Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest

Resuscitation for out-of-hospital cardiac arrest in Ireland 2012-2020: Modelling national temporal developments and survival predictors

Aim

To explore potential predictors of national out-of-hospital cardiac arrest (OHCA) survival, including health system developments and the COVID pandemic in Ireland.

Methods

National level OHCA registry data from 2012 through to 2020, relating to unwitnessed, and bystander witnessed OHCA were interrogated. Logistic regression models were built by including predictors through stepwise variable selection and enhancing the models by adding pairwise interactions that improved fit. Missing data sensitivity analyses were conducted using multiple imputation.

Results

The data included 18,177 cases. The final model included seventeen variables. Of these nine variables were involved in pairwise interactions. The COVID-19 period was associated with reduced survival (OR 0.61, 95%CI 0.43, 0.87), as were increasing age in years (OR 0.96, 95% CI 0.96, 0.97) and call response interval in minutes (OR 0.97, 95% CI 0.96, 0.99). Amiodarone administration (OR 3.91, 95% CI 2.80, 5.48), urban location (OR 1.40, 95% CI 1.12, 1.77), and chronological year over time (OR 1.14, 95% CI 1.08, 1.20) were associated with increased survival.

Conclusions

National survival from OHCA has significantly increased incrementally over time in Ireland. The COVID-19 pandemic was associated with decreased survival even after accounting for potential disruption to key elements of bystander and EMS care. Further research is needed to understand and address the discrepancy between urban and rural OHCA survival. Information concerning pre-event patient health status and inpatient care process may yield important additional insights in future.

The early change in pH values after out-of-hospital cardiac arrest is not associated with neurological outcome at hospital discharge

Background

The association between pH values and outcome for patients after out-of-hospital cardiac arrest (OHCA) was not fully elucidated; besides, the relationship of change in pH values and neurological outcome was unknown. The aim was to explore the association of pH values as well as change in pH values and neurological outcome for OHCA cardiac patients.

Methods

The adult patients with non-traumatic out-of-hospital cardiac arrest, shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, and at least two arterial blood gases analysis recorded after admission were included. The change in pH values is calculated as the difference between the second and first pH value, and divided by time interval got the rate of change in pH values. The primary outcome was modified Rankin Score (mRS), dichotomized to good (mRS 0-3) and poor (mRS 4-6) outcomes at hospital discharge. The independent relationship of the first pH value, second pH value, and changes in pH values with neurological outcome was investigated with multivariable logistic regression models, respectively.

Results

A total of 1388 adult patients were included for analysis, of which 514 (37%) had good neurological outcome. The median first pH value and second pH value after admission were 7.21 (interquartile range [IQR] 7.09-7.29) and 7.28 (IQR 7.20-7.36), respectively. The median absolute, relative change, and rate of changes in pH values were 0.08 (IQR 0.01-0.16), 1.10% (IQR 0.11-2.22%), and 0.02 (IQR 0-0.06) per hour, respectively. After adjusting for confounders, the higher first pH value (odds ratio [OR] 3.81, confidence interval [CI] 1.60-9.24, P = 0.003) and higher second pH value (OR 9.54, CI 3.45-26.87, P < 0.001) after admission were associated with good neurological outcome, respectively. The absolute (OR 1.58, CI 0.58-4.30, P = 0.368) and relative (OR 1.03, CI 0.96-1.11, P = 0.399) change as well as the rate of change (OR 0.98, CI 0.33-2.71, P = 974) in pH values were not associated with neurological outcome.

Conclusions

For OHCA patients, abnormality in pH values was very common, with a more acidic pH value indicating poor neurological outcome. However, the change in pH values was not associated with outcomes.

Randomized controlled trials in resuscitation

Randomized controlled trials (RCTs) are a gold standard in research and crucial to our understanding of resuscitation science. Many trials in resuscitation have had neutral findings, questioning which treatments are effective in cardiac resuscitation. While it is possible than many interventions do not improve patient outcomes, it is also possible that the large proportion of neutral findings are partially due to design limitations. RCTs can be challenging to implement, and require extensive resources, time, and funding. In addition, conducting RCTs in the out-of-hospital setting provides unique challenges that must be considered for a successful trial. This article will outline many important aspects of conducting trials in resuscitation in the out-of-hospital setting including patient and outcome selection, trial design, and statistical analysis.

