Recurrent Arrest Research Articles

Factors Associated with Pediatric In-Hospital Recurrent Cardiac Arrest.

The objective of this article was to identify demographic and clinical factors associated with early recurrent arrest (RA; <48 hours) and late RA (≥48 hours) among pediatric inpatients following an initial in-hospital cardiac arrest. A retrospective cohort study of inpatients was performed in a free-standing academic quaternary care children's hospital. All inpatients were <18 years old with a cardiac arrest event requiring ≥1 minute of cardiopulmonary resuscitation with the return of spontaneous circulation sustained for ≥20 minutes at Seattle Children's Hospital from February 1, 2012, to September 18, 2019. Of the 237 included patients, 20 (8%) patients had an early RA and 30 (13%) had a late RA. Older age and severe prearrest acidosis were associated with a higher risk of early RA, odds ratios (OR) = 1.2 (95% confidence interval [CI]: 1.1-1.3) per additional year and 4.6 (95% CI: 1.2-18.1), respectively. Prearrest organ dysfunction was also associated with a higher risk of early RA with an OR of 3.3 (95% CI: 1.1-9.4) for respiratory dysfunction, OR = 1.4 (95% CI: 1.1-1.9) for each additional dysfunctional organ system, and OR = 1.1 (95% CI: 1-1.2) for every one-point increase in PELOD2 score. The neonatal illness category was associated with a lower risk of late RA, OR 0.3 (95% CI: 0.1-0.97), and severe postarrest acidosis was associated with a higher risk of late RA, OR = 4.2 (95% CI: 1.1-15). Several demographic and clinical factors offer some ability to identify children who sustain a recurrent cardiac arrest, offering a potential opportunity for intervention to prevent early recurrent arrest.

Recurrent Arrest is Strongest Predictor of Poor Outcomes After In-Hospital Cardiac Arrest.

According to this study: Among survivors of in-hospital cardiac arrest, recurrent cardiac arrest is the strongest predictor of poor outcomes and is associated with fivefold lower survival chances.

Survival, neurological and safety outcomes after out of hospital cardiac arrests treated by using prehospital therapeutic hypothermia: A systematic review and meta-analysis

Survival after pre-hospital cardiac arrest (PHCA) remains low. Pre-hospital therapeutic hypothermia (PTH) is believed to improve patient's outcomes, but data on efficacy and safety remains scarce. Herein, we aimed to assess the influence of PTH on survival, neurological outcome, and adverse effects in patients with PHCA. A literature search of PubMed CENTRAL, EMBASE, and The Cochrane Central Register of Controlled Trials databases from inception to August 2019 was conducted and retrieved abstracts were independently assessed by two reviewers. The primary outcome was survival to hospital discharge with a favorable neurological outcome. Secondary outcomes were survival to hospital discharge and temperature upon hospital admission. The safety outcomes included pulmonary edema and recurrent arrest during transport to the hospital. We also considered a favorable neurological function to hospital discharge or longest post arrest follow-up. Eleven studies including 4891 patients were included into final analysis. The survival to hospital discharge did not differ between PTH and control group (RR 1.02; 95%CI 0.93 to 1.12). Among 4891 participants (2466 in PTH group and 2425 in control group), 1087 participants (564 vs. 523, respectively) had a favorable neurological outcome. Pulmonary edema occurred in 320 cases in PTH group and 273 in control group with significant heterogeneity (RR 0.90, 95%CI 0.59–1.38; I2 = 80%). The pooled results showed a significant difference in rearrests between the PTH and control group (RR 1.19; 95%CI 1.00 to 1.42). Our analysis demonstrates that PTH does not improve survival at discharge or neurological outcome.

Turn-to-Shockable Rhythm Has Comparable Neurologic Outcomes to Initial Shockable Rhythm in Out-of-Hospital Cardiac Arrest Patients Who Underwent Targeted Temperature Management.

