Out-of-hospital Sudden Cardiac Arrest Research Articles

Variation in community and ambulance care processes for out-of-hospital cardiac arrest during the COVID-19 pandemic: a systematic review and meta-analysis

Bystander cardiopulmonary resuscitation (BCPR), early defibrillation and timely treatment by emergency medical services (EMS) can double the chance of survival from out-of-hospital sudden cardiac arrest (OHCA). We investigated the effect of the COVID-19 pandemic on the pre-hospital chain of survival. We searched five bibliographical databases for articles that compared prehospital OHCA care processes during and before the COVID-19 pandemic. Random effects meta-analyses were conducted, and meta-regression with mixed-effect models and subgroup analyses were conducted where appropriate. The search yielded 966 articles; 20 articles were included in our analysis. OHCA at home was more common during the pandemic (OR 1.38, 95% CI 1.11–1.71, p = 0.0069). BCPR did not differ during and before the COVID-19 pandemic (OR 0.94, 95% CI 0.80–1.11, p = 0.4631), although bystander defibrillation was significantly lower during the COVID-19 pandemic (OR 0.65, 95% CI 0.48–0.88, p = 0.0107). EMS call-to-arrival time was significantly higher during the COVID-19 pandemic (SMD 0.27, 95% CI 0.13–0.40, p = 0.0006). Resuscitation duration did not differ significantly between pandemic and pre-pandemic timeframes. The COVID-19 pandemic significantly affected prehospital processes for OHCA. These findings may inform future interventions, particularly to consider interventions to increase BCPR and improve the pre-hospital chain of survival.

Abstract 10508: Variation in Community and Emergency Medical Systems Processes for Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

Introduction: Bystander cardiopulmonary resuscitation (B-CPR) with early defibrillation and immediate emergency medical services (EMS) care significantly increases a victim's chance of survival from out-of-hospital sudden cardiac arrest (OHCA). Few studies have assessed the overall effect of the COVID-19 pandemic on the prehospital chain of survival. Objectives: We sought to quantify the effect of the COVID-19 pandemic on prehospital processes including B-CPR, bystander defibrillation, community characteristics, and EMS process measures. We hypothesized that B-CPR rates would decrease and OHCA occurring in the home would increase during the pandemic. Methods: We conducted a systematic review and meta-analysis of studies identified through 05/03/2021. We examined 5 bibliographic databases and searched terms including cardiac arrest, OHCA, and COVID-19. Data were abstracted and independently coded. Subgroup analysis and meta-regression analysis were performed. Our primary outcome was B-CPR; our secondary outcomes were community processes and EMS characteristics. Results: The original search yielded 966 articles; 20 articles were included in our analysis. Studies originated from 10 different countries and were retrospective in study design. There was no difference in B-CPR rates during COVID-19 compared to Pre-COVID-19 (OR: 0.94 (0.80-1.11), p=0.46). Patients had a 1.38 (1.11-1.71) higher likelihood of having an OHCA at home during COVID-19 compared to Pre-COVID-19 (p=0.01). Receipt of bystander defibrillation was significantly lower during COVID-19 compared to Pre-COVID-19 (OR: 0.65 (0.48-0.88), p=0.01). There was a significant increase in EMS call to arrival time during COVID-19 compared to Pre-COVID-19 (Mean difference in minutes= 0.27 (0.13-0.40), p<0.01). Statistical heterogeneity was moderate-to-high; findings were robust to sensitivity analyses with no publication bias detected. Conclusion: B-CPR rates remained unchanged during the pandemic, while OHCA in the home increased. Bystander defibrillation decreased, while EMS response time increased during the pandemic. These findings may inform future public programing, particularly to consider interventions to improve the prehospital chain of survival.

