Post Return Of Spontaneous Circulation Research Articles

Ischemic Post-Conditioning in a Rat Model of Asphyxial Cardiac Arrest.

Ischemic post-conditioning (IPoC) has been shown to improve outcomes in limited pre-clinical models. As down-time is often unknown, this technique needs to be investigated over a range of scenarios. As this tool limits reperfusion injury, there may be limited benefit or even harm after short arrest and limited ischemia-reperfusion injury. Eighteen male Wistar rats underwent 7 min of asphyxial arrest. Animals randomized to IPoC received a 20 s pause followed by 20 s of compressions, repeated four times, initiated 40 s into cardiopulmonary resuscitation. If return of spontaneous circulation (ROSC) was achieved, epinephrine was titrated to mean arterial pressure (MAP) of 70 mmHg. Data were analyzed using t-test or Mann-Whitney test. Significance set at p ≤ 0.05. The rate of ROSC was equivalent in both groups, 88%. There was no statistically significant difference in time to ROSC, epinephrine required post ROSC, carotid flow, or peak lactate at any timepoint. There was a significantly elevated MAP with IPoC, 90.7 mmHg (SD 13.9), as compared to standard CPR, 76.7 mmHg (8.5), 2 h after ROSC, p = 0.03. IPoC demonstrated no harm in a model of short arrest using a new arrest etiology for CPR based IPoC intervention in a rat model.

ROLE OF ST–SEGMENT ELEVATION AT POST–ROSC ECG IN PATIENTS RESUSCITATED FROM OUT–OF–HOSPITAL CARDIAC ARREST

Abstract Background A 12–lead electrocardiogram (ECG), performed after return of spontaneous circulation (ROSC) in out–of–hospital cardiac arrest (OHCA), is essential for the identification of ST–segment elevation). The aim of the study is to investigate whether the presence of ST elevation may be a prognostic determinant in post–OHCA patients. Materials and Methods A total of 878 post–ROSC ECGs were collected from patients enrolled from 01/01/2015 to 12/31/2022 from the Lombardy Region Cardiac Arrest Registry (LombardiaCARe). Univariable and multivariable Cox regression models were applied to test the association between the presence of and morphology of supraST and mortality at 30 days after the event. Results Among the 878 post–ROSC ECGs, 406 (46.2%) had ST elevation [49 with tombstone morphology; 26 with lambda morphology; 45 with triangular morphology; and 8 with wave morphology]. Patients with ST elevation were more frequently males (73% vs 59%, p<0.001), younger [66 years old (57–75) vs 71 (61–80), p<0.01], and with a more frequently non–defibrillating rhythm of presentation (25%vs59%, p<0.01) and an event more frequently witnessed by 118 (30% vs 21%, p=0.008). Thirty–day survival was higher in patients with ST elevation (56% vs 41%, p<0.001). Correcting for variables associated with 30–day survival (age, sex, QRS amplitude, ECG acquisition time, first rhythm of presentation), the presence of ST elevation was not significantly associated with 30–day mortality [HR: 0.67 (95% CI: 0.27–1.64); p=0.05], while the number of segments was [1.1 (95%CI 0.85–0.15), p=0.004]. No morphology was independently associated with mortality when compared with standard morphology. Conclusions The presence of ST elevation on ECG post ROSC possesses, in addition to a known diagnostic role, a prognostic role in predicting 30–day survival especially if present in more than one segment.

Circulating Extracellular Vesicle-Mediated Immune Activation After Resuscitation From Cardiac Arrest in Swine

