from 7 provinces covered by the same regional emergency system (population covered 4.2mln. inhabitants) but equipped with three different types of mechanical compressor: Autopulse®; LUCAS® and Easy Pulse®. Patients treated with mechanical CPR and manual CPR were randomly matched via a multivariable logistic regression propensity score considering age, gender, witnessed OHCA, presence of bystander CPR, first rhythm recorded, EMS arrival time and lay defibrillation before EMS arrival. Logistic regression and COX regression models were performed and adjusted for resuscitation duration to investigate the association between the type of CPR and the probability of ROSC and of 30-day mortality. Results Among 13,203 OHCAs with attempted CPR, 10,497 (79.5%) received manual CPR and in 2,405 (18.2%) mechanical CPR [Easy Pulse® in 1,102(45.8%), Autopulse® in 776 (32.3%) and LUCAS® in 521 (21.7%)]. ROSC before hospital admission was obtained in 1,712 patients (13.0%) and 762 (5.8%) were alive after 30 days. After propensity score matching two homogeneous groups of 1,946 patients each (manual and mechanical CRP) were identified. The rate of ROSC and of 30-day survival were lower in the mechanical CPR group (ROSC: 14.7% vs 24.1%; p&amp;lt;0.001; 30-day survival 6% vs 14%; p&amp;lt;0.001). The three devices showed an independent association with the probability of ROSC as compared to manual CPR [Autopulse®: OR 1.76, 95% CI (1.36-2.28) p&amp;lt;0.001; LUCAS®:OR 1.55, 95% CI (1.13-2.13), p=0.006 and Easy Pulse®:OR 0.49; 95% CI (0.37-0.65), p&amp;lt;0.001] (Figure 1A). Only Autopulse® was independently associated with 30-day mortality [AutoPulse HR 0.87, 95%CI (0.79-0.97), p=0.01; LUCAS®: HR 1.00, 95%CI (0.88-1.14), p=0.97) and Easy Pulse®: HR: 1.06, 95%CI (0.97-1.16), p=0.19] (Figure 1B). Conclusions This is the first study comparing the performance of three devices for mechanical chest compressions revealing that they differently affect the probability of ROSC and of 30-day survival.

Extracorporeal CPR versus conventional CPR for refractory out-of-hospital cardiac arrest: a meta-analysis of randomised clinical trials

Abstract Background Refractory out of hospital cardiac arrest carry poor outcomes. Extracorporeal cardiopulmonary resuscitation (CPR) help restore perfusion and oxygenation in a patient who does not have spontaneous circulation. Recently published randomized clinical trials (RCT) have conflicting evidence supporting use of early extracorporeal CPR and have small sample size. Purpose To compare Extracorporeal CPR versus conventional CPR in improving neurologically favorable survival. Methods We conducted an electronic database search of all published data for all RCT that compared Extracorporeal CPR versus conventional CPR for refractory out of hospital cardiac arrest and reported on neurologically favorable survival rates. Event rates were compared using a forest plot of odds ratios using a fixed-effects model assuming interstudy heterogeneity. Results Three RCT (n= 428; Extracorporeal CPR = 208, conventional CPR = 210) were included in the final analysis. Mean follow-up period 6 months. In our analysis, extracorporeal CPR compared with conventional CPR had favorable effect on survival with a favorable neurologic outcome (OR = 1.71, 95% CI = 1.08-2.71, P = 0.02, I2= 28). Conclusions In patients with refractory out-of-hospital cardiac arrest, extracorporeal CPR compared with conventional CPR had favorable effect on survival with a favorable neurologic outcome

A machine learning algorithm to predict a culprit lesion after out of hospital cardiac arrest