Shockable rhythm in out-of-hospital cardiac arrest (OHCA) implies better outcome and underlying coronary stenosis. We investigated the neurologic outcome and coronary lesions between initial shockable rhythm and turn-to-shockable rhythm. This multicenter, retrospective observational study included adult nontraumatic OHCA survivors with any shockable rhythm during cardiopulmonary resuscitation (CPR) who underwent targeted temperature management between January 2010 and December 2016. Patients were divided into two groups according to the first monitored rhythm: initial shockable rhythm or turn-to-shockable rhythm. The primary outcome was good neurologic outcome at discharge based on cerebral performance categories, and the secondary outcomes were survival discharge, recurrent arrest, and coronary lesions. The two groups were matched in a 1:1 ratio using propensity score (PS). Of 426 patients, 137 and 289 patients were divided into the turn-to-shockable and initial shockable rhythm groups, respectively. Overall, 224 (52.6%) patients had good neurologic outcomes. The turn-to-shockable rhythm group had less patients with good neurologic outcome (57/137 vs. 167/289; p = 0.002) and less culprit lesions in the left anterior descending and left circumflex arteries. However, survival discharge and recurrent arrest were not different between the two groups, and the turn-to-shockable rhythm had no independent association with neurologic outcome (odds ratio, 1.874; 95% confidence interval, 0.909-3.863). In the PS-matched cohort, the turn-to-shockable rhythm group had similar good neurologic outcome (47/100 vs. 35/100, p = 0.083). Survival discharge, recurrent arrest, and coronary culprit lesions were not different between the two groups. In this PS-matched study, OHCA with any shockable rhythm during CPR had similar neurologic outcome and coronary culprit lesions, irrespective of the first monitored rhythm.

Use of amplitude-integrated electroencephalography in decision-making for extracorporeal membrane oxygenation in comatose cardiac arrest patients whose eventual neurologic recovery is uncertain.

Comatose cardiac arrest patients frequently experience cardiogenic shock or recurrent arrest. Extracorporeal membrane oxygenation (ECMO) can be used to salvage patients with cardiogenic shock or cardiac arrest refractory to conventional therapies. However, in comatose cardiac arrest patients whose neurologic recovery is uncertain, the use of ECMO is restricted because it requires considerable financial and human resources. Amplitude-integrated electroencephalography is an easily applicable, real-time electroencephalography monitoring tool that has been increasingly used to monitor brain activity in comatose cardiac arrest patients. We describe our experience of using amplitude-integrated electroencephalography in decision-making to place ECMO for comatose cardiac arrest patients whose eventual neurologic recovery appeared uncertain at the time of ECMO placement.

Ratification of C87 and C98: A means of regression?

