Resuscitated Out-of-hospital Cardiac Arrest Patients Research Articles

Performance of ECG-Derived Digital Biomarker for Screening Coronary Occlusion in Resuscitated Out-of-Hospital Cardiac Arrest Patients: A Comparative Study between Artificial Intelligence and a Group of Experts.

Acute coronary syndrome is a significant part of cardiac etiology contributing to out-of-hospital cardiac arrest (OHCA), and immediate coronary angiography has been proposed to improve survival. This study evaluated the effectiveness of an AI algorithm in diagnosing near-total or total occlusion of coronary arteries in OHCA patients who regained spontaneous circulation. Conducted from 1 July 2019 to 30 June 2022 at a tertiary university hospital emergency department, it involved 82 OHCA patients, with 58 qualifying after exclusions. The AI used was the Quantitative ECG (QCG™) system, which provides a STEMI diagnostic score ranging from 0 to 100. The QCG score's diagnostic performance was compared to assessments by two emergency physicians and three cardiologists. Among the patients, coronary occlusion was identified in 24. The QCG score showed a significant difference between occlusion and non-occlusion groups, with the former scoring higher. The QCG biomarker had an area under the curve (AUC) of 0.770, outperforming the expert group's AUC of 0.676. It demonstrated 70.8% sensitivity and 79.4% specificity. These findings suggest that the AI-based ECG biomarker could predict coronary occlusion in resuscitated OHCA patients, and it was non-inferior to the consensus of the expert group.

Acute coronary occlusion and percutaneous coronary intervention after out-of-hospital cardiac arrest.

Early coronary angiography (CAG) has been recommended in selected patients following out-of-hospital-cardiac-arrest (OHCA). We aimed to identify clinical features associated with acute coronary occlusion (ACO) and evaluate the associations between ACO, successful percutaneous coronary intervention (PCI) and outcomes in this population. We included comatose OHCA patients treated with targeted temperature management (TTM) between December 2005 and September 2016 who underwent early CAG within 24 hours. The co-primary outcomes were all-cause 30-day mortality and good neurological outcome (modified Rankin Score [mRS] ≤2) at hospital discharge. Among 155 patients (93% shockable arrest rhythm, 55% with ST elevation), 133 (86%) had coronary artery stenosis ≥50% and 65 (42%) had ACO. ST elevation (sensitivity 74%, specificity 59%, OR 4.0, 95% CI 2.0-8.1) and elevated first troponin (sensitivity 88%, specificity 26%, OR 2.5, 95% CI 1.1-6.1) had limited sensitivity and specificity for ACO. Unadjusted 30-day mortality did not differ significantly by coronary disease severity or ACO. Successful PCI was associated with a lower risk of 30-day mortality (adjusted HR 0.5, 95% CI 0.2-0.9, P=.03), especially among patients with ACO (adjusted HR 0.4, 95% CI 0.1-0.9, P=0.03). After adjustment, ACO and PCI were not associated with the probability of good neurological outcome. In this select cohort of resuscitated OHCA patients undergoing CAG, unstable coronary disease is highly prevalent and successful PCI was associated with a higher probability of 30-day survival, especially among those with ACO. Neither ACO nor successful PCI were independently associated with good neurological outcome.

Abstract 278: Injuries and Outcomes Associated With Manual vs Mechanical CPR Post Out of Hospital Cardiac Arrest

Objectives: Mechanical CPR is increasingly being used for field out of hospital cardiac arrest (OHCA) care. However, existing literature does not identify a survival benefit of mechanical versus manual CPR. We hypothesized that CPR related injury may impact patient outcomes. For that reason, our primary objective is to compare mechanical and manual CPR-related injury in resuscitated OHCA patients. Our secondary objective is to compare hospital outcomes including length of stay (LOS) and survival between these two CPR methods. Methods: We performed a retrospective study of adult OHCA patients admitted to three teaching hospitals in Southeastern Michigan from 2017-2021. Resuscitated patients were matched to hospital electronic medical records (EMRs), included if they had CT imaging of chest or abdomen/pelvis, and then dichotomized by CPR method. Patients were excluded if no EMR match or CPR method was unknown. Hospital EMRs were queried for CT imaging results, LOS variables and survival to hospital discharge. Injuries are identified using hospital ICD-10 codes. Univariate statistics are reported. Results: There were 808 patients admitted after OHCA, with 235 (103 mechanical CPR, 132 manual CPR) meeting the inclusion criteria. Demographics between groups were similar in age, gender, or body mass index (BMI). There were no abdominal/visceral injuries and few patients (4) had a pneumothorax. CPR associated injury was more common with manual CPR (28.8% vs 15.5%, p=0.02) and an increased rate of rib(s), sternum, or thoracic spine fracture (27.3% vs 14.6%, p=0.02). . We identified no differences in survival to hospital discharge (39 (29.5%) vs. 29 (28.2%), p=0.8), median hospital LOS, ICU LOS, and ventilator time between groups. Paradoxically amongst survivors, mechanical CPR was associated with longer LOS (15.7 vs 11.0 days, p=0.012) and a non-significant increased ventilator time (143 vs 99 hours, p=0.23). Conclusion: We identified a higher rate of injury with manual CPR compared to mechanical CPR in resuscitated OHCA patients We also did not identify any association between CPR method and ICU LOS, ventilator time, and survival. Further work is needed to assess the impact on outcome of CPR method and injuries typically associated with resuscitation.

