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1.
JACC Heart Fail ; 9(3): 169-178, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33549560

RESUMO

Heart failure with preserved ejection fraction (HFpEF) is an increasingly diagnosed condition whose failure to respond to new drugs effective in heart failure with reduced ejection fraction is of great concern. HFpEF is an incompletely understood and markedly heterogeneous syndrome, but cardiac amyloidosis is increasingly recognized as one of its various causes. The specific hemodynamic and pathophysiological features of cardiac amyloidosis result in poor tolerance of heart failure medications and in worse outcomes compared with other causes. Until recently, patients considered for HFpEF trials were not routinely screened for cardiac amyloidosis. This review examines how real-world patients with cardiac amyloidosis met inclusion criteria for 8 major HFpEF clinical trials, including the recent PARAGON (Prospective Comparison of ARNI with ARB Global Outcomes in HF With Preserved Ejection Fraction) trial. This review discusses how the presence in the trial populations of a subset of patients with cardiac amyloidosis might contribute to explain the absence of efficacy of medications for HFpEF in trials so far. A multistep screening strategy is suggested in which patients with red flags for cardiac amyloidosis undergo both a light chain assay and technetium-labeled cardiac scintigraphy (technetium-labeled cardiac scintigraphy scan), which, when negative, rule out cardiac amyloidosis. Using this strategy would allow the testing of new medications for HFpEF in populations containing no patients with cardiac amyloidosis, thus potentially increasing the likelihood of showing therapeutic efficacy, and finally making some effective treatment available.

3.
Ann Intensive Care ; 10(1): 170, 2020 Dec 14.
Artigo em Inglês | MEDLINE | ID: mdl-33315152

RESUMO

A post-resuscitation shock occurs in 50-70% of patients who had a cardiac arrest. It is an early and transient complication of the post-resuscitation phase, which frequently leads to multiple-organ failure and high mortality. The pathophysiology of post-resuscitation shock is complex and results from the whole-body ischemia-reperfusion process provoked by the sequence of circulatory arrest, resuscitation manoeuvers and return of spontaneous circulation, combining a myocardial dysfunction and sepsis features, such as vasoplegia, hypovolemia and endothelial dysfunction. Similarly to septic shock, the hemodynamic management of post-resuscitation shock is based on an early and aggressive hemodynamic management, including fluid administration, vasopressors and/or inotropes. Norepinephrine should be considered as the first-line vasopressor in order to avoid arrhythmogenic effects of other catecholamines and dobutamine is the most established inotrope in this situation. Importantly, the optimal mean arterial pressure target during the post-resuscitation shock still remains unknown and may probably vary according to patients. Mechanical circulatory support by extracorporeal membrane oxygenation can be necessary in the most severe patients, when the neurological prognosis is assumed to be favourable. Other symptomatic treatments include protective lung ventilation with a target of normoxia and normocapnia and targeted temperature management by avoiding the lowest temperature targets. Early coronary angiogram and coronary reperfusion must be considered in ST-elevation myocardial infarction (STEMI) patients with preserved neurological prognosis although the timing of coronary angiogram in non-STEMI patients is still a matter of debate. Further clinical research is needed in order to explore new therapeutic opportunities regarding inflammatory, hormonal and vascular dysfunction.

