The Public Health and Economic Impact of Drug Overdose Out-of-Hospital Cardiac Arrest in the United States.

OBJECTIVE: To calculate disability-adjusted life years (DALY) and labor productivity loss due to drug overdose out-of-hospital cardiac arrest (DO-OHCA) and compare its contribution to the burden of disease and economic impact of all-cause nontraumatic out-of-hospital cardiac arrest (OHCA) in the US. METHODS: We performed a retrospective observational cohort analysis of all adult (age ≥18 years) nontraumatic emergency medical services-treated OHCA events, including those due to DO-OHCA, from the national Cardiac Arrest Registry to Enhance Survival (CARES) database from January 1, 2017 and December 31, 2020. The main outcome measures of interest were disability-adjusted life years, annual, and lifetime labor productivity loss over the 4-year study period. The findings for the study population were extrapolated to a national level using the CARES population catchment and U.S. population estimates by year. RESULTS: A total of 378,088 adult OHCA events, including 23,252 DO-OHCA (6.2%) met study inclusion criteria. The DO-OHCA DALY increased from 156,707 in 2017 to 265,692 in 2020. Per year, DO-OHCA contributed to 11.4%, 12.0%, 10.5%, and 11.4% of all OHCA DALY lost from 2017-2020, respectively. The mean annual and lifetime productivity losses for all OHCA were stable over time (annual: $47K in 2017 to $50K in 2020; lifetime: $647K in 2017 to $692K in 2020). The CARES population catchment increased by 39.8% over the study period (102.6 M in 2017 to 143.4 M in 2020). For DO-OHCA, the mean annual productivity loss was approximately 30% higher than non-DO-OHCA ($64K vs. $49K in 2020, respectively). The mean lifetime productivity loss for DO-OHCA was 2.5 times higher than non-DO-OHCA ($1.6 M vs. $630K in 2020, respectively). CONCLUSIONS: The DALY due to DO-OHCA has increased over time with expansion of the CARES dataset, but its relative contribution to total OHCA DALY (all non-traumatic etiologies) remained fairly stable. The DO-OHCAs represent approximately 6% of all adult non-traumatic EMS-treated OHCA events but has a disproportionately greater economic impact. Continued efforts to reduce DO-OHCA through public health initiatives are warranted to lessen the societal impact of OHCA in the U.S.

Cardiac Arrest Following Drug Overdose in the United States: An Analysis of the Cardiac Arrest Registry to Enhance Survival.

BACKGROUND: Given increases in drug overdose-associated mortality, there is interest in better understanding of drug overdose out-of-hospital cardiac arrest (OHCA). A comparison between overdose-attributable OHCA and nonoverdose-attributable OHCA will inform public health measures. METHODS AND RESULTS: We analyzed data from 2017 to 2021 in the Cardiac Arrest Registry to Enhance Survival (CARES), comparing overdose-attributable OHCA (OD-OHCA) with OHCA from other nontraumatic causes (non-OD-OHCA). Arrests involving patients <18 years, health care facility residents, patients with cancer diagnoses, and patients with select missing data were excluded. Our main outcome of interest was survival with good neurological outcome, defined as Cerebral Performance Category score 1 or 2. From a data set with 537 100 entries, 29 500 OD-OHCA cases and 338 073 non-OD-OHCA cases met inclusion criteria. OD-OHCA cases involved younger patients with fewer comorbidities, were less likely to be witnessed, and less likely to present with a shockable rhythm. Unadjusted survival to hospital discharge with Cerebral Performance Category score =1 or 2 was significantly higher in the OD-OHCA cohort (OD: 15.2% versus non-OD: 6.9%). Adjusted results showed comparable survival with Cerebral Performance Category score =1 or 2 when the first monitored arrest rhythm was shockable (OD: 28.9% versus non-OD: 23.5%, P=0.087) but significantly higher survival rates with Cerebral Performance Category score =1 or 2 for OD-OHCA when the first monitored arrest rhythm was nonshockable (OD: 9.6% versus non-OD: 3.1%, P<0.001). CONCLUSIONS: Among patients presenting with nonshockable rhythms, OD-OHCA is associated with significantly better outcomes. Further research should explore cardiac arrest causes, and public health efforts should attempt to reduce the burden from drug overdoses.

