Out-of-hospital cardiac arrest: racial differences in outcome in Seattle

Females of childbearing age have a survival benefit after out-of-hospital cardiac arrest

BACKGROUND

There is controversy regarding the association between age and being female and survival to hospital discharge after out-of-hospital cardiac arrest (OHCA). We hypothesized that younger females (aged 12-49 years) would be independently associated with increased survival after OHCA when compared to other age and sex groups.

METHODS

We conducted a secondary analysis of prospectively collected data from 29 United States cities that participate in the Cardiac Arrest Registry to Enhance Survival (CARES). Patients were included if they were ≥12 years of age and had a documented resuscitation attempt from October 1, 2005 through December 31, 2009. Hierarchical multivariable logistic regression analyses were used to estimate the associations between age and sex groups and survival to hospital discharge.

RESULTS

Females were less likely to have a cardiac arrest in public, was witnessed, or was treatable with defibrillation. Females in the 12-49 year old age group had a similar proportion of survival to hospital discharge when compared to age-matched males (females 11.6% vs. males 11.2%), while males ≥50 years old were more likely to survive when compared to age matched females (females 6.9% vs. males 9.6%). Age stratified regression models demonstrated that 12-49 year old females had the largest association with survival to hospital discharge (OR 1.55, 95% CI 1.20-2.00), while females in the ≥50 year old age group had a smaller increased odds of survival to hospital discharge (OR 1.18, 95% CI 1.03-1.35), which only lasted until the age of 55 years (OR 1.12, 95% CI 0.97-1.29).

CONCLUSIONS

Younger aged females were associated with increased odds of survival despite being found with poorer prognostic arrest characteristics.

Survival advantage from ventricular fibrillation and pulseless electrical activity in women compared to men: the Oregon Sudden Unexpected Death Study

OBJECTIVE

Studies evaluating a possible survival advantage from sudden cardiac arrest (SCA) in women have produced mixed results possibly due to a lack of comprehensive analyses. We hypothesized that race, socioeconomic status (SES), and elements of the lifetime clinical history influence gender effects and need to be incorporated within analyses of survival.

METHODS

Cases of SCA were identified from the ongoing, prospective, multiple-source Oregon Sudden Unexpected Death Study (population approximately one million). Subjects included were age ≥18 years who underwent attempted resuscitation by EMS providers. Pearson's chi-square tests and independent samples t tests or analysis of variance were used for univariate comparisons. We evaluated gender and race differences in survival adjusted for age, circumstances of arrest, disease burden, and socioeconomic status using a logistic regression model predicting survival.

RESULTS

A total of 1,296 cases had resuscitation attempted (2002-2007; mean age 65 years, male 67%). Women were older than men (68 vs. 63 years, p < 0.0001) and were more likely to have return of spontaneous circulation (41% vs. 33%, p = 0.004). Women were more likely to present with pulseless electrical activity (PEA) and asystole (p < 0.0001), and overall, PEA was more common among African Americans (p = 0.04). Higher survival to hospital discharge was observed in women compared to men presenting with ventricular fibrillation/tachycardia (34% vs. 24%, p = 0.02) or with PEA (10% vs. 3%, p = 0.007). In a multivariate model adjusting for age, race, presenting arrhythmia, arrest circumstances, arrest location, disease burden, and SES, women were more likely than men to survive to hospital discharge [odds ratio 1.85; 95% confidence interval (1.12-3.04)].

CONCLUSIONS

Despite older age, higher prevalence of SCA in the home, and higher rates of PEA, women had a survival advantage from ventricular fibrillation and pulseless electrical activity.

Racial differences in sudden cardiac death among hypertensive patients during antihypertensive therapy: the LIFE study

BACKGROUND

In the general population, blacks appear to have a higher risk of sudden cardiac death (SCD).

OBJECTIVES

To determine whether black hypertensive patients have a higher SCD incidence.

METHODS

The incidence of SCD was examined in 533 black and 8660 nonblack hypertensive patients with electrocardiographic left ventricular hypertrophy randomly assigned to losartan- or atenolol-based treatment.

RESULTS

During a mean follow-up of 4.8 ± 0.9 years, SCD occurred in 178 patients (1.9%); 5-year SCD incidence was significantly higher in black than in nonblack patients (3.9% vs 1.9%; P = .007). In univariate Cox analyses, black patients had a 97% higher risk of SCD (hazard ratio 1.97; 95% confidence interval 1.19-3.25; P = .015). In multivariate Cox analyses adjusting for randomized treatment, age, sex, body mass index, diabetes, history of heart failure, atrial fibrillation, myocardial infarction, ischemic heart disease, stroke, peripheral vascular disease, smoking, serum total and high-density lipoprotein cholesterol level, creatinine level, glucose level, and urine albumin/creatinine ratio and for incident myocardial infarction, in-treatment heart rate, QRS duration, diastolic and systolic pressure, Cornell voltage-duration product, and Sokolow-Lyon voltage left ventricular hypertrophy treated as time-varying covariates, black race remained associated with a 98% increased risk of SCD (hazard ratio 1.98; 95% confidence interval 1.12-3.59; P = .020).

CONCLUSIONS

Black hypertensive patients are at increased risk of SCD. The higher risk of SCD in black patients persists after adjusting for the higher prevalence of risk factors in black patients, in-treatment blood pressure, and the established predictive value of in-treatment electrocardiographic left ventricular hypertrophy and heart rate for SCD in this population.