4.
Resuscitation ; 2020 Oct 04.
Artigo em Inglês | MEDLINE | ID: mdl-33027618

RESUMO

PURPOSE: Mesenteric ischaemia after successfully resuscitated cardiac arrest (CA) has been insufficiently studied. We aimed to assess the frequency, risk factors, and outcomes of non-occlusive mesenteric ischaemia (NOMI) after CA. METHODS: We retrospectively included patients admitted to a CA centre with sustained return of spontaneous circulation between 2007 and 2017. NOMI was suspected based on clinical symptoms and classified as possible if no tests were feasible or the only test was a negative abdominal computed tomography (CT) scan and as confirmed if diagnosed by endoscopy, CT, or surgery. RESULTS: Of 1343 patients, 82 (6%) had suspected NOMI, including 33 (2.5%) with confirmed NOMI. Investigations for suspected NOMI were done in 47/82 (57%) patients (CT, n=30; lower digestive endoscopy, n=14; and upper digestive endoscopy, n=12); 11 patients underwent surgery. By multivariate analysis, factors associated with suspected NOMI were female sex (OR, 1.8; 95%CI, 1.1-2.9, p=0.02), cardiovascular comorbidities (OR, 1.6; 95%CI, 1.0-2.7; p=0.047), admission lactate >5 mmol/L (OR, 2.0; 95%CI, 1.2-3.4; p=0.01), low flow >17minutes (OR, 2.2; 95%CI, 1.3-3.8; p=0.003), and inotropic score >7µg/kg/min (OR, 1.8; 95%CI, 1.1- 3.2; p=0.03). ICU mortality was 96% (79/82), with 61% of patients dying from multi-organ failure (MOF) and 35% from post-anoxic brain injury. Of the eight patients who regained consciousness, 5 finally died from MOF, leaving 3 patients discharged alive from the ICU with a good neurologic outcome. CONCLUSIONS: NOMI may affect 2.5% to 6% of patients after CA. Mortality was extremely high in patients, and very few survived with a good neurological outcome.

5.
Circ Cardiovasc Interv ; 13(9): e009181, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32895006

RESUMO

BACKGROUND: Conflicting data exist regarding the benefit of urgent coronary angiogram and percutaneous coronary intervention (PCI) after sudden cardiac arrest, particularly in the absence of ST-segment elevation. We hypothesized that the type of lesions treated (stable versus unstable) influences the benefit derived from PCI. METHODS: Data were taken between May 2011 and 2014 from a prospective registry enrolling all sudden cardiac arrest in Paris and suburbs (6.7 million inhabitants). Patients undergoing emergent coronary angiogram were included. Decision to perform PCI was left to the discretion of local teams. We assessed the impact of emergent PCI on survival at discharge according to whether the treated lesion was angiographically unstable or stable, and we investigated the predictive factors for unstable coronary lesions. RESULTS: Among 9265 sudden cardiac arrests occurring during the study period, 1078 underwent emergent coronary angiogram (median age: 59.6 years, 78.3% males): 463 (42.9%) had an unstable lesion, 253 (23.5%) only stable lesions, and 362 (33.6%) no significant lesions. Emergent PCI was performed in 478 patients (91.4% of unstable and 21.7% of stable lesions). At discharge, PCI of unstable lesions was associated with twice-higher survival rate compared with untreated unstable lesions (47.9% versus 25.6%, P=0.013), while stable lesions PCI did not improve survival (25.5% versus 26.3%, P=1.00). After adjustment, PCI of unstable coronary lesions was independently associated with improved survival (odds ratio, 2.09 [95% CI, 1.42-3.09], P<0.001), contrary to PCI of stable lesions (odds ratio, 0.92 [95% CI. 0.44-1.87], P=0.824). Angina, initial shockable rhythm, ST-segment elevation, and absence of known coronary artery disease were independent predictors of unstable lesions. CONCLUSIONS: Emergent PCI of unstable lesions is associated with improved survival after sudden cardiac arrest, contrary to PCI of stable lesions. Accordingly, early PCI should only be performed in patients with unstable lesions. Four factors (chest pain, ST-elevation, absence of coronary artery disease history, and shockable initial rhythm) could help identify patients with unstable lesions who would, therefore, benefit from emergent coronary angiogram.

