Post-resuscitation myocardial dysfunction in out-of-hospital cardiac arrest patients randomized to immediate coronary angiography versus standard of care.
ABSTRACT: Background:Immediate coronary angiography with subsequent percutaneous coronary intervention (PCI) has the potential to reduce post-resuscitation myocardial dysfunction in out-of-hospital cardiac arrest (OHCA) patients. The aim of this study was to see if immediate coronary angiography, with potential PCI, in patients without ST-elevation on the ECG, influenced post-resuscitation myocardial function and cardiac biomarkers. Methods:A secondary analysis of the Direct or Subacute Coronary Angiography in Out-of-Hospital Cardiac Arrest (DISCO) trial (ClinicalTrials.gov ID: NCT02309151). Patients with bystander-witnessed OHCA, without ST-elevations on the ECG were randomly assigned to immediate coronary angiography within two hours of cardiac arrest (n = 38) versus standard-of-care with deferred angiography (n = 40). Outcome measures included left ventricle ejection fraction (LVEF) at 24 h, peak Troponin T levels, lactate clearance and NT-proBNP at 72 h. Results:In the immediate-angiography group, median LVEF at 24 h was 47% (Q1-Q3; 30-55) vs. 46% (Q1-Q3; 35-55) in the standard-of-care group. Peak Troponin-T levels during the first 24 h were 362 ng/L (Q1-Q3; 174-2020) in the immediate angiography group and 377 ng/L (Q1-Q3; 205-1078) in the standard-of-care group. NT-proBNP levels at 72 h were 931 ng/L (Q1-Q3; 396-2845) in the immediate-angiography group and 1913 ng/L (Q1-Q3; 489-3140) in the standard-of-care group. Conclusion:In this analysis of OHCA patients without ST-elevation on the ECG randomized to immediate coronary angiography or standard-of-care, no differences in post-resuscitation myocardial dysfunction parameters between the two groups were found. This finding was consistent also in patients randomized to immediate coronary angiography where PCI was performed compared to those where PCI was not performed.
Project description:Substantial geographic variation exists in percutaneous coronary intervention (PCI) use across the United States. It is unclear the extent to which high PCI utilization can be explained by PCI for inappropriate indications. The objective of this study was to examine the relationship between PCI rates across regional healthcare markets utilizing hospital referral regions (HRRs) and PCI appropriateness.The number of PCI procedures in each HRR was obtained from the 2010 100% Medicare limited data set. HRRs were divided into quintiles of PCI utilization with increasing rates of utilization progressing to quintile 5. NCDR CathPCI Registry® data were used to evaluate patient characteristics, appropriate use criteria (AUC), and outcomes across the HRR quintiles defined by PCI utilization with the study population restricted to HRRs where ? 80% of the PCIs were performed at institutions participating in the registry. PCI appropriateness was defined using 2012 AUC by the American College of Cardiology (ACC)/American Heart Association (AHA)/The Society for Cardiovascular Angiography and Interventions (SCAI).Our study cohort comprised of 380,981 patients treated at 178 HRRs. Mean PCI rates per 1,000 increased from 4.6 in Quintile 1 to 10.8 in Quintile 5. The proportion of non-acute PCIs was 27.7% in Quintile 1 increasing to 30.7% in Quintile 5. Significant variation (p < 0.001) existed across the quintiles in the categorization of appropriateness across HRRs of utilization with more appropriate PCI in lower utilization areas (Appropriate: Q1, 76.53%, Q2, 75.326%, Q3, 75.23%, Q4, 73.95%, Q5, 72.768%; Inappropriate: Q1 3.92%, Q2 4.23%, Q3 4.32%, Q4 4.35%, Q5 4.05%; Uncertain: Q1 8.29%, Q2 8.84%, Q3 8.08%, Q4 9.01%, Q5 8.93%; Not Mappable: Q1 11.26%, Q2 11.67%, Q3 12.37%, Q4 12.69%, Q5 14.34%). There was no difference in risk-adjusted mortality across quintiles of PCI utilization.Geographic regions with lower PCI rates have a higher proportion of PCIs performed for appropriate indications. Areas that perform more PCIs also appear to perform more elective PCI and many could not be mapped by the AUC.