Predicting Neurologically Intact Survival for Advanced Age Adults After Successful Resuscitation of Out-of-Hospital Cardiac Arrest.

We sought to predict survival to hospital discharge with favorable neurologic outcome for advanced age adults (≥65 years) after successful resuscitation of non-traumatic out-of-hospital cardiac arrest (OHCA). A retrospective observational cohort analysis was performed using the national Cardiac Arrest Registry to Enhance Survival database from January 1, 2013 to December 31, 2021. All nontraumatic OHCA occurring in advanced age adults who survived to hospital admission were included. The primary outcome was survival with favorable neurologic outcome defined as a cerebral performance category score of 1 or 2 at hospital discharge. Multivariable logistic regression including patient variables (age category, gender, co-morbidities) and OHCA characteristics (location, rhythm category, witnessed status, and who initiated cardiopulmonary resuscitation) were used to predict hospital outcome. 83,574 patients met study inclusion criteria with 19,298 (23.1%) surviving with favorable neurologic outcome. The median age was 75 years (interquartile range 69 to 82 years), 58.9% were male, and a majority of events occurred at home (67.3%). Age was found to have a linear, negative association with outcome. Survival with cerebral performance category 1 or 2 ranged from 28.8% in those between the age of 65 to 69 years (n = 23,161) and 13.7% for those age >90 years (n = 4,666). The regression model produced outcome probabilities ranging from 2.6% to 80.8% with a cross-validated AUROC of 0.742 (95% confidence interval 0.738 to 0.746) and a Brier score of 0.151. In conclusion, a simple model with basic patient and OHCA characteristics can predict hospital outcomes in advanced age adults with good discrimination and calibration.

Disability-Adjusted Life Years Due to Pediatric Out-of-Hospital Cardiac Arrest in the United States: A CARES Surveillance Group Study.

BACKGROUND: Disability-adjusted life years (DALY) are a common public health metric used to estimate disease burden. The DALY due to pediatric out-of-hospital cardiac arrest (OHCA) in the United States is unknown. We aimed to estimate pediatric OHCA DALY and to compare it with the other leading causes of pediatric death and disability in the United States. METHODS: We conducted a retrospective observational analysis of the national Cardiac Arrest Registry to Enhance Survival database. DALY were calculated as the sum of years of life lost and years lived with disability. Years of life lost were calculated using all pediatric (age <18 years) nontraumatic OHCA from the Cardiac Arrest Registry to Enhance Survival from 2016 to 2020. Disability weights based on cerebral performance category scores, an outcome measure of neurologic function, were used to estimate years lived with disability . Data were reported as total, mean, and rate per 100 000 individuals, and were compared with the leading causes of pediatric DALY in the United States published by the Global Burden of Disease study for 2019. RESULTS: Totally 11 177 OHCA met the study inclusion criteria. A modest increase in total OHCA DALY in the United States was observed from 407 500 (years of life lost = 407 435 and years lived with disability =65) in 2016 to 415 113 (years of life lost = 415 055 and years lived with disability =58) in 2020. The DALY rate increased from 553.3 per 100 000 individuals in 2016 to 568.3 per 100 000 individuals in 2020. For 2019, OHCA was the 10th leading cause of pediatric DALY lost behind neonatal disorders, injuries, mental disorders, premature birth, musculoskeletal disorders, congenital birth defects, skin diseases, chronic respiratory diseases, and asthma. CONCLUSIONS: Nontraumatic OHCA is one of the top 10 leading causes of annual pediatric DALY lost in the United States.