Abstract 101: Prehospital High-Dose Methylprednisolone Treatment Reduces Norepinephrine Need Following Resuscitated Out-of-Hospital Cardiac Arrest

Background: Resuscitated out-of-hospital cardiac arrest (OHCA) patients are hemodynamically unstable and have high mortality. Norepinephrine (NE) is recommended to maintain mean arterial pressure (MAP) above 65 mmHg, but excessive NE use, and a continuously low MAP are both associated with poor outcomes in OHCA. The glucocorticoid methylprednisolone (MP) has anti-inflammatory properties and may increase arterial sensitivity to NE, thereby improving MAP and reducing NE need. Aims: To determine if prehospital anti-inflammatory MP treatment could lower the need for NE without affecting MAP values following OHCA. Methods: The STEROHCA trial was a randomized, blinded, placebo-controlled, multicenter study, including adult comatose patients resuscitated from OHCA due to presumed cardiac etiology, and with a minimum of five minutes of return of spontaneous circulation. The intervention was intravenous MP 250 mg or placebo, administered prehospitally. In this sub-study, we repeatedly measured NE dose and MAP from admission until 48h and compared differences between the two groups at each time point. Results: In the STEROHCA trial, 137 patients were randomized to MP (n=68) or placebo (n=69). Patients were mainly male (85%) with a median age of 66 years (IQR 56, 75). The MP group demonstrated significantly lower NE use (mcg/kg/min) at 24h (0.22 (0.15; 0.31) vs. 0.38 (0.28; 0.49), p=0.02), 42h (0.13 (0.07; 0.20) vs. 0.25 (0.17; 0.35), p=0.03), and 48h (0.08 (0.03; 0.15) vs. 0.23 (0.15; 0.33), p=0.004), Figure 1 . We observed a higher MAP in the MP group with significantly higher MAP values (mmHg) at 6h (75 (72; 78) vs. 70 (67; 73), p=0.03), 12h (75 (71; 78) vs. 69 (66; 72), p=0.01), 18h (76 (73; 79) vs. 69 (66; 72), p=0.003), 24h (77 (74; 80) vs. 71 (68; 74), p=0.01), and 48h (86 (82; 89) vs. 79 (76; 82), p=0.004), Figure 1 . Conclusions: Prehospital treatment with high-dose MP reduced the need for NE while improving MAP values in resuscitated OHCA patients for the initial 48h of admission.

Indications for Cardiac Catheterization and Percutaneous Coronary Intervention in Patients with Resuscitated Out-of-Hospital Cardiac Arrest.

The role of emergent cardiac catheterization after resuscitated out-of-hospital cardiac arrest (OHCA) has evolved based on recent randomized evidence. This review aims to discuss the latest evidence and current indications for emergent coronary angiography (CAG) and mechanical circulatory support (MCS) use following OHCA. In contrast to previous observational data, recent RCTs evaluating early CAG in resuscitated OHCA patients without ST elevation have uniformly demonstrated a lack of benefit in terms of survival or neurological outcome. There is currently no randomized evidence supporting MCS use specifically in patients with resuscitated OHCA and cardiogenic shock. Urgent CAG should be considered in all patients with ST elevation, recurrent electrical or hemodynamic instability, those who are awake following resuscitated OHCA, and those receiving extracorporeal cardiopulmonary resuscitation (ECPR). Recent evidence suggests that CAG may be safely delayed in hemodynamically stable patients without ST-segment elevation following resuscitated OHCA.