7.
Clin Kidney J ; 13(3): 413-420, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32699621

RESUMO

Background: Acute kidney injury (AKI) is frequent in patients resuscitated from cardiac arrest (CA) and may worsen outcome. Experimental data suggest a renoprotective effect by treating these patients with a high dose of erythropoietin (Epo) analogues. We aimed to evaluate the efficacy of epoetin alpha treatment on renal outcome after CA. Methods: We did a post hoc analysis of the Epo-ACR-02 trial, which randomized patients with a persistent coma after a witnessed out-of-hospital CA. Only patients admitted in one intensive care unit were analysed. In the intervention group, patients received five intravenous injections of Epo spaced 12 h apart during the first 48 h, started as soon as possible after resuscitation. In the control group, patients received standard care without Epo. The main endpoint was the proportion of patients with persistent AKI defined by Kidney Disease: Improving Global Outcomes criteria at Day 2. Secondary endpoints included the occurrence of AKI through Day 7, estimated glomerular filtration rate (eGFR) at Day 28, haematological indices and adverse events. Results: A total of 162 patients were included in the primary analysis (74 in the Epo group, 88 in the control group). Baseline characteristics were similar in the two groups. At Day 2, 52.8% of the patients (38/72) in the intervention group had an AKI, as compared with 54.4% of the patients (46/83) in the control group (P = 0.74). There was no significant difference between the two groups regarding the proportion of patients with AKI through Day 7. Among patients with persistent AKI at Day 2, 33% (4/12) in the intervention group had an eGFR <75 mL/min/1.73 m2 compared with 25% (3/12) in the control group at Day 28 (P = 0.99). We found no significant differences in haematological indices or adverse events. Conclusion: After CA, early administration of Epo did not confer any renal protective effect as compared with standard therapy.

9.
Lancet Public Health ; 5(8): e437-e443, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32473113

RESUMO

BACKGROUND: Although mortality due to COVID-19 is, for the most part, robustly tracked, its indirect effect at the population level through lockdown, lifestyle changes, and reorganisation of health-care systems has not been evaluated. We aimed to assess the incidence and outcomes of out-of-hospital cardiac arrest (OHCA) in an urban region during the pandemic, compared with non-pandemic periods. METHODS: We did a population-based, observational study using data for non-traumatic OHCA (N=30 768), systematically collected since May 15, 2011, in Paris and its suburbs, France, using the Paris Fire Brigade database, together with in-hospital data. We evaluated OHCA incidence and outcomes over a 6-week period during the pandemic in adult inhabitants of the study area. FINDINGS: Comparing the 521 OHCAs of the pandemic period (March 16 to April 26, 2020) to the mean of the 3052 total of the same weeks in the non-pandemic period (weeks 12-17, 2012-19), the maximum weekly OHCA incidence increased from 13·42 (95% CI 12·77-14·07) to 26·64 (25·72-27·53) per million inhabitants (p<0·0001), before returning to normal in the final weeks of the pandemic period. Although patient demographics did not change substantially during the pandemic compared with the non-pandemic period (mean age 69·7 years [SD 17] vs 68·5 [18], 334 males [64·4%] vs 1826 [59·9%]), there was a higher rate of OHCA at home (460 [90·2%] vs 2336 [76·8%]; p<0·0001), less bystander cardiopulmonary resuscitation (239 [47·8%] vs 1165 [63·9%]; p<0·0001) and shockable rhythm (46 [9·2%] vs 472 [19·1%]; p<0·0001), and longer delays to intervention (median 10·4 min [IQR 8·4-13·8] vs 9·4 min [7·9-12·6]; p<0·0001). The proportion of patients who had an OHCA and were admitted alive decreased from 22·8% to 12·8% (p<0·0001) in the pandemic period. After adjustment for potential confounders, the pandemic period remained significantly associated with lower survival rate at hospital admission (odds ratio 0·36, 95% CI 0·24-0·52; p<0·0001). COVID-19 infection, confirmed or suspected, accounted for approximately a third of the increase in OHCA incidence during the pandemic. INTERPRETATION: A transient two-times increase in OHCA incidence, coupled with a reduction in survival, was observed during the specified time period of the pandemic when compared with the equivalent time period in previous years with no pandemic. Although this result might be partly related to COVID-19 infections, indirect effects associated with lockdown and adjustment of health-care services to the pandemic are probable. Therefore, these factors should be taken into account when considering mortality data and public health strategies. FUNDING: The French National Institute of Health and Medical Research (INSERM).