Project description:Extracorporeal cardiopulmonary resuscitation (ECPR) is a last resort treatment option for refractory cardiac arrest performed in specialized centers. Following consensus recommendations, ECPR is mostly offered to younger patients with witnessed collapse but without return of spontaneous circulation (ROSC). We report findings from a large single-center registry with 252 all-comers who received ECPR from 2011-2019. It took a median of 52?min to establish stable circulation by ECPR. Eighty-five percent of 112 patients with out-of-hospital cardiac arrest (OHCA) underwent coronary angiography, revealing myocardial infarction (MI) type 1 with atherothrombotic vessel obstruction in 70 patients (63% of all OHCA patients, 74% of OHCA patients undergoing coronary angiography). Sixty-six percent of 140 patients with intra-hospital cardiac arrest (IHCA) underwent coronary angiography, which showed MI type 1 in 77 patients (55% of all IHCA patients, 83% of IHCA patients undergoing coronary angiography). These results suggest that MI type 1 is a frequent finding and - most likely - cause of cardiac arrest (CA) in patients without ROSC, especially in OHCA. Hospital survival rates were 30% and 29% in patients with OHCA and IHCA, respectively. According to these findings, rapid coronary angiography may be advisable in patients with OHCA receiving ECPR without obvious non-cardiac cause of arrest, irrespective of electrocardiogram analysis. Almost every third patient treated with ECPR survived to hospital discharge, supporting previous data suggesting that ECPR may be beneficial in CA without ROSC. In conclusion, interventional cardiology is of paramount importance for ECPR programs.
Project description:BACKGROUND: Through the AMI-QUEBEC Study we sought to describe delays to reperfusion therapy for ST-segment elevation myocardial infarction (STEMI) and to identify factors associated with prolonged delays. METHODS: We reviewed the charts of all consecutive patients with STEMI admitted to 17 hospitals in the province of Quebec in 2003 to obtain data on the time from presentation to reperfusion therapy. Data were available for 1189 (83.0%) of 1432 patients. RESULTS: The median delay to reperfusion therapy was 32 minutes (first and third quartile [Q1, Q3] 20, 49) for 535 patients who received fibrinolytic therapy, 109 minutes (Q1, Q3 79, 150) for 455 patients who underwent primary percutaneous coronary intervention (PCI) at the initial hospital of presentation and 142 minutes (Q1, Q3 115, 194) for 199 patients who underwent primary PCI after an interhospital transfer. Patients who presented outside daytime working hours, those who received primary PCI and those who required interhospital transfer for primary PCI were less likely to receive reperfusion therapy within current recommended times (odds ratios [ORs] 0.49, 0.56 and 0.15, respectively). Increased age was associated with prolonged delays only among patients who received fibrinolytic therapy (OR for each 10-year increase in age 0.95, 95% credible interval [CrI] 0.93-0.99 for fibrinolytic therapy and 0.99, 95% CrI 0.95-1.05, for primary PCI). INTERPRETATION: In 2003, many patients with STEMI in Quebec were not treated within the recommended times. Delays may be reduced by reorganizing pre-and in-hospital care for patients with STEMI to expedite delivery of reperfusion therapy.
Project description:INTRODUCTION: Mild therapeutic hypothermia (MTH) has been shown to result in better neurological outcome after cardiopulmonary resuscitation. Percutaneous coronary intervention (PCI) may also be beneficial in patients after out-of-hospital cardiac arrest (OHCA). METHODS: A selected cohort study of 2,973 prospectively documented adult OHCA patients within the German Resuscitation Registry between 2004 and 2010. Data were analyzed by backwards stepwise binary logistic regression to identify the impact of MTH and PCI on both 24-hour survival and neurological outcome that was based on cerebral performance category (CPC) at hospital discharge. Odds ratios (95% confidence intervals) were calculated adjusted for the following confounding factors: age, location of cardiac arrest, presumed etiology, bystander cardiopulmonary resuscitation, witnessing, first electrocardiogram rhythm, and thrombolysis. RESULTS: The Preclinical care dataset included 2,973 OHCA patients with 44% initial return of spontaneous circulation (n = 1,302) and 35% hospital admissions (n = 1,040). Seven hundred and eleven out of these 1,040 OHCA patients (68%) were also registered within the Postresuscitation care dataset. Checking for completeness of datasets required the exclusion of 127 Postresuscitation care cases, leaving 584 patients with complete data for final analysis. In patients without PCI (n = 430), MTH was associated with increased 24-hour survival (8.24 (4.24 to 16.0), P < 0.001) and the proportion of patients with CPC 1 or CPC 2 at hospital discharge (2.13 (1.17 to 3.90), P < 0.05) as an independent factor. In normothermic patients (n = 405), PCI was independently associated with increased 24-hour survival (4.46 (2.26 to 8.81), P < 0.001) and CPC 1 or CPC 2 (10.81 (5.86 to 19.93), P < 0.001). Additional analysis of all patients (n = 584) revealed that 24-hour survival was increased by MTH (7.50 (4.12 to 13.65), P < 0.001) and PCI (3.88 (2.11 to 7.13), P < 0.001), while the proportion of patients with CPC 1 or CPC 2 was significantly increased by PCI (5.66 (3.54 to 9.03), P < 0.001) but not by MTH (1.27 (0.79 to 2.03), P = 0.33), although an unadjusted Fisher exact test suggested a significant effect of MTH (unadjusted odds ratio 1.83 (1.23 to 2.74), P < 0.05). CONCLUSIONS: PCI may be an independent predictor for good neurological outcome (CPC 1 or CPC 2) at hospital discharge. MTH was associated with better neurological outcome, although subsequent logistic regression analysis did not show statistical significance for MTH as an independent predictor for good neurological outcome. Thus, postresuscitation care on the basis of standardized protocols including coronary intervention and hypothermia may be beneficial after successful resuscitation. One of the main limitations may be a selection bias for patients subjected to PCI and MTH.