Abstract Background Between 50-90% of patients suffering from out-of-hospital cardiac arrest (OHCA) have a primary cardiac aetiology of arrest with the presence of a culprit coronary lesion. However, recent trials have failed to show a benefit from an early invasive angiographic approach following OHCA. Identification of patients with high likelihood of a culprit lesion may enable selection of patients likely to benefit from direct conveyance to cardiac arrest centres and for an early invasive approach. However, electrocardiogram (ECG) following return of spontaneous circulation, the current gold-standard, is a poor predictor of presence of a culprit lesion. Purpose We aimed to develop a machine learning algorithm to predict the presence of a culprit lesion in patients with OHCA. Methods We used a retrospective cohort of 398 patients admitted with primary cardiac aetiology OHCA to a tertiary cardiology centre in the United Kingdom, between May 2012 and December 2017. The primary outcome was the presence of a culprit coronary artery lesion, for which a Gradient Boosting model was optimised to predict. The algorithm was then validated in two independent European cohorts comprising 568 patients (346 and 222 patients respectively). Results The development cohort consisted of 398 patients (median age 64.3 years [IQR 53.3-75.4], 74.6% male), and the two validation cohorts consisted of 346 patients (median age 63.0 years [IQR 55.0-73.0], 81.5% male) and 222 patients (median age 63.0 years [IQR 52.0-74.0], 77.0% male). Of all patients, 85.6% had a witnessed arrest, 69.6% received bystander cardiopulmonary resuscitation, and 77.3% had an initial shockable rhythm. A culprit lesion was observed in 67.4% patients receiving early coronary angiography in the development cohort, and 67.9% and 61.1% in the two validation cohorts respectively. A Gradient Boosting model yielded an algorithm, named KOCAR Culprit Predictor, incorporating nine variables including age, a localising feature on ECG (≥2mm of ST change in contiguous leads), regional wall motion abnormality, history of vascular disease and initial shockable rhythm. This model had an AUC of 0.89 in the development and 0.83/0.81 in the validation cohorts with good calibration (Figure 1), and outperformed the current gold-standard ECG alone (AUC 0.69/0.67/0/67). Conclusions A novel simple machine learning derived algorithm (Figure 2) combining nine variables which are readily available to clinicians can be applied to patients with OHCA to predict a culprit coronary artery lesion with high accuracy. The algorithm, KOCAR Culprit Predictor, outperforms the current gold-standard ECG alone.Figure 1Figure 2

Abstract 18529: Early Coronary Revascularization Among "Stable" Patients With Non-ST-Segment Elevation Acute Coronary Syndromes: The Role of Diabetes and Age

Introduction: Despite improvement in the management of patients with non-ST-elevation acute coronary (NSTE-ACS), this condition is still linked to a substantially increased mortality and morbidity among diabetic patients. Specifically, it remains uncertain whether patients whose condition can safely be stabilized at hospital admission should routinely receive an early coronary revascularisation. Hypothesis: We tested the hypothesis that a strategy of early coronary revascularization within 24 hours of diagnosis is superior to an initial conservative strategy in terms of clinical outcomes in diabetic patients who met stabilisation criteria at hospital admission. Comparison was made with a cohort of nondiabetic patients. Methods: The ISACS-TC database was queried for a sample of diabetic and nondiabetic patients with diagnosis of NSTE-ACS. Those with recurrent angina after hospital admission, cardiac arrest, haemodynamic instability, and serious ventricular arrhythmias were excluded. The characteristics between groups were adjusted using inverse probability of treatment weighting models. Co-primary end points were all cause 30-day mortality and the composite end point of all cause 30-day mortality and left ventricular (LV) systolic dysfunction. Risk ratios (RRs) with their 95% CIs were employed. Results: Of the 7,473 NSTE-ACS patients identified, 2,220 were diabetics. Early revascularization was associated with survival benefit only in the elderly (≥65 years) both in diabetics (3.7% vs 6.6%; RR: 0.56; 95% CI: 0.32-0.96) and nondiabetic patients (2.8% vs 5.1%: RR: 0.55; 95% CI: 0.34-0.87). In the elderly population, an initial conservative strategy increased the risk of death or LV systolic dysfunction by 15.2% in diabetics compared with nondiabetic patients (37.7% vs 32.7%; RR: 1.15; 95% CI: 1.02-1.30). Conclusions: Early coronary revascularization does not lead to any survival advantage within 30 days from admission in a large number of NSTE-ACS patients who present to hospital in stable conditions. An early invasive management strategy may be best reserved for the elderly either with or without diabetes. The benefit of this strategy appears to be more pronounced in the diabetic population.