Objective: Systemic inflammation is a well-established contributor to morbidity and mortality in patients that are initially resuscitated from sudden cardiac arrest (SCA). However, our mechanistic understanding of immune activation in this context remains limited, impeding the development of targeted anti-inflammatory treatments. To address this knowledge gap, we tested the hypothesis that post-resuscitation immune cell activation is mediated, at least in part, by circulating extracellular vesicles (EVs). Methods: Swine (n=3) were subjected to 10 minutes of electrically-induced SCA followed by CPR with defibrillation and epinephrine (0.015 mg/kg iv) to achieve return of spontaneous circulation (ROSC). Blood samples were collected before SCA and 4-hours post-ROSC for isolation of plasma EVs from clarified plasma using 100kD filters, which were subsequently quantified by Nano-particle Tracking Analysis (ZetaView). Naïve PBMCs from healthy swine were cultured with basal media (negative control), lipopolysaccharide (LPS; positive control), or EVs isolated from pre-SCA or post ROSC plasma that were stained with lipophilic dye (DiD) to facilitate assessment of EV uptake (n=3 per group). After 24 hours in culture, PBMC activation was assessed via surface marker expression (flow cytometry) and inflammatory cytokine release (ELISA). Results: Compared with exposure to pre-SCA EVs and basal media, PBMCs exposed to post-ROSC EVs exhibited a significant shift toward an inflammatory phenotype, with enrichment of inflammatory dendritic cells (CD172+CD16+), inflammatory granulocytes (CD172+CD163-), and inflammatory macrophages (CD14+CD163+) in both DiD+ and DiD- cell populations (all p<0.05 vs. pre-SCA EVs). Although TNF-α, IFN-α, and IFN-γ were not detected after EV co-culture, a near-significant increase in IL-1β release was observed in PBMCs exposed to post-ROSC EVs vs. pre-SCA EVs (5.72±2.4 vs. 2.21±0.7 pg/mL; p=0.068). Conclusion: Our findings suggest that circulating plasma EVs may contribute to immune cell activation following systemic ischemia/reperfusion injury associated with resuscitation from SCA. Further studies to delineate mechanisms underlying EV-mediated pro-inflammatory shifts in immune cell phenotype and potentiation of IL-1β release may reveal novel therapeutic targets to mitigate post-resuscitation inflammation and improve patient outcomes following SCA. Supported by funding from the NIH and US Department of Veteran's Affairs. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Post-cardiac arrest temporal evolution of left ventricular function in a rat model: speckle-tracking echocardiography and cardiac circulating biomarkers.

There is little information from experimental studies regarding the evolution of post-resuscitation cardiac arrest [post-return of spontaneous circulation (post-ROSC)] myocardial dysfunction during mid-term follow-up. For this purpose, we assessed left ventricular (LV) function and circulating cardiac biomarkers at different time points in a rat model of cardiac arrest (CA). Rats were divided into two groups: control and post-ROSC rats. Eight minutes of untreated ventricular fibrillation were followed by 8 min of cardiopulmonary resuscitation. Conventional and speckle-tracking echocardiographic (STE) parameters and cardiac circulating biomarkers concentrations were assessed, at 3, 4, 72, and 96 h post-ROSC. At 3 and 4 h post-ROSC, LV systolic function was severely impaired, and high-sensitivity cardiac troponin T and N-terminal pro-atrial natriuretic peptide (NT-proANP) plasma concentrations were significantly increased, compared with control rats (P < 0.0001 for all). At 72 and 96 h post-ROSC, LV ejection fraction (LVEF) normalized. At 96 h, the following variables were significantly different from control rats: early trans-mitral peak velocity, 56.8 ± 3.1 vs. 87.8 ± 3.8 cm/s, P < 0.0001; late trans-mitral peak velocity, 50.6 ± 4.7 vs. 73.7 ± 4.2 cm/s, P < 0.0001; mean s' wave velocity, 4.6 ± 0.3 vs. 5.9 ± 0.3 cm/s, P < 0.0001, global longitudinal strain (GLS) -7.5 ± 0.5 and vs. -11 ± 1.2%, P < 0.01; GLS rate (GLSR) -0.9 ± 0.4 and -2.3 ± 0.2 1/s, P < 0.01; and NT-proANP concentration, 2.5 (0.2; 6.0) vs. 0.4 (0.01; 1.0) nmol/L, P < 0.01. s' velocity, GLS, and GLSR indicated that LV systolic function was still impaired 96 h post-ROSC. These findings agree with NT-proANP concentrations, which continue to be high. Normalization of LVEF supports the use of STE for its greater sensitivity for monitoring post-CA cardiac function. Further investigations are needed to provide evidence of the post-ROSC LV diastolic function pattern.

Post-return of spontaneous circulation (ROSC) management in STEMI patient with COVID-19: a case report

