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Awad A, Jonsson M, Holgersson J, Jakobsen JC, Hollenberg J, Thomas M, Garcia PDW, Ringh M, Grejs AM, Keeble TR, Bělohlávek J, Cariou A, Annoni F, Lilja G, Taccone FS, Rylander C, Nielsen N, Dankiewicz J, Nordberg P. Intravascular vs. surface cooling in out-of-hospital cardiac arrest patients receiving hypothermia after hospital arrival: a post hoc analysis of the TTM2 trial. Intensive Care Med 2025; 51:721-730. [PMID: 40293464 PMCID: PMC12055956 DOI: 10.1007/s00134-025-07883-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2024] [Accepted: 03/25/2025] [Indexed: 04/30/2025]
Abstract
PURPOSE To compare the performance of targeted temperature management (TTM) at 33 °C using intravascular (IC) vs. surface-cooling (SFC) devices after out-of-hospital cardiac arrest (OHCA). METHODS A post hoc analysis including OHCA patients randomized to hypothermia in the TTM2-trial (NCT02908308) comparing hypothermia with normothermia. The main outcome was cooling performance, defined as the proportion of patients reaching target temperature < 33.5 °C within 4 h, time outside temperature ranges during maintenance, rewarming rate and post-TTM fever. Exploratory outcomes included survival and good functional outcome, defined as modified Rankin Scale (mRS) scores of 0-3 at 6 months, analyzed using Inverse Probability Treatment Weighting (IPTW). RESULTS Among 930 patients randomized to hypothermia, 876 were treated with a cooling device and included in this study. Of those, 27.3% received IC devices, while 72.7% received SFC devices. The proportion reaching target temperature within 4 h was higher with IC (IC: 69.6% vs. SFC: 49.2%; p < 0.001). Temperature outside ranges during the cooling period and post-TTM fever were lower with IC compared to SFC (17.2% vs. 39.6%; p < 0.001 and 0% vs. 6.3%; p < 0.001, respectively). In the exploratory IPTW analysis, 6-month survival rates were 55.2% in the IC group and 50.2% in the SFC group (OR 1.22, 95% CI 0.89-1.68) and survival with good functional outcome at 6 months was 51.1% patients in the IC group and 44.9% in the SFC (OR 1.28, 95% CI 0.93-1.77). CONCLUSIONS Among OHCA patients randomized to hypothermia in the TTM2 study, intravascular cooling, compared with surface cooling, was associated with better cooling performance.
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Affiliation(s)
- Akil Awad
- Center for Resuscitation Sciences, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
| | - Martin Jonsson
- Center for Resuscitation Sciences, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Johan Holgersson
- Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund University, Helsingborg Hospital, Lund, Sweden
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit-Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Copenhagen, Denmark
| | - Jacob Hollenberg
- Center for Resuscitation Sciences, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Matthew Thomas
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Pedro D Wendel Garcia
- Institute of Intensive Care Medicine, University Hospital of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Mattias Ringh
- Center for Resuscitation Sciences, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Anders M Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Thomas R Keeble
- Essex Cardio Thoracic Centre, Basildon, Essex, UK Thurrock University Hospitals, Basildon, UK
- Faculty of Health Education Medicine & Social Care, MTRC, Anglia Ruskin University, Chelmsford, Essex, UK
| | - Jan Bělohlávek
- 2nd Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Alain Cariou
- Cochin University Hospital (APHP), Paris Cité University (Medical School), Paris, France
| | - Filippo Annoni
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Gisela Lilja
- Neurology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Neurology, Skane University Hospital, Lund, Sweden
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Christian Rylander
- Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund University, Helsingborg Hospital, Lund, Sweden
- Anesthesiology and Intensive Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Per Nordberg
- Center for Resuscitation Sciences, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Function, Perioperative Medicine and Intensive Care, Karolinska University Hospital, 17176, Stockholm, Sweden
- Department of Physiology and Pharcmacology, Karolinska Institute, Stockholm, Sweden
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van Gils P, Nutma S, Meeske K, van Heugten C, van den Bergh W, Foudraine N, le Feber J, Filius M, van Putten M, Beishuizen B, Hofmeijer J. Ghrelin for neuroprotection in post-cardiac arrest coma: a 1-year follow-up of cognitive and psychosocial outcomes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2025; 14:5-11. [PMID: 39445445 PMCID: PMC11783279 DOI: 10.1093/ehjacc/zuae119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 09/27/2024] [Accepted: 10/09/2024] [Indexed: 10/25/2024]
Abstract