Quality of care for sudden cardiac arrest: Proposed steps to improve the translation of evidence into practice

Sudden cardiac arrest (SCA) is the most common cause of death in the United States. Despite national guidelines, patients at risk for SCA often fail to receive evidence-based therapies. Racial and ethnic minorities and women are at particularly high risk for undertreatment. To address the persistent challenges in improving the quality of care for SCA, the Duke Center for the Prevention of Sudden Cardiac Death at the Duke Clinical Research Institute (Durham, NC) reconvened the Sudden Cardiac Arrest Thought Leadership Alliance. Experts from clinical cardiology, cardiac electrophysiology, health policy and economics, the US Food and Drug Administration, the Centers for Medicare and Medicaid Services, the Agency for Health Care Research and Quality, and device and pharmaceutical manufacturers discussed the development of SCA educational tools for patients and providers, mechanisms of implementing successful tools to help providers identify patients in their practice at risk for SCA, disparities in SCA prevention, and performance measures related to SCA care. This article summarizes the discussions held at this meeting.

Hospital racial composition: a neglected factor in cardiac arrest survival disparities

BACKGROUND

Racial disparities in survival after out-of-hospital cardiac arrest have been reported, but their causes remain uncertain. We sought to determine if hospital racial composition accounted for survival differences for patients hospitalized after cardiac arrest.

METHODS

We evaluated hospitalizations of white and black Medicare beneficiaries (2000-2007) admitted from the emergency department to the intensive care unit with a diagnosis of cardiac arrest or ventricular fibrillation. We examined unadjusted survival rates and developed a multivariable logistic regression model that included patient and hospital factors.

RESULTS

We analyzed 68,115 cardiac arrest admissions. Unadjusted survival to hospital discharge was worse for blacks (n = 7,942) compared with whites (n = 60,173) (30% vs 33%, P < .001). In multivariate analyses accounting for patient and hospital factors, adjusted probability of survival was worse for black patients at hospitals with higher proportions of black patients (31%, 95% CI 29%-32%) compared with predominately white hospitals (46%, 95% CI 36%-57%; P = .003). Similarly, whites had worse risk-adjusted survival at hospitals with higher proportions of black patients (28%, 95% CI 27%-30%) compared with predominately white hospitals (32%, 95% CI 31%-33%, P = .006). Blacks were more likely to be admitted to hospitals with low survival rates (23% vs 15%, P < .001).

CONCLUSION

Hospitals with large black patient populations had worse cardiac arrest outcomes than predominantly white hospitals, and blacks were more likely to be admitted to these high-mortality hospitals. Understanding these differences in survival outcomes may uncover the causes for these disparities and lead to improved survival for all cardiac arrest victims.

Quality management in resuscitation--towards a European cardiac arrest registry (EuReCa)

BACKGROUND

Knowledge about the epidemiology of cardiac arrest in Europe is inadequate.

AIM

To describe the first attempt to build up a Common European Registry of out-of-hospital cardiac arrest, called EuReCa.

METHODS

After approaching key persons in participating countries of the European Resuscitation Council, five countries or areas within countries (Belgium, Germany, Andalusia, North Holland, Sweden) agreed to participate. A standardized questionnaire including 28 items, that identified various aspects of resuscitation, was developed to explore the nature of the regional/national registries. This comprises inclusion criteria, data sources, and core data, as well as technical details of the structure of the databases.

RESULTS

The participating registers represent a population of 35 million inhabitants in Europe. During 2008, 12,446 cardiac arrests were recorded. The structure as well as the level of complexity varied markedly between the 5 regional/national registries. The incidence of attempted resuscitation ranged between registers from 17 to 53 per 100,000 inhabitants each year whilst the number of patients admitted to hospital alive ranged from 5 to 18 per 100,000 inhabitants each year. Bystander CPR varied 3-fold from 20% to 60%.

CONCLUSION

Five countries agreed to participate in an attempt to build up a common European Registry for out-of-hospital cardiac arrest. These regional/national registries show a marked difference in terms of structure and complexity. A marked variation was found between countries in the number of reported resuscitation attempts, the number of patients brought to hospital alive, and the proportion that received bystander CPR. At present, we are unable to explain the reason for the variability but our first findings could be a 'wake-up-call' for building up a high quality registry that could provide answers to this and other key questions in relation to the management of out-of-hospital cardiac arrest.

Association between deprivation status at community level and outcomes from out-of-hospital cardiac arrest: a nationwide observational study

STUDY OBJECTIVES

We sought to examine the association between area deprivation and outcomes of out-of-hospital cardiac arrest in Korea.

METHODS

Data were obtained from the emergency medical service (EMS) system. A nationwide OHCA cohort database from January 2006 to December 2007 was constructed via hospital chart review and ambulance run sheet data. We enrolled all EMS-assessed OHCA victims and excluded cases without available hospital outcome data or residential address. The Carstairs index was used to categorize districts according to level of deprivation into five quintiles, from (Q1, the least deprived) to (Q5, the most deprived). Main outcomes were survival to hospital discharge, survival to admission, and return of spontaneous circulation (ROSC).

RESULTS

34,227 patients were included. Initial rhythm, witnessed status, attempted bystander cardiopulmonary resuscitation (CPR), CPR by EMS, CPR in the emergency department (ED), and elapsed time interval significantly varied according to area deprivation level (p < 0.001). OHCA outcomes were consistently worse in the most deprived areas. The adjusted OR (95% CI) for survival to hospital discharge was 0.58 (0.45-0.77) in the most deprived areas compared to the least deprived areas.

CONCLUSION

Community deprivation was strongly associated with survival among out-of-hospital cardiac arrest patients in Korea.

Socioeconomic status is associated with provision of bystander cardiopulmonary resuscitation

OBJECTIVE

Although socioeconomic status (SES) has been linked to multiple health outcomes, there have been few studies of the effect of SES on the provision of bystander cardiopulmonary resuscitation (CPR) during cardiac arrest events and no studies that we know of on the effect of SES on the provision of dispatcher-assisted bystander CPR. This study sought to define the relationship between SES and the provision of bystander CPR in an emergency medical system that includes dispatcher-provided CPR instructions.

