Cardiac Catheterization Laboratory Management of the Comatose Adult Patient With an Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association.

Out-of-hospital cardiac arrest is a leading cause of death, accounting for ≈50% of all cardiovascular deaths. The prognosis of such individuals is poor, with <10% surviving to hospital discharge. Survival with a favorable neurologic outcome is highest among individuals who present with a witnessed shockable rhythm, received bystander cardiopulmonary resuscitation, achieve return of spontaneous circulation within 15 minutes of arrest, and have evidence of ST-segment elevation on initial ECG after return of spontaneous circulation. The cardiac catheterization laboratory plays an important role in the coordinated Chain of Survival for patients with out-of-hospital cardiac arrest. The catheterization laboratory can be used to provide diagnostic, therapeutic, and resuscitative support after sudden cardiac arrest from many different cardiac causes, but it has a unique importance in the treatment of cardiac arrest resulting from underlying coronary artery disease. Over the past few years, numerous trials have clarified the role of the cardiac catheterization laboratory in the management of resuscitated patients or those with ongoing cardiac arrest. This scientific statement provides an update on the contemporary approach to managing resuscitated patients or those with ongoing cardiac arrest.

Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society.

The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.

Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society.

The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.

Early coronary angiography in patients after out-of-hospital cardiac arrest without ST-segment elevation: Meta-analysis of randomized controlled trials.

OBJECTIVES: To compare early coronary angiography to a delayed or selective approach in out-of-hospital cardiac arrest (OHCA) without ST-segment elevation of possible cardiac cause by means of meta-analysis of available randomized controlled trials (RCTs). METHODS: We searched MEDLINE and the Cochrane Central Register of Controlled Trials for RCTs comparing early with delayed or selective coronary angiography in OHCA patients of possible cardiac origin without ST-segment elevation. The primary endpoint was all-cause short-term mortality (PROSPERO CRD42021271484). RESULTS: The search strategy identified three RCTs enrolling a total of 1167 patients. An early invasive approach was not associated with improved short-term mortality (odds ratio 1.19, 95% confidence interval 0.94-1.52; p = 0.15). Further, no significant differences were shown with respect to the risk of severe neurological deficit, the composite of all-cause mortality or severe neurological deficit, need for renal replacement therapy due to acute renal failure, and significant bleeding at short-term follow-up. CONCLUSION: Early coronary angiography in OHCA without ST-segment elevation is not superior compared to a delayed/selective approach.

A randomized controlled trial of simulation training in teaching coronary angiographic views.

INTRODUCTION: Simulation technology has an established role in teaching technical skills to cardiology fellows, but its impact on teaching trainees to interpret coronary angiographic (CA) images has not been systematically studied. The aim of this randomized controlled study was to test whether structured simulation training, in addition to traditional methods would improve CA image interpretation skills in a heterogeneous group of medical trainees. METHODS: We prospectively randomized a convenience sample of 105 subjects comprising of medical students (N = 20), residents (N = 68) and fellows (N = 17) from the University of Arizona. Subjects were randomized in a stratified fashion into a simulation training group which received simulation training in addition to didactic teaching (n = 53) and a control training group which received didactic teaching alone (n = 52). The change in pre and post-test score (delta score) was analyzed by a two-way ANOVA for education status and training arm. RESULTS: Subjects improved in their post-test scores with a mean change of 4.6 ± 4.0 points. Subjects in the simulation training arm had a higher delta score compared to control (5.4 ± 4.2 versus 3.8 ± 3.7, p = 0.04), with greatest impact for residents (6.6 ± 4.0 versus 3.5 ± 3.4) with a p = 0.02 for interaction of training arm and education status. CONCLUSIONS: Simulation training complements traditional methods to improve CA interpretation skill, with greatest impact on residents. This highlights the importance of incorporating high-fidelity simulation training early in cardiovascular fellowship curricula.

