Impact of intra-arrest therapeutic hypothermia in outcomes of prehospital cardiac arrest: a randomized controlled trial.

PURPOSE: Mild therapeutic hypothermia (TH) is recommended as soon as possible after the return of spontaneous circulation to improve outcomes after out-of-hospital cardiac arrest (OHCA). Preclinical data suggest that the benefit of TH could be increased if treatment is started during cardiac arrest. We aimed to study the impact of intra-arrest therapeutic hypothermia (IATH) on neurological injury and inflammation following OHCA. METHODS: We conducted a 1:1 randomized, multicenter study in three prehospital emergency medical services and four critical care units in France. OHCA patients, irrespective of the initial rhythm, received either an infusion of cold saline and external cooling during cardiac arrest (IATH group) or TH started after hospital admission (hospital-cooling group). The primary endpoint was neuron-specific enolase (NSE) serum concentrations at 24 h. Secondary endpoints included IL-6, IL-8, and IL-10 concentrations, and clinical outcome. RESULTS: Of the 245 patients included, 123 were analyzed in the IATH group and 122 in the hospital-cooling group. IATH decreased time to reach temperature ≤ 34 °C by 75 min (95% CI: 4; 269). The rate of patients admitted alive to hospital was not different between groups [IATH n = 41 (33%) vs. hospital cooling n = 36 (30%); p = 0.51]. Levels of NSE and inflammatory biomarkers were not different between groups [median NSE at 24 h: IATH 96.7 µg/l (IQR: 49.9-142.8) vs. hospital cooling 97.6 µg/l (IQR: 74.3-142.4), p = 0.64]. No difference in survival and cerebral performance were found at 1 month. CONCLUSIONS: IATH did not affect biological markers of inflammation or brain damage or clinical outcome.

French Registry on Acute ST-elevation and non ST-elevation Myocardial Infarction 2010. FAST-MI 2010.

AIM OF FAST-MI 2010: To gather data on characteristics, management and outcomes of patients hospitalised for acute myocardial infarction (AMI) at the end of 2010 in France. INTERVENTIONS: To provide cardiologists and health authorities national and regional data on AMI management every 5 years. SETTING: Metropolitan France. 213 academic (n=38), community (n=110), army hospitals (n=2), private clinics (n=63), representing 76% of centres treating AMI patients. Inclusion from 1 October 2010. POPULATION: Consecutive patients included during 1 month, with a possible extension of recruitment up to one additional month (132 centres); 4169 patients included over the entire recruitment period, 3079 during the first 31 days; 249 additional patients declining participation (5.6%). STARTPOINTS: Consecutive adults with ST-elevation and non-ST-elevation AMI with symptom onset ≤48 h. Patients with AMI following cardiovascular procedures excluded. DATA CAPTURE: Web-based collection of 385 items (demographic, medical, biologic, management data) recorded online from source files by external research technicians; case-record forms with automatic quality checks. Centralised biology in voluntary centres to collect DNA samples and serum. Long-term follow-up organised centrally with interrogation of municipal registry offices, patients' physicians, and direct contact with the patients. DATA QUALITY: Data management in Toulouse University. STATISTICAL ANALYSES: Université Paris Descartes, Université de Toulouse, Université Pierre et Marie Curie-Paris 06, Paris. ENDPOINTS AND LINKAGES TO OTHER DATA: In-hospital events; cardiovascular events, hospital admissions and mortality during follow-up. Linkage with Institute for National Statistics. ACCESS TO DATA: Available for research to any participating clinician upon request to executive committee (fastmi2010@yahoo.fr).

Efficacy and safety of glycoprotein IIb/IIIa receptor antagonists for patients undergoing percutaneous coronary intervention within twelve hours of fibrinolysis.

OBJECTIVE: To compare clinical outcomes between glycoprotein IIb/IIIa receptor antagonist recipients and nonrecipients who underwent percutaneous coronary intervention (PCI) within 12 hr of fibrinolysis. BACKGROUND: Despite limited evidence, glycoprotein IIb/IIIa receptor antagonists are widely used in ST-elevation myocardial infarction (STEMI) patients undergoing routine early or rescue PCI after fibrinolysis. METHODS: We evaluated 87 and 556 glycoprotein IIb/IIIa receptor antagonist recipients and nonrecipients enrolled in a regional registry of STEMI between October 2002 and December 2005. The primary efficacy endpoint was a composite of death from any cause, reinfarction, and stroke at 1 year of follow-up. The primary safety endpoint was the rate of in-hospital major bleeding that was not related to coronary artery bypass grafting. RESULTS: The primary efficacy endpoint occurred in 12% (10 of 81) and 13% (72 of 525) of glycoprotein IIb/IIIa receptor antagonist recipients and nonrecipients, respectively (P = 0.74). The corresponding rates of major bleeding during index hospitalization were 4.8% (4 of 84) and 5.1% (28 of 544) (P = 0.88), respectively. Two glycoprotein IIb/IIIa receptor antagonist recipients and five nonrecipients experienced intracranial hemorrhage. After adjusting for propensity score, the odds of primary efficacy (odds ratio, 0.79; 95% confidence interval, 0.34-1.83) and safety (odds ratio, 0.75; 95% confidence interval, 0.22-2.62) endpoints did not differ according to the use of glycoprotein IIb/IIIa receptor antagonists. CONCLUSION: In this observational cohort study of unselected patients with STEMI, the administration of glycoprotein IIb/IIIa receptor antagonists provided no additional benefit to PCI performed within 12 hr of fibrinolysis, nor did it compromise patient safety.