Assuntos
Infecções por Coronavirus/epidemiologia , Parada Cardíaca Extra-Hospitalar/epidemiologia , Pandemias , Pneumonia Viral/epidemiologia , Idoso , Feminino , Humanos , Masculino , Paris/epidemiologia
10.
Eur Heart J Acute Cardiovasc Care ; : 2048872620915655, 2020 May 27.
Artigo em Inglês | MEDLINE | ID: mdl-32458690

RESUMO

BACKGROUND: Acute mesenteric ischaemia is a severe complication in critically ill patients, but has never been evaluated in patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). This study was designed to determine the prevalence of mesenteric ischaemia in patients supported by V-A ECMO and to evaluate its risk factors, as well as to appreciate therapeutic modalities and outcome. METHODS: In a retrospective single centre study (January 2013 to January 2017), all consecutive adult patients who underwent V-A ECMO were included, with exclusion of those dying in the first 24 hours. Diagnosis of mesenteric ischaemia was performed using digestive endoscopy, computed tomography scan or first-line laparotomy. RESULTS: One hundred and fifty V-A ECMOs were implanted (65 for post-cardiotomy shock, 85 for acute cardiogenic shock, including 39 patients after refractory cardiac arrest). Overall, median age was 58 (48-69) years and mortality 56%. Acute mesenteric ischaemia was suspected in 38 patients, with a delay of four (2-7) days after ECMO implantation, and confirmed in 14 patients, that is, a prevalence of 9%. Exploratory laparotomy was performed in six out of 14 patients, the others being too unstable to undergo surgery. All patients with mesenteric ischaemia died. Independent risk factors for developing mesenteric ischaemia were renal replacement therapy (odds ratio (OR) 4.5, 95% confidence interval (CI) 1.3-15.7, p=0.02) and onset of a second shock within the first five days (OR 7.8, 95% CI 1.5-41.3, p=0.02). Conversely, early initiation of enteral nutrition was negatively associated with mesenteric ischaemia (OR 0.15, 95% CI 0.03-0.69, p=0.02). CONCLUSIONS: Acute mesenteric ischaemia is a relatively frequent but dramatic complication among patients on V-A ECMO.

11.
Eur Heart J ; 41(21): 1961-1971, 2020 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-31670793

RESUMO

AIMS: Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes. METHODS AND RESULTS: We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8-2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5-1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5-10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1-4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5-5.9; P = 0.002). CONCLUSIONS: In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

12.
J Inherit Metab Dis ; 43(3): 459-466, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31652339

RESUMO

Assessing long-term mortality and identifying predictors of death in adults with mitochondrial diseases. We retrospectively included adult patients with genetically proven mitochondrial diseases referred to our centre between January 2000 and June 2016, and collected information relative to their genetic testing, clinical assessments, and vital status. We performed single and multiple variable analyses in search of predictors of total mortality, and calculated hazard ratios (HR) and 95% confidence intervals (CI). We included 267 patients (women 59%; median age 43.3 [31.3-54.2] years), including 111 with mitochondrial DNA (mtDNA) single large-scale deletions, 65 with m.3243A>G, 24 with m.8344A>G, 32 with other mtDNA point mutations, and 36 patients with nuclear genes mutations. Over a median follow-up of 8.9 years (0.3 to 18.7), 61 patients (22.8%) died, at a median age of 50.7 (37.9-51.9) years. Primary cause of death was cardiovascular disease in 16 patients (26.2%), respiratory in 11 (18.0%), and gastrointestinal in 5 (8.1%). By multiple variable analysis, diabetes (HR 2.75; 95% CI 1.46-5.18), intraventricular cardiac conduction defects (HR 3.38; 95% CI 1.71-6.76) and focal brain involvement (HR 2.39; 95% CI 1.25-4.57) were independent predictors of death. Adult patients with mitochondrial diseases present high morbidity that can be independently predicted by the presence of diabetes, intraventricular cardiac conduction defects, and focal brain involvement.