Abstract 337: Bystander Defibrillation in High Risk Neighborhoods

Background: Whether public health efforts successfully prioritize bystander automated external defibrillator (AED) application in areas with highest of hospital cardiac arrest (OHCA) burden is unknown. Methods: Within the Cardiac Arrest Registry to Enhance Survival, we identified all adult, public OHCAs linked to a census tract between 2013- 2021. We ranked all census tracts by annual public OHCA volume to ascertain relative burden, then assessed the association of census tract OHCA burden and bystander AED application rate (application prior to emergency personnel arrival), using a hierarchical modified poisson regression model, to account for clustering within tracts, and arrest characteristics. Results: Among 25,787 tracts with 90,898 public OHCAs, the mean (SD) age was 57.1 (16.0) years, with 70,900 (78.0%) male and 45,388 (49.9%) White victims. Overall, bystander AED application rates were low (10.9%). There was a modest association between neighborhood OHCA burden and bystander AED application rates (ρ=0.243). After adjustment, neighborhoods with the highest OHCA burden (&gt;2/ year) had a higher relative risk of bystander AED application than those with lowest burden (&lt;1/ every other year) (RR 2.07; 95% CI 1.95, 2.20, p&lt;.0001). However, this was due to a small proportion of high performing communities, as 700/1145 (61.1%) of highest OHCA burden communities had a bystander AED application rate less than the overall mean, 10.9%. Conclusion: High OHCA burdened areas have increased odds of bystander AED application, however this is driven by a few high performing neighborhoods. Targeted, context informed strategies are necessary to improve application rates and survival for the majority of high-risk neighborhoods.

Abstract 245: A Validated Score to Predict Poor Neurological Outcome After 72 Hours of Refractory VF/VT in Out of Hospital Cardiac Arrest Patients Requiring Extracorporeal Cardiopulmonary Resuscitation

Introduction: The challenge with neuroprognostication is finding a multimodal prediction model that yields the lowest false positive rate for a poor outcome. Objectives: To develop and validate a score that accurately predicts poor neurological outcome after 72 hours of ECPR initiation. Methods: Single-center, retrospective cohort study included 361 OHCA patients who underwent ECPR at the University of Minnesota between December 2015-January 2023. In a 50% random modeling sample, we obtained a derivation (n=180) and validation sample (n=181). The primary outcome was poor neurological outcome (defined as CPC 3-5) at hospital discharge. Neurological predictors were neuro specific enolase (NSE)&gt;3ULN on day 1, myoclonus status epilepticus on day 1-3, neurological pupillary index (NPI)&lt;2 on day 3-6, Glasgow motor=3 on day 3-6, highly malignant pattern on EEG (hmEEG) on day 3-6, CT with anoxic brain injury on day 3, and absent of brainstem reflexes on day 3-6. Univariate and multivariate analysis were performed on each predictor. A simple prediction score tool was constructed and evaluated through ROC analysis. A youden index was used for optimal cut-off. Results: Of 361 patients, 170 (47%) survived to hospital discharge. Of these, 85% (145/170) survived with favorable neurological outcome. The final multivariate logistic regression model in the derivation sample retained eight predictors: Absence of witnessed status and bystander CPR; downtime≥ 7min, lactate≥ 9mmol, low flow≥ 55min, NSE&gt;3ULN, hmEEG, CT with anoxic brain injury and absence of brainstem reflexes, which were combined to develop an 8-point risk scoring model Minnesota OHCA using ECPR (MECPR). Model discrimination had an AUC of 0.87 [95%CI 0.82-0.92] in the derivation sample and 0.86 [95% CI 0.85-0.92] in the validation sample, and calibration (goodness of fit p=0.04). MECPR≥6 predicted poor neurological outcome with a sensitivity ~21%, specificity 100% and a FPR 0%. A MECPR ≥4 and ≥6 had an 89% and 97% probability of poor neurological outcome, respectively. Conclusions: A simple, accurate prediction scoring tool (MECPR) based on a multimodal approach after 72hrs of refractory cardiac arrest provides estimates of probability of poor neurological outcome among patients treated with ECPR.