Sport-related acute myocardial infarction. Contemporary data from IMACS survey

Abstract Background Sport-related (SR) acute cardiovascular (CV) events are the main cause of sudden cardiac death in the setting of sport activities. However, data are very scarce regarding onset and follow-up of SR acute myocardial infarction (AMI). Methods From the prospective study IMACS (Infarctus du Myocarde et Arret Cardiaque au cours du Sport) patients admitted for a SR-AMI in our university hospital from April 2018 to March 2020 were included. A 12 months follow-up (FU) was achieved through telephone interview to address CV outcomes and sport practice information. Information was obtained from relatives in case of out of hospital sudden cardiac arrest (OH-SCA). Results Among the 55 patients included, all were male, with median (IQR) age at 62 (55–69) y. Most common sports were cycling (n=21), fitness (n=7), swimming (n=5) and hiking (n=5). The SR-AMI occurred during effort for 39 subjects and during recovery for 16. Most SR-AMI occurred in public area (n=24), at home (n=16), or in a specific sport location (n=14). An Automated External Defibrillator (AED) was available in the SR-AMI location in only 10, but was missing in 43 (unknown for 2). In 1 subject with OH-SCA, cardiopulmonary resuscitation (CPR), initiated by witnesses, using a public AED, was unsuccessful. The 4 other patients with OH-SCA underwent successful CPR. Among the 55 subjects, 4 were vapers, of whom 1 was a dual user, 17 were current tobacco smokers, 18 were ex-smokers and 2 experienced cannabis and cocaine use. Among the smokers, most smoked (n=10) or consumed cannabis (n=1) <2h before the event. Strikingly, CV history and/or recent symptoms were present in almost half (n=25). Only 10 felt symptoms exclusively during the sport session. Moreover, a medical advice for recent symptoms was found only for 3 subjects. Three patients who experienced prior AMI have neglected symptoms during the index event. Most were ST segment elevated MI (n=35). Only one patient (with OH-SCA) died <3 days after hospital admission. During hospitalization, most underwent revascularization with coronary stenting (n=44) (drug eluting stent in 43 patients), or coronary artery bypass graft (n=6) and no death nor significant CV event occurred. At 1-FU, most attended a rehabilitation program (n=41) and the majority of smokers quitted (14/17), with 3 persistent smokers starting to vape. Almost half patients (n=23) decreased their physical activity, and 21 increased it. A significant rate of patient (n=9) added fitness in their usual activity, and as a main sport for 4 of them. Conclusions In this on-going monocentric prospective survey in SR-AMI, a high proportion of subjects had prodromal symptoms, of whom only few led to sport cessation and medical advices, when requested, failed to prevent the AMI. Our findings highlight that public and medical education are urgently warranted for SR-AMI prevention. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): CHU Dijon Bourgogne Franche Comté et ARS Bourgogne Franche Comté

Abstract 14316: Diurnal Variation of the Macrophage Expressed Gene-1 Inflammatory Marker in the Timing of Sudden Cardiac Arrest

Background: In the last decade, inflammatory biomarkers have been implicated in out of hospital sudden cardiac arrest (OH-SCA). However, the role of diurnal variation in these inflammatory markers in relation to the timing of OH-SCA is unknown. Here we report an increased macrophage-expressed gene-1 (MPEG-1) expression, an evolutionary conserved protein with membrane attack complex domain, in relation to the timing of OH-SCA and survival after resuscitation. Objectives: To examine the relationship between the circulating MPEG-1protein levels and the timing of OH-SCA. Methods: We prospectively enrolled 144 subjects from 4 different tertiary care centers who were successfully resuscitated from OH-SCA. The timing of OH-SCA and other clinical parameters were obtained from medical record review. Serum levels of a novel biomarker, MPEG-1, and other conventional clinical biomarkers including troponin-I and CK-MB were measured in the blood samples obtained within the 6 hours of OH-SCA. Results: Approximately 32% of the sudden cardiac arrest happened in the morning hours ( 5AM- 12PM ). The higher incidence of the OH-SCA occurring in morning hours correlated with elevated serum MPEG-1 levels as shown in figure 1 . In 71% of the OH-SCA, the etiology was of cardiac in nature, of which 32% were from acute myocardial infraction. At the end of the hospital stay, 46% of the patients had died. Conclusions: This study suggests that the diurinal variation in the propensity to develop OH-SCA is associated with elevated serum levels of MPEG-1. Further research examining this novel biomarkers in larger cohorts can form the basis for accurate and timely risk-prediction.