Out-of-Hospital Cardiac Arrest

Survival from out-of-hospital cardiac arrest (OHCA) is predicated on a community and system-wide approach that includes rapid recognition of cardiac arrest, capable bystander CPR, effective basic and advanced life support (BLS and ALS) by EMS providers, and coordinated postresuscitation care. Management of these critically ill patients continues to evolve. This article focuses on the management of OHCA by EMS providers.

Accuracy of etiological classification of out-of-hospital cardiac arrest: A scoping review

INTRODUCTION

The Utstein reporting template classifies the etiology of OHCA into "presumed cardiac" and "obvious non-cardiac" or "medical" and "non-medical" categories; however, the accuracy of these classifications is unclear. Ascertaining more accurately the etiology of OHCA is important to tailor advanced life support and identify etiologically consistent patient cohorts for reporting incidence and outcome and enrollment in clinical trials. This scoping review was proposed to identify the state of agreement on etiological classification based on emergency medical service (EMS) data using the Utstein format against other sources.

METHOD

We searched Medline, EBM-Cochrane, and Embase databases from 1946-2023 to identify studies that reported initial and confirmed etiologies of OHCA. A descriptive review of the included studies was conducted.

RESULT

The search yielded 22,994 citations. After excluding duplicates, 16,932 citations were reviewed for titles and abstracts. Twelve studies met the inclusion criteria of this review. The frequency of presumed cardiac etiologies based on EMS data was higher than confirmed cardiac etiologies (88% vs 33%) with 83-94% sensitivity and 73-76% specificity. In contrast, the frequency of presumed non-cardiac etiologies was lower than confirmed non-cardiac etiologies (3% vs 27%) with 52-74% sensitivity and 90-97.7% specificity estimated for respiratory disease.

CONCLUSION

Major disparities exist between current etiological classifications based on the Utstein reporting template and robust sources such as autopsy and medical records. Data linkage and validation are necessary to confirm the etiology of OHCA. Further research is needed on how this misclassification affects reported incidence and outcomes, and how contributing factors may improve etiological classifications.

The Pharmacologic Management of Cardiac Arrest

The effectiveness of pharmacologic management of cardiac arrest patients is widely debated; however, several studies published in the past 5 years have begun to clarify some of these issues. This article covers the current state of evidence for the effectiveness of the vasopressor epinephrine and the combination of vasopressin-steroids-epinephrine and antiarrhythmic medications amiodarone and lidocaine and reviews the role of other medications such as calcium, sodium bicarbonate, magnesium, and atropine in cardiac arrest care. We additionally review the role of β-blockers for refractory pulseless ventricular tachycardia/ventricular fibrillation and thrombolytics in undifferentiated cardiac arrest and suspected fatal pulmonary embolism.

Association of coronary angiography with ST-elevation and no ST-elevation in patients with refractory ventricular fibrillation - A substudy of the DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE-VF randomized control trial)

BACKGROUND

Refractory ventricular fibrillation or pulseless ventricular tachycardia (rVF/pVT) during out-of-hospital cardiac arrest (OHCA) is associated with poor survival. Double sequential defibrillation (DSED) and vector change (VC) improved survival for rVF/pVT in the DOSE-VF RCT. However, the role of angiography and percutaneous coronary intervention (angiography/PCI) during the trial is unknown.

OBJECTIVES

To determine the incidence of ST-elevation (STE) and no ST-elevation (NO-STE) on post-arrest ECG and the use of angiography/PCI in patients with rVF/pVT during the DOSE-VF RCT.

METHOD

Adults (≥18-years) with rVF/pVT OHCA randomized in the DOSE-VF RCT who survived to hospital admission were included. The primary analysis compared the proportion of angiography in STE and NO-STE. We performed regression modelling to examine association between STE, the interaction with defibrillation strategy, and survival to discharge controlling for known covariates.

RESULTS

We included 151 patients, 74 (49%) with STE and 77 (51%) with NO-STE. The proportion of angiography was higher in the STE cohort than NO-STE (87.8% vs 44.2%, p < 0.001); similarly the proportion of PCI was also higher (75.7% vs 9.1%, p < 0.001). Survival to discharge was similar between STE and NO-STE (63.5% vs 51.9%, p = 0.15). Use of angiography/PCI did not differ between defibrillation strategies. Decreased age (OR 0.95, 95% CI 0.92-0.98; p = 0.001) and angiography (OR 9.33, 95% CI 3.60-26.94; p < 0.001) were predictors of survival; however, STE was not.