Background: The COVID-19 pandemic is still a global emergency that causes higher mortality in patients with comorbidities. Current data shows the mortality rate of STEMI patients with COVID-19 is higher than that of STEMI patients without COVID-19. This study aims to improve the knowledge and skills in managing cardiac arrest in COVID-19 patients and post-ROSC management in STEMI patients with COVID-19. Case Presentation: A 43-year-old man came with a complaint of typical chest pain 3 days before admission, accompanied by symptoms of orthopnea and dyspnea on exercise, and had experienced syncope 3 days prior. History of diabetes mellitus and previous heart attack. The examination results showed tachycardia, tachypnea and oxygen desaturase. The supporting examinations were ESR 89, CRP 48.72, D-dimer: 2.04, and HbA1C 10.1%. Swab Polymerase Chain Reaction (PCR) SARS Cov-2 showed a positive result, with pulmonary edema that may be accompanied by pneumonia (CORADS-3), bilateral pleural effusions, calcification of the descending aorta and coronary arteries LAD, LCX, RCA on computed tomography (CT) imaging. ) Thorax. On bedside echocardiography, EF 28%, LA-LV dilatation, anterior akinetic RWMA, and mild-moderate MR due to functional, mild TR were found. Patients diagnosed with STEMI anterior late onset Killip III, CCS IV, Grace 129, TIMI 9/14; ADHF on ACS; DM, Confirmed Covid-19, Hypoalbuminemia, Hypercoagulation state and had a heart attack and cardiac-respiratory arrest on the 14th day of treatment, performed cardiopulmonary resuscitation (CPR) and entered a state of return of spontaneous circulation (ROSC). The patient continued the treatment until day 23 and was referred to another hospital for further care. Conclusion: In order to obtain good results in reducing mortality in STEMI patients with COVID-19, it is necessary to have the knowledge and skills of management of cardiac arrest in COVID-19 patients and post ROSC management in STEMI patients with COVID-19, as well as pay attention to and maintaining the safety of the rescuers.

Insight into the mechanisms of therapeutic hypothermia for asphyxia cardiac arrest using a comprehensive approach of GC-MS/MS and UPLC-Q-TOF-MS/MS based on serum metabolomics

Cardiac arrest (CA) is a severe worldwide health problem. Therapeutic hypothermia is widely used to reduce the cardiac injury and improve the neurological outcomes after CA. However, a few studies have reported the changes of serum metabolic characteristics after CA. The healthy male New Zealand Rabbits successfully resuscitated from 10-min asphyxia-induced CA were divided randomly into the normothermia (NT) group and mild therapeutic hypothermia (HT) group. The sham group underwent sham-operation. Survival was recorded and neurological deficit score (NDS) was assessed. The serum non-targeted metabolomics were detected using ultra-high-performance liquid chromatography-quadrupole time-of-flight tandem mass spectrometry (UPLC-Q-TOF-MS/MS) and gas chromatography tandem mass spectrometry (GC-MS/MS) at 15 min, 3 h, 6 h and 24 h after return of spontaneous circulation (ROSC). Our study showed that the heart rate (HR) significantly slowed down during 0.5–6 h post ROSC, consistent with the decreasing trend of body temperature in the HT group. Compared with the NT group, the levels of Lac and PCO2 at 24 h post ROSC were lower, while a significant increase in PO2 level at 24 h post ROSC was observed in the HT group. The survival rate of the HT group was significantly higher than that of the NT group, and NDS scores were remarkably increased at 24 h post ROSC in the NT group. Significant differences in metabolic profiles at 15 min, 3 h, 6 h and 24 h post ROSC were observed among the Sham, NT and HT groups. The differential metabolites detected by UPLC-Q-TOF-MS/MS and GC-MS/MS were screened for further study between every two groups (NT vs sham, HT vs sham and HT vs NT) at 15 min, 3 h, 6 h and 24 h post ROSC. Phenylalanine metabolism, alanine, aspartate and glutamate metabolism and tricarboxylic acid (TCA) cycle were enriched in NT vs sham, HT vs sham and HT vs NT respectively. Our study demonstrated that therapeutic hypothermia improves the survival and neurological outcomes in rabbit model of cardiac arrest, and firstly represents the dynamic metabolic changes in the hypothermia therapy for CA by comprehensive UPLC-Q-TOF-MS/MS- and GC-MS/MS-based metabolomics.

Out-of-hospital cardiac arrest: Do we have to perform coronary angiography?

Out-of-hospital cardiac arrest (OHCA) remains a leading cause of global mortality, while survivors are burdened with long-term neurological and cardiovascular complications. OHCA management at the hospital level remains challenging, due to heterogeneity of OHCA presentation, the critical status of OHCA patients reaching the return of spontaneous circulation (ROSC), and the demands of post ROSC treatment. The validity and optimal timing for coronary angiography is one important, yet not fully defined, component of OHCA management. Guidelines state clear recommendations for coronary angiography in OHCA patients with shockable rhythms, cardiogenic shock, or in patients with ST-segment elevation observed in electrocardiography after ROSC. However, there is no established consensus on the angiographic management in other clinical settings. While coronary angiography may accelerate the diagnostic and therapeutic process (provided OHCA was a consequence of coronary artery disease), it might come at the cost of impaired post-resuscitation care quality due to postponing of intensive care management. The aim of the current statement paper is to discuss clinical strategies for the management of OHCA including the stratification to invasive procedures and the rationale behind the risk-benefit ratio of coronary angiography, especially with patients in critical condition.