8 | International Union Rights | 26/3 TOWARDS UNIVERSAL RATIFICATION OF C87 AND 98 Ratification of C87 and C98: A means of regression? Ratification of the non-ratified ILO conventions has been the most unachievable goal in the Republic of Korea for the last decades. The country has yet to ratify the Conventions 87 and 98 on freedom of association and the right to collective bargaining, as well as Conventions 29 and 105 on forced labour. Whenever the ILO or UN recommended Korea to ratify the international labour standards, consecutive governments have repeatedly promised to consider the possibility to do so. Sometimes the government voluntarily pledged to consider the ratification when it ran for the UN Human Rights Council. Even though the government has chaired the Council, the promise was never fulfilled. The major obstacle to ratification, the government suggested, is the existing law of South Korea – a view that is shared by the international community. Indeed, the Committee on Freedom of Association (CFA) of the ILO has repeatedly pointed out the domestic laws, institutions and practices which run counter to the fundamental principle. These contain a wide variety of violations; prohibition of union membership for the unemployed, the dismissed and various types of workers who are misclassified as independent contractors. The discretional power given to the administrative agency for screening the validity of the union establishment report during the process of certification is another major violation of the principle. The recurrent arrest and imprisonment of union leaders and members for union activity including strike is a typical breach of fundamental labour rights. Article 314 of the Criminal Law is a notorious provision frequently used to penalise striking workers and leaders of trade unions. It is common practice that the prosecutors declare a strike illegal even before the workers go into a collective action. This is due to the law in which it is almost impossible for a strike to be recognised as legitimate. Addressing the freedom of association complaint filed in 1995 (Case No 1865, Complaint date: 14-DEC-95), the CFA pointed out all the violations above mentioned and delivered various recommendations to the government. However, consecutive governments kept ignoring the recommendations, which made the case the second longest pending case. However, we have to remember that the government joined in the adoption of the ILO Declaration of the Fundamental Principle and Right at Work, 1998 under which the government has an obligation to respect, promote and realise freedom of association. Non-ratification provoked an international dispute This long-standing negligence led to a dispute under Chapter 13 (Trade and Sustainable Development) of the Korea-EU Free Trade Agreement (FTA). This is the first case in which the EU has triggered the dispute settlement mechanism under the Trade and Sustainable Development Chapter of an FTA. According to Article 13.4, Korea commits to make continued and sustained efforts towards ratifying the fundamental ILO Conventions. At the same time Korea commits to meet the obligations deriving from membership of the ILO and the ILO 1998 Declaration. The European Commission stated in its official letter sent on December 18, 2018: ‘more than seven years after the entry into force of the EU-Korea FTA, Korea has still not ratified the aforementioned four fundamental ILO Conventions. Thus, Korea appears to have acted inconsistently with Article 13.4 paragraph 3 last sentence of the EU-Korea FTA’. The EU also specified articles of the Trade Union and Labour Relation Adjustment Act (TULRAA) that appeared to be inconsistent with Korea’s obligations. The parties spent 90 days for the formal consultation to resolve the dispute but failed. Once again, the European Commission moved to the next step based on the Article 13.15 and requested the Korean government to convene a Panel of Experts to examine the issues that have not been satisfactorily addressed through the consultation. Here, I would like remind readers that the current administration listed the ratification of the non-ratified fundamental conventions in its own 100-point agenda, published on the 100th day of its inauguration; these 100 policy tasks are intended to be implemented during its five-year term (by 2022). What made the EU find the effort to...

Takotsubo Cardiomyopathy Presenting with Sinoatrial Disease: A Rare Presentation

Takotsubo cardiomyopathy (TCM), or apical ballooning syndrome, is a distinct nonischemic cardiomyopathy mimicking acute coronary syndrome. A 76-year-old female presented with ST elevation in the inferior lead and a troponin level of 0.81 ng/dL. An immediate coronary angiography showed non-obstructive coronary artery disease. A subsequent ventriculogram and echocardiogram showed anteroapical and distal inferior wall hypokinesis suggestive of TCM. Despite therapy with beta blocker, she was observed to have two significant sinus pauses, one eight-second, and a second 29-second pause. An urgent transvenous pacemaker was put in place and later followed by a permanent pacemaker. The patient was discharged on carvedilol and losartan. Although other arrhythmias such as complete heart block, torsades, and ventricular arrhythmias have been commonly reported, the association of TCM with recurrent sinus arrest has rarely been reported in the literature. The occurrence observed in this case implies that patients with TCM should be monitored closely for arrhythmias, and, if such a condition is identified, planning for permanent pacemaker implantation should be started early enough to avoid recurrent life-threatening episodes.

Concealed resuscitation-related injuries as reversible cause of recurrent arrest following extracorporeal cardiopulmonary resuscitation.

A life-threatening cardiopulmonary resuscitation (CPR)-related injury can cause recurrent arrest after return of circulation. Such injuries are difficult to identify during resuscitation, and their contribution to failed resuscitation can be missed given the limitations of conventional CPR. Extracorporeal cardiopulmonary resuscitation (ECPR), increasingly being considered for selected patients with potentially reversible etiology of arrest, may identify previously occult CPR-related injuries by restoring arterial pressure and flow. Herein, we describe two cases of severe CPR-related injuries contributing to recurrent arrest. Each case had ECPR implemented within 60 minutes of the start of CPR. After the presumed cardiac etiology had been addressed with percutaneous coronary intervention, life-threatening cardiovascular injuries with recurrent arrest were noted, and resuscitative thoracotomy was performed under ECPR. One patient survived to hospital discharge. ECPR may provide an opportunity to identify and correct severe resuscitation-related injuries causing recurrent arrest. Chest compression depth >6 cm, especially in older women, may contribute to these injuries.