Cardiovascular changes induced by targeted mild hypercapnia after out of hospital cardiac arrest. A sub-study of the TAME cardiac arrest trial

AimHypercapnia may elicit detrimental haemodynamic effects in critically ill patients. We aimed to investigate the consequences of targeted mild hypercapnia versus targeted normocapnia on pulmonary vascular resistance and right ventricular function in patients resuscitated from out-of-hospital cardiac arrest (OHCA). MethodsPre-planned, single-centre, prospective, sub-study of the Targeted Therapeutic Mild Hypercapnia After Resuscitated Cardiac Arrest (TAME) trial. Patients were randomised to mild hypercapnia (PaCO2 = 6.7–7.3 kPa) or normocapnia (PaCO2 = 4.7–6.0 kPa) for 24 hours. Haemodynamic assessment was performed with right heart catheterisation and serial blood-gas analyses every4th hour for 48 hours. ResultsWe studied 84 patients. Mean pH was 7.24 (95% CI 7.22–7.30) and 7.32 (95% CI 7.31–7.34) with hypercapnia and normocapnia, respectively (P-group < 0.001). Pulmonary vascular resistance index (PVRI), pulmonary artery pulsatility index, and right atrial pressure did not differ between groups (P-group > 0.05). Mean cardiac index was higher with mild hypercapnia (P-group < 0.001): 2.0 (95% CI 1.85–2.1) vs 1.6 (95% CI 1.52–1.76) L/min/m2. Systemic vascular resistance index was 2579 dyne-sec/cm-5/ m2 (95% CI 2356–2830) with hypercapnia, and 3249 dyne-sec/cm-5/ m2 (95% CI 2930–3368) with normocapnia (P-group < 0.001). Stroke volumes (P-group = 0.013) and mixed venous oxygen saturation (P-group < 0.001) were higher in the hypercapnic group. ConclusionIn resuscitated OHCA patients, targeting mild hypercapnia did not increase PVRI or worsen right ventricular function compared to normocapnia. Mild hypercapnia comparatively improved cardiac performance and mixed venous oxygen saturation.

Blood Pressure Targets for Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis.

With ideal mean arterial pressure (MAP) targets in resuscitated out-of-hospital cardiac arrest (OHCA) patients unknown, we performed a meta-analysis of randomised controlled trials (RCTs) to compare the effects of higher versus lower MAP targets. We searched four databases until 1 May 2023 for RCTs reporting the effects of higher MAP targets (>70 mmHg) in resuscitated OHCA patients and conducted random-effects meta-analyses. The primary outcome was mortality while secondary outcomes were neurological evaluations, arrhythmias, acute kidney injury, and durations of mechanical ventilation and ICU stay. We conducted inverse-variance weighted strata-level meta-regression against a proportion of non-survivors to assess differences between reported MAPs. We also conducted a trial sequential analysis of RCTs. Four RCTs were included. Higher MAP was not associated with reduced mortality (OR: 1.09, 95%-CI: 0.84 to 1.42, p = 0.51), or improved neurological outcomes (OR: 0.99, 95%-CI: 0.77 to 1.27, p = 0.92). Such findings were consistent despite additional sensitivity analyses. Our robust variance strata-level meta-regression revealed no significant associations between mean MAP and the proportion of non-survivors (B: 0.029, 95%-CI: -0.023 to 0.081, p = 0.162), and trial sequential analysis revealed no meaningful survival benefit for higher MAPs. A higher MAP target was not significantly associated with improved mortality and neurological outcomes in resuscitated OHCA patients.

Influence of blood-pressure and oxygen levels on the prognostic value of quantitative pupillometry for comatose cardiac arrest patients - a BOX-trial substudy