Coronary angiography after cardiac arrest.

Acute coronary syndromes represent the commonest cause of out-of-hospital cardiac arrest (OHCA) in adults. Coronary angiography (CAG) followed by percutaneous coronary intervention (PCI) has been established as the treatment strategy for these patients. In this review, we aim first to discuss the potential risks and expected benefits from it, the caveats in its implementation, and the current tools for patient selection. Then summarize the recent evidence on the group of patients without ST-segment elevation on post-return of spontaneous circulation (ROSC) ECG. The implementation of this strategy still shows a wide variation among the various systems of care.The presence of ST-segment elevation on post-ROSC ECG remains the most reliable tool for patient selection for immediate CAG.A primary PCI strategy is currently recommended for patients with ST-segment elevation on post-ROSC ECG regardless of the conscious state of patients.Recently several randomised studies including patients without ST-segment elevation on post-ROSC ECG showed no benefit with immediate CAG compared to delayed/ elective CAG. This has led to a substantial although not uniform change in current recommendations. Recent studies show no benefit with immediate CAG in groups of patients without ST-segment elevation on post-ROSC ECG. Further refinements in selecting the appropriate patients for immediate CAG seem necessary.

The Effect of Resuscitation Residents on the Duration of Pre-induction of Targeted Temperature Management in Out-of-Hospital Cardiac Arrest.

Background The Resuscitation Rotation is a novel second-year emergency medicine rotation focusing on the highest acuity patients, including out-of-hospital cardiac arrest (OHCA). The resuscitation resident (RR) functions as an extra physician during resuscitation and post return of spontaneous circulation (ROSC). The objective of this study is to examine if the presence of a RR decreases the pre-induction interval of targeted temperature management (TTM) for patients following OHCA. Methods A retrospective study was conducted at a tertiary care level 1 trauma center with an annual ED census of 127,323 visits in 2019. We retrospectively reviewed consecutive OHCA patients from September 1, 2014, to July 20, 2020, who underwent TTM. Patients were identified as cases with or without a RR. Clinical characteristics were summarized by the status of RR involvement and compared by using t-test and χ2 test for continuous and categorical variables, respectively. All tests with p < 0.05 were considered to indicate statistical significance. Results Our study population identified 198 adult OHCA patients that underwent TTM from 2014-2020. There were exclusions for missing TTM start time and for missing patient characteristics leaving 176 for final analysis, of which 55 (33.3%) had RR involvement. The mean time (hours) to TTM initiation (ie, the pre-induction phase) for patients involving the RR versus those without was not statistically significant (3.11 vs 3.34, p=0.39). Linear regression analysis indicates that the adjusted effect of RR involvement was not associated with the mean hours of pre-induction (p=0.47). Conclusion There is no statistically significant association of a RR on the duration of the pre-induction phase. Limitations include that both arms had prolonged pre-induction phases. This may represent a non-optimized TTM protocol. Future work will aim to use the RR to improve our pre-induction phase.

Abstract 12005: Association of Prehospital Hypotension Depth and Dose With Survival Following Out-of-Hospital Cardiac Arrest

Introduction: Hypotension following resuscitation from out-of-hospital cardiac arrest (OHCA) may cause harm by exacerbating secondary brain injury; however, limited research has explored this relationship. Our objective was to examine the association between duration and depth of prehospital post return of spontaneous circulation (ROSC) hypotension and survival. Hypothesis: We hypothesized that increased severity and duration of post-ROSC hypotension in the prehospital setting would be associated with unfavorable patient outcomes. Methods: We utilized the 2019 and 2020 ESO Data Collaborative public use research data sets for this study (ESO, Austin, TX). Hypotension dose (mmHg*min.), average prehospital systolic blood pressure (SBP), and lowest recorded prehospital SBP were calculated. The association of these measures with survival to home (STH) and rearrest were explored using multivariable logistic regression. Time to hypotension resolution analyses were conducted using Cox proportional hazards models adjusted for known prognostic factors according to the Utstein template. We also assessed the association of hypotension management strategy (push dose vasopressors, vasopressor infusion, or fluid only) with survival, rearrest, and time to hypotension resolution. Results: 17,280 OHCA patients met inclusion criteria, of which 3,345 had associated hospital outcome data. Over one-third (37.8%; 6,526/17,280) of all patients had at least one recorded SBP below 90 mmHg. When modeled continuously, average prehospital SBP (1.19 [1.15, 1.23] per 10 mmHg), lowest prehospital SBP (1.20 [1.17, 1.24] per 10 mmHg), and hypotension dose (0.995 [0.993, 0.996] per mmHg*min.) were independently correlated with STH. Differences in hypotension management were not associated with differences in survival, rearrest, or time to hypotension resolution. Conclusion: Severity and duration of hypotension were significantly associated with poorer outcomes in this dataset. The incidence of hypotension was significantly associated with known unfavorable prognostic factors. Defining a threshold for hypotension requiring treatment above the classical SBP threshold of 90 mmHg may be warranted in the setting of prehospital post-resuscitation care.