Abstract 181: Adiponectin Alleviates Acute Murine Pulmonary Injury Post Cardiopulmonary Resuscitation

Objective: Patients with cardiac arrest (CA) are often suffering from pulmonary ischemia-reperfusion injury after active cardiopulmonary resuscitation (CPR) and return of spontaneous circulation (ROSC). In recent years, previous studies have found that acute lung injury (ALI) after ROSC could be an independent risk factor for the prognosis of out of hospital cardiac arrest (OHCA). However, there is still a lack of effective therapy for pulmonary injury caused by CA-CPR-ROSC with no side effects. Methods: C57BL/6 male mice, aged from 8 to 10 weeks were purchased from Dossy Experimental Animals Co. Ltd (Chengdu, China). All the mice were feeding and drinking freely in the animal room of Sichuan University West China Science and Technology Park for one week. The experiments involving mice were approved by the Ethics Committee from West China Hospital of Sichuan University (approval No.2017071A). At the day before experiment, mice were given fasting treatment but allowed to drink water freely. CA-CPR-ROSC could cause global cerebral ischemia injury in vivo. APN (10μg/0.05ml per mice) was intravenously injected to mice at 10 min after restoration of spontaneous circulation (ROSC). Computed tomography (CT) scan of the lungs was performed before executing the animals. We used the Opal Color Manual IHC staining Kit for multiplex immunofluorescence staining measurement. Western blot detected the expression of Nrf2, OCLN, and CLDN5 in murine pulmonary tissues. Results: The results of CT scanning and routine histological measurements showed that APN could protect mice against murine pulmonary injury caused by CA-CPR-ROSC, compared to that of mice in CA-CPR-ROSC group. The results of western blot suggested that the expression of Nrf2 significantly increased in mice pulmonary tissues in CA-CPR-ROSC, whereas the expression of OCLN and CLDN5 obviously decreased in murine pulmonary tissues in CA-CPR-ROSC. Conclusion: Current study indicated the protect role of Adiponectin against acute murine pulmonary injury caused by CA-CPR-ROSC. The protective role of Adiponectin against acute murine pulmonary injury caused by CA-CPR-ROSC might be associated to the Nrf2 signaling pathway.

Abstract 407: The Efficacy and Frequency of Early Left Heart Catheterization After Out of Hospital Cardiac Arrest Over That Last Decade

Background: The efficacy of early coronary intervention after return of spontaneous circulation (ROSC) from out of hospital cardiac arrest, (OHCA) is debated. A recent review of the Wayne County, (Mi) CARES dataset from 2014-18 noted that early LHC maintained the strongest correlation to survival to discharge with good neurological outcome, for all-cause OHCA. Though the overall rate of LHC remained relatively stable, there was a sizable reduction in early LHC and a comparable increase in late LHC in those with CPC 1 and 2 at discharge [ 12 ] Our objective is to utilize the national CARES data to analyze the effect of early LHC on survival with good neurological outcome and to describe the frequency and timing of LHC in OHCA. Methods: This observational study included patients enrolled in the national CARES registry from 2013-21. For the outcome of LHC by year, chi square analysis was performed. Outcome was cerebral performance category, (CPC) (good &lt;3 vs. poor &gt; 3) at hospital discharge. A propensity score (PS) model was constructed using variables predictive of LHC and good outcome to determine probability of LHC. The PS was then used in an inverse weighted random effects logistic regression model to determine the independent effect of early LHC on outcome. Results: 132,758 individual cases were identified. Median age was 60.3 years (s.d. 16.6), 61.8% were male. Early coronary angiography was performed in 26,999 (20.3%) patients. Patients who underwent early angiography often had shockable rhythms (78.% vs 34%), suffered the OHCA in a public location (36.9% vs 26.1%%), and were witnessed cardiac arrests (80% vs 48%). For the full model the odds ratio for a good outcome after early LHC was 2.54 (95% CI 2.36 - 2.73). Only initial shockable rhythm was more predictive of a good outcome with an OR of 3.9. The proportion undergoing early catheterization declined from 27.6 % to 17.3% from 2013 to 2021; p &lt; 0.0001), though the overall catheterization rate remained the same. Conclusion: In patients with OHCA, early left heart catheterization retains a strong association with good neurological outcome at hospital discharge. The use of early left heart catheterization has declined significantly over the last 9 years.