Disability-Adjusted Life-Years After Adult In-Hospital Cardiac Arrest in the United States.

We sought to estimate disability-adjusted life-years (DALYs) because of adult in-hospital cardiac arrest (IHCA) and to compare IHCA DALY to other leading causes of death and disability in the United States. DALY were calculated as the sum of years of life lost and years lived with disability. The years of life lost were calculated using all adult IHCA with complete data from the American Heart Association Get With The Guidelines-Resuscitation database for 2015 to 2019. Cerebral performance category scores and published disability weights were used to estimate the years lived with disability for survivors. The cohort's DALY were extrapolated to a national level to estimate the total United States DALY and were compared with a published ranking of the leading causes of DALY in the United States for 2018. Data were reported as DALY total and rate per 100,000. A total of 99,897 IHCA were included from 329 hospitals. The total IHCA DALY increased from 2,208,310 in 2015 to 2,225,722 in 2019. A modest decrease in the DALY rate was observed from 689 per 100,000 in 2015 to 678 per 100,000 in 2019. In 2018, the rate of IHCA DALY were 728 per 100,000, which represented the 11th leading cause of DALY. When combined with out-of-hospital cardiac arrest (1,322 per 100,000), sudden cardiac arrest (2,050 per 100,000) was found the be the 2nd leading cause of DALY after ischemic heart disease (2,681 per 100,000) in 2018. In conclusion, adult IHCA is a leading cause of DALY in the United States and has increased over time because of the expansion of the Get With The Guidelines-Resuscitation database.

Estimating the impact of the COVID-19 pandemic on out-of-hospital cardiac arrest burden of disease in the United States.

Background: The impact of the COVID-19 pandemic on out-of-hospital cardiac arrest (OHCA) burden of disease in the United States is unknown. We sought to estimate and compare disability-adjusted life years (DALYs) lost because of OHCA during the COVID-19 pandemic to prepandemic values. Methods: DALY were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). Adult non-traumatic emergency medical services-treated OHCA from the Cardiac Arrest Registry to Enhance Survival database for 2016 to 2020 were used to estimate YLL. Cerebral performance category score disability weights were used to estimate YLD. The calculated DALY for the study population was extrapolated to a national level to estimate total US DALY. Data were reported as DALY total and rate. Data for 2020 (pandemic) were compared prepandemic years (2016-2019) via the chi-square test or t-test, as appropriate. Results: A total of 440,438 OHCA met study inclusion criteria. Total OHCA DALY in the United States increased from 4,468,155 (YLL = 4,463,988; YLD = 4167) in 2019 to 5,379,660 (YLL = 5,375,464; YLD = 4197) in 2020. The DALY rate increased from 1357 per 100,000 individuals in 2019 to 1630 per 100,000 individuals in 2020. Bystander cardiopulmonary resuscitation (CPR) rates did not significantly change (47.96% in 2016-2019 vs. 47.89% in 2020; p = 0.157). Conclusion: The overall burden of disease because of adult OHCA increased significantly during the COVID-19 pandemic. We observed no change in the willingness of layperson bystanders to perform CPR on a national level in the United States.

ECPR2: Expert Consensus on PeRcutaneous Cannulation for Extracorporeal CardioPulmonary Resuscitation.

AIM: Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a promising resuscitation strategy for select patients suffering from refractory out-of-hospital cardiac arrest (OHCA), though limited data exist regarding the best practices for ECPR initiation after OHCA. METHODS: We utilized a modified Delphi process consisting of two survey rounds and a virtual consensus meeting to systematically identify detailed best practices for ECPR initiation following adult non-traumatic OHCA. A modified Delphi process builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. Consensus was achieved when items reached a high level of agreement, defined as greater than 80% responses for a particular item rated a 4 or 5 on a 5-point Likert scale. RESULTS: Snowball sampling generated a panel of 14 content experts, composed of physicians from four continents and five primary specialties. Seven existing institutional protocols for ECPR cannulation following OHCA were identified and merged into a single comprehensive list of 207 items. The panel reached consensus on 101 items meeting final criteria for inclusion: Prior to Patient Arrival (13 items), Inclusion Criteria (8), Exclusion Criteria (7), Patient Arrival (8), ECPR Cannulation (21), Go On Pump (18), and Post-Cannulation (26). CONCLUSION: We present a list of items for ECPR initiation following adult nontraumatic OHCA, generated using a modified Delphi process from an international panel of content experts. These findings may benefit centers currently performing ECPR in quality assurance and serve as a template for new ECPR programs.