Abstract 141: Associations Between Sex Steroids And Cardiac Arrest Outcomes

Introduction: Sudden cardiac arrest (SCA) is one of the leading causes of death in both males and females although females tend to have better outcomes. While sex steroids influence cardiovascular disease, and low level of testosterone and high level of estradiol is associated with the risk of SCA, little is known about their changes after a cardiac arrest, and their association to outcomes. We sought to characterize the temporal trajectories in sex steroids (estrogens [estrone and estradiol], progesterone, and testosterone) in the post-return of spontaneous circulation (ROSC) phase and determine associations with survival and neurological outcomes. Hypothesis: Sex steroids and their temporal trajectories post-SCA are associated with survival and neurological outcomes. Methods: Plasma samples from SCA patients (n=65, 74% males) were collected at the University of Texas Houston between May 2018-March 2020 at four serial time points (0, 6, 24, 48h) post-ROSC. Quantitative sex hormone analysis was performed using LCMS. Data was analyzed by t-test, Chi 2 test and Generalized Estimating Equation (GEE) with p&lt;0.05 indicating significance. Results: There were no differences in demographic and clinical characteristics between males and females. Plasma estrogens peaked at 24 hours, whereas progesterone and testosterone peaked at 6 hours. Estrogens and testosterone were higher in males, while progesterone trended higher in females. Hormonal trajectories did not differ by survival, however, testosterone concentrations were lower in patients with good neurological recovery. Lower estradiol was associated with survival (β: -13.80, p=0.016) adjusting for sex, time, and age, while a lower testosterone was associated with good neurological recovery (β: -0.68, p=0.031) adjusting for time. Conclusion: Increased circulating sex steroid concentrations were observed in the post-ROSC phase after SCA. High levels of estrogens were associated with worse survival independent of sex, and lower testosterone levels were associated with better neurological recovery. A larger sample size and simultaneous measurement of cortisol will be important to better understand the role of sex hormones in outcomes after SCA.

The monoacylglycerol lipase inhibitor, JZL184, has comparable effects to therapeutic hypothermia, attenuating global cerebral injury in a rat model of cardiac arrest

Post-resuscitation cerebral ischemia-reperfusion injury (IRI) is a vital contributor to poor neurological prognosis. Exploring novel therapeutics that attenuate cerebral IRI is of great significance. Inflammation plays a role in the development of cerebral IRI after successful cardiopulmonary resuscitation (CPR). Monoacylglycerol lipase (MAGL) is an enzyme that is predominantly responsible for the metabolism of endocannabinoid 2-arachidonoylglycerol (2-AG) to arachidonic acid (AA) metabolites, which are associated with inflammation. Therefore, we investigated the efficacy of the MAGL inhibitor, JZL184, on cerebral IRI and further compared the effects to therapeutic hypothermia (TH). Thirty-six rats were randomized into three groups: 1) JZL184; 2) Control; 3) TH (N = 12 for each group). Animals underwent 6 min of ventricular fibrillation (VF) followed with 8 min of CPR. After return of spontaneous circulation (ROSC), rats received an intraperitoneal injection of JZL184 (16 mg/kg) or DMSO (20 mg/ml) or body cooling was initiated. Cerebral microcirculation, brain edema, blood brain barrier (BBB) permeability, serum neuron-specific enolase (NSE), S-100β, interleukin-6 (IL-6) and interleukin-10 (IL-10) were quantified at 6 h post ROSC. Compared to control, treatment with JZL184 or TH was associated with significantly ameliorated cerebral microcirculation, mitigated brain edema, attenuated BBB permeability, decreased serum levels of NSE, S-100β and IL-6, and increased serum IL-10 levels (p < 0.05). There was no significant difference in the above measurements between JZL184 and TH. JZL184 has comparable neuroprotective effects to therapeutic hypothermia on global cerebral IRI in a rat model of cardiac arrest (CA).