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Novo Nordisk Foundation Background Quantitative pupillometry has been implemented in resuscitation guidelines as part of multimodal prognostication in comatose out-of-hospital cardiac arrest (OHCA) patients. Post-resuscitation intensive care allows for different blood-pressure and oxygen targets, but evidence on the implication of these targets on prognostication is limited. Purpose To assess the impact of different blood-pressure and oxygen targets in resuscitated OHCA patients on the prognostic ability of the quantitatively assessed percentage reduction of pupillary size (qPLR, %) and the neurological pupil index (NPi, 0-5). Methods The BOX-trial is a multicenter, double-blind, randomized trial, comparing low (63 mm Hg) versus high (77 mm Hg) mean arterial blood-pressure targets and restrictive (9 to 10 kPa) versus liberal (13 to 14 kPa) partial pressure of arterial oxygen targets in comatose survivors of OHCA. In this predefined, prospective substudy, quantitative pupillometry measurements were obtained from consecutively enrolled patients at 0, 24, 48, 72, 96, and 120 hours after OHCA (t0-t120). The prognostic performance of qPLR and NPi for high and low blood-pressure groups, and liberal and restrictive oxygen target groups were illustrated through the area under the receiver operating characteristic (ROC) curves (AUC). The time point achieving the highest AUC was used for further analyses. AUCs were compared with DeLong’s test. Results The highest AUC for qPLR and NPi were achieved for measurements made 48 hours after OHCA. qPLR produced AUC at 0.79 [95%CI 0.73-0.85] and 0.81 [95%CI 0.75-0.86] for high and low blood-pressure groups, and 0.79 [95%CI 0.73-0.85] and 0.80 [95%CI 0.74-0.86] for liberal and restrictive oxygen target groups, respectively (Fig 1). For NPi AUC were 0.79 [95%CI 0.73-0.85] and 0.78 [95%CI 0.72-0.84] in high and low blood-pressure groups, and 0.77 [95%CI 0.71-0.83] and 0.80 [95%CI 0.75-0.86] in liberal and restrictive oxygen target groups, respectively (Fig 2). No significant difference between any groups, for either blood-pressure or oxygen targets, was found. Conclusion Prognostic value of quantitative pupillometry for predicting outcome in resuscitated OHCA patients was high and consistent across different blood-pressure and oxygen level targets.

Blood pressure targets in out-of-hospital cardiac arrest according to the time to return of spontaneous circulation

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Novo Nordisk Foundation and Lundbeck Foundation. Introduction Time to return of spontaneous circulation (ROSC) in patients resuscitated after out-of-hospital cardiac arrest (OHCA) is associated with the severity of brain damage and is an important predictor of mortality. We have recently shown no difference in mortality or neurological outcome with different mean arterial blood pressure targets (63 or 77 mmHg) in the initial phase of post-cardiac arrest management in resuscitated OHCA patients who remained comatose. Accordingly, in this post-hoc analysis, we explored whether time to ROSC modifies the effect of different blood pressure targets on mortality and neurological outcome. Method In a double-blind, randomized trial, a mean arterial blood-pressure target of 63 mm Hg vs. 77 mm Hg in comatose adults who had been resuscitated after an out-of-hospital cardiac arrest of presumed cardiac cause was investigated (BOX-trial, N Engl J Med 2022). Primary outcome for the present analysis was a composite of discharge from hospital severe brain damage or death from any cause within 365 days from randomization for the blood pressure target intervention was analyzed in a proportional hazard model with time to ROSC (tertiles: short, medium, and long) as a subgroup following testing for interaction. The analysis was conducted in the intention to treat the population. Results A total of 789 patients were included in the analysis. The time to ROSC in the three tertiles was: Short [0 min - 13 min], medium [14 min - 22 min], and long [23 min - 117 min]. The three groups were well balanced in the two blood pressure target groups (In the high group (77 mmHg): Short, n=124 (49%); medium, n= 133 (50%), long, n=136 (51%). Age (short: 62.7 (± 14), medium 62.4 (± 13), and 62.6 (± 13) and sex (short: 19.5% female, medium: 19.0% female, long: 19.4% female) were similar in the three groups. The first monitored rhythm did not differ in the three groups (shockable in 82.6%, 86.2%, and 85.3% of patients, respectively). Time to the first defibrillation did, however, differ between the three groups ((short 6.2 min (± 3.3), medium 9.0 min (± 3.8), and long 11.0 min (± 6.6), p&amp;lt;0.0001). The primary outcome occurred in 44 (17.3%), 92 (34.3%), and 153 (57.5%) in the short, medium, and long groups, respectively (p&amp;lt;0.0001). No interaction of time to ROSC and blood pressure target was found (p=0.62). Hazard ratios in the high (77 mmHg) group for the three tertiles were: short: HR 1.34 (95% CI: 0.75 – 2.40), medium: HR: 0.99 (95% CI: 0.68 – 1.45) and long: HR 0.97 (95% CI: 0.71 – 1.32). Conclusion Longer time to ROSC is associated with an adverse outcome, but it does not modify the effect of different blood pressure targets in comatose OHCA patients.