Annual and lifetime economic productivity loss due to adult out-of-hospital cardiac arrest in the United States: A study for the CARES Surveillance Group.

OBJECTIVE: To estimate the annual and lifetime economic productivity loss due to adult out-of-hospital cardiac arrest (OHCA) in the United States (U.S.). METHODS: All adult (age ≥ 18 years) non-traumatic EMS-treated OHCA with complete data for age, sex, race, and survival outcomes from the CARES database for 2013-2018 were included. Annual and lifetime labor productivity values, based on age and gender, were obtained from previously published national economic data. Productivity losses for OHCA events were calculated by year in U.S. dollars. Productivity losses for survivors were assigned by cerebral performance category score (CPC): CPC 1 and 2 = 0% productivity loss; CPC 3-5 = 100% productivity loss. Sensitivity analyses were performed assigning CPC 2 varying productivity losses (0-100%) based on CPC score and discharge location. Lifetime productivity values assumed 1% annual growth and 3% discount rate and were adjusted for inflation based on 2016 values. Results were extrapolated to annual U.S. population estimates for the study period. RESULTS: A total of 338,492 (96.5%) cases met inclusion criteria. The mean annual and lifetime productivity losses per OHCA in 2018 were $48,224 and $638,947 respectively. The total annual economic productivity loss due to OHCA in the U.S. increased from $7.4B in 2013 to $11.3B in 2018. Lifetime economic productivity loss increased from $95.2B in 2013 to $150.2B in 2018. Sensitivity analyses yielded similar findings. Per annual death, OHCA ranked third ($10.2B) in annual economic productivity loss in the U.S. behind cancer ($22.9B) and heart disease ($20.3B) in 2018. CONCLUSION: Adult non-traumatic OHCA events are associated with significant annual and lifetime economic productivity losses and should be the focus of public health resources to improve preventative measures and survival outcomes.

National Institutes of Health investment into cardiac arrest research: A study for the CARES Surveillance Group.

OBJECTIVE: To calculate and compare the National Institutes of Health (NIH) research investment for cardiac arrest (CA) to other leading causes of disability-adjusted life years (DALY) in the United States (U.S.). METHODS: A search within NIH RePORTER for 2017 was performed using single common resuscitation terms. Grants were individually reviewed and categorized as CA research (yes/no) using predefined criteria. DALY were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD) using all adult non-traumatic out-of-hospital CA (OHCA) from the CARES database for 2017. Total DALY for the study population were extrapolated to a national level. Leading causes of DALY were obtained from the Global Burden of Disease study and funding data were extracted from the NIH Categorical Spending Report for comparison. The outcome measure was U.S. dollars invested per annual DALY. RESULTS: The search yielded 290 grants, of which 87 (30%) were classified as CA research. Total funding for CA research in 2017 was $37.1M. A total of 73,915 (97%) cases from CARES met study inclusion criteria for the DALY analysis. The total DALY following adult OHCA in the U.S. population were 4,335,949 (YLL 4,332,166, YLD 3784). Per annual DALY, the NIH invested $287 for diabetes, $92 for stroke, $55 for ischemic heart disease, and $9 for CA research. CONCLUSION: The NIH investment into CA research is far less than other comparable causes of death and disability in the U.S. These results should help inform utilization of limited resources to improve public health.