Association of prehospital hypotension depth and dose with survival following out-of-hospital cardiac arrest

IntroductionHypotension following resuscitation from out-of-hospital cardiac arrest (OHCA) may cause harm by exacerbating secondary brain injury; however, limited research has explored this relationship. Our objective was to examine the association between duration and depth of prehospital post return of spontaneous circulation (ROSC) hypotension and survival. MethodsWe utilized the 2019 and 2020 ESO Data Collaborative public use research data sets for this study (ESO, Austin, TX). Hypotension dose (mmHg*min.), average prehospital systolic blood pressure (SBP), and lowest recorded prehospital SBP were calculated. The association of these measures with survival to home (STH) and rearrest were explored using multivariable logistic regression. Time to hypotension resolution analyses by hypotension management strategy (push dose vasopressors, vasopressor infusion, or fluid only) were conducted using adjusted Cox proportional hazards models. Results17,280 OHCA patients met inclusion criteria, of which 3,345 had associated hospital outcome data. Over one-third (37.8%; 6,526/17,280) of all patients had at least one recorded SBP below 90 mmHg. When modeled continuously, average prehospital SBP (1.19 [1.15, 1.23] per 10 mmHg), lowest prehospital SBP (1.20 [1.17, 1.24] per 10 mmHg), and hypotension dose (0.995 [0.993, 0.996] per mmHg*min.) were independently associated with STH. Differences in hypotension management were not associated with differences in survival or time to hypotension resolution. ConclusionSeverity and duration of hypotension were significantly associated with worse outcomes in this dataset. Defining a threshold for hypotension requiring treatment above the classical SBP threshold of 90 mmHg may be warranted in the setting of prehospital post-resuscitation care.

P58 IMMEDIATE CORONARY ANGIOGRAPHY AND SYSTEMATIC TARGETED TEMPERATURE MANAGEMENT ARE ASSOCIATED WITH IMPROVED OUTCOME IN COMATOSE SURVIVORS OF CARDIAC ARREST

Abstract Background Rapid and systematic access to coronary angiography (CAG) and target temperature management (TTM) might improve outcome in comatose patients who survive cardiac arrest (CA). However, there is controversy around indicating immediate CAG in the absence of transmural ischemia on the electrocardiogram after return of spontaneous circulation (ROSC). We evaluated the short– and long–term outcome of our retrospective cohort of patients undergoing systematic CAG and TTM, based on whether culprit lesion percutaneous coronary intervention (PCI) was performed. Methods All consecutive comatose CA survivors with no obvious extracardiac causes undergoing TTM were included. Analysis involved the entire population and subgroups, namely patients with initial unshockable rhythm, no ST–elevation on electrocardiogram, and good neurological recovery. Results We enrolled 107 patients with a median age of 64.9 (57.7–73.6) years. The initial rhythm was shockable in 83 (77.6%). Sixty–six (61.7%) patients underwent PCI. In–hospital survival was 71%. It was 78.8% and 58.5% in those undergoing or not PCI (p = 0.022), respectively. Age, time from CA to ROSC and culprit lesion PCI were independent predictors of in–hospital survival. Long–term survival was significantly higher in patients who underwent PCI (respectively 61.5% vs 34.1%; Log–rank: p = 0.002). Revascularization was associated with better outcomes regardless of initial rhythm (shockable vs non–shockable) and ST–deviation (elevation vs no–elevation), and improved the long–term survival of patients discharged with good neurological recovery. Conclusion Systematic CAG and revascularization, when indicated, were associated with higher survival in comatose patients undergoing TTM, regardless of initial rhythm and ST–deviation in the post–ROSC electrocardiogram. The benefit was sustained at long–term particularly in those with neurological recovery.