METHODS

This study was a retrospective, cohort analysis of cardiac arrests due to cardiac causes occurring in private residences in King County, Washington, from January 1, 1999, to December 31, 2005. We used the tax-assessed value of the location of the cardiac arrest as an estimate of the SES of potential bystanders as well as multiple measures from 2000 Census data (education, employment, median household income, and race/ethnicity). We also examined the effect of patient and system characteristics that may affect the provision of bystander CPR. Logistic regression models were used to analyze the association of these factors with two outcomes: the provision of bystander CPR with and without dispatcher assistance.

RESULTS

Forty-four percent (1,151/2,618) of cardiac arrest victims received bystander CPR. Four hundred fifty-seven people (17.5% of the entire study population, 39.7% of those who received any bystander CPR) received CPR without telephone instructions. A total of 694 people received dispatcher-assisted bystander CPR (25.6% of the entire population, 60.4% of those receiving any bystander CPR). After adjusting for demographic and care factors, we found a strong association between the tax-assessed value of the cardiac arrest location and increased odds of the provision of bystander CPR without dispatcher instructions and bystander CPR with dispatcher assistance compared with no bystander CPR.

CONCLUSIONS

This study suggests that higher bystander SES is associated with increased rates of bystander CPR with and without dispatcher instructions. CPR training programs that target lower-SES communities and assessment of these training methods may be warranted.

Socioeconomic status influences bystander CPR and survival rates for out-of-hospital cardiac arrest victims

OBJECTIVES

While lower socioeconomic status is associated with lower level of education and increased incidence of cardiovascular diseases, the impact of socioeconomic status on out-of-hospital cardiac arrest outcomes is unclear. We used residential property values as a proxy for socioeconomic status to determine if there was an association with: (1) bystander CPR rates and (2) survival to hospital discharge for out-of-hospital cardiac arrest.

METHODS

We performed a secondary data analysis of cardiac arrest cases prospectively collected as part of the Ontario Prehospital Advanced Life Support study, conducted in 20 cities with ALS and BLS-D paramedics. We measured patient and system characteristics for cardiac arrests of cardiac origin, not witnessed by EMS, occurring in a single residential dwelling. We obtained property values from the Municipal Property Assessment Corporation. Analyses included descriptive statistics with 95% CIs and stepwise logistic regression.

RESULTS

Three thousand six hundred cardiac arrest cases met our inclusion criteria between 1 January 1995 and 31 December 1999. Patient characteristics were: mean age 69.2, male 67.8%, witnessed 44.7%, bystander CPR 13.2%, VF/VT 33.8%, time to vehicle stop 5:36min:s, return of spontaneous circulation 12.7%, and survival 2.7%. Median property value was $184,000 (range $25,500-2,494,000). For each $100,000 increment in property value, the likelihood of receiving bystander CPR increased (OR=1.07; 95% CI 1.01-1.14; p=0.03) and survival decreased (OR=0.77; 95% CI 0.61-0.97; p=0.03).

CONCLUSIONS

This is the largest study showing an association between socioeconomic status and survival, and the first study showing an association with bystander CPR. Our findings suggest targeting CPR training among lower socioeconomic groups.

Epidemiology and outcomes of out-of-hospital cardiac arrest in Rochester, New York

OBJECTIVE

To characterize out-of-hospital cardiac arrest (OHCA) and factors that affect survival in a medium sized city that uses system status management for dispatch.

METHODS

A retrospective cohort study of all adult OHCA patients treated by EMS between 1998 and 2001 was conducted using Utstein definitions. The primary endpoint was 1-year survival.

RESULTS

Of the 1177 patients who experienced OHCA during the study period, 539 (46%) met inclusion criteria. Age ranged from 18 to 98 years (median 67). The median call-response interval was 5 min (range 0-21), and 93% were 9 min or less. There was no significant difference in the median call-response intervals between call location zip (Post) codes (p=0.07). Twenty percent of experienced ROSC (95% CI 17-23), 7% survived more than 30 days (95% CI 5-9%), and 5% survived to 1 year (95% CI 3-7%). In bivariate analysis, first rhythm and bystander CPR affected survival to 1 year. There was no significant difference in survival between male (4%) and female (7%), black (4%) and white (6%), or witnessed (7%) and unwitnessed arrest (4%). Logistic regression identified younger age, CPR initiated by bystander (19%) or first responder (41%), and presenting rhythm of VF/VT (32%) as factors associated with survival to 1 year.

CONCLUSIONS

This study finds a 5% survival to 1 year among OHCA patients in Rochester, NY. A presenting rhythm of VF/VT and bystander CPR were associated with increased survival.

Acute coronary syndromes in the emergency department: diagnostic characteristics, tests, and challenges

Failure to diagnose patients who have acute coronary syndromes (ACSs)-either acute myocardial infarction (AMI) or unstable angina pectoris (UAP)-who present to the emergency department (ED) remains a serious public health issue. Better understanding of the pathophysiology of coronary artery disease has allowed the adoption of a unifying hypothesis for the cause of ACSs: the conversion of a stable atherosclerotic lesion to a plaque rupture with thrombosis. Thus, physicians have come to appreciate UAP and AMI as parts of a continuum of ACSs. This article reviews the state of the art regarding the diagnosis of ACSs in the emergency setting and suggests reasons why missed diagnosis continues to occur, albeit infrequently.

The National EMS Research strategic plan

One of the eight major recommendations put forth by the National EMS Research Agenda Implementation Project in 2002 was the development of an emergency medical services (EMS) research strategic plan. Using a modified Delphi technique along with a consensus conference approach, a strategic plan for EMS research was created. The plan includes recommendations for concentrating efforts by EMS researchers, policy makers, and funding resources with the ultimate goal of improving clinical outcomes. Clinical issues targeted for additional research efforts include evaluation and treatment of patients with asthma, acute cardiac ischemia, circulatory shock, major injury, pain, acute stroke, and traumatic brain injury. The plan calls for developing, evaluating, and validating improved measurement tools and techniques. Additional research to improve the education of EMS personnel as well as system design and operation is also suggested. Implementation of the EMS research strategic plan will improve both the delivery of services and the care of individuals who access the emergency medical system.