Randomized Pilot Clinical Trial of Early Coronary Angiography Versus No Early Coronary Angiography After Cardiac Arrest Without ST-Segment Elevation: The PEARL Study.

BACKGROUND: The benefit of emergency coronary angiography after resuscitation from out-of-hospital cardiac arrest is uncertain for patients without ST-segment elevation. The aim of this randomized trial was to evaluate the efficacy and safety of early coronary angiography and to determine the prevalence of acute coronary occlusion in resuscitated patients with out-of-hospital cardiac arrest without ST-segment elevation. METHODS: Adult (>18 years) comatose survivors without ST-segment elevation after resuscitation from out-of-hospital cardiac arrest were prospectively randomized in a 1:1 fashion under exception to informed consent regulations to early coronary angiography versus no early coronary angiography in this multicenter study. Early angiography was defined as ≤120 minutes from arrival at the percutaneous coronary intervention-capable facility. The primary end point was a composite of efficacy and safety measures, including efficacy measures of survival to discharge, favorable neurologic status at discharge (Cerebral Performance Category score ≤2), echocardiographic measures of left ventricular ejection fraction >50%, and a normal regional wall motion score of 16 within 24 hours of admission. Adverse events included rearrest, pulmonary edema on chest x-ray, acute renal dysfunction, bleeding requiring transfusion or intervention, hypotension (systolic arterial pressure ≤90 mm Hg), and pneumonia. Secondary end points included the incidence of culprit vessels with acute occlusion. RESULTS: The study was terminated prematurely before enrolling the target number of patients. A total of 99 patients were enrolled from 2015 to 2018, including 75 with initially shockable rhythms. Forty-nine patients were randomized to early coronary angiography. The primary end point of efficacy and safety was not different between the 2 groups (55.1% versus 46.0%; P=0.64). Early coronary angiography was not associated with any significant increase in survival (55.1% versus 48.0%; P=0.55) or adverse events (26.5% versus 26.0%; P=1.00). Early coronary angiography revealed a culprit vessel in 47%, with a total of 14% of patients undergoing early coronary angiography having an acutely occluded culprit coronary artery. CONCLUSIONS: This underpowered study, when considered together with previous clinical trials, does not support early coronary angiography for comatose survivors of cardiac arrest without ST elevation. Whether early detection of occluded potential culprit arteries leads to interventions that improve outcomes requires additional study. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02387398.

The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association.

Coronary artery disease is prevalent in different causes of out-of-hospital cardiac arrest (OHCA), especially in individuals presenting with shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). The purpose of this report is to review the known prevalence and potential importance of coronary artery disease in patients with OHCA and to describe the emerging paradigm of treatment with advanced perfusion/reperfusion techniques and their potential benefits on the basis of available evidence. Although randomized clinical trials are planned or ongoing, current scientific evidence rests principally on observational case series with their potential confounding selection bias. Among patients resuscitated from VF/pVT OHCA with ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 70% to 85%. More than 90% of these patients have had successful percutaneous coronary intervention. Conversely, among patients resuscitated from VF/pVT OHCA without ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 25% to 50%. For these patients, early access to the cardiac catheterization laboratory is associated with a 10% to 15% absolute higher functionally favorable survival rate compared with more conservative approaches of late or no access to the cardiac catheterization laboratory. In patients with VF/pVT OHCA refractory to standard treatment, a new treatment paradigm is also emerging that uses venoarterial extracorporeal membrane oxygenation to facilitate return of normal perfusion and to support further resuscitation efforts, including coronary angiography and percutaneous coronary intervention. The burden of coronary artery disease is high in this patient population, presumably causative in most patients. The strategy of venoarterial extracorporeal membrane oxygenation, coronary angiography, and percutaneous coronary intervention has resulted in functionally favorable survival rates ranging from 9% to 45% in observational studies in this patient population. Patients with VF/pVT should be considered at the highest severity in the continuum of acute coronary syndromes. These patients have a significant burden of coronary artery disease and acute coronary thrombotic events. Evidence from randomized trials will further define optimal clinical practice.