Trend analysis of disability-adjusted life years following adult out-of-hospital cardiac arrest in the United States: A study from the CARES Surveillance Group.

AIM: To estimate and trend disability-adjusted life years (DALY) following adult out-of-hospital cardiac arrest (OHCA) over time, and to compare OHCA DALY to other leading causes of death and disability in the U.S. METHODS: DALY were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). Adult non-traumatic emergency medical services-treated OHCA from the Cardiac Arrest Registry to Enhance Survival (CARES) database for 2013-2018 were used to estimate YLL. Cerebral performance category score disability weights were used to estimate YLD. The calculated DALY for the study population was extrapolated to a national level to estimate total U.S. DALY. Data were reported as DALY total and rate. Data were compared to the top 10 causes of DALY in the U.S. RESULTS: 337,991 OHCA met study inclusion criteria. Total U.S. OHCA DALY increased from 3,005,308 in 2013 to 4,326,745 in 2018. The DALY rate increased from 950.9 per 100,000 individuals to 1322.4 per 100,000 individuals. OHCA DALY ranked fifth in the U.S. behind ischemic heart disease (2470), drug use disorders (1703), chronic obstructive pulmonary disease (1449), and back pain (1336). OHCA represented the largest percent increase in DALY rate (40.3%) over the study period. CONCLUSION: Adult non-traumatic OHCA is a leading cause of DALY in the U.S. and the burden of disease due to OHCA has increased rapidly over time. These findings are likely due to more precise national OHCA surveillance, and suggest that the public health impact of OHCA is larger than previously described.

The association between scene time interval and neurologic outcome following adult bystander witnessed out-of-hospital cardiac arrest.

OBJECTIVE: To analyze the association between Emergency Medical Services (EMS) scene time interval (STI) and survival with functional neurologic recovery following adult out-of-hospital cardiac arrest (OHCA). METHODS: A retrospective analysis of prospectively collected data from the national Cardiac Arrest Registry to Enhance Survival from January 2013 to December 2018. All adult non-traumatic, EMS-treated, bystander-witnessed OHCA with complete data were included. Patients with STI times >60 min, defined as the time from EMS arrival at the patient's side to the time the transport vehicle left the scene, unwitnessed OHCA, nursing home events, EMS-witnessed OHCA, or patients with termination of resuscitation in the field were excluded. The primary outcome was survival with functional recovery (Cerebral Performance Category [CPC] = 1 or 2). Multivariable logistic regression was used to quantify the association of STI with the primary. RESULTS: 67,237 patients met inclusion criteria with 12,098 (18.0%) surviving with functional recovery. Mean STI (SD) for survivors with CPC 1 or 2 was 19 (8.4) and 22.8 (10.5) for those with poor outcomes (death or CPC 3-4; p < 0.001). For every 1-min increase in STI, the adjusted odds of a poor outcome increased by 3.5%; odds ratio = 1.035; 95% CI (1.027, 1.044); p < 0.001. Restricted cubic spline analysis showed increased risk of poor outcome after approximately 20 min. CONCLUSION: Longer STI times are strongly associated with poor neurologic outcome in bystander-witnessed OHCA patients. After a STI duration of approximately 20 min, the associated risk of a poor neurologic outcome increased more rapidly.

Supplemental thiamine for the treatment of acute heart failure syndrome: a randomized controlled trial.