AIMS Effective treatments to improve brain recovery after cardiac arrest are needed. Ghrelin showed efficacy in experimental models and was associated with lower neuron-specific enolase levels in the clinical Ghrelin in Coma (GRECO) trial. Here, we present cognitive and psychosocial outcomes at 1-year follow-up. METHODS AND RESULTS GRECO was a Phase 2 multicentre, double-blind, randomized, placebo-controlled trial in comatose patients after cardiac arrest. The intervention was intravenous acyl-ghrelin 600 μg twice daily or placebo for 1 week, starting within 12 h after the arrest. Patients were assessed after 1 year using cognitive tests and questionnaires measuring participation, health-related quality of life, mood, and caregiver strain. Composite z-scores of the cognitive tests were computed by comparing the scores with those of a norm population and averaging the tests for memory, attention, and executive functioning separately. Groups were compared based on composite z-scores and cut-off scores for psychosocial outcomes. Of the 160 participants originally included, 66 of the 85 participants who survived to 1 year after OHCA completed the psychosocial and cognitive follow-up. The intervention group scored numerically higher across the cognitive domains compared with the control group, but the differences were not statistically significant (memory median = -0.850 vs. -1.385, U = 424.5, P = 0.587; attention median = -0.733 vs. -0.717, U = 420.5, P = 0.548; and executive functioning median = -0.311 vs. -0.482, U = 408.5, P = 0.323). There were significantly fewer signs of depression in the intervention group (U = 322.5, P = 0.014). CONCLUSION This predefined secondary analysis found that ghrelin treatment was associated with non-significantly but consistently better cognitive outcomes and significantly fewer signs of depression. This is in line with the primary outcomes. CLINICAL TRIAL REGISTRATION Clinicaltrialsregister.eu: EUCTR2018-000005-23-NL.
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Affiliation(s)
- Pauline van Gils
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
- Limburg Brain Injury Center, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Sjoukje Nutma
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
- Department of Neurology, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, The Netherlands
| | - Karen Meeske
- Department of Medical Psychology, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, The Netherlands
| | - Caroline van Heugten
- Limburg Brain Injury Center, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Walter van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Norbert Foudraine
- Department of Critical Care, VieCuri Medical Center, Tegelseweg 210, 5912 BL Venlo, The Netherlands
| | - Joost le Feber
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
| | - Margreet Filius
- Department of Clinical Pharmacy, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| | - Michel van Putten
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
- Department of Neurology, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, The Netherlands
| | - Bert Beishuizen
- Department of Critical Care, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, The Netherlands
| | - Jeannette Hofmeijer
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
- Department of Neurology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
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Liu S, Zhu H, Zhang N. Description of current status of implementation and management of cardiac arrest in China. Sci Rep 2025; 15:3471. [PMID: 39870834 PMCID: PMC11772617 DOI: 10.1038/s41598-025-88076-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 01/23/2025] [Indexed: 01/29/2025] Open
Abstract
Variation in the incidence, survival rate and factors associated with survival after cardiac arrest in China is reported. Some studies have tried to fill the knowledge gap regarding the epidemiology of cardiac arrest in China but were unable to identify reasons for the reported differences. Therefore, the purpose of this study was to describe Chinese management of cardiac arrest, particularly from the perspective of compression, ventilation, monitoring, treatment, and extracorporeal cardiopulmonary resuscitation. An online questionnaire with 56 questions was designed about demographic characteristics, management of cardiac arrest, compression, ventilation, treatment and medicine, as well as advanced life support and resuscitation skill training. A total of 814 copies of questionnaire were received from 23 provinces, 4 autonomous regions and 4 municipalities of China. Results were combined with official information on population density. Throughout China, hospitals resuscitate according to the guideline, however, there are still differences varies in implement with regard to chest compression, ventilation, medicine, monitoring, as well as advanced life support and resuscitation skills training because of economical and developmental level from different regions. All the startup of chest compression is manual, whereas mechanical compression instruments are increasingly involved in sequential resuscitation. Most of clinicians rotate during resuscitation every five cycles other than the guideline recommends every 2 min or when they are tired. About half of the participants don't build the advanced airway rather than use bag valve mask to ventilate, and 75% of the rest use mechanical ventilation whether they succeed to ROSC. Most of rescuers choose endotracheal intubation which is consistent with many other clinical trials results. Various compression feedback devices play increasingly significant roles in assessment of ROSC. More and more regional hospitals have access to ECPR and implement TTM, but still lead to various divergences. Thus, more elaborate clinical trials need to be designed to verify and explore every procedure in the CPR life cycle.