Derivation and Validation of the CREST Model for Very Early Prediction of Circulatory Etiology Death in Patients Without ST-Segment-Elevation Myocardial Infarction After Cardiac Arrest.

BACKGROUND: No practical tool quantitates the risk of circulatory-etiology death (CED) immediately after successful cardiopulmonary resuscitation in patients without ST-segment-elevation myocardial infarction. We developed and validated a prediction model to rapidly determine that risk and facilitate triage to individualized treatment pathways. METHODS: With the use of INTCAR (International Cardiac Arrest Registry), an 87-question data set representing 44 centers in the United States and Europe, patients were classified as having had CED or a combined end point of neurological-etiology death or survival. Demographics and clinical factors were modeled in a derivation cohort, and backward stepwise logistic regression was used to identify factors independently associated with CED. We demonstrated model performance using area under the curve and the Hosmer-Lemeshow test in the derivation and validation cohorts, and assigned a simplified point-scoring system. RESULTS: Among 638 patients in the derivation cohort, 121 (18.9%) had CED. The final model included preexisting coronary artery disease (odds ratio [OR], 2.86; confidence interval [CI], 1.83-4.49; P≤0.001), nonshockable rhythm (OR, 1.75; CI, 1.10-2.77; P=0.017), initial ejection fraction<30% (OR, 2.11; CI, 1.32-3.37; P=0.002), shock at presentation (OR, 2.27; CI, 1.42-3.62; P<0.001), and ischemic time >25 minutes (OR, 1.42; CI, 0.90-2.23; P=0.13). The derivation model area under the curve was 0.73, and Hosmer-Lemeshow test P=0.47. Outcomes were similar in the 318-patient validation cohort (area under the curve 0.68, Hosmer-Lemeshow test P=0.41). When assigned a point for each associated factor in the derivation model, the average predicted versus observed probability of CED with a CREST score (coronary artery disease, initial heart rhythm, low ejection fraction, shock at the time of admission, and ischemic time >25 minutes) of 0 to 5 was: 7.1% versus 10.2%, 9.5% versus 11%, 22.5% versus 19.6%, 32.4% versus 29.6%, 38.5% versus 30%, and 55.7% versus 50%. CONCLUSIONS: The CREST model stratified patients immediately after resuscitation according to risk of a circulatory-etiology death. The tool may allow for estimation of circulatory risk and improve the triage of survivors of cardiac arrest without ST-segment-elevation myocardial infarction at the point of care.

Mechanical chest compressions for cardiac arrest in the cath-lab: when is it enough and who should go to extracorporeal cardio pulmonary resuscitation?

BACKGROUND: Treating patients in cardiac arrest (CA) with mechanical chest compressions (MCC) during percutaneous coronary intervention (PCI) is now routine in many coronary catheterization laboratories (cath-lab) and more aggressive treatment modalities, including extracorporeal CPR are becoming more common. The cath-lab setting enables monitoring of vital physiological parameters and other clinical factors that can potentially guide the resuscitation effort. This retrospective analysis attempts to identify such factors associated with ROSC and survival. METHODS: In thirty-five patients of which background data, drugs used during the resuscitation and the intervention, PCI result, post ROSC-treatment and physiologic data collected during CPR were compared for prediction of ROSC and survival. RESULTS: Eighteen (51%) patients obtained ROSC and 9 (26%) patients survived with good neurological outcome. There was no difference between groups in regards of background data. Patients arriving in the cath-lab with ongoing resuscitation efforts had lower ROSC rate (22% vs 53%; p = 0.086) and no survivors (0% vs 50%, p = 0.001). CPR time also differentiated resuscitation outcomes (ROSC: 18 min vs No ROSC: 50 min; p = 0.007 and Survivors: 10 min vs No Survivors: 45 min; p = 0.001). Higher arterial diastolic blood pressure was associated with ROSC: 30 mmHg vs No ROSC: 19 mmHg; p = 0.012). CONCLUSION: Aortic diastolic pressure during CPR is the most predictive physiological parameter of resuscitation success. Ongoing CPR upon arrival at the cath-lab and continued MCC beyond 10-20 min in the cath-lab were both predictive of poor outcomes. These factors can potentially guide decisions regarding escalation and termination of resuscitation efforts.