High Serum Tumor Necrosis Factor Levels in the Early Post-Cardiac Arrest Period Are Associated with Poor Short-Term Survival in a Swine Model of Ventricular Fibrillation.

Most resuscitated victims of out-of-hospital cardiac arrest who survive to hospital expire due to the postresuscitation syndrome. This syndrome is characterized by a sepsis-like proinflammatory state. The objective of this investigation was to determine whether a relationship exists between the rise of tumor necrosis factor (TNF), a proinflammatory cytokine, following return of spontaneous circulation (ROSC), and early postarrest survival in a clinically relevant animal model of spontaneous ventricular fibrillation (VF). Mixed-breed Yorkshire swine (n = 20), weighing 39 ± 5 kg, were anesthetized and catheters placed in the right atrium and left ventricle/ascending aorta for continuous pressure monitoring. VF was induced by occluding the left anterior descending coronary artery with an angioplasty balloon. After 7 min of untreated VF, advanced life support resuscitation attempts were made for up to 20 min. Animals achieving ROSC were monitored for 3 h and fluid and pressor support was administered as needed. TNF levels were measured before VF and at 0, 15, and 30 min after ROSC using quantitative sandwich enzyme-linked immunosorbent assay. Twelve (60%) animals experienced early death, expiring during the 3 hour postarrest period (9 pulseless electrical activity, 2 VF, and 1 asystole). The TNF level at 15 min post-ROSC was significantly associated with death within the first 3 h post-ROSC with a univariate odds ratio of 1.4 [95% confidence interval (CI) 1.05-2.2, P = 0.01]. Using a cutoff TNF level of 525 pg/mL at 15 min post-ROSC had 100% negative predictive value (95% CI 0%-37%) and 67% positive predictive value (95% CI 35%-90%) for early death with a hazard ratio of 6.6 (95% CI 1.9-23.5). TNF increases shortly after ROSC and is predictive of early death. Early identification of resuscitated victims at greatest risk for hemodynamic collapse and recurrent arrest might facilitate the use of early hospital-based interventions to decrease the likelihood of a poor outcome.

Outcomes Following Single and Recurrent In-Hospital Cardiac Arrests in Children With Heart Disease: A Report From American Heart Association's Get With the Guidelines Registry-Resuscitation.

Little is known regarding patient characteristics and outcomes associated with cardiac arrest in hospitalized children with underlying heart disease. We described clinical characteristics and in-hospital outcomes in cardiac patients with both single and recurrent cardiac arrests. Retrospective analysis evaluating characteristics and outcomes in single versus recurrent arrest groups in unadjusted and adjusted analyses. American Heart Association's Get with the Guidelines-Resuscitation registry (2000-2010). Children younger than 18 years, identified with medical or surgical cardiac disease and one or more in-hospital cardiac arrest. None. One thousand eight hundred and eighty-nine patients with 2,387 cardiac arrests from 157 centers met inclusion criteria: 1,546 (82%) with a single arrest and 343 (18%) with a recurrent arrest. More than two thirds of recurrent cardiac arrests occurred in ICUs, and those with recurrent arrest had a higher prevalence of baseline comorbidities (e.g., more likely to be mechanically ventilated and receiving vasoactive infusions). Overall survival to hospital discharge was 51%, and was lower in the recurrent versus single arrest group (41% vs 53%; p < 0.001). In analysis adjusted for baseline comorbidities, there was no longer a statistically significant association between recurrent arrest and survival (odds ratio, 0.74; 95% CI, 0.33-1.63; p = 0.45). In stratified analysis, the relationship between recurrent arrest and lower survival was more prominent in the surgical-cardiac (odds ratio, 0.39; 95% CI, 0.14-1.11; p = 0.09) versus medical-cardiac (odds ratio, 0.96; 95% CI, 0.28-3.30; p = 0.95) group. In this large multicenter study, half of pediatric cardiac patients who suffered a cardiac arrest survived to hospital discharge. Lower survival in the group with recurrent arrest may be explained in part by the higher prevalence of baseline comorbidities in these patients, and surgical cardiac patients appeared to be at greatest risk. Further study is necessary to develop strategies to reduce subsequent mortality in these high-risk patients.