Project description:BACKGROUND:Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death worldwide, with acute coronary syndromes accounting for most of the cases. While the benefit of early revascularization has been clearly demonstrated in patients with ST-segment-elevation myocardial infarction (STEMI), diagnostic pathways remain unclear in the absence of STEMI. We aimed to characterize OHCA patients presenting to 2 tertiary cardiology centers and identify predicting factors associated with survival. METHODS:We retrospectively analyzed 519 patients after OHCA from February 2003 to December 2017 at 2 centers in Munich, Germany. Patients undergoing immediate coronary angiography (CAG) were compared to those without. Multivariate regression analysis and inverse probability treatment weighting (IPTW) were performed to identify predictors for improved outcome in a matched population. RESULTS:Immediate CAG was performed in 385 (74.1%) patients after OHCA with presumed cardiac cause of arrest. As a result of multivariate analysis after propensity score matching, we found that immediate CAG, return of spontaneous circulation (ROSC) at admission, witnessed arrest and former smoking were associated with improved 30-days-survival [(OR, 0.46; 95% CI, 0.26-0.84), (OR, 0.21; 95% CI, 0.10-0.45), (OR, 0.50; 95% CI, 0.26-0.97), (OR, 0.43; 95% CI, 0.23-0.81)], and 1-year-survival [(OR, 0.39; 95% CI, 0.19-0.82), (OR, 0.29; 95% CI, 0.12-0.7), (OR, 0.43; 95% CI, 0.2-1.00), (OR, 0.3; 95% CI, 0.14-0.63)]. CONCLUSIONS:In our study, immediate CAG, ROSC at admission, witnessed arrest and former smoking were independent predictors of survival in cardiac arrest survivors. Improvement in prehospital management including bystander CPR and best practice post-resuscitation care with optimized triage of patients to an early invasive strategy may help ameliorate overall outcome of this critically-ill patient population.
Project description:INTRODUCTION: Between 1 and 31% of patients suffering out-of-hospital cardiac arrest (OHCA) survive to discharge from hospital. International studies have shown that the level of care provided by the admitting hospital determines survival for patients suffering from OHCA. These data may only be partially transferable to the German medical system where responders are in-field emergency medical physicians. The present study determines the influence of the emergency physician's choice of admitting hospital on patient outcome after OHCA in a large urban setting. METHODS: All data for patients collected in the German Resuscitation Registry for the city of Dortmund during 2007 and 2008 were analyzed. Patients under 18 years of age, with traumatic mechanism, and with incomplete charts were excluded. Admitting hospitals were divided into two groups: those without the capability for percutaneous coronary intervention (PCI), and those with PCI capability. Data were analyzed by multivariate statistics, taking into account the effects of mild therapeutic hypothermia treatment and PCI capability of the admitting hospital with respect to the neurological status upon hospital discharge. RESULTS: Between 2007 and 2008 a total of 1,109 cardiopulmonary resuscitation attempts were registered for the city of Dortmund, of which 889 could be included in our study. Return of spontaneous circulation was achieved in 360 of 889 patients (40.5%). In total, 282 of 889 patients displayed return of spontaneous circulation during transport to the hospital (31.7%); 152 were transported with ongoing cardiopulmonary resuscitation (17.1%). Of the total 434 patients admitted to hospital, 264 were admitted to hospitals without PCI capability and 170 to hospitals with PCI capability. Multivariate analysis demonstrated a significant influence on patient discharge with good neurological status for those admitted to PCI hospitals (odds ratio 3.14 (95% confidence interval 1.51 to 6.56)), independent of receiving mild therapeutic hypothermia and/or PCI. Compared with patients admitted to hospitals without PCI capability, significantly more patients in PCI hospitals were discharged alive (41% vs. 13%, P < 0.001) and remained alive 1 year after the event (28% vs. 6%, P < 0.001). CONCLUSIONS: The choice of admitting hospital for patients suffering OHCA significantly influences treatment and outcome. This influence is independent of PCI performance and of mild therapeutic hypothermia. Further analysis is required to determine the possible parameters determining patient outcome.