Sudden cardiac death.

Introduction: Sudden cardiac arrest continues to be the leading cause of death in the industrialized world. Sources of data: Original papers, reviews and guidelines. Areas of agreement: Community programs for lay bystander cardiopulmonary resuscitation (CPR) and automatic external defibrillation improve outcomes. Post-arrest care, including targeted temperature management (TTM) combined with early coronary angiography and percutaneous coronary intervention, is helpful for those suffering cardiac arrest during an ST-segment elevation myocardial infarction. Areas of controversy: (1) The optimal approach to encourage lay bystanders to assist with resuscitation efforts. (2) Whether TTM combined with early coronary angiography is cost effective for those without ST elevation on their post-arrest ECG is unknown. Growing points: Increasing data show that chest compression-only CPR is preferred by lay rescuers and improves local survival rates. Areas timely for developing research: Randomized clinical trials are underway to examine the utility of early coronary angiography in the treatment of post-arrest patients without ST-segment elevation.

Mechanical Cardiopulmonary Resuscitation In and On the Way to the Cardiac Catheterization Laboratory.

Cardiac arrest, though not common during coronary angiography, is increasingly occurring in the catheterization laboratory because of the expanding complexity of percutaneous interventions (PCI) and the patient population being treated. Manual chest compression in the cath lab is not easily performed, often interrupted, and can result in the provider experiencing excessive radiation exposure. Mechanical cardiopulmonary resuscitation (CPR) provides unique advantages over manual performance of chest compression for treating cardiac arrest in the cardiac cath lab. Such advantages include the potential for uninterrupted chest compressions, less radiation exposure, better quality chest compressions, and less crowded conditions around the catheterization table, allowing more attention to ongoing PCI efforts during CPR. Out-of-hospital cardiac arrest patients not responding to standard ACLS therapy can be transported to the hospital while mechanical CPR is being performed to provide safe and continuous chest compressions en route. Once at the hospital, advanced circulatory support can be instituted during ongoing mechanical CPR. This article summarizes the epidemiology, pathophysiology and nature of cardiac arrest in the cardiac cath lab and discusses the mechanics of CPR and defibrillation in that setting. It also reviews the various types of mechanical CPR and their potential roles in and on the way to the laboratory. (Circ J 2016; 80: 1292-1299).

Neurologic outcomes and postresuscitation care of patients with myoclonus following cardiac arrest.

