Survival rate and factors associated with 1-month survival of witnessed out-of-hospital cardiac arrest of cardiac origin with ventricular fibrillation and pulseless ventricular tachycardia: The Utstein Osaka project

Association between sex and survival after non-traumatic out of hospital cardiac arrest: A systematic review and meta-analysis

BACKGROUND

Existing studies have shown conflicting results regarding the relationship of sex with survival after out of hospital cardiac arrest (OHCA). This systematic review evaluates the association of female sex with survival to discharge and survival to 30 days after non-traumatic OHCA.

METHODS

We searched Medline, Embase, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception through June 2021 for studies evaluating female sex as a predictor of survival in adult patients with non-traumatic cardiac arrest. Random-effects inverse variance meta-analyses were performed to calculate pooled odds ratios (ORs) with 95% confidence intervals (CI). The GRADE approach was used to assess evidence quality.

RESULTS

Thirty studies including 1,068,788 patients had female proportion of 41%. There was no association for female sex with survival to discharge (OR 1.03, 95% CI 0.95-1.12; I²=89%). Subgroup analysis of low risk of bias studies demonstrated increased survival to discharge for female sex (OR 1.20, 95% CI 1.18-1.23; I²=0%) and with high certainty, the absolute increase in survival was 2.2% (95% CI 0.1%-3.6%). Female sex was not associated with survival to 30 days post-OHCA (OR 1.02, 95% CI 0.92-1.14; I²=79%).

CONCLUSIONS

In adult patients experiencing OHCA, with high certainty in the evidence from studies with low risk of bias, female sex had a small absolute difference for the outcome survival to discharge and no difference in survival at 30 days. Future models that aim to stratify risk of survival post-OHCA should focus on sex-specific factors as opposed to sex as an isolated prognostic factor.

Task-shift Model in Pre-hospital Care and Standardized Nationwide Data Collection in Japan: Improved Outcomes for Out-of-hospital Cardiac Arrest Patients

Out-of-hospital cardiac arrest (OHCA) is a growing worldwide public health concern. Previously, Japan experienced poorer outcomes among OHCA patients than in other high-income countries. In the early 1990s, through policy changes, the Japanese government introduced a task-shift model in pre-hospital care. Some medical practices previously provided by physicians exclusively were delegated to non-physicians, including laypeople. Additionally, we initiated a nationwide data collection system for evaluation. We started a nationwide registry of OHCA patients, a paramedic system to provide advanced life-support care, and basic life-support training for laypeople. In the 2000s, the procedures paramedics could provide were expanded, laypeople were allowed to use automated external defibrillators, and the Utstein style was introduced to the national registry.

Consequently, pre-hospital advanced care and bystander first-aid increased, registry-based research contributed to evidence-based practices, and―most importantly―outcomes of OHCA patients considerably improved. These Japanese experiences demonstrate that streamlining pre-hospital care, including bystander interventions and standardized data collection, can improve OHCA patient outcomes. Despite this progress, however, there still exist many issues to be addressed in response to the changing and increasing care demands within Japan’s aging population.

Clinical Predictive Models of Sudden Cardiac Arrest: A Survey of the Current Science and Analysis of Model Performances

Background

More than 500 000 sudden cardiac arrests (SCAs) occur annually in the United States. Clinical predictive models (CPMs) may be helpful tools to differentiate between patients who are likely to survive or have good neurologic recovery and those who are not. However, which CPMs are most reliable for discriminating between outcomes in SCA is not known.

Methods and Results

We performed a systematic review of the literature using the Tufts PACE (Predictive Analytics and Comparative Effectiveness) CPM Registry through February 1, 2020, and identified 81 unique CPMs of SCA and 62 subsequent external validation studies. Initial cardiac rhythm, age, and duration of cardiopulmonary resuscitation were the 3 most commonly used predictive variables. Only 33 of the 81 novel SCA CPMs (41%) were validated at least once. Of 81 novel SCA CPMs, 56 (69%) and 61 of 62 validation studies (98%) reported discrimination, with median c‐statistics of 0.84 and 0.81, respectively. Calibration was reported in only 29 of 62 validation studies (41.9%). For those novel models that both reported discrimination and were validated (26 models), the median percentage change in discrimination was −1.6%. We identified 3 CPMs that had undergone at least 3 external validation studies: the out‐of‐hospital cardiac arrest score (9 validations; median c‐statistic, 0.79), the cardiac arrest hospital prognosis score (6 validations; median c‐statistic, 0.83), and the good outcome following attempted resuscitation score (6 validations; median c‐statistic, 0.76).