Coronary angiography characteristics of out-of-hospital sudden cardiac arrest occurring in sport-related acute myocardial infarction

Although out-of-hospital sudden cardiac arrest (OHSCA) frequently occurs in sport-related acute myocardial infarction (AMI), contemporary clinical and coronary angiography (CA) findings remains poorly described. In a large retrospective study at a French regional scale, we aimed to investigate clinical and CA characteristics of patients who experienced OHSCA in sport-related AMI. From the RICO database, a French regional AMI survey, we retrospectively analysed the consecutive patients admitted in cardiology intensive care unit of a single university hospital from January 2011 to January 2018 for sport-related AMI and who underwent CA ( n = 100). Data from patients with OHSCA (OHSCA +) were compared with patients without OHSCA (OHSCA -). Among the study population, 20% had OHSCA. Main characteristics are presented in Table 1 (Median (IQR) or %). AMI patients with OHSCA were 6 y older, and were characterized by a higher rate of culprit lesion involving LAD, and had much poorer hospital outcome. CAD extent and proximal distribution of lesions showed a trend toward a more severe profile. Larger studies are needed to confirm our findings.

Management of acute myocardial infarction occurring during sport practice: Contemporary data from the ‘obseRvatoire des Infarctus de Côte d’Or’ (RICO) survey

Over the last decade, acute myocardial infarction (AMI) management has considerably evolved, but current management of sport-related AMI remains poorly investigated. We aimed to analyze the acute therapeutic strategies used in AMI occurring during sport activity. We retrospectively analyze consecutive patients from an AMI database (RICO survey) who underwent a coronary angiography (CA) in a university hospital after a sport-related AMI within 2011 to 2017 ( n = 100). Most were male (86%), with median age at 58 (50–67) y. Out-of-hospital sudden cardiac arrest (OHSCA) was experienced by 20%; at admission. At the acute phase, 3% underwent ECMO and 2% had an IABP. Intravenous fibrinolysis was given in 14% (26% of the 54 STEMI patients), successfully in 64%. CA was performed through a radial approach in 89%; OCT or IVUS was used in 2 patients. Thromboaspiration was performed in 30%, balloon predilatation in 26% and direct stenting in 73%. Most PCI were performed using drug eluting stent (DES) (69%) with 1 stent (78%), 2 stents (15%), 3 stents (7%) or no stent (5%). Median time from symptoms to reperfusion was 145 (105–228) and to PCI 163 (126–240) min. A re-intervention during hospitalization was performed in 20% of patients, with implantation of 1 stent (39%) 2 stents (35%), 3 stents (17%), 4 stents (4%); all stents but one were DES. Seven patients underwent CABG surgery in addition to PCI. No ICD was implanted. During hospitalization, 10 patients died (all initially presented with OHSCA); all victims treated with ECMO died and only one with IABP survived (used for management of early stent thrombosis). From this large series, thrombolysis was rare, but thromboaspiration was performed in nearly one third of patients; culprit lesions were often treated by direct stenting, with a DES in more than 2/3 of cases. A re-intervention procedure was often needed to treat other lesions, more often with DES rather than CABG.

Incidence of out-of-hospital sudden cardiac arrest at exercise and sport facilities in Queensland, Australia

Aim: Exercise and sport facilities (ESF) contribute to the preventive health policies of the governments by helping people to be more physically active. Hence, unaccustomed exercise can be a trigger for cardiovascular events in people with known or hidden cardiovascular conditions. The aim of this study was to analyse the incidence of out-of-hospital sudden cardiac arrest (OHSCA) at ESF in Queensland, Australia.