Prognostic importance of neuron-specific enolase measured in plasma or serum in patients resuscitated after out-of-hospital cardiac arrest

Abstract Funding Acknowledgements Type of funding sources: None. Background Patients who are successfully resuscitated from out-of-hospital cardiac arrest (OHCA) and admitted to the hospital in a comatose stage are in high risk for anoxic brain injury. Multimodal approach for neuroprognostication include measurement of neuron-specific enolase (NSE) as a biomarker for neurological injury. NSE has been intensively studied over the past years and has shown a valid predictive value for neurological outcome. However, there has been no clinical studies comparing NSE analyzed on plasma and serum samples. Purpose To compare NSE at 48 hours obtained from both in serum and plasma samples, and to investigate the performance of both these measuring techniques in predicting all-cause mortality at 365-days among patients resuscitated from out-of-hospital cardiac arrest. Methods This is a post-hoc sub study of the BOX trial in which resuscitated OHCA patients admitted to the hospital in comatose stage were included. NSE was measured 48 hours after admission, both in serum samples used for clinical analysis with no freeze-thaw cycle (NSE-Serum), and plasma samples from biobank (NSE-Plasma). The comparison of NSE-Serum and NSE-Plasma was performed by Spearmans correlation. The area under the receiver operating characteristics curve (AUROC) for predicting all-cause mortality at 365-days for both NSE-Serum and NSE-Plasma were determined. Results 369 patients had NSE values from both serum and plasma at 48 hours available for comparison. In these patients the NSE-Serum was median 21.2 µg/L (IQR 15.7 - 45.5), NSE-Plasma was median 19.3 µg (IQR 11.3 - 40.9), and mortality at 365-days was 32.5%. The correlation between NSE-Serum and NSE-Plasma was r=0.63 P&amp;lt;0.001. AUROC for NSE-Serum and NSE-Plasma were 0.94 and 0.83 respectively (FIGURE), and the differences in AUROC was -0.10 (95% confidence limits: -0.14 to -0.06), p&amp;lt;0.001. Conclusion In this sub study, we found moderate correlation between serum NSE values and plasma NSE values. Moreover, both measuring techniques had good predictive value against 1 year mortality, with clinically measured NSE from serum being slightly superior to NSE from plasma in predicting mortality.

British Cardiovascular Interventional Society Consensus Position Statement on Out-of-Hospital Cardiac Arrest 1: Pathway of Care.

Out-of-hospital cardiac arrest (OHCA) affects 80,000 patients per year in the UK; despite improvements in care, survival to discharge remains lower than 10%. NHS England and several societies recommend all resuscitated OHCA patients be directly transferred to a cardiac arrest centre (CAC). However, evidence is limited that all patients benefit from transfer to a CAC, and there are significant organisational, logistic and financial implications associated with such change in policies. Furthermore, there is significant variability in interventional cardiovascular practices for OHCA. Accordingly, the British Cardiovascular Interventional Society established a multidisciplinary group to address variability in practice and provide recommendations for the development of cardiac networks. In this position statement, we recommend: the formal establishment of dedicated CACs; a pathway of conveyance to CACs; and interventional practice to standardise our approach. Further research is needed to understand the role of CACs and which interventions benefit patients with OHCA to support wide-scale changes in networks of care across the UK.

Rationale and methods of the Antioxidant and NMDA receptor blocker Weans Anoxic brain damage of KorEa OHCA patients (AWAKE) trial

BackgroundIschemic brain injury is a major hurdle that limits the survival of resuscitated out-of-hospital cardiac arrest (OHCA).MethodsThe aim of this study is to assess the feasibility and potential for reduction of ischemic brain injury in adult OHCA patients treated with high- or low-dose Neu2000K, a selective blocker of N-methyl-d-aspartate (NMDA) type 2B receptor and also a free radical scavenger, or given placebo. This study is a phase II, multicenter, randomized, double-blinded, prospective, intention-to-treat, placebo-controlled, three-armed, safety and efficacy clinical trial. This trial is a sponsor-initiated trial supported by GNT Pharma. Successfully resuscitated OHCA patients aged 19 to 80 years would be included. The primary outcome is blood neuron-specific enolase (NSE) level on the 3rd day. The secondary outcomes are safety, efficacy defined by study drug administration within 4 h in > 90% of participants, daily NSE up to 5th day, blood S100beta, brain MRI apparent diffusion coefficient imaging, cerebral performance category (CPC), and Modified Rankin Scale (mRS) at 5th, 14th, and 90th days. Assuming NSE of 42 ± 80 and 80 ± 80 μg/L in the treatment (high- and low-dose Neu2000K) and control arms with 80% power, a type 1 error rate of 5%, and a 28% of withdrawal prior to the endpoint, the required sample size is 150 patients.DiscussionThe AWAKE trial explores a new multi-target neuroprotectant for the treatment of resuscitated OHCA patients.Trial registrationClinicalTrials.gov NCT03651557. Registered on August 29, 2018.

