Early recurrent arrhythmias after out-of-hospital cardiac arrest associated with obstructive coronary artery disease: Analysis of the PROCAT registry.

OBJECTIVE: After out-of-hospital cardiac arrest (OHCA) associated with obstructive coronary artery disease (CAD), the risk of recurrence during the early period is unclear and the indication for anti-arrhythmic treatment is debated. We assessed the incidence and predisposing factors for severe cardiac arrhythmias in this population. DESIGN: Retrospective study in a cardiac arrest center. SETTINGS: The primary endpoint was the occurrence of major cardiac arrhythmias from hospital admission to intensive care unit (ICU) discharge in patients admitted after an OHCA associated with obstructive CAD. A major arrhythmia was defined as any arrhythmic event (auricular or ventricular) associated with cardiac arrest recurrence and/or severe arterial hypotension. Secondary outcomes were time from ICU admission to arrhythmia occurrence and all-cause in-ICU mortality. Risk factors for recurrence of a major arrhythmia were assessed using multivariate analysis. PATIENTS: We included all consecutive OHCA patients resuscitated from ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) as initial rhythm associated with obstructive CAD, and who had a successful primary percutaneous coronary intervention. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Among 256 patients, a major arrhythmia occurred in 29 (11.3%), within the first 24 h in 79.3% of cases and were mostly VF (44.8%). Mortality rate was significantly increased in patients with major arrhythmia recurrence (69% vs 41%; p = 0.006). Factor significantly associated with recurrence of severe arrhythmia was male gender (OR 0.32 [0.12-0.92]; p = 0.034). Treatment with prophylactic anti-arrhythmic in the ICU was not associated with a change in the risk of recurrence (OR 0.85 [0.21-3.65], p = 0.82). CONCLUSION: An early recurrence of major arrhythmia was observed in more than 10% of post-cardiac arrest patients. These events happened mostly within the first 24 h. The interest of prophylactic anti-arrhythmic treatment remains to be evaluated in this population.

A simple functional marker to predict the need for prolonged mechanical ventilation in patients with Guillain-Barré syndrome.

INTRODUCTION: Patients suffering from Guillain-Barré syndrome (GBS) may frequently develop an acute respiratory failure and need ventilatory support. Immune therapy using plasma exchange or immunoglobulins has modified the natural course of the disease and by decreasing the length of the plateau phase, may induce a rapid improvement in ventilatory function. However a substantial proportion of patients still require prolonged mechanical ventilation (MV) and tracheotomy. The present study was designed to search for simple functional markers that could predict the need for prolonged MV just after completion of immune therapy. METHODS: We analyzed the data collected in a cohort of patients with GBS admitted to the intensive care unit (ICU) of our university hospital between 1996 and 2009. Demographic, clinical, biological and electrophysiologic data, results of sequential spirometry, and times of endotracheal intubation, tracheotomy, and MV weaning were prospectively collected for all patients. Sequential daily neurological testing used standardized data collection by the same investigators all along the study period. Results were compared by single and multiple regression analysis at admission to ICU and at the end of immune therapy, according to the need and duration of MV (≤ or > 15 days). RESULTS: Sixty-one patients with severe GBS were studied. Sixty-six percent required MV (median length: 24 days). The lack of foot flexion ability at ICU admission and at the end of immunotherapy was significantly associated with MV length > 15 days (positive predictive value: 82%; odds ratio: 5.4 [1.2 - 23.8] and 82%; 6.4 [1.4 - 28.8], respectively). The association of a sciatic nerve motor conduction block with the lack of foot flexion at the end of immunotherapy was associated with prolonged MV with a 100% positive predictive value. CONCLUSIONS: In patients admitted to ICU with Guillain-Barré syndrome and acute respiratory failure, the lack of foot flexion ability at the end of immune therapy predicts a prolonged duration of MV. Combined with a sciatic motor conduction block, it may be a strong argument to perform an early tracheotomy.

Stroke and action slowing: mechanisms, determinants and prognosis value.

AIM: The present study aimed to determine the mechanisms and determinants of stroke-related action slowing. METHODS: Thirty-six stroke patients not presenting any clinical motor deficit of the preferred hand (mean post-stroke delay 11 months) were compared to matched controls on Finger Tapping test (motor speed), Visual Inspection Time test (visual perceptual speed) and Simple and Choice Reaction Time tests. RESULTS: Patients were slower on all tests except Choice Reaction Time: Visual Inspection (p = 0.003), Finger Tapping test (p = 0.001), Simple Reaction Time (p = 0.002) tests were impaired including performance measured with the ipsi-lesional hand. This pattern and the uniform lengthening across the entire reaction time distribution both suggest that psychomotor slowing was due to slowing of perceptual and motor processes. The main determinant of action slowing was lesion location: (1) Visual Inspection Time = right inferior parietal lobulus (OR 18, 95% CI 2.9-108); (2) Finger Tapping = left frontal middle gyrus (OR 18, 95% CI 2.9-108) and lenticular nucleus (OR 59, 95% CI 1.9-1,775), and (3) Simple Reaction Time = right lenticular nucleus (OR 110, 95% CI 8-1,490) and posterior fossa (OR 55, 95% CI 3.4-890). Finally poor outcome depended on Tapping Frequency measured with the contra-lesional index (OR 0.1, 95% CI 0.02-0.5; p = 0.0005) and impairment on the Token test (OR 151, 95% CI 2.24-1136; p = 0.02). CONCLUSIONS: This study shows that stroke-related action slowing is mainly due to slowing of perceptual and motor processes. Action slowing was related to lesions of the large network. Finally Tapping Frequency is an independent predictor of outcome. This supports that action slowing is an important consequence of stroke and that it is a promising prognosis index.