Emergency response management and outcomes of out-of-hospital sudden cardiac arrest patients at exercise and sport facilities in Queensland, Australia

Aim: In the event of an out-of-hospital sudden cardiac arrest (OHSCA), timely cardiopulmonary resuscitation (CPR) and utilisation of an automated external defibrillator (AED) are crucial to increase the chances of survival. This study aims to analyse the emergency response management and outcomes of OHSCA patients at exercise and sport facilities (ESF) in Queensland, Australia.

Emergency medical system response time does not affect incidence of return of spontaneous circulation after prehospital resuscitation in one million central European agglomeration residents.

The survival of out-of-hospital sudden cardiac arrest (OHSCA) in Europe still remains low. The State Medical Rescue System is composed of several elements. The efficacy of each of these elements may have an influence on the victim's survival. Until now, the incidence of return of spontaneous circulation (ROSC) and its correlation with rescue services time in the city of Poznan has not been determined. The main purpose of this study was to assess incidents of OHSCA and prehospital frequency of ROSC after OHSCA in Poznan city and district. We also wanted to analyse whether ROSC depends on Emergency Medical System (EMS) reaction time. Retrospective analysis based on medical documentation conducted in 2015 in Poznan EMS. Return of spontaneous circulation was achieved in 68.88% of cases. It was most frequent when OHSCA occurred in public places (p = 0.000, contingency factor = 0.233) and victims were younger (p = 0.042, contingency factor = 0.129). 63.17% of patients were male, but sex did not affect the incidence of ROSC. The median time of system response was 8.53 min, while time from ambulance departure to arrival was 5.42 min. We did not find any statistically significant difference between the number of deaths and those parameters (p = 0.723, p = 0.891). However, longer team response time correlated with the highest mortality (p = 0.042, contingency factor = 0.126). In the group where ROSC was achieved the median time of EMS response was 8.18 min, while among the group of deceased the median was 8.63 min. The incidence of OHSCA in our region is similar to other Polish and European cities. EMS response time does not affect the frequency of ROSC. ROSC was achieved more often if OHSCA occurred in public and the victim was younger.

Determinants of unfavorable prognosis for out-of-hospital sudden cardiac arrest in Bielsko-Biala district.

IntroductionThe prognosis in out-of-hospital sudden cardiac arrest (OHCA) remains unfavorable and depends on a number of demographic and clinical variables, the reversibility of its causes and its mechanisms.AimTo investigate the risk factors of prehospital death in patients with OHCA in Bielsko County.Material and methodsThe study analyzed all dispatch cards of the National Emergency Medical Services (EMS) teams in Bielsko-Biala for the year 2013 (n = 23 400). Only the cards related to sudden cardiac arrest in adults were ultimately included in the study (n = 272; 190 men, 82 women; median age: 71 years).ResultsSixty-seven victims (45 men, 22 women) were pronounced dead upon the arrival of the EMS team, and cardiopulmonary resuscitation (CPR) was not undertaken. In the remaining group of 205 subjects, CPR was commenced but was ineffective in 141 patients (97 male, 44 female). Although univariate analysis indicated 6 predictors of prehospital death, including OHCA without the presence of witnesses (odds ratio (OR) = 4.2), OHCA occurring in a public place (OR = 3.1), no bystander CPR (OR = 9.7), no bystander cardiac massage (OR = 13.1), initial diagnosis of non-shockable cardiac rhythm (OR = 7.0), and the amount of drugs used for CPR (OR = 0.4), logistic regression confirmed that only the lack of bystander cardiac massage (OR = 6.5) and non-shockable rhythm (OR = 4.6) were independent determinants of prehospital death (area under ROC curve = 0.801).ConclusionsNon-shockable rhythm of cardiac arrest and lack of bystander cardiac massage are independent determinants of prehospital death in Bielsko-Biala inhabitants suffering from OHCA.

Factors Affecting the Occurrence of Out-of-Hospital Sudden Cardiac Arrest.