Immediate prehospital hypothermia protocol in comatose survivors of out-of-hospital cardiac arrest.

Therapeutic hypothermia (TH) improves the outcomes of cardiac arrest (CA) survivors. The aim of this study was to evaluate retrospectively the efficacy and safety of an immediate prehospital cooling procedure implemented just after the return of spontaneous circulation with a prehospital setting. During 30 months, the case records of comatose survivors of out-of-hospital CA presumably due to a cardiac disease were studied. A routine protocol of immediate postresuscitation cooling had been tested by an emergency team, which consisted of an infusion of large-volume, ice-cold intravenous saline. We decided to assess the efficacy and tolerance of this procedure. A total of 99 patients were studied; 22 were treated with prehospital TH, and 77 consecutive patients treated with prehospital standard resuscitation served as controls. For all patients, TH was maintained for 12 to 24 hours. The demographic, clinical, and biological characteristics of the patients were similar in the 2 groups. The rate of patients with a body temperature of less than 35 degrees C upon admission was 41% in the cooling group and 18% in the control group. Rapid infusion of fluid was not associated with pulmonary edema. After 1 year of follow-up, 6 (27%) of 22 patients in the cooling group and 30 (39%) of 77 patients in the control group had a good outcome. Our preliminary observation suggests that in comatose survivors of CA, prehospital TH with infusion of large-volume, ice-cold intravenous saline is feasible and can be used safely by mobile emergency and intensive care units.

Model for predicting short-term mortality of severe sepsis.

INTRODUCTION: To establish a prognostic model for predicting 14-day mortality in ICU patients with severe sepsis overall and according to place of infection acquisition and to sepsis episode number. METHODS: In this prospective multicentre observational study on a multicentre database (OUTCOMEREA) including data from 12 ICUs, 2268 patients with 2737 episodes of severe sepsis were randomly divided into a training cohort (n = 1458) and a validation cohort (n = 810). Up to four consecutive severe sepsis episodes per patient occurring within the first 28 ICU days were included. We developed a prognostic model for predicting death within 14 days after each episode, based on patient data available at sepsis onset. RESULTS: Independent predictors of death were logistic organ dysfunction (odds ratio (OR), 1.22 per point, P < 10-4), septic shock (OR, 1.40; P = 0.01), rank of severe sepsis episode (1 reference, 2: OR, 1.26; P = 0.10 >or= 3: OR, 2.64; P < 10-3), multiple sources of infection (OR; 1.45, P = 0.03), simplified acute physiology score II (OR, 1.02 per point; P < 10-4), McCabe score ([greater than or equal to]2) (OR, 1.96; P < 10-4), and number of chronic co-morbidities (1: OR, 1.75; P < 10-3, >or= 2: OR, 2.24, P < 10-3). Validity of the model was good in whole cohorts (AUC-ROC, 0.76; 95%CI, 0.74 to 0.79; and HL Chi-square: 15.3 (P = 0.06) for all episodes pooled). CONCLUSIONS: In ICU patients, a prognostic model based on a few easily obtained variables is effective in predicting death within 14 days after the first to fourth episode of severe sepsis complicating community-, hospital-, or ICU-acquired infection.

The severity of oxygen desaturation is predictive of carotid wall thickening and plaque occurrence.

STUDY OBJECTIVES: To characterize carotid intima-media thickness (IMT) and plaque occurrence in patients with newly diagnosed obstructive sleep apnea (OSA) without known cardiovascular disease. DESIGN: Prospective study. SETTING: Sleep Laboratory and Department of Cardiology of Grenoble University Hospital. PATIENTS AND INTERVENTION: OSA syndrome is associated with an increased cardiovascular risk. Carotid IMT is recognized as a marker of preclinic atheroma. A small number of studies have analyzed large-artery wall modifications in OSA syndrome. Eighty-three patients (74 men; mean age +/- SD, 48 +/- 11 years; mean body mass index, 27.4 +/- 4.2 kg/m(2)) were included. Mean respiratory disturbance index was 40.7 +/- 19.2/h, mean nocturnal arterial oxygen saturation (Sao(2)) was 93.1 +/- 2.0%, and mean percentage of recording time spent at Sao(2) < 90% was 8.6 +/- 16.8%. Clinical BP was measured following European Society of Hypertension/European Society of Cardiology recommendations, and 24-h ambulatory BP monitoring was assessed. Ultrasonography was used to determine the carotid IMT and atheromatous plaque occurrence. MEASUREMENTS AND RESULTS: Twenty-five of 83 patients (30%) had carotid wall hypertrophy (IMT > 0.8 mm). In a logistic regression model, mean nocturnal Sao(2) < 92% (odds ratio [OR], 3.9; 95% confidence interval [CI], 1.1 to 12.7) was associated with carotid wall hypertrophy. ORs were even higher after adjustment for BP status (OR, 10.6; 95% CI, 1.6 to 50.9 in normotensive patients) and glucose levels (OR, 4.5; 95% CI, 1.0 to 20.9). Mean nocturnal Sao(2) < 92% and minimal nocturnal Sao(2) < 80% (ORs, 3.1 and 3.1; 95% CIs, 1.0 to 9.4 and 1.0 to 8.5, respectively) were associated with the presence of carotid plaque formation independently of the BP status (hypertensive or normotensive). CONCLUSIONS: The severity of oxygen desaturation appears to be one of the best predictors for carotid IMT and plaque occurrence in OSA patients without known cardiovascular disease. Thus, carotid IMT and plaque formation appeared as early cardiovascular consequences in OSA patients.