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Affiliation(s)
- Shuai Liu
- Emergency Department, The State Key Laboratory for Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huadong Zhu
- Emergency Department, The State Key Laboratory for Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Nan Zhang
- Emergency Department, The State Key Laboratory for Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Beekman R, Khosla A, Buckley R, Honiden S, Gilmore EJ. Temperature Control in the Era of Personalized Medicine: Knowledge Gaps, Research Priorities, and Future Directions. J Intensive Care Med 2024; 39:611-622. [PMID: 37787185 DOI: 10.1177/08850666231203596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Hypoxic-ischemic brain injury (HIBI) is the leading cause of death and disability after cardiac arrest. To date, temperature control is the only intervention shown to improve neurologic outcomes in patients with HIBI. Despite robust preclinical evidence supporting hypothermia as neuroprotective therapy after cardiac arrest, there remains clinical equipoise regarding optimal core temperature, therapeutic window, and duration of therapy. Current guidelines recommend continuous temperature monitoring and active fever prevention for at least 72 h and additionally note insufficient evidence regarding temperature control targeting 32 °C-36 °C. However, population-based thresholds may be inadequate to support the metabolic demands of ischemic, reperfused, and dysregulated tissue. Promoting a more personalized approach with individualized targets has the potential to further improve outcomes. This review will analyze current knowledge and evidence, address research priorities, explore the components of high-quality temperature control, and define critical future steps that are needed to advance patient-centered care for cardiac arrest survivors.
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Affiliation(s)
- Rachel Beekman
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Akhil Khosla
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Ryan Buckley
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Shyoko Honiden
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Emily J Gilmore
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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Cooper AS. Hypothermia for Neuroprotection in Adults After Cardiac Arrest. Crit Care Nurse 2023; 43:77-79. [PMID: 38035613 DOI: 10.4037/ccn2023253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Adam S Cooper
- Adam S. Cooper is the Director of Nursing Continuous Improvement and Affiliate Nursing Quality and Director of the UCSF JBI Centre for Evidence Implementation, UCSF Health, San Francisco, California. He is also a member of the Cochrane Nursing Care Field
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Fernandez Hernandez S, Barlow B, Pertsovskaya V, Maciel CB. Temperature Control After Cardiac Arrest: A Narrative Review. Adv Ther 2023; 40:2097-2115. [PMID: 36964887 PMCID: PMC10129937 DOI: 10.1007/s12325-023-02494-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/08/2023] [Indexed: 03/26/2023]
Abstract
Cardiac arrest (CA) is a critical public health issue affecting more than half a million Americans annually. The main determinant of outcome post-CA is hypoxic-ischemic brain injury (HIBI), and temperature control is currently the only evidence-based, guideline-recommended intervention targeting secondary brain injury. Temperature control is a key component of a post-CA care bundle; however, conflicting evidence challenges its wide implementation across the vastly heterogeneous population of CA survivors. Here, we critically appraise the available literature on temperature control in HIBI, detail how the evidence has been integrated into clinical practice, and highlight the complications associated with its use and the timing of neuroprognostication after CA. Future clinical trials evaluating different temperature targets, rates of rewarming, duration of cooling, and identifying which patient phenotype benefits from different temperature control methods are needed to address these prevailing knowledge gaps.
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Affiliation(s)
| | - Brooke Barlow
- Department of Pharmacy, Memorial Hermann the Woodlands Medical Center, The Woodlands, TX, USA
| | - Vera Pertsovskaya
- The George Washington University School of Medicine and Health Sciences, Washington, DC, 20037, USA
| | - Carolina B Maciel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, 32611, USA
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, 32611, USA
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Department of Neurology, University of Utah, Salt Lake City, UT, 84132, USA
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Targeted Temperature Management After Out-of-Hospital Cardiac Arrest: Integrating Evidence Into Real World Practice. Can J Cardiol 2023; 39:385-393. [PMID: 36610519 DOI: 10.1016/j.cjca.2022.12.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/27/2022] [Accepted: 12/27/2022] [Indexed: 01/06/2023] Open
Abstract
Targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) has been a focus of debate in an attempt to improve post-arrest outcomes. Contemporary trials examining the role of TTM after cardiac arrest suggest that targeting normothermia should be the standard of care for initially comatose survivors of cardiac arrest. Differences in patient populations have been demonstrated across trials, and important subgroups may be under-represented in clinical trials compared with real-world registries. In this review, we aimed to describe the populations represented in international OHCA registries and to propose a pathway to integrate clinical trial evidence into practice. The patient case mix among registries including survivors to hospital admission was similar to the pivotal trials (shockable rhythm, witnessed arrest), suggesting reasonable external validity. Therefore, for the majority of OHCA, targeted normothermia should be the strategy of choice. There remains conflicting evidence for patients with a nonshockable rhythm, with no clear evidence-based justification for mild hypothermia over targeted normothermia.
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