13.
J Inherit Metab Dis ; 43(3): 478-485, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31762033

RESUMO

The prevalence of arterial hypertension in mitochondrial diseases remains unknown. Between January 2000 and May 2014, we retrospectively included patients with genetically proven mitochondrial diseases. We recorded clinical, genetic and cardiac exploration data, including the measure of arterial pressure. Among the 260 patients included in the study (mean age = 44 ± 15 years, women = 158), 108 (41.5%) presented with arterial hypertension. The prevalence of hypertension by sex and age was higher than that observed in the general population for all groups. The prevalence of hypertension was significantly higher in patients with MELAS (mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes) mutations (66%) and MERRF (myoclonus, epilepsy, ataxia with ragged ref fibres) mutations (61%). In patients with MELAS mutation, the presence of hypertension was significantly associated with age and mutation rate in the blood (odds ratio = 1.12; P = .02) in multivariate analysis. The prevalence of hypertension was more important in patients having a mitochondrial disease. The increased risk was more important in patient with MELAS or MERRF and depended on the rate of heteroplasmy.

14.
Resuscitation ; 147: 34-42, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-31857140

RESUMO

AIM: Coronary artery disease (CAD) has recently been emphasized as a major cause of sudden cardiac arrest (SCA) in young adults. We aim to assess the rate of immediate coronary angiography performance in young patients resuscitated from SCA. METHODS: From May 2011 to May 2017, all cases of out-of-hospital SCA aged 18-40 years alive at hospital admission were prospectively included in 48 hospitals of the Great Paris area. Cardiovascular causes of SCA were centrally adjudicated, and management including immediate coronary angiography performance was assessed. RESULTS: Out of 3579 SCA admitted alive, 409 (11.4%) patients were under 40 years of age (32.3 ± 6.2 years, 69.7% males), with 244 patients having a definite cause identified. Among those, CAD accounted for 72 (29.5%) cases, of which 64 (88.9%) were acute coronary syndromes. The rate of immediate coronary angiography was only 41.7% compared to 65.1% among those ≥40-years (P < 0.001). During the study period, while the rate of immediate coronary angiography increased from 60.5% to 70.3% (P < 0.001) in patients aged ≥40 years, the rate in patients aged less than 40 years remained stable (43.5% to 45.3%, P = 0.795). Patients younger than 40 years were significantly less likely to undergo immediate coronary angiography (OR = 0.34, 95% CI: 0.25-0.47), although early angiography was associated with survival at hospital discharge (OR = 2.68, 95% CI: 1.21-6.00). CONCLUSION: CAD is the first cause of SCA in young adults aged less than 40 years. The observed low rates of immediate coronary angiography suggest a missed opportunity for early intervention.