Geographic methods for understanding and responding to disparities in mammography use in Toronto, Canada

OBJECTIVE

To use spatial and epidemiologic analyses to understand disparities in mammography use and to formulate interventions to increase its uptake in low-income, high-recent immigration areas in Toronto, Canada.

DESIGN

We compared mammography rates in four income-immigration census tract groups. Data were obtained from the 1996 Canadian census and 2000 physician billing claims. Risk ratios, linear regression, multilayer maps, and spatial analysis were used to examine utilization by area for women age 45 to 64 years.

SETTING

Residential population of inner city Toronto, Canada, with a 1996 population of 780,000.

PARTICIPANTS

Women age 45 to 64 residing in Toronto's inner city in the year 2000.

MEASUREMENTS AND MAIN RESULTS

Among 113,762 women age 45 to 64, 27,435 (24%) had received a mammogram during 2000 and 91,542 (80%) had seen a physician. Only 21% of women had a mammogram in the least advantaged group (low income--high immigration), compared with 27% in the most advantaged group (high income--low immigration) (risk ratio, 0.79; 95% confidence interval, 0.75 to 0.84). Multilayer maps demonstrated a low income-high immigration band running through Toronto's inner city and low mammography rates within that band. There was substantial geographic clustering of study variables.

CONCLUSIONS

We found marked variation in mammography rates by area, with the lowest rates associated with low income and high immigration. Spatial patterns identified areas with low mammography and low physician visit rates appropriate for outreach and public education interventions. We also identified areas with low mammography and high physician visit rates appropriate for interventions targeted at physicians.

Cardiopulmonary Resuscitation Programs Revisited: Results of a Community Study Among Older African Americans

Early cardiopulmonary resuscitation (CPR) performed by a layperson and prompt defibrillation in the field are critical links in the chain of survival of out-of-hospital sudden cardiac arrest. It has been suggested that minorities, women, and elderly persons are often left out of CPR training programs. To examine knowledge and attitudes toward CPR and automatic external defibrillation among African Americans, the author and colleagues conducted home interviews in a population sample of 425 older men and women in Miami-Dade County, FL. It was found that 25% of the participants did not know what CPR was. Only 18% of men and 28% of women had ever taken CPR classes. Mean age the time of CPR training was for men 36 years and for women 46 years. About 74% of all subjects did not know whom to contact for CPR training, and fewer than 5% knew about the American Heart Association Heartsaver Program (including automatic external defibrillation performed by laypersons). The majority of participants suggested churches or community organizations as organizers of CPR training. This study shows that there is a major need for improving knowledge and intensifying CPR training programs among older African Americans. Community organizations and churches may play a critical role in reaching this goal.

Racial differences in outcome in the Multicenter UnSustained Tachycardia Trial (MUSTT): a comparison of whites versus blacks

BACKGROUND

The Multicenter UnSustained Tachycardia Trial (MUSTT) demonstrated the benefit of implantable cardioverter-defibrillators (ICDs) in patients with coronary disease, asymptomatic nonsustained ventricular tachycardia, and reduced left ventricular function. Previous studies have shown racial differences in risk of sudden death in patients with ischemic heart disease.

METHODS AND RESULTS

We analyzed the influence of race on results of MUSTT. Whites were more likely to have prior revascularization and inducible, randomizable sustained ventricular arrhythmias and less likely to have left ventricular hypertrophy than were blacks. Compared with blacks, whites randomly assigned to electrophysiologically (EP)-guided therapy had a lower risk of arrhythmic death/cardiac arrest (adjusted P=0.003) and lower total mortality rates (adjusted P=0.051). In contrast, there was no racial difference in the risk of arrhythmic death/cardiac arrest among patients randomly assigned to no EP-guided therapy (adjusted P=0.477). Among whites, EP-guided therapy resulted in a survival benefit compared with no EP-guided therapy. However, survival of blacks randomly assigned to no EP-guided therapy was better than blacks receiving EP-guided therapy. This difference is partially explained by a higher ICD implantation rate in whites versus blacks (50% versus 28%, P=0.034). Whites were more likely to remain inducible after serial EP-guided drug testing (67% versus 42%, P=0.011), making them more likely to become eligible for ICDs.

CONCLUSIONS

The outcome in this trial and the benefit of EP-guided therapy appeared to be influenced by race. In addition to differences in ICD implantation rates, differences in arrhythmic substrates and proarrhythmic responses to antiarrhythmic drugs may have influenced outcome.

Relationship of race to sudden cardiac death in competitive athletes with hypertrophic cardiomyopathy

OBJECTIVES

The goal of this study was to determine the impact of race on identification of hypertrophic cardiomyopathy (HCM).

BACKGROUND

Sudden death in young competitive athletes is due to a variety of cardiovascular diseases (CVDs) and, most commonly, HCM. These catastrophes have become an important issue for African Americans, although HCM has been previously regarded as rare in this segment of the U.S. population.

METHODS

We studied the relationship of race to the prevalence of CVDs causing sudden death in our national athlete registry, and compared these findings with a representative multicenter hospital-based cohort of patients with HCM.

RESULTS

Of 584 athlete deaths, 286 were documented to be due to CVD at ages 17 +/- 3 years; 156 (55%) were white, and 120 (42%) were African American. Most were male (90%), and 67% participated in basketball and football. Among the 286 cardiovascular deaths, most were due to HCM (n = 102; 36%) or anomalous coronary artery of wrong sinus origin (n = 37; 13%). Of the athletes who died of HCM, 42 (41%) were white, but 56 (55%) were African American. In contrast, of 1,986 clinically identified HCM patients, only 158 (8%) were African American (p < 0.001).