OBJECTIVES: To evaluate the outcomes of cardiac arrest survivors with myoclonus receiving modern postresuscitation care. DESIGN: Retrospective review of registry data. SETTING: Cardiac arrest receiving centers in Europe and the United States from 2002 to 2012. PATIENTS: Two thousand five hundred thirty-two cardiac arrest survivors 18 years or older enrolled in the International Cardiac Arrest Registry. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eighty-eight percent of patients underwent therapeutic hypothermia and 471 (18%) exhibited myoclonus. Patients with myoclonus had longer time to professional cardiopulmonary resuscitation (8.6 vs 7.0 min; p < 0.001) and total ischemic time (25.6 vs 22.3 min; p < 0.001) and less often presented with ventricular tachycardia/ventricular fibrillation, a witnessed arrest, or had bystander cardiopulmonary resuscitation. Electroencephalography demonstrated myoclonus with epileptiform activity in 209 of 374 (55%), including status epilepticus in 102 of 374 (27%). Good outcome (Cerebral Performance Category 1-2) at hospital discharge was noted in 9% of patients with myoclonus, less frequently in myoclonus with epileptiform activity (2% vs 15%; p < 0.001). Patients with myoclonus with good outcome were younger (53.7 vs 62.7 yr; p < 0.001), had more ventricular tachycardia/ventricular fibrillation (81% vs 46%; p < 0.001), shorter ischemic time (18.9 vs 26.4 min; p = 0.003), more witnessed arrests (91% vs 77%; p = 0.02), and fewer "do-not-resuscitate" orders (7% vs 78%; p < 0.001). Life support was withdrawn in 330 of 427 patients (78%) with myoclonus and poor outcome, due to neurological futility in 293 of 330 (89%), at 5 days (3-8 d) after resuscitation. With myoclonus and good outcome, median ICU length of stay was 8 days (5-11 d) and hospital length of stay was 14.5 days (9-22 d). CONCLUSIONS: Nine percent of cardiac arrest survivors with myoclonus after cardiac arrest had good functional outcomes, usually in patients without associated epileptiform activity and after prolonged hospitalization. Deaths occurred early and primarily after withdrawal of life support. It is uncertain whether prolonged care would yield a higher percentage of good outcomes, but myoclonus of itself should not be considered a sign of futility.

Usefulness of cardiac arrest centers - extending lifesaving post-resuscitation therapies: the Arizona experience - .

The post-cardiac arrest syndrome is a complex, multisystems response to the global ischemia and reperfusion injury that occurs with the onset of cardiac arrest, its treatment (cardiopulmonary resuscitation) and the re-establishment of spontaneous circulation. Regionalization of post-cardiac arrest care, utilizing specified cardiac arrest centers (CACs), has been proposed as the best solution to providing optimal care for those successfully resuscitated after out-of-hospital cardiac arrest. A multidisciplinary team of intensive care specialists, including critical care/pulmonologists, cardiologists (general, interventional, and electrophysiology), neurologists, and physical medicine/rehabilitation experts, is crucial for such centers. Particular attention to the timely initiation of targeted temperature management and early coronary angiography/percutaneous coronary intervention is best provided by such CACs. A State-wide program of CACs was started in Arizona in 2007. This is a voluntary program, whereby medical centers agree to provide all resuscitated cardiac arrest patients brought to their facility with state-of-the-art post-resuscitation care, including targeted temperature management for comatose patients and strong consideration for emergent coronary angiography for all patients with a likely cardiac etiology for their cardiac arrest. Survival improved by more than 50% at facilities that became CACs with a commitment to provide aggressive post-resuscitation care to all such patients. Providing aggressive, post-resuscitation care is the next real opportunity to increase long-term survival for cardiac arrest patients.

Doubling survival and improving clinical outcomes using a left ventricular assist device instead of chest compressions for resuscitation after prolonged cardiac arrest: a large animal study.