Abstract 13162: Post-Cardiac Arrest Serum TNF-α Levels Are Associated With Short-Term Survival in a Swine Model of Ventricular Fibrillation

Introduction: Most resuscitated victims of out-of-hospital cardiac arrest who survive to hospital expire due to the post-resuscitation syndrome. This syndrome is characterized by a sepsis-like pro-inflammatory state. Hypothesis: We hypothesized that a relationship exists between the rise of TNF-α, a pro-inflammatory cytokine, following return of spontaneous circulation (ROSC) and early post-arrest survival in a clinically relevant animal model of spontaneous VF. Methods: Mixed-breed Yorkshire swine (n=20), weighing 39 + 5 kg, were anesthetized and catheters placed in the right atrium and left ventricle/ascending aorta for continuous pressure monitoring. VF was induced by occluding the LAD with an angioplasty balloon. After 7 min of untreated VF, ALS resuscitation attempts were made for up to 20 min. Animals achieving ROSC were monitored for 3 hrs and fluid and pressor support was administered as needed. TNF-α levels were measured prior to VF and at 0, 15, and 30 min after ROSC using quantitative sandwich ELISA. Exact logistic regression and binomial proportions were used for analysis. Results: Twelve (60%) animals experienced early death, expiring during the 3-hour post-arrest period (9 PEA, 2 VF, and 1 asystole). The TNF-α level at 15 minutes post-ROSC was significantly associated with death within the first 3 hours post ROSC with a univariate odds ratio (OR) of 1.4 (95% confidence interval [CI] 1.05-2.2, p=0.01). Using a cutoff TNF-α level of 525 pg/mL at 15 min post ROSC had 100% negative predictive value (95% CI 0-37%) and 67% positive predictive value (95% CI 35-90%) for early death. Conclusions: The pro-inflammatory cytokine TNF-α increases shortly after ROSC and is predictive of early death. Early identification of resuscitated victims at greatest risk for hemodynamic collapse and recurrent arrest might facilitate the use of early hospital-based interventions to decrease the likelihood of a poor outcome.

Recurrent Profound Hypercapnea and Respiratory Arrest - A Mystery Solved

Recurrent Profound Hypercapnea and Respiratory Arrest - A Mystery Solved

Recurrent Pseudomonas aortic root abscess complicating mitral valve endocarditis

We report on a man with Pseudomonas aeruginosa endocarditis causing an aortic root abscess. He underwent surgery with a homograft aortic root replacement and insertion of a tissue aortic valve. The patient then manifested recurrent aortic root infection and respiratory arrest, and eventually succumbed to sepsis. This case highlights the aggressive nature of an uncommon pathogen causing an atypical but lethal form of endocarditis, despite modern medical and surgical treatment.