CONCLUSIONS

In this autopsy series, HCM represented a common cause of sudden death in young and previously undiagnosed African American male athletes, in sharp contrast with the infrequent clinical identification of HCM in a hospital-based population (i.e., by seven-fold). This discrepancy suggests that many HCM cases go unrecognized in the African American community, underscoring the need for enhanced clinical recognition of HCM to create the opportunity for preventive measures to be employed in high-risk patients with this complex disease.

Diagnosis of acute cardiac ischemia

A better understanding of coronary syndromes allow physicians to appreciate UAP and AMI as part of a continuum of ACI. ACI is a life-threatening condition whose identification can have major economic and therapeutic importance as far as threatening dysrhythmias and preventing or limiting myocardial infarction size. The identification of ACI continues to challenge the skill of even experienced clinicians, yet physicians continue (appropriately) to admit the overwhelming majority of patients with ACI; in the process, they admit many patients without acute ischemia [2], overestimating the likelihood of ischemia in low-risk patients because of magnified concern for this diagnosis for prognostic and therapeutic reasons. Studies of admitting practices from a decade ago have yielded useful clinical information but have shown that neither clinical symptoms nor the ECG could reliably distinguish most patients with ACI from those with other conditions. Most studies have evaluated the accuracy of various technologies for diagnosing ACI, yet only a few have evaluated the clinical impact of routine use. The prehospital 12-lead ECG has moderate sensitivity and specificity for the diagnosis of ACI. It has demonstrated a reduction of the mean time to thrombolysis by 33 minutes and short-term overall mortality in randomized trials. In the general ED setting, only the ACI-TIPI has demonstrated, in a large-scale multicenter clinical trial, a reduction in unnecessary hospitalizations without decreasing the rate of appropriate admission for patients with ACI. The Goldman chest pain protocol has good sensitivity for AMI but was not shown to result in any differences in hospitalization rate, length of stay, or estimated costs in the single clinical impact study performed. The protocol's applicability to patients with UAP has not been evaluated. Single measurement of biomarkers at presentation to the ED has poor sensitivity for AMI, although most biomarkers have high specificity. Serial measurements can greatly increase the sensitivity for AMI while maintaining their excellent specificity. Biomarkers cannot identify most patients with UAP. Finally, diagnostic technologies to evaluate ACI in selected populations, such as echocardiography, sestamibi perfusion imaging, and stress ECG, may have very good to excellent sensitivity; however, they have not been sufficiently studied.

The defibrillation system of basic emergency medical technicians in Japan: a comparison with other systems from a 14-year review of out-of-hospital cardiac arrest reports

Although seven years have passed after basic emergency medical technician (EMT) defibrillation system was introduced in Japan, the overall survival for out-of-hospital cardiac arrest (OHCA) remains poor. We investigated factors leading to such an unanticipated result in Japan by comparing the data of OHCA in Japan with those in other countries. We obtained population-based OHCA data from three communities in Japan. We also performed a comprehensive literature and manual search to identify reports that included rates for incidence and survival or provided sufficient data for the calculation of these rates of OHCA. Statistical analysis was performed to compare survival and incidence rates between the communities. We identified 36 articles from 16 countries by a comprehensive literature search. There was no significant difference in incidence and survival rates among communities in Japan. Although the incidence rate of collapse-witnessed OHCA with ventricular fibrillation (VF) was much lower in Japan than western countries, the proportions of survival from it were comparable to those. Basic-EMT defibrillation system in Japan has yielded excellent result in terms of the survival of VF cases. However, much lower proportion of VF to all cases is responsible for lower overall rates of survival from OHCA in Japan.

Successful cardiopulmonary resuscitation outcome reviews

An implicit question in every pre-hospital cardiopulmonary resuscitation (CPR) scenario is 'what will be the quality of life if a save is achieved?' This issue has implications for doctrine, policy, training and post-CPR counselling of both resuscitator and victim. Post-salvage neurological syndromes in surviving victims include amnesia, personality change, cognitive loss, depression, Parkinsonian syndromes, decorticate and decerebrate states and permanent brain damage with vegetative existence. Children who are salvaged by CPR rarely have pre-existing co-morbidities; but 75% of adults have pre-existing cardiac disease, cancer or diabetes. Such, of course, continue after a successful resuscitation. In the case of children who are resuscitated from acute hypoxic insults, the quality of life is generally good and, in the specific instance of survivors from near-drowning, some 95% will lead lives relatively unmodified. Although successful CPR resuscitation rates remain low in adults, the quality of life of those who leave hospital remains generally high. CPR involves two feature subjects, the resuscitator and the victim. Just as for the victim, so too the resuscitator's life is modified by CPR and its aftermath, whether immediate salvage has been achieved or not. This review addresses these issues, as a successful CPR (dramatic as it is) is not a conclusion but the beginning of a new phase of life for both resuscitator and victim.

Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation

BACKGROUND

Despite extensive training of citizens of Seattle in cardiopulmonary resuscitation (CPR), bystanders do not perform CPR in almost half of witnessed cardiac arrests. Instructions in chest compression plus mouth-to-mouth ventilation given by dispatchers over the telephone can require 2.4 minutes. In experimental studies, chest compression alone is associated with survival rates similar to those with chest compression plus mouth-to-mouth ventilation. We conducted a randomized study to compare CPR by chest compression alone with CPR by chest compression plus mouth-to-mouth ventilation.

METHODS

The setting of the trial was an urban, fire-department-based, emergency-medical-care system with central dispatching. In a randomized manner, telephone dispatchers gave bystanders at the scene of apparent cardiac arrest instructions in either chest compression alone or chest compression plus mouth-to-mouth ventilation. The primary end point was survival to hospital discharge.