Conclusions

Although only a small number of SCA CPMs have been rigorously validated, the ones that have been demonstrate good discrimination.

Outcomes following cardiopulmonary resuscitation in an emergency department of a low- and middle-income country

BACKGROUND

Cardiopulmonary resuscitation (CPR) is a key component of emergency care following cardiac arrest. A better understanding of factors that influence CPR outcomes and their prognostic implications would help guide care. A retrospective analysis of 800 adult patients that sustained an in- or out-of-hospital cardiac arrest and underwent CPR in the emergency department of a tertiary care facility in Karachi, Pakistan, between 2008 and 15 was conducted.

METHODS

Patient demographics, clinical history, and CPR characteristics data were collected. Logistic regression model was applied to assess predictors of return of spontaneous circulation and survival to discharge. Analysis was conducted using SPSS v.21.0.

RESULTS

Four hundred sixty-eight patients met the study's inclusion criteria, and overall return of spontaneous circulation and survival to discharge were achieved in 128 (27.4%) and 35 (7.5%) patients respectively. Mean age of patients sustaining return of spontaneous circulation was 52 years and that of survival to discharge was 49 years. The independent predictors of return of spontaneous circulation included age ≤ 49 years, witnessed arrest, ≤ 30 min interval between collapse-to-start, and 1-4 shocks given during CPR (aOR (95% CI) 2.2 (1.3-3.6), 1.9 (1.0-3.7), 14.6 (4.9-43.4), and 3.0 (1.4-6.4) respectively), whereas, age ≤ 52 years, bystander resuscitation, and initial rhythm documented (pulseless electrical activity and ventricular fibrillation) were independent predictors of survival to discharge (aOR (95% CI) 2.5 (0.9-6.5), 1.4 (0.5-3.8), 5.3 (1.5-18.4), and 3.1 (1.0-10.2) respectively).

CONCLUSION

Our study notes that while the majority of arrests occur out of the hospital, only a small proportion of those arrests receive on-site CPR, which is a key contributor to unfavorable outcomes in this group. It is recommended that effective pre-hospital emergency care systems be established in developing countries which could potentially improve post-arrest outcomes. Younger patients, CPR initiation soon after arrest, presenting rhythm of pulseless ventricular tachycardia and ventricular fibrillation, and those requiring up to four shocks to revive are more likely to achieve favorable outcomes.

Analysis of out-of-hospital cardiac arrest in Croatia - survival, bystander cardiopulmonary resuscitation, and impact of physician's experience on cardiac arrest management: a single center observational study

AIM

To analyze the initial rhythm, bystander cardiopulmonary resuscitation (CPR) rate, and survival after out-of-hospital cardiac arrests (OHCA) in Varaľdin County (Croatia), and to investigate whether physician's inexperience in emergency medical services (EMS) has an impact on resuscitation management.

METHODS

We reviewed clinical records and Revised Utstein cardiac arrest forms of all out-of-hospital resuscitations performed by EMS Varaľdin (EMSVz), Croatia, from 2007-2013. To analyze the impact of physician's inexperience in EMS (<1 year in EMS) on resuscitation management, we assessed physician's turnover in EMSVz, as well as OHCA survival, airway management, and adherence to resuscitation guidelines in regard to physician's EMS experience.

RESULTS

Of 276 patients (median age 68 years, interquartile range [IQR] 16; 198 male; 37% ventricular fibrillation/ventricular tachycardia, bystander CPR rate 25%), 80 were transferred to hospital and 39 were discharged (median survival after discharge 23 months, IQR 46 months). During the 7-year study period, 29 newly graduated physicians inexperienced in EMS started to work in EMSVz (performing 77 resuscitations), while 48% of them stayed for less than one year. Airway management depended on physician's EMS experience (P=0.018): inexperienced physicians performed bag-valve-mask ventilation (BMV) more than the experienced, with no impact on survival rate. Physician's EMS experience did not influence adherence to resuscitation guidelines (P=0.668), survival to hospital discharge (P=0.791), or survival time (P=0.405).