BACKGROUND: The purpose of this pilot study was to determine if a definitive clinical trial of thiamine supplementation was warranted in patients with acute heart failure. We hypothesized that thiamine, when added to standard of care, would improve dyspnea (primary outcome) in hospitalized patients with acute heart failure. Peak expiratory flow rate, type B natriuretic peptide, free fatty acids, glucose, hospital length of stay, as well as 30-day rehospitalization and mortality were pre-planned secondary outcome measures. METHODS: This was a blinded experimental study at two urban academic hospitals. Consecutive patients admitted from the Emergency Department with a primary diagnosis of acute heart failure were recruited over 2 years. Patients on a daily dietary supplement were excluded. Randomization was stratified by type B natriuretic peptide and diabetes medication categories. Subjects received study drug (100 mg thiamine or placebo) in the evening of their first and second day. Outcome measures were obtained 8 h after study drug infusion. Dyspnea was measured on a 100-mm visual analog scale sitting up on oxygen, sitting up off oxygen, and lying supine off oxygen with 0 indicating no dyspnea. Data were analyzed using mixed-models as well as linear, negative binomial and logistic regression models to assess the impact of group on outcome measures. RESULTS: Of 130 subjects randomized, 118 had evaluable data (55 in the control and 63 in the treatment groups), 89% in both groups were adjudicated to have primarily AHF. Thiamine values increased significantly in the treatment group and were unchanged in the control group. One patient had thiamine deficiency. Only dyspnea measured sitting upright on oxygen differed significantly by group over time. No change was found for the other measures of dyspnea and all of the secondary measures. CONCLUSIONS: In mild-moderate acute heart failure patients without thiamine deficiency, a standard dosing regimen of thiamine did not improve dyspnea, biomarkers, or other clinical parameters. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00680706 , May 20, 2008 (retrospectively registered).

Disability-Adjusted Life Years Following Adult Out-of-Hospital Cardiac Arrest in the United States.

Background Disability-adjusted life years (DALY) are a common public health metric used to consistently estimate and compare health loss because of both fatal and nonfatal disease burden. The annual number of DALY because of adult out-of-hospital cardiac arrest (OHCA) in the United States is unknown. Our objective was to estimate the DALY after adult nontraumatic, emergency medical services-treated OHCA, and to compare OHCA DALY to other leading causes of death and disability in the US. Methods and Results The DALY were calculated as the sum of years of life lost and years lived with disability. The years of life lost were calculated using all adult nontraumatic emergency medical services-treated OHCA with complete data from the national Cardiac Arrest Registry to Enhance Survival database for 2016, and actuarial data for remaining life expectancy at the age of death. Cerebral performance category scores from the Cardiac Arrest Registry to Enhance Survival database and previously established disability weights were used to estimate years lived with disability. The cohort's calculated DALY were extrapolated to a national level to estimate total US DALY. Data were reported as total, mean, and DALY per 100 000 individuals. A total of 59 752 OHCA met study inclusion criteria. The DALY for the study population were 1 194 993 (years of life lost, 1 194 069; years lived with disability, 924) in 2016. The estimated total DALY following adult nontraumatic emergency medical services-treated OHCA in the US were 4 354 192 (years of life lost, 4 350 825; years lived with disability, 3365) for the index year 2016. The rate of OHCA DALY were 1347 per 100 000 population, which ranked third in the US behind ischemic heart disease (2447) and low back and neck pain (1565). Sensitivity analyses yielded similar findings. Conclusions Adult nontraumatic OHCA is a leading cause of annual DALY in the US and should be a focus of public health policy and resources.

Intrastate Variation in Treatment and Outcomes of Out-of-Hospital Cardiac Arrest.