CONCLUSION

We found high rates of angiography/PCI in patients with STE compared to NO-STE, however similar rates of survival. Angiography was an independent predictor of survival. Improved rates of survival employing DSED and VC were independent of angiography/PCI.

Recurrence of ventricular fibrillation in out-of-hospital cardiac arrest: Clinical evidence and underlying ionic mechanisms

Defibrillation remains the optimal therapy for terminating ventricular fibrillation (VF) in out-of-hospital cardiac arrest (OHCA) patients, with reported shock success rates of ∼90%. A key persistent challenge, however, is the high rate of VF recurrence (∼50-80%) seen during post-shock cardiopulmonary resuscitation (CPR). Studies have shown that the incidence and time spent in recurrent VF are negatively associated with neurologically-intact survival. Recurrent VF also results in the administration of extra shocks at escalating energy levels, which can cause cardiac dysfunction. Unfortunately, the mechanisms underlying recurrent VF remain poorly understood. In particular, the role of chest-compressions (CC) administered during CPR in mediating recurrent VF remains controversial. In this review, we first summarize the available clinical evidence for refibrillation occurring during CPR in OHCA patients, including the postulated contribution of CC and non-CC related pathways. Next, we examine experimental studies highlighting how CC can re-induce VF via direct mechano-electric feedback. We postulate the ionic mechanisms involved by comparison with similar phenomena seen in commotio cordis. Subsequently, the hypothesized contribution of partial cardiac reperfusion (either as a result of CC or CC independent organized rhythm) in re-initiating VF in a globally ischaemic heart is examined. An overview of the proposed ionic mechanisms contributing to VF recurrence in OHCA during CPR from a cellular level to the whole heart is outlined. Possible therapeutic implications of the proposed mechanistic theories for VF recurrence in OHCA are briefly discussed.

Management of incessant ventricular arrhythmias in a patient with left ventricular assist device: a case report

BACKGROUND

The implantation of left ventricular assist devices (LVADs) as a bridge to transplantation or as destination therapy in end-stage heart failure patients is frequently complicated by the emergence of ventricular arrhythmias (VAs). These arrhythmias have been implicated in precipitating deleterious clinical outcomes, increased mortality rates and augmented healthcare expenditures.

CASE PRESENTATION

We present a challenging case of a 49-year-old male with a history of dilated cardiomyopathy who received an LVAD. Post-implantation, the patient suffered from intractable VAs, leading to multiple rehospitalizations and hemodynamic deterioration. Despite exhaustive medical management and electrical cardioversion attempts, the patient's VAs persisted, ultimately necessitating prioritization for cardiac transplantation.

DISCUSSION

This case highlights the challenges in managing VAs in LVAD patients and the importance of multidisciplinary collaboration. While pharmacological intervention is the initial strategy, catheter ablation may be considered in selected cases when medication is insufficient. In instances of intractable VAs, expeditious listing for heart transplantation as a high-priority candidate is advisable when feasible.

The link between initial cardiac rhythm and survival outcomes in in-hospital cardiac arrest using propensity score matching, adjustment, and weighting