15.
Artigo em Inglês | MEDLINE | ID: mdl-33609105

RESUMO

BACKGROUND: Acute mesenteric ischaemia is a severe complication in critically ill patients, but has never been evaluated in patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). This study was designed to determine the prevalence of mesenteric ischaemia in patients supported by V-A ECMO and to evaluate its risk factors, as well as to appreciate therapeutic modalities and outcome. METHODS: In a retrospective single centre study (January 2013 to January 2017), all consecutive adult patients who underwent V-A ECMO were included, with exclusion of those dying in the first 24 hours. Diagnosis of mesenteric ischaemia was performed using digestive endoscopy, computed tomography scan or first-line laparotomy. RESULTS: One hundred and fifty V-A ECMOs were implanted (65 for post-cardiotomy shock, 85 for acute cardiogenic shock, including 39 patients after refractory cardiac arrest). Overall, median age was 58 (48-69) years and mortality 56%. Acute mesenteric ischaemia was suspected in 38 patients, with a delay of four (2-7) days after ECMO implantation, and confirmed in 14 patients, that is, a prevalence of 9%. Exploratory laparotomy was performed in six out of 14 patients, the others being too unstable to undergo surgery. All patients with mesenteric ischaemia died. Independent risk factors for developing mesenteric ischaemia were renal replacement therapy (odds ratio (OR) 4.5, 95% confidence interval (CI) 1.3-15.7, p=0.02) and onset of a second shock within the first five days (OR 7.8, 95% CI 1.5-41.3, p=0.02). Conversely, early initiation of enteral nutrition was negatively associated with mesenteric ischaemia (OR 0.15, 95% CI 0.03-0.69, p=0.02). CONCLUSIONS: Acute mesenteric ischaemia is a relatively frequent but dramatic complication among patients on V-A ECMO.

16.
Crit Care ; 23(1): 391, 2019 Dec 03.
Artigo em Inglês | MEDLINE | ID: mdl-31796127

RESUMO

PURPOSE: Recent doubts regarding the efficacy may have resulted in a loss of interest for targeted temperature management (TTM) in comatose cardiac arrest (CA) patients, with uncertain consequences on outcome. We aimed to identify a change in TTM use and to assess the relationship between this change and neurological outcome. METHODS: We used Utstein data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (capturing CA data from all secondary and tertiary hospitals located in the Great Paris area, France) between May 2011 and December 2017. All cases of non-traumatic OHCA patients with stable return of spontaneous circulation (ROSC) were included. After adjustment for potential confounders, we assessed the relationship between changes over time in the use of TTM and neurological recovery at discharge using the Cerebral Performance Categories (CPC) scale. RESULTS: Between May 2011 and December 2017, 3925 patients were retained in the analysis, of whom 1847 (47%) received TTM. The rate of good neurological outcome at discharge (CPC 1 or 2) was higher in TTM patients as compared with no TTM (33% vs 15%, P < 0.001). Gender, age, and location of CA did not change over the years. Bystander CPR increased from 55% in 2011 to 73% in 2017 (P < 0.001) and patients with a no-flow time longer than 3 min decreased from 53 to 38% (P < 0.001). The use of TTM decreased from 55% in 2011 to 37% in 2017 (P < 0.001). Meanwhile, the rate of patients with good neurological recovery remained stable (19 to 23%, P = 0.76). After adjustment, year of CA occurrence was not associated with outcome. CONCLUSIONS: We report a progressive decrease in the use of TTM in post-cardiac arrest patients over the recent years. During this period, neurological outcome remained stable, despite an increase in bystander-initiated resuscitation and a decrease in "no flow" duration.


Assuntos
Hipotermia Induzida/normas , Parada Cardíaca Extra-Hospitalar/terapia , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hipotermia Induzida/métodos , Hipotermia Induzida/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Parada Cardíaca Extra-Hospitalar/epidemiologia , Avaliação de Resultados em Cuidados de Saúde/normas , Paris/epidemiologia , Sistema de Registros/estatística & dados numéricos
18.
Crit Care ; 23(1): 285, 2019 Aug 23.
Artigo em Inglês | MEDLINE | ID: mdl-31443696