INTRODUCTION: Despite improvements in pre-hospital and post-arrest critical care, sudden cardiac arrest (CA) remains one of the leading causes of death. Improving circulation during cardiopulmonary resuscitation (CPR) may improve survival rates and long-term clinical outcomes after CA. METHODS: In a porcine model, we compared standard CPR (sCPR; n =10) with CPR using an intravascular cardiac assist device without additional chest compressions (iCPR; n =10) following 10 minutes of electrically induced ventricular fibrillation (VF). In a separate crossover experiment, 10 additional pigs were subjected to 10 minutes of VF and 6 minutes of sCPR; the iCPR device was then implanted if a return of spontaneous circulation (ROSC) was not achieved using sCPR. Animals were evaluated in respect to intra- and post-arrest hemodynamics, survival, functional outcome and cerebral and myocardial lesions following CPR. We hypothesized that iCPR would result in more frequent ROSC and better functional recovery than sCPR. RESULTS: iCPR produced a mean flow of 1.36 ± 0.02 L/min, leading to significantly higher coronary perfusion pressure (CPP) values during the early period of CPR (22 ± 10 mmHg vs. 9 ± 5 mmHg, P ≤0.01, 1 minute after start of CPR; 20 ± 11 mmHg vs. 10 ± 7 mmHg, P =0.03, 2 minutes after start of CPR), resulting in high ROSC rates (100% in iCPR vs. 50% in sCPR animals; P =0.03). iCPR animals showed significantly lower serum S100 levels at 10 and 30 minutes following ROSC (3.5 ± 0.6 ng/ml vs. 7.4 ± 3.0 ng/ml 30 minutes after ROSC; P ≤0.01), as well as superior clinical outcomes based on overall performance categories (2.9 ± 1.0 vs. 4.6 ± 0.8 on day 1; P ≤0.01). In crossover experiments, 80% of animals required treatment with iCPR after failed sCPR. Notably, ROSC was still achieved in six of the remaining eight animals (75%) after a total of 22.8 ± 5.1 minutes of ischemia. CONCLUSIONS: In a model of prolonged cardiac arrest, the use of iCPR instead of sCPR improved CPP and doubled ROSC rates, translating into improved clinical outcomes.

Association of gender to outcome after out-of-hospital cardiac arrest--a report from the International Cardiac Arrest Registry.

INTRODUCTION: Previous studies have suggested an effect of gender on outcome after out-of-hospital cardiac arrest (OHCA), but the results are conflicting. We aimed to investigate the association of gender to outcome, coronary angiography (CAG) and adverse events in OHCA survivors treated with mild induced hypothermia (MIH). METHODS: We performed a retrospective analysis of prospectively collected data from the International Cardiac Arrest Registry. Adult patients with a non-traumatic OHCA and treated with MIH were included. Good neurological outcome was defined as a cerebral performance category (CPC) of 1 or 2. RESULTS: A total of 1,667 patients, 472 women (28%) and 1,195 men (72%), met the inclusion criteria. Men were more likely to receive bystander cardiopulmonary resuscitation, have an initial shockable rhythm and to have a presumed cardiac cause of arrest. At hospital discharge, men had a higher survival rate (52% vs. 38%, P < 0.001) and more often a good neurological outcome (43% vs. 32%, P < 0.001) in the univariate analysis. When adjusting for baseline characteristics, male gender was associated with improved survival (OR 1.34, 95% CI 1.01 to 1.78) but no longer with neurological outcome (OR 1.24, 95% CI 0.92 to 1.67). Adverse events were common; women more often had hypokalemia, hypomagnesemia and bleeding requiring transfusion, while men had more pneumonia. In a subgroup analysis of patients with a presumed cardiac cause of arrest (n = 1,361), men more often had CAG performed on admission (58% vs. 50%, P = 0.02) but this discrepancy disappeared in an adjusted analysis. CONCLUSIONS: Gender differences exist regarding cause of arrest, adverse events and outcome. Male gender was independently associated with survival but not with neurological outcome.

Geriatric experience following cardiac arrest at six interventional cardiology centers in the United States 2006-2011: interplay of age, do-not-resuscitate order, and outcomes.