CONCLUSION

OHCA survival rate of EMSVz resuscitations was higher than in Europe, but bystander CPR needs to be improved. Compared to experienced physicians, inexperienced physicians preferred BMV over intubation, but with similar adherence to resuscitation guidelines and survival after OHCA.

An exploration of attitudes toward bystander cardiopulmonary resuscitation in university students in Tianjin, China: A survey

BACKGROUND

Despite the importance of early effective bystander cardiopulmonary resuscitation (CPR) to improve survival rates from out-of-hospital cardiac arrest, the attitudes toward performing, learning and disseminating CPR in university students of China are still unclear.

METHODS AND AIMS

To assess the attitudes regarding performing, learning and disseminating bystander CPR in university students of China.

RESULTS

The results indicated that except for the scenario where the victim was their own family member or close friend, all other scenarios showed a relatively dismally lower rate of positive response. Besides, it showed a greater willingness to perform chest compression only CPR (CC) than chest compression with mouth-to-mouth ventilation (CCMV) (P < 0.05). Females were more willing to perform CC across seven of the hypothetic scenarios than males. University students of medical-related specialties (45.3%) than university students of non-medical specialties (29.9%) were more willing to perform bystander CPR (P < 0.05). The top four reasons for being unwilling to perform bystander CPR were lack of confidence (32.9%), fear of legal disputes (17.2%), fear of disease transmission (16.0%) and feeling embarrassed (14.0%). 92.6% of respondents wanted to learn CPR and 80.3% of respondents were willing to disseminate CPR.

CONCLUSIONS

CPR technique, victim's status, respondent's specialty and respondent's gender affected the attitudes of respondents toward performing bystander CPR. The top four reasons for being unwilling to perform bystander CPR were lack of confidence, fear of legal disputes, fear of disease transmission and feeling embarrassed. However, the key reason for being unwilling to perform bystander CPR differed in different specialties and particularly 'feeling embarrassment' might be a cultural phenomenon. The attitudes toward learning and disseminating CPR were positive and affected by respondent's gender and specialty.

Development of a first-responder dispatch system using a smartphone

We constructed a prototype community first responder (CFR) dispatch system. The system sends incident information, including a map, to the chosen CFR's mobile phone. We tested it in a simulation of 30 out-of-hospital cardiac arrest incidents which had occurred in the town of Motegi during the previous year. Thirty off-duty firefighters acted as CFRs and were sent to the same locations. The mean response time (from the CFR receiving dispatch information to arrival at the scene) was 3 min 37s faster than the actual response time in the corresponding historical control, i.e. the response time was reduced by 36% (P < 0.01). The median travel distance of the CFRs was 3.4 km and there was a positive correlation between response time and travel distance. The study showed that interactive communication between dispatcher and CFR was important for effective operation and that CFRs could reach an OHCA patient before the Emergency Medical Service arrives.

Bystander-initiated CPR in an Asian metropolitan: does the socioeconomic status matter?

OBJECTIVES

To determine the association of neighborhood socioeconomic status (SES) with bystander-initiated cardiopulmonary resuscitation (CPR) and patient outcomes of out of hospital cardiac arrests (OHCAs) in an Asian metropolitan area.

METHODS

We performed a retrospective study in a prospectively collected cohort from the Utstein registry of adult non-traumatic OHCAs in Taipei, Taiwan. Average real estate value was assessed as the first proxy of SES. Twelve administrative districts in Taipei City were categorized into low versus high SES areas to test the association. The primary outcome was bystander-initiated CPR, and the secondary outcome was patient survival status. Factors associated with bystander-initiated CPR were adjusted for in multivariate analysis. The mean household income was assessed as the second proxy of SES to validate the association.

RESULTS

From January 1, 2008 to December 30, 2009, 3573 OHCAs received prehospital resuscitation in the community. Among these, 617 (17.3%) cases received bystander CPR. The proportion of bystander CPR in low-SES vs. high-SES areas was 14.5% vs. 19.6% (p<0.01). Odds ratio of receiving bystander-initiated CPR in low-SES areas was 0.72 (95% confidence interval: [0.60-0.88]) after adjusting for age, gender, witnessed status, public collapse, and OHCA unrecognized by the online dispatcher. Survival to discharge rate was significantly lower in low-SES areas vs. high-SES areas (4.3% vs. 6.8%; p<0.01). All results above remained consistent in the analyses by mean household income.