Objective. This paper aims to discover the risk factors for sudden cardiac arrest (out-of-hospital sudden cardiac arrest (OHSCA)) which significantly affect the decision about prioritizing emergency interventions before dispatching medical emergency teams, risk of deterioration of the patient's condition at the scene, and emergency procedures. Methods. A retrospective study taking into account the international classification of diseases ICD-10 based on an analysis of medical records of Emergency Medical Service in Wroclaw (Poland). Results. The main risk factor of OHSCA is coexistence of external cause leading to illness or death (ICD Group V-10) as well as the occurrence of diseases from the group of endocrine disorders (group E), in particular diabetes. The increase in the risk of OHSCA incidence is affected by nervous system diseases (group G), especially epilepsy of various etiologies, respiratory diseases (group J), mainly COPD, and bronchial asthma or mental and behavioral disorders (group F), with particular emphasis on the drugs issue. The procedure for receiving calls for Emergency Notification Centre does not take into account clinical risk factors for sudden cardiac arrest (SCA). Conclusion. Having knowledge of OHSCA risk factors can increase the efficiency of rescue operations from rapid assessment and provision of appropriate medical team, through effective performance of medical emergency treatment and prevention of SCA or finally reducing the costs.

Surviving out-of-hospital cardiac arrest: just a matter of defibrillators?

Out-of-hospital sudden cardiac arrest (OHCA) is a leading cause of death all over the world. Although the outcome of OHCA resulting from 'nonshockable' rhythms (asystole and pulseless electrical activity) is poor regardless of resuscitation efforts, 'shockable' rhythms such as ventricular tachycardia or fibrillation may carry a good prognosis if early defibrillation is performed. At present, simplified cardiopulmonary resuscitation techniques (hands-only cardiopulmonary resuscitation) and automated external defibrillators (AEDs) offer lay people the possibility to provide lifesaving treatment to OHCA victims in the critical minutes before the arrival of the emergency medical system. Programs aimed at increasing provision of cardiopulmonary resuscitation and use of AEDs by lay people have been set up in different countries, including Italy, and have contributed to improve survival rates. However, success of these programs critically depends on appropriate planning and design, and on cultural predisposition of witnesses to undertake immediate measures of resuscitation in the case of OHCA. Placement of a large number of AEDs may carry high costs and little benefits if it is uncoordinated and not preceded by educational campaigns to spread widely the 'culture of resuscitation' in the population.

Estimating Outcomes of Astronauts with Myocardial Infarction in Exploration Class Space Missions

We estimate likelihood of presenting rhythms and survival to hospital discharge outcome after acute cardiac ischemia with arrhythmia and/or myocardial infarction (AMI) during long-duration space missions (LDSM) using selected terrestrial cohorts in medical literature. Medical scenarios were risk-stratified by coronary artery calcium score (CAC) and Framingham risk factors (FRF). AMI with and without sudden cardiac arrest (SCA) likelihoods and clinically significant rhythm scenarios and associated outcomes in "astronaut-like" cohorts were derived from two prospective trials identified by an evidence-based literature review. Results are presented using an event sequence diagram and event time line. The association of increasing CAC scores and FRF with AMI and SCA outcomes was calculated. Low AMI likelihoods are estimated in individuals with CAC scores of zero or < 100 and a low number of FRF. Survival rate to hospital discharge after out of hospital SCA in a large urban environment study was 5.2%. EMS-witnessed ventricular tachycardia and/or ventricular fibrillation survival rate of 37.5% represents < 1% of all urban out of hospital AMI, and these patients have a high proportion of known ischemic cardiovascular and pulmonary disease "disqualifying for spaceflight." Multiple factors may be expected to delay or defeat rapid access to "chain of survival" resources during LDSM, lowering survival rates below urban levels of 5.2%. Low CAC and FRF reflect lower risk for AMI events. Zero CAC was associated with the lowest risk of AMI after 3.5 yr of follow-up. Quantifiable incidence and outcome characterization suggests AMI in LDSM outcomes will be relatively independent of in-flight medical resources.