Night-time and diastolic hypertension are common and underestimated conditions in newly diagnosed apnoeic patients.

BACKGROUND: In newly diagnosed apnoeic patients without a history of hypertension, clinical hypertension is underdiagnosed in at least 40% of the cases. An increase in diastolic blood pressure is the most frequent pattern encountered. OBJECTIVE: To assess clinic and 24-h blood pressure, baroreflex sensitivity and left ventricular mass for identifying the prevalence, the type and the consequences of hypertension in newly diagnosed apnoeic patients. PATIENTS AND METHODS: Fifty-nine unselected patients (age = 48 +/- 12 years, body mass index = 28.1 +/- 4.5 kg/m2) referred to a university hospital sleep laboratory for symptoms suggesting obstructive sleep apnoea were included. Diagnosis of apnoea was accepted when respiratory disturbance index was > or = 15/h of sleep. Blood pressure was considered as normal by their general practitioner and all of them were free of any medication for hypertension. Echocardiography, 24-hour ambulatory blood pressure monitoring and assessment of the baroreflex sensitivity were performed. RESULTS: Forty-two percent of the apnoeic patients demonstrated a clinical hypertension, 34 subjects (58%) had a daytime hypertension, and 45 patients (76%) had a night-time hypertension, using 24-h monitoring. All the daytime hypertensives also had night-time hypertension. Forty-seven of the 59 patients (80%) were hypertensive either in the clinic or using 24-h recording. Diastolic and systolo-diastolic hypertension were the prominent types of hypertension observed both by clinic or ambulatory measurements. Respiratory disturbance index was significantly higher in apnoeic patients suffering isolated diastolic hypertension than in the normotensives (50.9 +/- 26.5/h versus 36.0 +/- 12.3/h, respectively; P = 0.02). The prevalence rate of left ventricular hypertrophy was high (between 15 and 20%) and occurred independently of associated hypertension. Baroreflex sensitivity was altered whatever the type of hypertension and decreased with the severity of obstructive sleep apnoea. CONCLUSION: Hypertension is hugely underdiagnosed in apnoeic patients unknown to be hypertensive. Use of 24-h blood pressure monitoring allowed the diagnosis of twice as much hypertension than did clinical measurement. Even at the beginning of their history of hypertension, apnoeic patients exhibited chronic adaptations of their cardiovascular system, as shown by early changes in baroreflex sensitivity and an increased prevalence of left ventricular hypertrophy.

Circumstances of discovery of phaeochromocytoma: a retrospective study of 41 consecutive patients.

OBJECTIVE: Phaeochromocytoma is a rare tumour of the chromaffin cells, the diagnosis of which is based on an assay of metanephrines and treatment is surgical excision of the tumour. It is usually discovered due to a rich and varied symptomatology or classic paroxysmal hypertension. The main purpose of this study was to specify the exact circumstances of discovery of the phaeochromocytomas operated on in our university hospital between 1990 and 2002. DESIGN AND METHODS: Forty-one consecutive and complete case reports of patients who had surgery for phaeochromocytoma were analysed retrospectively. This series includes 10 patients with a genetic disorder predisposing to phaeochromocytoma. RESULTS: The association of headaches and palpitations with sweating was found in only 24% of cases (10/41). Blood pressure anomalies led to the discovery of phaeochromocytoma in only 51% of cases (21/41) and 59% (24/41) of all the patients suffered from hypertension. In almost half the cases (20/41), the tumour was discovered by an imaging method (ultrasonography, CT scan or MRI) which had been performed for reasons unrelated to a blood pressure abnormality. CONCLUSIONS: Phaeochromocytoma, the symptoms of which are not very specific and during which hypertension is present in only half the patients, is a disease that remains rare. Its incidence could be increasing because of changes in the method of detection. Indeed, in our study, different imaging techniques led to its incidental discovery in half of the cases.