CONCLUSIONS

Patients who experienced an OHCA in low-SES areas were less likely to receive bystander-initiated CPR, and demonstrated worse survival outcomes.

Outcomes from prehospital cardiac arrest in blunt trauma patients

BACKGROUND

There are few strategies for treating patients who have suffered cardiopulmonary arrest due to blunt trauma (BT-CPA). The aim of this population-based case series observational study was to clarify the outcome of BT-CPA patients treated with a standardized strategy that included an emergency department thoracotomy (EDT) under an emergency medical service (EMS) system with a rapid transportation system.

METHODS

The 477 BT-CPA registry data were augmented by a review of the detailed medical records in our emergency department (ED) and action reports in the prehospital EMS records.

RESULTS

Of those, 76% were witnessed and 20% were CPA after leaving the scene. In all, 18% of the patients went to the intensive care unit (ICU), the transcatheter arterial embolization (TAE) room, or the operating room (OR). Only 3% survived to be discharged. Among the 363 witnessed patients-11 of whom had ventricular fibrillation (VF) as the initial rhythm, 134 exhibiting pulseless electrical activity (PEA), and 221 with asystole-13, 1, and 3%, respectively, survived to discharge. The most common initial rhythm just after collapse was not VF but PEA, and asystole increased over the 7 min after collapse. There were no differences in the interval between arrival at the hospital and the return of spontaneous circulation between the patients that survived to discharge and deceased patients in the ED, OR, TAE room, or ICU. The longest interval was 17 min.

CONCLUSIONS

In BT-CPA patients, a 20-min resuscitation effort and termination of the effort are thought to be relevant. The initial rhythm is not a prognostic indicator. We believe that the decision on whether to undertake aggressive resuscitation efforts should be made on a case-by-case basis.

Clinical characteristics and long-term prognosis of vasospastic angina patients who survived out-of-hospital cardiac arrest: multicenter registry study of the Japanese Coronary Spasm Association

BACKGROUND

Coronary artery spasm plays an important role in the pathogenesis of ischemic heart disease; however, its role in sudden cardiac death remains to be fully elucidated. We examined the clinical characteristics and outcomes of patients with vasospastic angina (VSA) in our nationwide multicenter registry by the Japanese Coronary Spasm Association.

METHODS AND RESULTS

Between September 2007 and December 2008, 1429 patients with VSA (male/female, 1090/339; median, 66 years) were identified. They were characterized by a high prevalence of smoking and included 35 patients who survived out-of-hospital cardiac arrest (OHCA). The OHCA survivors, as compared with the remaining 1394 non-OHCA patients, were characterized by younger age (median, 58 versus 66 years; P<0.001) and higher incidence of left anterior descending coronary artery spasm (72% versus 53%, P<0.05). In the OHCA survivors, 14 patients underwent implantable cardioverter-defibrillator (ICD) implantation while intensively treated with calcium channel blockers. Survival rate free from major adverse cardiac events was significantly lower in the OHCA survivors compared with the non-OHCA patients (72% versus 92% at 5 years, P<0.001), including appropriate ICD shocks for ventricular fibrillation in 2 patients. Multivariable analysis revealed that OHCA events were significantly correlated with major adverse cardiac events (hazard ratio, 3.25; 95% confidence interval, 1.39 to 7.61; P<0.01).

CONCLUSIONS

These results from the largest vasospastic angina cohort indicate that vasospasm patients who survived OHCA are high-risk population. Further studies are needed to determine whether implantable cardioverter-defibrillator therapy improves patient prognosis.

Incidence and outcomes of out-of-hospital cardiac arrest with shock-resistant ventricular fibrillation: Data from a large population-based cohort

BACKGROUND

The increasing survival rates after out-of-hospital cardiac arrests (OHCA) are due mainly to improvements in the first 3 steps of the chain of survival. The aim of this study was to describe the temporal trends of OHCA incidence and outcomes with shock-resistant ventricular fibrillation (VF) requiring advanced life support procedures.

METHODS

All our subjects were persons aged 18 years or more who had suffered OHCA of presumed cardiac etiology, were witnessed by bystanders, treated by emergency medical service (EMS), and had VF as initial rhythm. Our study was conducted in Osaka Prefecture, Japan from May 1, 1998 through December 31, 2006. Data were collected by EMS personnel using an Utstein-style database. We evaluated the temporal trends of incidence and outcomes of shock-resistant VF.