Project description:No well-defined protocols currently exist regarding the optimal rate and duration of normal saline administration to prevent contrast-induced acute kidney injury (CI-AKI) in patients with renal insufficiency.Hydration volume ratios (hydration volume/weight; HV/W) were calculated in 1406 patients with renal insufficiency (estimated glomerular filtration rate [eGFR], <90 mL/min per 1.73 m(2)) undergoing percutaneous coronary intervention (PCI) with routine speed hydration (1 or 0.5 mL/kg per hour). We investigated the relationship between hydration volume, risk of CI-AKI (increase in serum creatinine ?0.5 mg/dL or 25% within 48-72 hours), and prognosis. Mean follow-up duration was 2.85±0.88 years. Individuals with higher HV/W were more likely to develop CI-AKI (quartiles: Q1, Q2, Q3, and Q4: 4.3%, 6.6%, 10.9%, and 15.0%, respectively; P<0.001). After adjusting 12 confounders, including age, sex, eGFR, anemia, emergent PCI, diabetes mellitus, chronic heart failure, diuretics, contrast volume, lesions, smoking status, and number of stents, multivariate analysis showed that a higher HV/W ratio was not associated with a decreased CI-AKI risk (Q2 vs Q1: adjusted odds ratio [OR], 1.13; Q3 vs Q1: adjusted OR, 1.51; Q4 vs Q1: adjusted OR, 1.87; all P>0.05) and even increased CI-AKI risk (HV/W >25 mL/kg: adjusted OR, 2.11; 95% CI, 1.24-3.59; P=0.006). Additionally, higher HV/W was significantly associated with an increased risk of death (Q4 vs Q1: adjusted hazard ratio, 3.44; 95% CI, 1.20-9.88; P=0.022).Excessively high hydration volume at routine speed might be associated with increased risk of CI-AKI and death post-PCI in patients with renal insufficiency.
Project description:This study aimed to identify the association between ambient temperature (AT) and patient outcome of witnessed out-of-hospital cardiac arrest (OHCA) occurring outdoors. This retrospective nationwide, population-based cohort study recruited witnessed adult OHCA patients in South Korea from January 2012 to December 2016. Meteorological data of 17 metropolitan cities and provinces were retrieved from the Korea Meteorological Administration database. Primary outcome was sustained return of spontaneous circulation (ROSC) in hospital. Secondary outcome was survival to hospital discharge. By the standard of quartile categories of AT (Q1 = 7.1 °C; Q2 = 17.7 °C; Q3 = 23.5 °C), three comparative analyses for ROSC and survival were performed between low and high AT groups. Propensity score matching (1:1) was performed for both AT groups. Among the 142,906 OHCA patients, 1,295 were included. In the multivariate analysis for matched groups by the standard of 7.1 °C (Q1), proportion of ROSC was significantly higher in the high AT-Q1 group than in the low AT-Q1 group (adjusted odds ratio [aOR] 2.02, 95% confidence interval [CI] 1.19-3.44). No significant difference in survival was shown between both AT-Q1 groups (aOR 1.24, 95% CI 0.61-2.52). In the standard of 17.7 °C (Q2) and 23.5 °C (Q3), no significant differences in ROSC and survival were found between the low and high AT groups. In conclusion, no obvious correlation existed between AT and patient outcomes such as sustained ROSC or survival to discharge in this study.