Association between inflammatory markers and survival in comatose, resuscitated out-of-hospital cardiac arrest patients

Objectives Prognostication after out-of-hospital cardiac arrest (OHCA) remains challenging. The inflammatory response after OHCA has been associated with increased mortality. This study investigates the associations and predictive value between inflammatory markers and outcome in resuscitated OHCA patients. Design The study is based on post hoc analyses of a double-blind controlled trial, where resuscitated OHCA patients were randomized to receive either exenatide or placebo. Blood was analyzed for levels of inflammatory markers the day following admission. Primary endpoint was time to death for up to 180 days. Secondary endpoints included 180-day mortality and poor neurological outcome after 180 days, defined as a cerebral performance category (CPC) of 3 to 5. Results Among 110 included patients we found significant associations between higher leucocyte quartile and increasing mortality in univariable analysis (OR 2.6 (95%CI 1.6–4.2), p < .001), as well as in multivariable analysis (OR 2.1 (95%CI 1.1–4.0), p = .02). A significant association was found between higher neutrophil quartile and increasing mortality in univariable analysis (OR 3.0 (95%CI 1.8–5.0), p < .001) as well as multivariable analysis (OR 2.4 (95%CI 1.2–4.6), p = .01). Leucocyte and neutrophil levels were predictive of poor outcome after 180 days with area under the receiver operating characteristics curves of 0.79 and 0.81, respectively. We found no associations between CRP and lymphocyte levels versus outcome. Conclusions Total leucocyte count and neutrophil levels measured the first day following OHCA were significantly associated with 180-day all-cause mortality and may potentially act as early predictors of outcome. Clinical trial registration www.clinicaltrials.gov, unique identifier: NCT02442791

The impact of lesion complexity on predicting mortality of coronary artery disease patients after out-of-hospital cardiac arrest.

Coronary artery disease (CAD) is the most frequent cause of out-of-hospital cardiac arrest (OHCA). Nevertheless, there have been limited studies focusing on the impact of lesion complexity on resuscitated CAD patients. The purpose of the present study was to investigate the association between coronary lesion complexity and the mortality of CAD patients after OHCA. From pooled database of two centers, which comprised 706 successfully resuscitated OHCA patients, 172 patients undergoing coronary angiography were retrospectively investigated. A total of 148 patients exhibited coronary stenosis on angiogram and were included in the final analysis. Baseline characteristics, pre-and post-hospital care, general status after resuscitation and angiographical findings were compared between the patients who deceased within 30days and those who survived and the predictors of 30-day mortality were determined. Ninety-four patients (63.5%) survived at 30days. Bystander cardiopulmonary resuscitation (CPR) (Odds ratio (OR) 0.36; 95% confidence interval (CI) 0.14-0.96; P = 0.041), revascularization of coronary stenosis (OR 0.15; 95% CI 0.19-0.86; P < 0.001), GRACE risk score (OR 1.04; 95% CI 1.02-1.05; P < 0.001) and SYNTAX score (OR 1.07; 95% CI 1.01-1.13; P = 0.025) were independent predictors of 30-day mortality. As multiple predictors such as bystander CPR, GRACE score and SYNTAX score were combined, the 30-day mortality gradually deteriorated. In addition to bystander CPR, GRACE score and revascularization, SYNTAX score independently predicted 30-day mortality of CAD patients after OHCA.

Computed-Tomography as First-line Diagnostic Procedure in Patients With Out-of-Hospital Cardiac Arrest.