OBJECTIVE: Our objective was to analyze and compare out-of-hospital cardiac arrest (OHCA) system of care performance and outcomes at the Medical Control Authority (MCA) level in the state of Michigan. We hypothesized that clinically and statistically significant variations in treatment and outcomes of OHCA exists within a single U.S. state. METHODS: We performed a retrospective, observational study of all non-traumatic EMS-treated OHCA from the state of Michigan CARES registry for 2014-2015. Geocoding of the OHCA incident address was used to assign records to individual MCAs. MCA-based demographics, arrest characteristics, system of care performance and outcomes were quantified and compared. Associations between demographics, system of care parameters, and outcomes were examined at the MCA level. RESULTS: A total of 8,115 records with complete data were available for analysis. Eleven MCAs met study inclusion criteria of >100 cases, producing a final sample size of 7,788 records (96%). Statistically significant variations in survival to hospital discharge ranged from 4.5% to 15% (p < 0.001) (Adjusted odds ratio [AOR] range 0.6-2.0) and survival with good neurologic outcome 2.7-12.5% (p < 0.001; AOR range 0.5-2.2,) were observed across MCAs. Bystander CPR ranged from 32% to 53% (p < 0.001) and bystander AED application ranged from 3.5% 11.5% (p < 0.05). Of patients admitted to the hospital alive, 29-68% received targeted temperature management. In hospital mortality ranged from 53.1% to 73.9% (p < 0.05). CONCLUSION: Significant intrastate variability in OHCA system of care performance and outcomes currently exist and are similar to what has been previously reported across North America almost a decade ago. This degree of variability highlights the opportunity to optimize modifiable factors within local systems of care to improve OHCA outcomes.

Descriptive analysis of extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest-An ELSO registry study.

AIM: Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging therapy for refractory cardiac arrest. The purpose of this study was to analyze and report characteristics and outcomes of adult patients treated with ECPR after out-of-hospital cardiac arrest (OHCA) in a large international registry. METHODS: The Extracorporeal Life Support Organization's Extracorporeal Life Support Registry was queried for adult cardiac arrests with arrest location of "EMT Transport" or "Outside Hospital." RESULTS: From 2010-2016, 217 cases of ECPR following OHCA were reported in Europe (47%), Asia-Pacific (29%), and North America (24%). The median age was 52 years (IQR 45-62, range 18-87); 73% were male. The median duration of ECPR was 47h (IQR 17-94, range 0-711). Reported complications included hemorrhage (31.3%), limb complications (11.1%), circuit complications (8.8%), infection (7.4%), and seizures (5.5%). The rate of percutaneous coronary intervention (PCI) was higher in Europe (35.6%) and Asia-Pacific (25.8%) than North America (9.4%; p<0.01). Survival to hospital discharge was 27.6% (95% CI 22.1-34.0%), and male gender was independently associated with mortality (adjusted odds ratio 2.1 [95% CI 1.1-4.2], p<0.05). Survival did not differ by region, race, age, or year. Brain death was reported in 16.6% [95% CI 12.2-22.1%]; organ donation rate was not reported. CONCLUSION: This international analysis of ECPR for refractory OHCA reveals a survival rate of 27.6%, demonstrates association of male gender with mortality, and highlights regional differences in PCI utilization. These results will help inform implementation and research of this potentially life-saving strategy for refractory OHCA.

National Institutes of Health-Funded Cardiac Arrest Research: A 10-Year Trend Analysis.

BACKGROUND: Cardiac arrest (CA) is a leading cause of death in the United States, claiming over 450 000 lives annually. Improving survival depends on the ability to conduct CA research and on the translation and implementation of research findings into practice. Our objective was to provide a descriptive analysis of annual National Institutes of Health (NIH) funding for CA research over the past decade. METHOD AND RESULTS: A search within NIH RePORTER for the years 2007 to 2016 was performed using the terms: "cardiac arrest" or "cardiopulmonary resuscitation" or "heart arrest" or "circulatory arrest" or "pulseless electrical activity" or "ventricular fibrillation" or "resuscitation." Grants were reviewed and categorized as CA research (yes/no) using predefined criteria. The annual NIH funding for CA research, number of individual grants, and principal investigators were tabulated. The total NIH investment in CA research for 2015 was calculated and compared to those for other leading causes of death within the United States. Interrater reliability among 3 independent reviewers for fiscal year 2015 was assessed using Fleiss κ. The search yielded 2763 NIH-funded grants, of which 745 (27.0%) were classified as CA research (κ=0.86 [95%CI 0.80-0.93]). Total inflation-adjusted NIH funding for CA research was $35.4 million in 2007, peaked at $76.7 million in 2010, and has decreased to $28.5 million in 2016. Per annual death, NIH invests ≈$2200 for stroke, ≈$2100 for heart disease, and ≈$91 for CA. CONCLUSIONS: This analysis demonstrates that the annual NIH investment in CA research is low relative to other leading causes of death in the United States and has declined over the past decade.