OBJECTIVES: It is not known if aggressive postresuscitation care, including therapeutic hypothermia and percutaneous coronary intervention, benefits cardiac arrest survivors more than 75 years old. We compared treatments and outcomes of patients at six regional percutaneous coronary intervention centers in the United States to determine if aggressive care of elderly patients was warranted. DESIGN: Retrospective evaluation of registry data. SETTING: Six interventional cardiology centers in the United States. PATIENTS: Six hundred and twenty-five unresponsive cardiac arrest survivors aged 18-75 were compared with 129 similar patients aged more than 75. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Cardiac arrest survivors aged more than 75 had more comorbidities (3.0 ± 1.6 vs 2.0 ± 1.6, p < 0.001), but were matched to younger patients in initial heart rhythm, witnessed arrests, bystander cardiopulmonary resuscitation, and total ischemic time. Patients aged more than 75 frequently underwent therapeutic hypothermia (97.7%), urgent coronary angiography (44.2%), and urgent percutaneous coronary intervention (24%). They had more sustained hyperglycemia (70.5% vs 59%, p = 0.015), less postcooling fever (25.2% vs 35.2%, p = 0.03), were more likely to have do-not-resuscitate orders (65.9% vs 48.2%, p < 0.001), and undergo withdrawal of life support (61.2% vs 47.5%, p = 0.005). Good functional outcome at 6 months (Cerebral Performance Category 1-2) was seen in 27.9% elderly versus 40.4% younger patients overall (p = 0.01) and in 44% versus 55% (p = 0.13) of patients with an initial shockable rhythm. Of 35 survivors more than 75 years old, 33 (94.8%) were classified as Cerebral Performance Category 1 or 2 at (mean) 6.5-month follow-up. In multivariable logistic regression modeling, age more than 75 was significantly associated with outcome only when the presence of a do-not-resuscitate order was excluded from the model. CONCLUSIONS: Elderly patients were more likely to have do-not-resuscitate orders and to undergo withdrawal of life support. Age was independently associated with outcome only when correction for do-not-resuscitate status was excluded, and functional outcomes of elderly survivors were similar to younger patients. Exclusion of patients more than 75 years old from aggressive care is not warranted on the basis of age alone.

Safety, feasibility, and outcomes of induced hypothermia therapy following in-hospital cardiac arrest-evaluation of a large prospective registry*.

OBJECTIVES: Despite a lack of randomized trials, practice guidelines recommend that mild induced hypothermia be considered for comatose survivors of in-hospital cardiac arrest. This study describes the safety, feasibility, and outcomes of mild induced hypothermia treatment following in-hospital cardiac arrest. DESIGN: Prospective, observational, registry-based study. SETTING: Forty-six critical care facilities in eight countries in Europe and the United States reporting in the Hypothermia Network Registry and the International Cardiac Arrest Registry. PATIENTS: A total of 663 patients with in-hospital cardiac arrest and treated with mild induced hypothermia were included between January 2004 and February 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A cerebral performance category of 1 or 2 was considered a good outcome. At hospital discharge 41% of patients had a good outcome. At median 6-month follow-up, 34% had a good outcome. Among in-hospital deaths, 52% were of cardiac causes and 44% of cerebral cause. A higher initial body temperature was associated with reduced odds of a good outcome (odds ratio, 0.79; 95% CI, 0.68-0.92). Adverse events were common; bleeding requiring transfusion (odds ratio, 0.56; 95% CI, 0.31-1.00) and sepsis (odds ratio, 0.52; 95% CI, 0.30-0.91) were associated with reduced odds for a good outcome. CONCLUSIONS: In this registry study of an in-hospital cardiac arrest population treated with mild induced hypothermia, we found a 41% good outcome at hospital discharge and 34% at follow-up. Infectious complications occurred in 43% of cases, and 11% of patients required a transfusion for bleeding. The majority of deaths were of cardiac origin.

Statewide regionalization of postarrest care for out-of-hospital cardiac arrest: association with survival and neurologic outcome.