RESUMO

BACKGROUND: Although targeted temperature management (TTM) is recommended in comatose survivors after cardiac arrest (CA), the optimal method to deliver TTM remains unknown. We performed a meta-analysis to evaluate the effects of different TTM methods on survival and neurological outcome after adult CA. METHODS: We searched on the MEDLINE/PubMed database until 22 February 2019 for comparative studies that evaluated at least two different TTM methods in CA patients. Data were extracted independently by two authors. We used the Newcastle-Ottawa Scale and a modified Cochrane ROB tools for assessing the risk of bias of each study. The primary outcome was the occurrence of unfavorable neurological outcome (UO); secondary outcomes included overall mortality. RESULTS: Our search identified 6886 studies; 22 studies (n = 8027 patients) were included in the final analysis. When compared to surface cooling, core methods showed a lower probability of UO (OR 0.85 [95% CIs 0.75-0.96]; p = 0.008) but not mortality (OR 0.88 [95% CIs 0.62-1.25]; p = 0.21). No significant heterogeneity was observed among studies. However, these effects were observed in the analyses of non-RCTs. A significant lower probability of both UO and mortality were observed when invasive TTM methods were compared to non-invasive TTM methods and when temperature feedback devices (TFD) were compared to non-TFD methods. These results were significant particularly in non-RCTs. CONCLUSIONS: Although existing literature is mostly based on retrospective or prospective studies, specific TTM methods (i.e., core, invasive, and with TFD) were associated with a lower probability of poor neurological outcome when compared to other methods in adult CA survivors (CRD42019111021).


Assuntos
Hipotermia Induzida/normas , Parada Cardíaca Extra-Hospitalar/terapia , Resultado do Tratamento , Humanos , Hipotermia Induzida/métodos , Análise de Sobrevida
19.
Resuscitation ; 141: 144-150, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31271728

RESUMO

BACKGROUNDS: In survivors of out-of-hospital cardiac arrest (OHCA), acute kidney injury (AKI) is frequent and is associated with numerous factors of definitive renal injury. We made the hypothesis that AKI after OHCA was a strong risk factor of long-term chronic kidney disease (CKD). We aimed to evaluate long-term renal outcome of OHCA survivors according the occurrence of AKI in ICU. METHODS: We used prospectively collected data from consecutive OHCA patients admitted between 2007 and 2012 in a tertiary medical ICU. AKI was defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Long-term creatinine level was the last blood creatinine assessment we were able to retrieve. The main outcome was the occurrence of CKD, defined by an estimated glomerular filtration rate (eGFR) lower than 60 mL/min/1.73m2 according to the MDRD equation. Long-term mortality was evaluated as well. Factors associated with CKD occurrence were evaluated by competing risk survival analysis (Fine Gray and Cox cause specific models). RESULTS: Among the 246 OHCA patients who were discharged alive, outcome of 133 patients was available (median age 55 [iqr 46, 68], 75.2% of male). During a median follow-up time of 1.8 [0.8-2.5] years, CKD occurred in 17 (12.7%) patients and 24 (18%) patients died. A previous history of arterial hypertension (sHR = 3.28[1.15;9.39], p = 0.027; CSH = 4.83 [1.57;14.9], p = 0.006), AKI during ICU stay (sHR = 3.72[1.40;9.84], p = 0.008; CSH = 5.41[1.79;16.3], p = 0.003) and an age higher than 55 (sHR = 6.13[1.55;24.3], p = 0.009; CSH = 2.16[1.72;43.8], p = 0.006) were independently associated with CKD occurrence. AKI was not associated with long-term mortality (sHR = 0.73 [0.27;1.99], p = 0.55; CSH = 0.75 [0.28;2.01], p = 0.57). CONCLUSION: In OHCA survivors, CKD was a frequent long-term complication. AKI during ICU stay was a strong determinant of long-term CKD occurrence.


Assuntos
Lesão Renal Aguda/epidemiologia , Parada Cardíaca Extra-Hospitalar/complicações , Insuficiência Renal Crônica/epidemiologia , Adulto , Idoso , Estudos de Coortes , Cuidados Críticos , Progressão da Doença , Feminino , Taxa de Filtração Glomerular , Hospitalização , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/mortalidade , Análise de Sobrevida
20.
Resuscitation ; 141: 81-87, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31185259

RESUMO

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.


Assuntos
Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/etiologia , Estenose Coronária/complicações , Parada Cardíaca Extra-Hospitalar/etiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Recidiva , Sistema de Registros , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de Tempo
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