Electronically self-assessed functional capacity and exercise testing: A comparison of the Duke Activity Status Index and Patient-Reported Outcomes Measurement Information System tools.

PURPOSE: Electronic screening tools, such as Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short-Form 12a (PF-SF12a), may aid in the assessment of functional capacity. However, PROMIS PF-SF12a has not been validated against exercise capacity, or compared with established questionnaires, including the Duke Activity Status Index (DASI). We compared the DASI and PROMIS PF-SF12a to the maximum metabolic equivalents (METs) achieved during exercise stress testing. METHODS: DASI and PROMIS PF-SF12a were electronically administered to 100 adult patients (median age 56years, 61% male) immediately before exercise stress testing. DASI-predicted METs and PROMIS T score were calculated. Correlations with exercise METs with and without age adjustment were examined. Linear regression lines were derived and adjusted r2 statistic was calculated. We compared models with the Davidson-Mackinnon J test. RESULTS: The median (interquartile range) DASI-predicted METs, PROMIS Tscore, and exercise METs were 8.97 (7.61-9.89), 47.90 (43.33-52.40), and 10.10 (10.10-12.80), respectively. In unadjusted correlation analyses, PROMIS accounted for 26% of the variance in exercise METs compared with 38% with DASI. With age adjustment, the r2values increased to 0.36 (PROMIS) and 0.46 (DASI). In both unadjusted and age-adjusted analyses, inclusion of DASI improved prediction of exercise METs beyond PROMIS T score (P<.0001). In contrast, PROMIS T score did not improve exercise MET prediction compared with DASI alone (P>.10). CONCLUSION: Among patients undergoing clinically indicated exercise stress testing, DASI outperformed PROMIS PF-SF12a as a predictor of exercise METs.

Targeted Temperature Management Effectiveness in the Elderly: Insights from a Large Registry.

Targeted temperature management (TTM) is recommended for all comatose adult out-of-hospital cardiac arrest (OHCA) patients with shockable first documented rhythm. However, studies examining the use and benefits of TTM among patients aged 75 and older are lacking. Using the Cardiac Arrest Registry to Enhance Survival (CARES) dataset registry from 2013 to 2015. Study criteria included being 75 years of age or older, survival to hospital admission, and known in-hospital mortality and CPC (Cerebral Performance Categories Scale) Scores. The study outcomes were in-hospital mortality and poor neurologic outcomes (CPC Scores 3 or 4) at hospital discharge among survivors. Hierarchical logistic regression and propensity score matching were used for multivariable adjustment. Two thousand nine hundred eighty-two patients met study inclusion criteria. One thousand three hundred fifty-seven (45.5%) received TTM in the admitting hospital. Receipt of TTM was more likely among men, those with a shockable first documented rhythm, and those with their event witnessed. There was no significant association with TTM and in-hospital mortality among patients with ventricular fibrillation (odds ratio [OR] = 0.88; 95% confidence interval [CI] [0.62-1.25]), p = 0.487 within the cohort. However, patients with a nonshockable first rhythm receiving TTM had higher odds of in-hospital mortality (p < 0.001). Propensity score results showed a modest association with TTM and increased mortality (OR) = 1.22, 95% CI [1.01-1.47]; p = 0.036 and no association with poor neurologic outcome (OR = 1.18; 95% CI [0.82-1.69]; p = 0.379) in the elderly. TTM is often provided to OHCA patients over age 75 though the benefits, particularly among nonshockable first documented rhythm patients are unclear. A randomized trial is needed to definitively answer who among OHCA event survivors aged 75 and older should receive this treatment.