Surgical coronary revascularization and antiarrhythmic therapy in survivors of out-of-hospital cardiac arrest

Background Patients who survive out-of-hospital cardiac arrest are at high risk for recurrent arrest. Coronary artery bypass grafting (CABG) confers a survival advantage, but it is unclear whether antiarrhythmic drugs or an implanted defibrillator confer added benefit. This study was designed to determine predictors for further treatment, survival, and therapeutic internal cardiac defibrillator (ICD) discharge in this patient population. Methods One hundred and eight patients undergoing CABG after out-of-hospital cardiac arrest were identified over a 12-year period. Case records were retrospectively reviewed. Follow-up was obtained and predictors of outcome events were analyzed. Results Fifty-four (50%) patients underwent CABG only. Fifty-four received additional treatment that included ICD placement in 23 (21%), antiarrhythmic medications in 19 (18%), or both in 12 (11%). Predictors of ICD placement included left ventricular ejection fraction (LVEF) less than 40% and perioperative intraaortic balloon counterpulsation. ICD or medical management increased survival in patients with LVEF <40%. Predictors of increased mortality included age >65 years, Cleveland Severity Score >8, and female gender. Predictors of therapeutic ICD discharge included age >65 years, reoperative CABG, LVEF <40%, and positive postoperative electrophysiological (EP) study. No patient with a negative postoperative EP study received an ICD, and none suffered sudden cardiac death during follow-up. Conclusions Patients with coronary artery disease anatomically suitable for CABG who survive an acute out-of-hospital cardiac arrest should undergo EP testing after CABG. Approximately half of these patients are adequately treated by CABG alone. The remainder may benefit from ICD placement or medical antiarrhythmic management.

経過中に洞停止を来した頚髄損傷の１例

経過中に洞停止を来した頚髄損傷の１例

Characteristics of patients with nonfatal cardiac arrest 3 to 180 days after acute myocardial infarction

Patients who survive a tachyarrhythmic cardiac arrest in the first 6 months after acute myocardial infarction (AMI) are at risk for recurrent arrests, but the magnitude, timing and characteristics of this phenomenon are unknown. This study characterizes the nature of recurrent tachyarrhythmic cardiac arrests in the absence of reversible factors or new myocardial necrosis in patients between 3 and 180 days after AMI. We retrospectively assessed 28 patients (mean age 61 ± 12 years) who survived an initial cardiac arrest a median of 10 days after AMI. Mean left ventricular ejection fraction was 36 ± 9%. Fourteen patients (50%) had at least 1 recurrence of cardiac arrest, and 10 had >2 arrests. Almost all (92%) recurrent cardiac arrests occurred within 5 days of the preceding arrest, and the high-risk periods were similar after the first, second or third cardiac arrest. Very fast ventricular tachycardia (mean cycle length 212 ± 30 ms) was the documented responsible arrhythmia in 44 of 51 cardiac arrests. The morphology was either polymorphic, monomorphic or sinusoidal. No clinical or laboratory values could be found that predicted whether a patient would have a recurrent arrest. Nineteen patients (68%) survived to leave the hospital and have been followed for up to 96 months. For these, actuarial 5-year overall survival was 76% and actuarial 5-year arrhythmia4ree probability was 80%. Thus, patients who survive a cardiac arrest in the first 6 months after AMI are at high risk of recurrent cardiac arrest for a further 5 days, and the arrests are due to characteristically fast ventricular tachycardias. If the patient survives to leave the hospital, long-term survival after hospital discharge is excellent.

The long-term prognosis of patients with out-of-hospital cardiac arrest but no inducible ventricular tachycardia