RESULTS

During the study period, there were 8782 witnessed OHCA cases of presumed cardiac etiology. Among them, 1733 had VF as an initial rhythm, 392 of whom were shock-resistant. While the age-adjusted annual incidence of witnessed VF increased from 2.0 to 3.3 per 100,000 inhabitants, that of shock-resistant VF underwent little change during the study period. The proportion of shock-resistant VF among witnessed VF decreased from 37.0% to 19.0%. Neurologically intact 1-month survival rates after shock-resistant VF remained low at 5.6% even in 2006.

CONCLUSION

The actual incidence of shock-resistant VF has remained unchanged, and their outcomes continue to be dismal. Further efforts are required to reduce the mortality rates of such shock-resistant VF to achieve improved survival after OHCA.

Effectiveness of the new 'Mobile AED Map' to find and retrieve an AED: A randomised controlled trial

BACKGROUND

Although early shock with an automated external defibrillator (AED) is one of the several key elements to save out-of-hospital cardiac arrest (OHCA) victims, it is not always easy to find and retrieve a nearby AED in emergency settings. We developed a cell phone web system, the Mobile AED Map, displaying nearby AEDs located anywhere. The simulation trial in the present study aims to compare the time and travel distance required to access an AED and retrieve it with and without the Mobile AED Map.

METHODS

DESIGN

Randomised controlled trial.

SETTING

Two fields where it was estimated to take 2min (120-170m) to access the nearest AED. Participants were randomly assigned to either the Mobile AED Map group or the control group. We provided each participant in both groups with an OHCA scenario, and measured the time and travel distance to find and retrieve a nearby AED.

RESULTS

Forty-three volunteers were enrolled and completed the protocol. The time to access and retrieve an AED was not significantly different between the Mobile AED Map group (400±238s) and the control group (407±256s, p=0.92). The travel distance was significantly shorter in the Mobile AED Map group (606m vs. 891m, p=0.019). Trial field conditions affected the results differently.

CONCLUSIONS

Although the new Mobile AED Map reduced the travel distance to access and retrieve the AED, it failed to shorten the time. Further technological improvements of the system are needed to increase its usefulness in emergency settings (UMIN000002043).

Impact of the 2005 American Heart Association cardiopulmonary resuscitation and emergency cardiovascular care guidelines on out-of-hospital cardiac arrest survival

OBJECTIVE

To describe changes in out-of-hospital cardiac arrest (OOHCA) survival before and after the release of the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC).

METHODS

Data were extracted from an OOHCA registry for 1,681 adult cases of cardiac arrest treated by one emergency medical services (EMS) system between April 1, 2004, and December 31, 2007, in a large city (2005 population 730,657). The primary endpoint was survival to hospital discharge. A convenience sample of 69 electronic electrocardiogram (ECG) recordings was reviewed to assess CPR quality parameters using impedance waveform analysis during corresponding time periods. Intervention. Implementation of the 2005 AHA guidelines for CPR and ECC in spring 2006.

RESULTS

The annual treated OOHCA incidence rate was 68/100,000; and the treated ventricular fibrillation (VF) incidence rate was 15/100,000. Bystanders performed CPR in 28% of cases. Public automated external defibrillator (AED) use was < 2% over the entire study, and few patients received hypothermia therapy. Unadjusted OOHCA survival rates were significantly higher in the postguidelines period at 9.4% (n = 1,021) than in the preguidelines period at 6.1% (n = 660), despite similarities in all major predictors of outcome (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.1 to 2.4). Bystander-witnessed OOHCA survival for victims in VF on EMS arrival was 19 of 78 (24%) in the preguidelines period versus 34 of 112 (30%) in the postguidelines period (OR 1.4; 95% CI 0.7 to 2.6). CPR quality measures showed significant improvement in the postguidelines period. The mean no-flow fraction in the preguidelines group was 0.46 and dropped to 0.34 in the postguidelines group, a difference of 0.12 (95% CI 0.05 to 0.19). Multivariate regression analysis adjusting for significant predictors of survival showed that OOHCA in the postguidelines period was associated with 1.8 greater odds of survival than in the preguidelines period (95% CI 1.2 to 2.7).

CONCLUSION

In this large city, substantial improvement occurred in overall OOHCA survival rates following the implementation of the 2005 AHA guidelines for CPR and ECC. These changes were associated with improvements in the quality of CPR.