BackgroundMortality after out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) remains high despite numerous efforts to improve outcome. For patients with suspected coronary cause of arrest, coronary angiography is crucial. However, there are other causes and potentially life-threatening injuries related to cardiopulmonary resuscitation (CPR), which can be detected by routine computed tomography (CT).Materials and MethodsAt Hannover Medical School, rapid coronary angiography and CT are performed in successfully resuscitated OHCA patients as a standard of care prior to admission to intensive care. We analyzed all patients who received CT following OHCA with ROSC over a three-year period.ResultsThere were 225 consecutive patients with return of spontaneous circulation following out-of-hospital cardiac arrest. Mean age was 64 ± 13 years, 75% were male. Of them, 174 (77%) had witnessed arrest, 145 (64%) received bystander CPR, and 123 (55%) had a primary shockable rhythm. Mean time to ROSC was 24 ± 20 min. There were no significant differences in CT pathologies in patients with or without ST-segment elevations in the initial ECG. Critical CT findings qualifying as a potential cause for cardiac arrest were intracranial bleeding (N = 6), aortic dissection (N = 5), pulmonary embolism (N = 17), pericardial tamponade (N = 3), and tension pneumothorax (N = 11). Other pathologies were regarded as consequences of CPR and relevant for further treatment: aspiration (N = 62), rib fractures (N = 161), sternal fractures (N = 50), spinal fractures (N = 11), hepatic bleeding (N = 12), and intra-abdominal air (N = 3).ConclusionEarly CT fallowing OHCA uncovers a high number of causes and consequences of OHCA and CPR. Those are relevant for post-arrest care and are frequently life-threatening, suggesting that CT can contribute to improving prognosis following OHCA.

Feasibility of early waking cardiac arrest patients whilst receiving therapeutic hypothermia: The therapeutic hypothermia and early waking (THAW) trial

AimTo determine the safety and feasibility of an early (12 h) waking and extubation protocol for out-of-hospital cardiac arrest (OHCA) patients receiving targeted temperature management (TTM). MethodsThis was a single-centre, prospective, non-randomised, observational, safety and feasibility pilot study which included successfully resuscitated OHCA patients, of presumed cardiac cause. Inclusion criteria were: OHCA patients aged over 18 years with a return of spontaneous circulation, who were going to receive TTM33 (TTM at 33 °C for 24 h and prevention of hyperthermia for 72 h) as part of their post cardiac arrest care. Clinical stability was measured against physiological and neurological parameters as well as clinical assessment. Results50 consecutive patients were included (median age 65.5 years, 82% male) in the study. Four (8%) patients died within the first twelve hours and were excluded from the final cohort (n = 46). Twenty-three patients (46%) were considered clinically stable and suitable for early waking based on the intention to treat analysis; 12 patients were extubated early based on a variety of clinical factors (21.4 ± 8.6 h) whilst continuing to receive TTM33 with a mean core temperature of 34.2 °C when extubated. Of these, five patients were discharged from the intensive care unit (ICU) <48 h after admission with a mean ICU length of stay 1.8 ± 0.4 days. Twenty-eight patients (56%) were discharged from the ICU with a modified Rankin Score of 0–2. The overall intra-hospital mortality was 50% (n = 25). ConclusionsIt is safe and feasible to wake selected comatose OHCA patients at 12 h, allowing for earlier positive neuro-prognostication and reduced ICU stay.

Early Coronary Angiography Is Associated with Improved 30-Day Outcomes among Patients with Out-of-Hospital Cardiac Arrest.

We evaluated the association between early coronary angiography (CAG) and outcomes in resuscitated out-of-hospital cardiac arrest (OHCA) patients, by linking data from the Singapore Pan-Asian Resuscitation Outcomes Study, with a national registry of cardiac procedures. The 30-day survival and neurological outcome were compared between patients undergoing early CAG (within 1-calender day), versus patients not undergoing early CAG. Inverse probability weighted estimates (IPWE) adjusted for non-randomized CAG. Of 976 resuscitated OHCA patients of cardiac etiology between 2011–2015 (mean(SD) age 64(13) years, 73.7% males), 337 (34.5%) underwent early CAG, of whom, 230 (68.2%) underwent PCI. Those who underwent early CAG were significantly younger (60(12) vs. 66(14) years old), healthier (42% vs. 59% with heart disease; 29% vs. 44% with diabetes), more likely males (86% vs. 67%), and presented with shockable rhythms (69% vs. 36%), compared with those who did not. Early CAG with PCI was associated with better survival and neurological outcome (adjusted odds ratio 1.91 and 1.82 respectively), findings robust to IPWE adjustment. The rates of bleeding and stroke were similar. CAG with PCI within 24 h was associated with improved clinical outcomes after OHCA, without increasing complications. Further studies are required to identify the characteristics of patients who would benefit most from this invasive strategy.