RESULTS

Data were analyzed for 241 patients randomly assigned to receive chest compression alone and 279 assigned to chest compression plus mouth-to-mouth ventilation. Complete instructions were delivered in 62 percent of episodes for the group receiving chest compression plus mouth-to-mouth ventilation and 81 percent of episodes for the group receiving chest compression alone (P=0.005). Instructions for compression required 1.4 minutes less to complete than instructions for compression plus mouth-to-mouth ventilation. Survival to hospital discharge was better among patients assigned to chest compression alone than among those assigned to chest compression plus mouth-to-mouth ventilation (14.6 percent vs. 10.4 percent), but the difference was not statistically significant (P=0.18).

CONCLUSIONS

The outcome after CPR with chest compression alone is similar to that after chest compression with mouth-to-mouth ventilation, and chest compression alone may be the preferred approach for bystanders inexperienced in CPR.

Simple CPR: A randomized, controlled trial of video self-instructional cardiopulmonary resuscitation training in an African American church congregation

STUDY OBJECTIVE

Despite the proven efficacy of cardiopulmonary resuscitation (CPR), only a small fraction of the population knows how to perform it. As a result, rates of bystander CPR and rates of survival from cardiac arrest are low. Bystander CPR is particularly uncommon in the African American community. Successful development of a simplified approach to CPR training could boost rates of bystander CPR and save lives. We conducted the following randomized, controlled study to determine whether video self-instruction (VSI) in CPR results in comparable or better performance than traditional CPR training.

METHODS

This randomized, controlled trial was conducted among congregational volunteers in an African American church in Atlanta, GA. Subjects were randomly assigned to receive either 34 minutes of VSI or the 4-hour American Heart Association "Heartsaver" CPR course. Two months after training, blinded observers used explicit criteria to assess CPR performance in a simulated cardiac arrest setting. A recording manikin was used to measure ventilation and chest compression characteristics. Participants also completed a written test of CPR-related knowledge and attitudes.

RESULTS

VSI trainees displayed a comparable level of performance to that achieved by traditional trainees. Observers scored 40% of VSI trainees competent or better in performing CPR, compared with only 16% of traditional trainees (absolute difference 24%, 95% confidence interval 8% to 40%). Data from the recording manikin confirmed these observations. VSI trainees and traditional trainees achieved comparable scores on tests of CPR-related knowledge and attitudes.

CONCLUSION

Thirty-four minutes of VSI can produce CPR of comparable quality to that achieved by traditional training methods. VSI provides a simple, quick, consistent, and inexpensive alternative to traditional CPR instruction, and may be used to extend CPR training to historically underserved populations.

Neighborhoods matter: a population-based study of provision of cardiopulmonary resuscitation

STUDY OBJECTIVE

Cardiorespiratory resuscitation (CPR) nonprovision-the failure of bystanders to provide CPR to cardiac arrest victims-remains a well-documented public health problem associated with significant mortality. Multivariate data on failure to provide CPR are limited. Given the established independent contributions of neighborhoods to explaining many behaviors, we asked the following questions: Do neighborhood characteristics affect the likelihood of CPR nonprovision? In particular, we sought to identify the characteristics of areas that have had the most success in providing CPR.

METHODS

We performed multivariable logistic regression analysis of a prospectively collected cohort of 4,379 cardiac arrests linked at an individual level to neighborhood data from the US Census. These arrests represent all out-of-hospital cardiac arrests in the City of Chicago in 1987 and 1988.

RESULTS

In multivariate analysis, patients who had cardiac arrests who lived in neighborhoods where cardiac arrests were more common were significantly more likely to receive CPR. Patients with arrests in racially integrated neighborhoods were most likely to be provided with CPR, followed by those in predominately white neighborhoods, with the lowest rates of CPR provision in predominately black neighborhoods. Neither the socioeconomic status, number of elderly, nor the occupational characteristics of the neighborhood appeared to influence CPR provision. At the individual level, in-home arrests and arrests among middle-aged black residents (relative to older black and all white residents) were less likely to receive CPR.

CONCLUSION

Substantial variation in rates of CPR nonprovision exists between neighborhoods; the variation is associated with neighborhood characteristics. Combining individual and neighborhood data allows identification of important factors associated with the failure to provide CPR.

Does race or socioeconomic status predict adverse outcome after out of hospital cardiac arrest: a multi-center study

OBJECTIVE

To assess whether socioeconomic status (SES) or race is associated with adverse outcome after an out-of-hospital cardiac arrest (OHCA).

METHODS

A convenience sample of OHCA of presumed cardiac origin from seven suburban cities in Michigan, 1991-1996. Median household income (HHI), utilizing patient home address and 1990 census tract data, was dichotomized above and below 1990 state median income. Patient race was dichotomized as black or white. Outcome was defined as survival to hospital discharge (DC). Multiple logistic regression and Pearson's chi2 values were used for analysis.

RESULTS

Of 1317 cases with complete data for analysis, the average age was 67.3 +/- 16.0, 939 (71.1%) were white, 587 (44.4%) arrests were witnessed (WIT), and 65 (4.9%) were DC alive. There was no significant difference between races with respect to WIT arrests, V(T)/V(F) arrest rhythms, and a small difference in EMS response interval. Whites were more likely to be above median HHI (57.1 vs. 26.2%, P < 0.001). Adjusted odds ratios for predictors of survival were WIT arrest (OR = 3.76, 95% CI (1.7, 8.2)), V(T)/V(F) (OR = 8.74, 95% CI (3.7, 10.8), but not race (OR = 0.68, 95% CI (0.3, 1.4)) or SES (OR = 1.51, 95% C1 0.8, 2.8).