Project description:To investigate the association between growth differentiation factor-15 (GDF-15) and contrast-induced nephropathy (CIN) in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI).A total of 311 patients with AMI were studied retrospectively. All patients were divided into two groups according to the occurrence of CIN after PCI. Baseline clinical data were compared between two groups. Multivariate logistic regression analysis was used to identify the risk factors for CIN. Cox regression analysis was used to identify the association between GDF-15, CIN and short-term outcome.There were 80 patients in CIN group (average age was 71.60 ± 13.00 years; 67.5% male) and 231 patients in non-CIN group (average age was 63.80 ± 11.70 years; 71.9%male). The concentration of GDF-15 in CIN group was higher than that of non-CIN group (1232 ± 366.6 ng/L vs. 939.20 ± 309.6 ng/L, P <0.001). According to GDF-15 quartiles, patients were divided into four groups. Multivariate logistic model indicated that the highest quartile(Q4) was significantly associated with an increased risk of CIN compared with lower level of GDF-15 (Q1, Q2 and Q3) (OR : 3.572, 1.803-7.078, P < 0.001). Of 243 patients who could calculate the ACEF risk score, area under the curve (AUC) of GDF-15 was 0.793, 95%CI: 0.729-0.856, P < 0.001, while AUC of ACEF was 0.708, 95%CI: 0.630-0.786, P < 0.001. Using 10% and 30% as arbitrary thresholds to define patients at low, intermediate, and high risk, GDF-15 achieved a net reclassification improvement (NRI) of 0.32 (95%CI: 0.123-0.518, P = 0.001) compared with the ACEF risk score. Cox regression model showed that high concentration of GDF-15 (Q4) was significantly associated with an increased risk of all-cause mortality and major adverse clinical events (MACE) (HR: 8.434, 95%CI: 2.650-26.837, P <0.001; HR: 3.562, 95%CI: 1.658-7.652, P = 0.001) compared with low level of GDF-15 (Q1, Q2 and Q3). CIN was an independent predictor of all-cause mortality and MACE in AMI patients (HR: 3.535, 95%CI: 1.135-11.005, P = 0.029; HR: 5.154, 95%CI: 2.228-11.925, P <0.001).GDF-15 levels increased in CIN group in AMI patients underwent PCI. GDF-15 was an independent risk factor for CIN in AMI patients underwent PCI. GDF-15 level and CIN are independent risk factors for all-cause mortality and MACE in short-term follow-ups.
Project description:The American Heart Association (AHA) recommends regionalized care following out-of-hospital cardiac arrest (OHCA) at cardiac resuscitation centers (CRCs). Key level 1 CRC criteria include 24/7 percutaneous coronary intervention (PCI) capability, therapeutic hypothermia capability, and annual volume of ?40 patients resuscitated from OHCA. Our objective was to characterize the availability and utilization of resources relevant to post-cardiac arrest care, including level 1 CRCs in California.We combined data from the AHA, the California Office of Statewide Health Planning and Development (OSHPD), and surveys to identify CRCs. We surveyed emergency department directors and nurse managers at all 24/7 PCI centers identified by the AHA to determine their post-OHCA care capabilities. The survey included questions regarding therapeutic hypothermia use and specialist availability and was pilot-tested prior to distribution. Cases of OHCA were identified in the 2011 OSHPD Patient Discharge Database using a "present on admission" diagnosis of cardiac arrest (ICD-9-CM code 427.5). We defined key level 1 CRC criteria as 24/7 PCI capability, therapeutic hypothermia, and annual volume ?40 patients admitted with a "present on admission" diagnosis of cardiac arrest. Our primary outcome was the proportion of hospitals meeting these criteria. Descriptive statistics and 95% CI are presented.Of the 333 acute care hospitals in California, 31 (9.3%, 95% CI 6.4-13%) met level 1 CRC criteria. These hospitals treated 25% (1937/7780; 95% CI 24-26%) of all admitted OHCA patients in California in 2011. Of the 125 hospitals identified as 24/7 PCI centers by the AHA, 54 (43%, 95% CI 34-52%) admitted ?40 patients following OHCA in 2011. Seventy (56%, 95% CI 47-65%) responded to the survey; 69/70 (99%, 95% CI 92-100%) reported having a therapeutic hypothermia protocol in effect by 2011. Five percent of admitted OHCA patients (402/7780; 95% CI 4.7-5.7%) received therapeutic hypothermia and 18% (1372/7780; 95% CI 17-19%) underwent cardiac catheterization.Approximately 10% of hospitals met key criteria for AHA level 1 CRCs. These hospitals treated one-quarter of patients resuscitated from OHCA in 2011. The feasibility of regionalized care for OHCA requires detailed evaluation prior to widespread implementation.