External validation of simplified out-of-hospital cardiac arrest and cardiac arrest hospital prognosis scores in a Japanese population: a multicentre retrospective cohort study

BackgroundThe novel simplified out-of-hospital cardiac arrest (sOHCA) and simplified cardiac arrest hospital prognosis (sCAHP) scores used for prognostication of hospitalised patients have not been externally validated. Therefore, this study aimed...

Prognostic value of repeated thromboelastography measurement for favorable neurologic outcome during targeted temperature management in out-of-hospital cardiac arrest survivors

BackgroundCardiac arrest can activate blood coagulation, which clinically manifests as obstruction of the microcirculation and multiple organ dysfunction. Thromboelastography (TEG) provides a rapid and comprehensive assessment of hemostatic processes, but there are limited data on the use of sequential TEG values during targeted temperature management (TTM) in out-of-hospital cardiac arrest (OHCA) survivors. The aim of this study was to investigate the prognostic value of coagulopathy assessed by repeated TEG to predict neurologically intact survival. MethodsA prospective cohort of consecutive non-trauma OHCA patients who were successfully resuscitated and treated with TTM. Patients with a target temperature of 36 ℃, no TEG data, and who declined appropriate treatment were excluded. TEG was measured at three time points of TTM (initial phase, target phase, and rewarming phase). The primary outcome was 28 day favorable neurologic function, defined as a Cerebral Performance Category of 1 or 2. ResultsA total of 125 patients (mean age, 61 years; 63.2% male) were analyzed. A favorable neurologic outcome at 28 days was seen in 40 patients (32.0%). TEG values of R and LY30 in the initial phase were significantly lower in the favorable neurologic outcome group than in the unfavorable group (5.8 vs. 8.1 and 0.1 vs. 0.7, respectively; p < 0.01). TEG values of R < 5 or LY30 < 7.5 in the initial phase were more frequently seen in the favorable outcomes group than in the unfavorable group (37.5% vs. 12.9%, p = 0.002 and 95.0% vs. 72.9%, p = 0.004, respectively). However, no significant differences were seen between the two groups in other TEG values (R, K, alpha, and MA) in the target and rewarming phases (p > 0.05 for all). Univariate analysis showed higher D-dimer levels, prothrombin time, and activated partial thromboplastin time in the unfavorable outcome group. In the multivariable analysis, TEG values of combination of R < 5 and LY30 < 7.5 in the initial phase were the only coagulation profiles seen to be independently associated with favorable neurologic outcome (OR, 4.508, 95% CI, 1.254–16.210). ConclusionTEG results are available within minutes, and shorted R values or the absence of prolonged LY30 values in the initial phase are an early predictor of neurologically intact survival in successfully resuscitated OHCA patients.

Optimal ventilator settings after return of spontaneous circulation.

To describe current practice, recent advances in knowledge and future directions for research related to the post return of spontaneous circulation (ROSC) ventilatory management of cardiac arrest patients. Out-of-hospital cardiac arrest (OHCA) is a major public health problem with an estimated incidence of approximately one per 1000 persons per year. A priority of intensive care management of resuscitated OHCA patients is to reduce secondary reperfusion injury. Most OHCA patients are mechanically ventilated. Most of these require mechanical ventilation as they are unconscious and for oxygen (O2) management and carbon dioxide (CO2) control. Low levels of O2 and CO2 following OHCA is associated with poor outcome. Recently, very high fraction of inspired oxygen has been associated with poor outcomes and elevated CO2 levels have been associated with improved neurological outcomes. Moreover, it is increasingly being appreciated that the ventilator may be a tool to adjust physiological parameters to enhance the chances of favourable outcomes. Finally, ventilator settings themselves and the adoption of protective ventilation strategies may affect lung-brain interactions and are being explored as other avenues for therapeutic benefit. Current evidence supports the targeting of normal arterial O2 and CO2 tensions during mechanical ventilation following ROSC after cardiac arrest. Use of protective lung strategies during mechanical ventilation in resuscitated cardiac arrest patients is advocated. The potential therapeutic benefits of conservative O2 therapy, mild hypercapnia and the optimal ventilator settings to use post-ROSC period will be confirmed or refuted in clinical trials.