C60 12–LEAD POST–ROSC ELECTROCARDIOGRAM DISCRIMINATES SURVIVAL TO HOSPITAL DISCHARGE. A SUB–ANALYSIS OF THE PEACE STUDY

Abstract Background Once the return of spontaneous circulation (ROSC) after an out–of–hospital cardiac arrest (OHCA) is achieved in patients with an ST–elevation myocardial infarction, the acquisition of a 12–lead electrocardiogram (ECG) is strongly recommended in order to determine candidates for urgent coronary angiography. However, little is known so far about the association of ECG features and survival to hospital discharge in OHCA patients. Methods We analysed all the post–ROSC ECGs collected from January 2015 to December 2018 in three European centres (Pavia, Lugano and Vienna). For every ECG, the main features were analysed and filed in the database together with the pre–hospital data collected for every patient according to the Utstein style. Results We collected 370 ECGs: 287 males (77.6%); median age 62 years old (IQR 53–70 years); 121 from Pavia (32.7%), 38 from Lugano (10.3%) and 211 from Vienna (57.0%). In Cox univariable regression, age older than 62 years [HR 1.7 (95% IC 1.1–2.4), p = 0.007], QRS wider than 120 msec [HR 1.87 (95% IC 1.3–2.7), p &amp;lt; 0.001], ST elevation in more than one segment [HR 1.7(95% IC 1.2–2.5),p=0.003], the presence of left bundle branch block (LBBB) [HR 1.7 (95% IC 1.1–2.9), p = 0.03] and a right bundle branch block [HR 1.8 (95% IC 1.1–2.8), p = 0.01] were all associated with death before hospital discharge. In multivariable Cox regression, adjusted for the ROSC–to–ECG time, age older than 62 years [HR 1.6 (95% IC 1.1–2.3), p = 0.01], QRS wider than 120 msec [HR 1.7 (95%IC 1.2–2.5), p = 0.004] and the presence of ST elevation in more than one segment [HR 1.7 (95%IC 1.2–2.5), p = 0.004] were independently associated with death before hospital discharge. By considering these latter three risk factors, the rate of survival to hospital discharge was significantly influenced by their number [no risk factor: 80.8%; 1 factor: 71.2%; 2 factors: 61.9%; 3 factors: 34.4%; p &amp;lt; 0.001, p for trend &amp;lt;0.001]. With a Cox regression model, considering the absence of risk factor as a reference, we confirmed that having 2 or 3 risk factors was significantly associated with death before hospital discharge [HR 1.9 (95%IC 1–3.5), p = 0.037 e HR 5.1(95%IC 2.6–10.1), p &amp;lt; 0.001 respectively]. Conclusions Our study confirms the central role of ECG in STEMI patients resuscitated after an OHCA and proves that post–ROSC ECG features can be used for both the selection of patients who may benefit from urgent coronary angiography as well as for prognostic stratifications.

Determining consistency of care after resuscitation from in-hospital cardiac arrest, a retrospective analysis at a tertiary care academic medical center

BackgroundFew guidelines have focused on the care delivered after return of spontaneous circulation (ROSC). Post ROSC best practice guidelines lack clarity about important tasks to accomplish in the first hours after ROSC. Objectives and methodsWe conducted a retrospective cohort analysis of adults who had suffered an in hospital cardiac arrest (IHCA) with ROSC over a two-year period to determine the completion rate of critical tasks in the immediate post-ROSC period: ECG within one hour, ABG within one hour, physician documentation within six hours, and surrogate communication within six hours. ResultsIn the 113 reviewed cases, there was significant variance between completion of all four (19.4%), three (35.3%), two (32.7%), one (20.6%) and none (1.7%) of these critical post ROSC tasks. We observed that 62.8% of IHCA with ROSC had an ECG obtained within one hour of ROSC. The rate of obtaining an ABG within one hour of ROSC was 76.9%. 49.5% of cases had physician documentation of the resuscitation within six hours of ROSC. The rate of documenting surrogate communication within six hours of ROSC was 69.9%. ConclusionsOur study demonstrated that the completion rates of critical tasks in the post ROSC setting were suboptimal within our patient cohort. This provides a baseline for the development of future best practice guidelines and clinical decision-making aids for post ROSC care after IHCA. This can lead to future research in coupling specific care tasks to post ROSC patient outcomes.

Early Thalamocortical Reperfusion Leads to Neurologic Recovery in a Rodent Cardiac Arrest Model.