The association between the initial cardiac rhythm and short-term survival in patients with in-hospital cardiac arrest (IHCA) has not been extensively studied despite the fact that it is thought to be a prognostic factor in patients with out-of-hospital cardiac arrest. This study aimed to look at the relationship between initial shockable rhythm and survival to hospital discharge in individuals with IHCA. 1516 adults with IHCA who received chest compressions lasting at least two minutes at the National Taiwan University Hospital between 2006 and 2014 made up the study population. Propensity scores were estimated using a fitted multivariate logistic regression model. Various statistical methodologies were employed to investigate the association between shockable rhythm and the probability of survival to discharge in patients experiencing IHCA, including multivariate adjustment, propensity score adjustment, propensity score matching, and logistic regression based on propensity score weighting. In the original cohort, the multivariate-adjusted odds ratio (OR) was 2.312 (95% confidence interval [CI]: 1.515-3.531, P < 0.001). In additional propensity score adjustment, the OR between shockable rhythm and the probability of survival to hospital discharge in IHCA patients was 2.282 (95% CI: 1.486, 3.504, P < 0.001). The multivariate-adjusted logistic regression model analysis revealed that patients with shockable rhythm had a 1.761-fold higher likelihood of surviving to hospital release in the propensity score-matched cohort (OR = 2.761, 95% CI: 1.084-7.028, P = 0.033). The multivariate-adjusted OR of the inverse probability for the treatment-weighted cohort was 1.901 (95% CI: 1.507-2.397, P < 0.001), and the standardized mortality ratio-weighted cohort was 2.692 (95% CI: 1.511-4.795, P < 0.001). In patients with in-hospital cardiac arrest, Initial cardiac rhythm is an independent predictor of survival to hospital discharge. Depending on various statistical methods, patients with IHCA who have a shockable rhythm have a one to two fold higher probability of survival to discharge than those who have a non-shockable rhythm. This provides a reference for optimizing resuscitation decisions for IHCA patients and facilitating clinical communication.

Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Clinical Practice Update on Optimal Post Cardiac Arrest and Refractory Cardiac Arrest Patient Care

Survival to hospital discharge among patients with out-of-hospital cardiac arrest (OHCA) is low and important regional differences in treatment practices and survival have been described. Since the 2017 publication of the Canadian Cardiovascular Society's position statement on OHCA care, multiple randomized controlled trials have helped to better define optimal post cardiac arrest care. This working group provides updated guidance on the timing of cardiac catheterization in patients with ST-elevation and without ST-segment elevation, on a revised temperature control strategy targeting normothermia instead of hypothermia, blood pressure, oxygenation, and ventilation parameters, and on the treatment of rhythmic and periodic electroencephalography patterns in patients with a resuscitated OHCA. In addition, prehospital trials have helped craft new expert opinions on antiarrhythmic strategies (amiodarone or lidocaine) and outline the potential role for double sequential defibrillation in patients with refractory cardiac arrest when equipment and training is available. Finally, we advocate for regionalized OHCA care systems with admissions to a hospital capable of integrating their post OHCA care with comprehensive on-site cardiovascular services and provide guidance on the potential role of extracorporeal cardiopulmonary resuscitation in patients with refractory cardiac arrest. We believe that knowledge translation through national harmonization and adoption of contemporary best practices has the potential to improve survival and functional outcomes in the OHCA population.

Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence?

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.

Comparison of the Effects of Lidocaine and Amiodarone on Patients With Cardiac Arrest: A Systematic Review and Meta-Analysis

The objective of this study was to compare the impact of amiodarone and lidocaine on survival and neurological outcomes following cardiac arrest. A systematic review of randomized controlled trials (RCTs) as well as cohort and cross-sectional trials was undertaken, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Potential relevant studies were searched in databases, including PubMed, Embase, Cochrane Library, and Web of Science, from the beginning of databases to February 15, 2024. Outcomes assessed in this study were survival to hospital discharge, survival to hospital admission or 24 hours, favorable neurological outcomes, and return of spontaneous circulation (ROSC). A total of seven studies (five observational and two RCTs) were included in this meta-analysis encompassing 19,081 patients with cardiac arrest. Pooled analysis showed no difference between amiodarone and lidocaine in terms of survival to hospital discharge (odds ratio (OR): 0.88, 95% confidence interval (CI): 0.75 to 1.04), ROSC (OR: 0.94, 95% CI: 0.84 to 1.05, p-value: 0.25), favorable neurological outcomes (OR: 0.88, 95% CI: 0.66 to 1.17, p-value: 0.38), and survival to 24 hours (OR: 0.82, 95% CI: 0.55 to 1.21, p-value: 0.31). While lidocaine demonstrated a slight survival advantage, the differences were statistically insignificant. Similarly, no significant variations were observed in ROSC incidence, neurological outcomes, or survival at 24 hours. These findings align with current guidelines but underscore the necessity for further rigorous RCTs to provide conclusive recommendations.

Racial and ethnic disparities in bystander resuscitation for out-of-hospital cardiac arrests

INTRODUCTION

Bystander-provided cardiopulmonary resuscitation (CRP) influences the survival rates of out-of-hospital cardiac arrests (OHCAs). Disparities on bystander resuscitation measures between Black, Hispanic, Asians and Non-Hispanic White OHCAs is unclear. Examining racial and ethnic differences in bystander resuscitations is essential to better target interventions.