CONCLUSION

In this population, neither race nor SES was independently associated with a worse outcome after OHCA.

Race and survival after out-of-hospital cardiac arrest in a suburban community

STUDY OBJECTIVE

To determine whether race, when controlled for income, is an independent predictor of survival to hospital discharge after out-of-hospital cardiac arrest (OHCA).

METHODS

Prospective OHCA data were collected over 4 years (1991-1994) from a convenience sample of OHCA patients transported to nine hospitals in three suburban counties. Race was determined from hospital and vital statistics records. The average household income was identified from ZIP codes and used as a marker of socioeconomic status. Demographic data and known predictors of survival were compared between blacks and whites. A logistic regression analysis was used to assess the association between race, income, and survival.

RESULTS

Of the 1,690 patients, 223 (13%) were blacks and 1,467 (87%) were whites. Average household income was less for blacks than for whites ($40,225 versus $46,193; P < .001), but both populations were affluent by national standards (national percentile ranks were 73% and 88%, respectively). The populations were no different in percentage of witnessed arrests (57% versus 61%; P = .465). Blacks were younger (mean +/- SD, 62 +/- 16 versus 68 +/- 15 years; P < .001); less frequently received bystander CPR (11% versus 20%; P = .002); less often had ventricular tachycardia or ventricular fibrillation (37% versus 50%; P < .001); and had a shorter advanced life support call-response interval (median, 4 versus 6 minutes; P < .001). The odds ratio for survival (white/black) was .931 (95% confidence interval, .446 to 1.945).

CONCLUSION

Race was not found to predict adverse OHCA outcomes in this affluent population.

Causes of chest pain and symptoms suggestive of acute cardiac ischemia in African-American patients presenting to the emergency department: a multicenter study

This study examines whether race is a significant determinant of the diagnoses of acute myocardial infarction or angina pectoris in patients with symptoms suggestive of acute cardiac ischemia. The study population was comprised of 3401 (34%) African-American and 6600 (66%) white patients who presented to emergency departments with symptoms suggestive of acute cardiac ischemia. The main outcome measure was a diagnosis of acute myocardial infarction or angina pectoris. African Americans were younger, predominantly female, and more often had hypertension, diabetes mellitus, or smoked. The diagnosis of acute myocardial infarction was confirmed in 6% of African-American and 12% of white men, and in 4% of African-American and 8% of white women. After adjusting for age, gender, medical history, signs and symptoms, and hospital, African Americans were half as likely to develop acute myocardial infarction and were 60% as likely to have acute cardiac ischemia. Despite having less acute cardiac ischemia, African Americans in this study had high risk levels for coronary artery disease.

Sudden cardiac death in Hispanic Americans and African Americans

OBJECTIVES

The goal of this study was to estimate rates of sudden cardiac death in US Hispanics and African Americans.

METHODS

Data on coronary deaths occurring outside of the hospital or in emergency rooms were examined for 1992.

RESULTS

In 1992, 53% (8194) of coronary heart disease deaths among Hispanic Americans 25 years of age and older occurred outside of the hospital or in emergency rooms. The percentage was lower among Hispanics than among non-Hispanic Whites and Blacks. Age-adjusted rates per 100,000 were lower in Hispanics than in non-Hispanic Whites or Blacks (Hispanic men, 75; White men, 166; Black men, 209; Hispanic women, 35; White women, 74; Black women, 108). The percentages dying outside of the hospital or in emergency rooms were higher in young persons, those living in nonurban areas, and those who were single.

CONCLUSIONS

The percentage and rate of coronary deaths occurring outside of the hospital or in emergency rooms were lower in Hispanics than in non-Hispanics; African Americans had the highest rates. Further research is needed on sudden coronary death in Hispanic Americans and African Americans.

Out-of-hospital cardiac arrests: an 8-year New York City experience

A retrospective study was conducted to determine the outcome of out-of-hospital cardiac arrests by one prehospital system in New York City from January, 1986, through December, 1993. The results were recorded consistent with the Utstein Style. Of 481 attempted patient resuscitations 406 were of cardiac etiology, with 382 patients having arrested prior to EMS arrival; their overall survival rate was 2.1% (8/382). Cardiac arrests were witnessed in 246 patients. Of the witnessed arrest patients found in ventricular fibrillation (96/246), the overall survival rate was 7.3% (7/96). Of the 7 survivors who were discharged from the hospital, 71.4% (5/7) had a good cerebral performance/good overall performance. Of 24 patients who arrested in the presence of EMS, the survival rate was 12.5% (3/24). This study confirms a poor survival rate for patients suffering out-of-hospital cardiac arrests in New York City.

Influence of comorbidity on the outcome of patients treated for out-of-hospital ventricular fibrillation

BACKGROUND

A number of factors have previously been shown to be predictive of survival from out-of-hospital ventricular fibrillation. These include witnessed collapse, prompt initiation of cardiopulmonary resuscitation, early application of defibrillation, and younger age. Arrests occurring away from home are also associated with improved survival. Additionally, hospital mortality after successful resuscitation has been related to a history of congestive heart failure as well as to some of the factors noted above. An association of prearrest comorbidity with outcome has not been systematically evaluated.

METHODS AND RESULTS

We define here a comorbidity index, which is constructed from histories of chronic conditions as well as a number of recent symptoms in 282 victims of out-of-hospital VF. This indicator of comorbidity is strongly associated with outcome (P = .004). However, when analyzing a comprehensive set of predictors of survival after out-of-hospital ventricular fibrillation, including the index of comorbidity, we could identify overall only about one fourth of the variation that one might hope to account for.

CONCLUSIONS

Comorbidity appears to be an important (but usually overlooked) predictor of survival from out-of-hospital ventricular fibrillation. However, most of the statistical variability in predicting survival remains unexplained when we consider comorbidity in conjunction with previously identified predictors of survival.

