Rapidly improving stroke symptoms: a pilot, prospective study.

BACKGROUND: Rapidly improving stroke symptoms (RISSs) are a controversial exclusion for intravenous recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke (AIS). We estimated the frequency of 4 prespecified RISS definitions and explored their relationship to clinical outcome. METHODS: Pilot, prospective study of AIS patients admitted within 4.5 hours of symptom onset. Serial assessments using National Institute of Health Stroke Scale (NIHSS) were performed every 20 ± 5 minutes until a rt-PA treatment decision was made, independent of the study. Improvement was calculated as the difference between baseline NIHSS and treatment decision NIHSS. RISS was defined as a 4-point or greater improvement, 25% or greater, 50% or greater, and according to the previously reported TREAT (The Re-examining Acute Eligibility for Thrombolysis) criteria. Unfavorable outcome was defined as modified Rankin Scale score more than 1 at 90 days after stroke. Logistic regression determined if RISS definition(s) related to the outcome. RESULTS: Fifty patients with AIS were enrolled: mean age 65 years; median baseline NIHSS score 5 (interquartile range, 2-11). RISS frequencies were 10%-22% based on definition. Median treatment decision NIHSS score is 5 (interquartile range, 2-9). Twenty-three (46%) patients received rt-PA. None of the 3 non-TREAT RISS definitions was independently associated with the outcome. Five of fifty (10%) were RISS according to the TREAT criteria, all 5 had good outcome without rt-PA. CONCLUSIONS: A Serial NIHSS assessment before treatment decision is feasible and may help determine the frequency and magnitude of RISS. This is the first prospective estimate of RISS frequency and outcome according to various prespecified definitions. The TREAT RISS frequency as a more restrictive definition may better predict good outcome of RISS in future, larger studies.

Association of pulmonary hypertension with survival and neurologic outcomes in adults with in-hospital cardiac arrest.

BACKGROUND: Pulmonary hypertension (PH) has been associated with poor survival in multiple cardiopulmonary conditions, however its association with outcomes in cardiac arrest remains unknown. We aimed to evaluate the association of PH with survival and neurologic outcomes in adults with in-hospital cardiac arrest (IHCA). METHODS: The study population included adults with IHCA undergoing resuscitation at an academic tertiary-care medical center from 2011 to 2019. Patients were classified based upon the presence versus absence of PH, defined as a pulmonary artery systolic pressure >35 mmHg on pre-arrest echocardiogram. Survival to discharge and favorable neurological outcome (defined as a Glasgow Outcome Score of 4-5) served as the primary and secondary outcomes of interest respectively. RESULTS: Of the 371 patients studied, 203 (54.7%) had PH while 168 (45.3%) did not. Patients with PH had higher Charlson Comorbidity Score with higher rates of multiple baseline comorbidities. They also had worse multi-chamber enlargement, left ventricular diastolic dysfunction, right ventricular systolic dysfunction, and valvular heart disease compared to non-PH patients. Rates of survival to discharge (11.5% vs 10.9%, p = 0.881) and favorable neurologic outcome (8.0% vs 6.2%, p = 0.550) were similar in PH and non-PH patients respectively. In multivariable analysis, PH was not associated with survival to discharge (OR 1.23, 95%CI 0.57-2.65) or favorable neurologic outcome (OR 1.69, 95%CI 0.64-4.45). CONCLUSIONS: In this contemporary registry of adults with IHCA, while PH was associated with a higher risk patient profile, it was not associated with survival or neurologic outcomes in this population.

Impact of chronic obstructive pulmonary disease on survival and neurologic outcomes in adults with in-hospital cardiac arrest.

BACKGROUND: Little data exists regarding the association of chronic obstructive pulmonary disease (COPD) on outcomes in the setting of in-hospital cardiac arrest (IHCA). We sought to assess the impact of COPD on mortality and neurologic outcomes in adults with IHCA. METHODS: The study population included 593 consecutive hospitalized patients with IHCA undergoing ACLS-guided resuscitation at an academic tertiary medical center from 2012-2018. The primary and secondary outcomes of interest were survival to discharge and favorable neurological outcome (defined as a Glasgow Outcome Score of 4-5) respectively. RESULTS: Of the 593 patients studied, 162 (27.3%) had COPD while 431 (72.7%) did not. Patients with COPD were older, more often female, and had higher Charlson Comorbidity score. Location of cardiac arrest, initial rhythm, duration of cardiopulmonary resuscitation, and rates of defibrillation and return of spontaneous circulation were similar in both groups. Patients with COPD had significantly lower rates of survival to discharge (10.5% vs 21.6%, p = 0.002) and favorable neurologic outcomes (7.4% vs 15.9%, p = 0.007). In multivariable analyses, COPD was independently associated with lower rates of survival to discharge [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.30-0.98, p = 0.041]. CONCLUSIONS: In this contemporary prospective registry of adults with IHCA, COPD was independently associated with significantly lower rates of survival to discharge.