The long-term prognosis of patients successfully resuscitated from cardiac arrest who do not have acute precipitating factors and in whom ventricular arrhythmias cannot be induced during baseline electrophysiologic testing is controversial. The purpose of this investigation was to evaluate the long-term risk of recurrent sudden death and determine the clinical, angiographic, hemodynamic, and electrophysiologic predictors of recurrent cardiac arrest in such patients. Twenty-six (37%) of 71 consecutive patients with a single episode of aborted sudden death did not have inducible ventricular arrhythmias (< 7 intraventricular responses) during baseline drug-free electrophysiologic study and they form the basis of this report. Their mean age was 54 ± 13 (mean ± SD) years and the left ventricular ejection fraction (LVEF) was 0.47 ± 0.17. After a mean follow-up period of 16 months, 11 patients (42%) had a recurrent cardiac arrest (fatal in 10 patients). The actuarial incidence of recurrent cardiac arrest was 30 ± 10% at 1 year and 55 ± 13% at 3 years. Patients with LVEF ≤ 0.40 had a significantly higher occurrence of recurrent cardiac arrest than those with LVEF > 0.40 ( p = 0.02; 1-year actuarial incidence of 57 ± 17% versus 13 ± 19%). Patients with recurrent sudden death had a significantly greater incidence of dilated cardiomyopathy (55% versus 7%; p = 0.02) and baseline frequent premature ventricular contractions (PVCs > 10/hr; 64% versus 17%, p = 0.036) or nonsustained ventricular tachycardia (36% versus 0%; p = 0.37) than patients without these characteristics. The latter results were obtained despite the treatment of the majority of patients (six of eight) who manifested frequent ectopy with an antiarrhythmic agent that significantly suppressed PVC frequency and eliminated salvos of nonsustained ventricular tachycardia. All six patients with frequent ectopy and LVEF ≤ 0.40 developed recurrent arrest compared with 5 of 20 patients without these characteristics ( p = 0.002). Thus specific subgroups of patients with aborted sudden cardiac death without inducible ventricular arrhythmias during baseline drug-free electrophysiologic study are still at significant risk for recurrent cardiac arrest and 24-hour ambulatory electrocardiographic guided therapy was ineffective in preventing recurrent cardiac arrest. Those patients with left ventricular systolic dysfunction, dilated cardiomyopathy, and frequent baseline ventricular ectopy have a high likelihood of recurrent sudden death and should be considered for aggressive therapeutic interventions.

Smoking as a risk factor for recurrence of sudden cardiac arrest.

We obtained information about cessation of smoking in 310 survivors of out-of-hospital cardiac arrest who had been habitual cigarette smokers at the time of their arrest. Patients with coronary heart disease were stratified according to mortality risk on the basis of recognized criteria. The expected first-year rate of recurrent arrest ranged from 2 to 40 percent among the strata. Life-table analyses showed that reformed smokers had a lower incidence of recurrent arrest than patients who continued to smoke (19 vs. 27 percent at three years; P = 0.038 by one-sided test adjusted across strata). This effect occurred to varying degrees in all but the highest risk stratum. No differences in survival were observed for mortality due to other causes. It is possible that continued smoking in these patients led to acceleration of an ongoing atherosclerotic process, but the differences in early survival suggest that smoking may also act in the short term to enhance vulnerability to cardiac arrest.

Control of sudden recurrent arrhythmic deaths: Role of amiodarone

Patients resuscitated after out-of-hospital cardiac arrest have electrical instability of the myocardium, with 30% to 40% propensity for recurrent arrest in the first year. About 85% to 90% of such patients have complex ventricular ectopy and runs of ventricular tachycardia; in 70% to 80%, ventricular tachycardia or fibrillation are inducible by programmed electrical stimulation. The attempt to control recurrent cardiac arrest using these parameters and conventional antiarrhythmic drugs has yielded conflicting or variable results. Amiodarone was therefore studied in 40 consecutive patients (with previous cardiac arrests) in whom conventional antiarrhythmic therapy had proved ineffective or was not tolerated. The mean ejection fraction of the group was 0.29 ± 0.12. At a mean follow-up of 16 months (range 5 to 40 months) six patients had died, three from heart failure, one from liver failure (not drug induced), and two from sudden (presumably arrhythmic) death. Late occurrences of arrhythmia were found in two patients (complicated by digitalis intoxication in one). Ambulatory ECG recordings showed that amiodarone had a potent suppressant effect on ventricular ectopy and runs of VT, but electrophysiologic studies demonstrated that it did not inhibit inducible VT VF in 65% despite an excellent clinical outcome. Limiting adverse reaction was seen in only one patient; other relatively minor side effects occurred in 10% to 15% of patients receiving maintenance therapy. Our data provide further evidence for the effectiveness of amiodarone in life-threatening ventricular arrhythmias, with a potential for the prolongation of survival in patients resuscitated after out-of-hospital cardiac arrests.