Abstract 21: Elevated Resting Heart Rate Is Associated with Pulseless Electrical Activity Independent of β-Blocker Use

Introduction: Higher heart rate (HR) has been associated with increased cardiovascular mortality but mechanisms are poorly understood. Sudden cardiac arrest (SCA) presenting with pulseless electrical activity (PEA) has a significantly higher mortality than ventricular fibrillation/tachycardia (VF/VT). Hypothesis: We investigated the hypothesis that resting HR has a predictive role in subjects with future PEA versus VF/VT. Methods: Cases of out of hospital SCA, age ≥18 years, with resuscitation attempted were identified from an ongoing prospective community-based study in the Northwest US (pop. approx. 1 million). HR was measured from resting 12-lead ECG prior and unrelated to the cardiac arrest. Pearson's chi-square tests and independent samples t -tests were used for comparisons of presenting arrhythmia, arrest circumstances and heart rate. A general linear model was used to identify gender and age differences in heart rate between PEA and VF/VT. Significant predictors of PEA were determined using logistic regression. Results: A total of 913 cases (mean age 65±16 years, 68% male) with resuscitation attempted (2002-2009) presented with VF/VT (45%) or PEA (26%). PEA cases were older, more likely to be female and to arrest at home, whereas VF/VT cases were more likely to be witnessed, to have bystander CPR, return of spontaneous circulation and to survive to hospital discharge. There was no difference in the use of beta-blockers between PEA and VF/VT (p=0.19). PEA cases had higher resting HR compared with VF/VT (81 bpm vs. 74 bpm, p=0.0007, n=322). Males with PEA had higher HR than males with VF/VT (83 bpm vs. 75 bpm, p=0.001), but the difference in HR between PEA vs. VF/VT among females was smaller and borderline significant (78 bpm vs. 72 bpm, p=0.06). Heart rate was a significant predictor of PEA after adjustment for age, gender and circumstances of arrest [OR for a 10-beat per minute increase 1.35; 95% CI (1.17-1.56)]. Heart rate remained a significant predictor of PEA after additional adjustment for beta-blockers [OR 1.36; 95% CI (1.18-1.57)]. Conclusions: Resting HR is a significant predictor of future cardiac arrest manifesting with PEA, independent of beta-blocker use and could, in part, explain the association between higher HR and increased mortality.

Implementation Strategies for Improving Survival After Out-of-Hospital Cardiac Arrest in the United States

The goal of the 2009 American Heart Association (AHA) Cardiac Arrest Survival Summit was to develop consensus recommendations for implementation strategies to optimize the care of patients with out-of-hospital sudden cardiac arrest (OHCA). For the purposes of this conference, implementation was broadly defined as the translation of best practices into common practice. The scope was the entire system of care, including recognition and response by laypeople, emergency medical services (EMS) dispatch, EMS care, and hospital-based care. The conference planning committee included representatives from multiple disciplines involved in all stages of cardiac arrest care. Conference participants included stakeholders from the lay public, EMS systems, relevant clinical specialties, health insurance providers, and federal regulatory and funding agencies. Conference speakers were either selected by the conference planning committee on the basis of their content expertise or nominated by the organization they represented. Before the conference, participants provided written input by responding to a preconference questionnaire. The content of this questionnaire is available in the http://circ.ahajournals.org/cgi/content/full/CIR.0b013e31821d79f3/DC1. The questions were developed by the conference planning committee. All responses were free text. The responses were collated and distributed to the writing group for review. Writing group members drafted preliminary recommendations based on the survey results and the existing literature. These recommendations were refined through conference calls with invited speakers and panelists before the conference. Individual sessions focused on epidemiology, incidence and outcomes monitoring, systems of care, and culture change. The initial conference sessions consisted of invited speakers who highlighted key issues and presented evidence for best practices. These presentations were followed by panel discussions with audience participation. During the panel discussions, the preconference draft recommendations were further modified. The fourth session consisted of multiple breakout groups that addressed issues of culture change among lay providers, EMS providers, in-hospital providers, policy makers, and payers. These sessions …