Outcomes in African-American women with suspected acute myocardial infarction: the Myocardial Infarction Triage and Intervention Project

Increasing attention has been given to the investigation of cardiovascular disease in women, although African-American women have received little attention. This study compares characteristics and outcomes in women admitted to coronary care units for suspected acute myocardial infarction (MI). Between January 1988 and December 1991, a total of 554 (5%) African-American and 9738 (95%) white women with suspected acute MI were admitted to coronary care units in metropolitan Seattle, Washington. Relevant demographic socioeconomic, clinical, and outcome data were abstracted from the medical record and entered in the Myocardial Infarction Triage and Intervention registry. African-American women were younger, more often single and unemployed, and were less likely to have health insurance than their white counterparts. In addition, a higher proportion of African-American women reported a history of hypertension and diabetes mellitus. After adjustment for age, African-American women were equally as likely to develop acute MI and were more likely to die in the hospital. In addition, a higher proportion of African-American women were readmitted to coronary care units for suspected MI. Compared with their white counterparts, African-American women with suspected acute MI were considerably worse off from both socioeconomic and clinical standpoints, and their relative disadvantage was apparent in poor outcomes.

Access to hospitals with high-technology cardiac services: how is race important?

OBJECTIVES

Relatively few hospitals in the United States offer high-technology cardiac services (cardiac catheterization, bypass surgery, or angioplasty). This study examined the association between race and admission to a hospital offering those services.

METHODS

Records of 11,410 patients admitted with acute myocardial infarction to hospitals in New York State in 1986 were analyzed.

RESULTS

Approximately one third of both White and Black patients presented to hospitals offering high-technology cardiac services. However, in a multivariate model adjusting for home-to-hospital distance, the White-to-Black odds ratio for likelihood of presentation to such a hospital was 1.68 (95% confidence interval = 1.42, 1.98). This discrepancy between the observed and "distance-adjusted" probabilities reflected three phenomena: (1) patients presented to nearby hospitals; (2) Blacks were more likely to live near high-technology hospitals; and (3) there were racial differences in travel patterns. For example, when the nearest hospitals did not include a high-technology hospital, Whites were more likely than Blacks to travel beyond those nearest hospitals to a high-technology hospital.

CONCLUSIONS

Whites and Blacks present equally to hospitals offering high-technology cardiac services at the time of acute myocardial infarction. However, there are important underlying racial differences in geographic proximity and tendencies to travel to those hospitals.

Demographics of cardiac arrest: association with residence in a low-income area

OBJECTIVE

To report cardiac arrest demographics and assess whether arrest rate is associated with differences in intracity regional population densities, incomes, or race distributions.

METHODS

One-year retrospective review of out-of-hospital cardiac arrests in a city with a two-tier emergency medical service (EMS) system. Associations of population density, median income, and race data with age- and gender-adjusted cardiac arrest rates for seven city regions and groupings of high- and low-income census tracts were made.

RESULTS

Median income, but not race or population density, was associated with sex- and age-adjusted intracity regional cardiac arrest rates (p = 0.034). This association of cardiac arrest rate with income status was magnified when the 20 lowest and the 20 highest income census tracts were compared. Cardiac arrest victims in these two income groups did not differ in regard to rate of witnessed arrest, bystander-administered CPR, or previous cardiac disease. Rates of survival to hospital discharge were not significantly different between the two groups.

CONCLUSION

The association of lower income with cardiac arrest suggests that cardiac health promotion and EMS intervention measures, including CPR instruction, should be targeted to lower-income neighborhoods. These findings may help explain previous studies suggesting a racial or population density association with cardiac arrest rates.

Do blacks get bystander cardiopulmonary resuscitation as often as whites?

STUDY OBJECTIVE

To determine whether there is an association between the race of a victim of out-of-hospital cardiac arrest and the provision of bystander-initiated CPR.

DESIGN

Record review of 1,068 consecutive cases of nontraumatic out-of-hospital cardiac arrest.

SETTING

Memphis, Tennessee, a city of more than 600,000 with roughly equal numbers of white and black residents.

PARTICIPANTS

Every adult who was seen by municipal emergency medical services personnel for nontraumatic cardiac arrest between March 1, 1989, and June 5, 1992.

INTERVENTION

None.

RESULTS

Although black and white cardiac arrest victims were similar in many respects, black victims received bystander CPR substantially less frequently than whites (9.8% versus 21.4%; odds ratio, 0.46; 95% confidence interval, 0.34 to 0.61). This difference was slightly more pronounced when the victim collapsed in a public place. In addition to race of the victim, location of the arrest outside the home and having the arrest witnessed were independent determinants of whether a victim was given bystander CPR. Multiple logistic regression analysis showed that the effect of race was independent of the other variables studied.

CONCLUSION

Black victims of out-of-hospital cardiac arrest receive bystander CPR less frequently than white victims. Targeted training programs may be needed to improve the rates of bystander CPR among certain groups.

Task Force 1: The underserved

The ACC has affirmed its commitment to universal access to health care. Underserved populations exist in urban and rural centers. Common to each is a paucity of personnel trained in cardiovascular care and a lack of access to preventive and highly technologic services. These factors contribute to a poor health outcome (75). Part of the rural problem can be corrected by the transfer of information to local providers by the use of new information systems. Included would be real-time electronic consultation, on-site subspecialty visits and the appropriate use of nonphysician providers (15). The urban problem requires changes in priorities and responsibilities of the academic health centers toward the communities they serve. Curricula changes of cardiovascular specialists, internists, generalists and nonphysician health care personnel must include diversity in training, physician training of ethnically matched providers in addition to technical excellence and research into methods of patient education and motivation for a healthier life-style (51). Reimbursement must appropriately reward those caring for underserved patients and those providing evaluation and management services (43,52).