Cerebral blood flow (CBF) plays an important role in neurological recovery after cardiac arrest (CA) resuscitation. However, the variations of CBF recovery in distinct brain regions and its correlation with neurologic recovery after return of spontaneous circulation (ROSC) have not been characterized. This study aimed to investigate the characteristics of regional cerebral reperfusion following resuscitation in predicting neurological recovery. Twelve adult male Wistar rats were studied, ten resuscitated from 7-min asphyxial CA and two uninjured rats, which were designated as healthy controls (HCs). Dynamic changes in CBF in the cerebral cortex, hippocampus, thalamus, brainstem, and cerebellum were assessed by pseudocontinuous arterial spin labeling magnetic resonance imaging, starting at 60min after ROSC to 156min (or time to spontaneous arousal). Neurologic outcomes were evaluated by the neurologic deficit scale at 24h post-ROSC in a blinded manner. Correlations between regional CBF (rCBF) and neurological recovery were undertaken. All post-CA animals were found to be nonresponsive during the 60-156min post ROSC, with reductions in rCBF by 24-42% compared with HC. Analyses of rCBF during the post-ROSC time window from 60 to 156min showed the rCBF recovery of hippocampus and thalamus were positively associated with better neurological outcomes (rs = 0.82, p = 0.004 and rs = 0.73, p < 0.001, respectively). During 96min before arousal, thalamic and cortical rCBF exhibited positive correlations with neurological recovery (rs = 0.80, p < 0.001 and rs = 0.65, p < 0.001, respectively); for predicting a favorable neurological outcome, the thalamic rCBF threshold was above 50.84ml/100g/min (34% of HC) (area under the curve of 0.96), whereas the cortical rCBF threshold was above 60.43ml/100g/min (38% of HC) (area under the curve of 0.88). Early magnetic resonance imaging analyses showed early rCBF recovery in thalamus, hippocampus, and cortex post ROSC was positively correlated with neurological outcomes at 24h. Our findings suggest new translational insights into the regional reperfusion and the time window that may be critical in neurological recovery and warrant further validation.

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

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

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

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

THE EFFECT OF A CHECKLIST ON VARIABILITY OF CARE AFTER IN HOSPITAL CARDIAC ARREST AT A TERTIARY ACADEMIC MEDICAL CENTER

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: There are approximately 290,000 in hospital cardiac arrests (IHCA) annually in the United States. Recent evidence suggests that post IHCA outcomes may be more related to post return of spontaneous circulation (ROSC) care than intra cardiac arrest resuscitation. The purpose of this study is to assess the effect of a post ROSC checklist on variability care after IHCA with ROSC. METHODS: We performed a retrospective analysis of inpatient adults with an IHCA with ROSC at Harborview Medical Center (HMC) between 1/1/2018-12/31/2019. Included patients had an ICHA on an acute care or intensive care unit (ICU), were over the age of 18, and not placed on extra corporeal membrane oxygenation. IHCA was defined as cardiopulmonary resuscitation delivered by healthcare personnel. Demographics, clinical variables, and process of care metrics were abstracted from the electronic medical record. We then developed a post ROSC checklist utilizing our retrospective data and expert opinion. The checklist was implemented at HMC in January 2020. We conducted a follow up analysis of post-ROSC care since checklist implementation between 1/1/2020-12/31/2020. Pre and post implementation results were compared. RESULTS: 125 IHCA were included in the pre implementation cohort and 47 were included in the post implementation cohort. The mean age of the pre implementation cohort was 55.1 versus 55.9 post implementation. Women comprised 36.8% in the pre implementation cohort and 37.0% in the post implementation cohort. The rate of obtaining an electrocardiogram within one hour of ROSC was 60.8% prior to checklist implementation, and 76.6% after implementation. The rate of obtaining a formal transthoracic echocardiogram within six hours of ROSC was 32.8% prior to checklist implementation, and 34.0% after implementation. The rate of physician documentation occurring within six hours of ROSC was 47.0% prior to checklist implementation, and 85.1% after implementation. The rate of documented notification of family within six hours of ROSC in 67.2% of cases prior to checklist implementation, and 80.8% after implementation. CONCLUSIONS: The introduction of a post ROSC checklist correlated with an increase in obtaining ECGs and completing documentation tasks after IHCA with ROSC at HMC. This study was limited by the small number patients included as well as being a single site study. Confounding circumstances in code blue management related to COVID-19 must be acknowledged. Further research is needed to assess the durability of these findings, and what impact this may have on post IHCA outcomes. CLINICAL IMPLICATIONS: While there will be differences in the management and evaluation of patients who suffer an IHCA, some interventions such as a timely ECG and documentation should be completed with little variance between patients. The use of a checklist decreased the rate of variance, by providing a cognitive aid to guide clinical decisions in a stressful scenario. The use of a post ROSC checklist has the potential to decrease variance in diagnostic and documentation tasks after IHCA. DISCLOSURES: No relevant relationships by David Carlbom, source=Web Response No relevant relationships by Stephen Ferraro, source=Web Response No relevant relationships by Vince Raikhel, source=Web Response No relevant relationships by Vera Schulte, source=Web Response No relevant relationships by James Town, source=Web Response