STUDY OBJECTIVE: For out-of-hospital cardiac arrest, authoritative, evidence-based recommendations have been made for regionalization of postarrest care. However, system-wide implementation of these guidelines has not been evaluated. Our hypothesis is that statewide regionalization of postarrest interventions, combined with emergency medical services (EMS) triage bypass, is associated with improved survival and neurologic outcome. METHODS: This was a prospective before-after observational study comparing patients admitted to cardiac receiving centers before implementation of the interventions ("before") versus those admitted after ("after"). In December 2007, the Arizona Department of Health Services began officially recognizing cardiac receiving centers according to commitment to provide specified postarrest care. Subsequently, the State EMS Council approved protocols allowing preferential EMS transport to these centers. Participants were adults (≥ 18 years) experiencing out-of-hospital cardiac arrest of presumed cardiac cause who were transported to a cardiac receiving center. Interventions included (1) implementation of postarrest care at cardiac receiving centers focusing on provision of therapeutic hypothermia and coronary angiography or percutaneous coronary interventions (catheterization/PCI); and (2) implementation of EMS bypass triage protocols. Main outcomes included discharged alive from the hospital and cerebral performance category score at discharge. RESULTS: During the study (December 1, 2007, to December 31, 2010), 31 hospitals were recognized as cardiac receiving centers statewide. Four hundred forty patients were transported to cardiac receiving centers before and 1,737 after. Provision of therapeutic hypothermia among patients with return of spontaneous circulation increased from 0% (before: 0/145; 95% confidence interval [CI] 0% to 2.5%) to 44.0% (after: 300/682; 95% CI 40.2, 47.8). The post return of spontaneous circulation catheterization PCI rate increased from 11.7% (17/145; 95% CI 7.0, 18.1) before to 30.7% (210/684; 95% CI 27.3, 34.3) after. All-rhythm survival increased from 8.9% (39/440) to 14.4% (250/1,734; adjusted odds ratio [aOR] = 2.22; 95% CI 1.47 to 3.34). Survival with favorable neurologic outcome (cerebral performance category score = 1 or 2) increased from 5.9% (26/439) to 8.9% (153/1,727; aOR = 2.26 [95% CI 1.37, 3.73]). For witnessed shockable rhythms, survival increased from 21.4% (21/98) to 39.2% (115/293; aOR = 2.96 [95% CI 1.63, 5.38]) and cerebral performance category score = 1 or 2 increased from 19.4% (19/98) to 29.8% (87/292; aOR = 2.12 [95% CI 1.14, 3.93]). CONCLUSION: Implementation of a statewide system of cardiac receiving centers and EMS bypass was independently associated with increased overall survival and favorable neurologic outcome. In addition, these outcomes improved among patients with witnessed shockable rhythms.

Early versus delayed coronary angiography in patients with out-of-hospital cardiac arrest and no ST-segment elevation: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Recent randomized controlled trials did not show benefit of early/immediate coronary angiography (CAG) over a delayed/selective strategy in patients with out-of-hospital cardiac arrest (OHCA) and no ST-segment elevation. However, whether selected subgroups, specifically those with a high pretest probability of coronary artery disease may benefit from early CAG remains unclear. METHODS: We included all randomized controlled trials that compared a strategy of early/immediate versus delayed/selective CAG in OHCA patients and no ST elevation and had a follow-up of at least 30 days. The primary outcome of interest was all-cause death. Odds ratios (OR) were calculated and pooled across trials. Interaction testing was used to assess for heterogeneity of treatment effects. RESULTS: In total, 1512 patients (67 years, 26% female, 23% prior myocardial infarction) were included from 5 randomized controlled trials. Early/immediate versus delayed/selective CAG was not associated with a statistically significant difference in odds of death (OR 1.12, 95%-CI 0.91-1.38), with similar findings for the composite outcome of all-cause death or neurological deficit (OR 1.10, 95%-CI 0.89-1.36). There was no effect modification for death by age, presence of a shockable initial cardiac rhythm, history of coronary artery disease, presence of an ischemic event as the presumed cause of arrest, or time to return of spontaneous circulation (all P-interaction > 0.10). However, early/immediate CAG tended to be associated with higher odds of death in women (OR 1.52, 95%-CI 1.00-2.31, P = 0.050) than in men (OR 1.04, 95%-CI 0.82-1.33, P = 0.74; P-interaction 0.097). CONCLUSION: In OHCA patients without ST-segment elevation, a strategy of early/immediate versus delayed/selective CAG did not reduce all-cause mortality across major subgroups. However, women tended to have higher odds of death with early CAG.