METHODS

15,542 witnessed OHCAs were identified between April 1, 2011, and June 30, 2015 using the Resuscitation Outcomes Consortium Epidemiologic Registry 3, a multi-center, controlled trial about OHCAs in the United States and Canada. Multivariable logistic regression model was used to analyze the differences in bystander resuscitation (bystander CRP [B-CPR], CPR plus ventilation, automated external defibrillators/defibrillator application [B-AED/D], or delivery of shocks) and clinical outcomes (death at the scene or en route, return of spontaneous circulation upon first arrival at the emergency department [ROSC-ED], survival until ED discharge [S-ED], survival until hospital discharge [S-HOS], and favorable neurological outcome at discharge) between Black, Hispanic, or Asian victims and Non-Hispanic White victims.

RESULTS

Compared to OHCA victims in Non-Hispanic Whites, Black, Hispanic, and Asians were less likely to receive B-CPR (adjusted OR: 0.79; 95 % CI: 0.63-0.99), and B-AED/D (adjusted OR: 0.80; 95 % CI: 0.65-0.98) in public locations. And, Black, Hispanic, and Asian OHCAs were less likely to receive bystander resuscitation in street/highway locations and public buildings, and less likely to have better clinical outcomes, including ROSC-ED, S-ED and S-HOS.

CONCLUSION

Black, Hispanic and Asian victims with witnessed OHCAs are less likely to receive bystander resuscitation and more likely to get worse outcomes than Non-Hispanic White victims.

Supraglottic Airway Versus Tracheal Intubation for Airway Management in Out-of-Hospital Cardiac Arrest: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials

OBJECTIVES

Given the uncertainty regarding the optimal approach for airway management for adult patients with out-of-hospital cardiac arrest (OHCA), we conducted a systematic review and meta-analysis to compare the use of supraglottic airways (SGAs) with tracheal intubation for initial airway management in OHCA.

DATA SOURCES

We searched MEDLINE, PubMed, Embase, Cochrane Library, as well as unpublished sources, from inception to February 7, 2023.

STUDY SELECTION

We included randomized controlled trials (RCTs) of adult OHCA patients randomized to SGA compared with tracheal intubation for initial prehospital airway management.

DATA EXTRACTION

Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model. We used the modified Cochrane risk of bias 2 tool and assessed certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We preregistered the protocol on PROSPERO (CRD42022342935).

DATA SYNTHESIS

We included four RCTs ( n = 13,412 patients). Compared with tracheal intubation , SGA use probably increases return of spontaneous circulation (ROSC) (relative risk [RR] 1.09; 95% CI, 1.02-1.15; moderate certainty) and leads to a faster time to airway placement (mean difference 2.5 min less; 95% CI, 1.6-3.4 min less; high certainty). SGA use may have no effect on survival at longest follow-up (RR 1.06; 95% CI, 0.84-1.34; low certainty), has an uncertain effect on survival with good functional outcome (RR 1.11; 95% CI, 0.82-1.50; very low certainty), and may have no effect on risk of aspiration (RR 1.04; 95% CI, 0.94 to 1.16; low certainty).

CONCLUSIONS

In adult patients with OHCA, compared with tracheal intubation, the use of SGA for initial airway management probably leads to more ROSC, and faster time to airway placement, but may have no effect on longer-term survival outcomes or aspiration events.

2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve outcomes. This "2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support" summarizes the most recent published evidence for and recommendations on the use of medications, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation, and seizure management in this population. We discuss the lack of data in recent cardiac arrest literature that limits our ability to evaluate diversity, equity, and inclusion in this population. Last, we consider how the cardiac arrest population may make up an important pool of organ donors for those awaiting organ transplantation.

Temporal elevation of blood pressure is associated with increased risk of sudden cardiac arrest

Hypertension is a known risk factor for sudden cardiac arrest (SCA). However, the role of temporal changes in blood pressure on the risk of SCA is not fully understood. This study was conducted to determine whether a temporal increase or decrease in blood pressure is associated with the risk of SCA. This study was based on nationwide healthcare insurance data. Individuals who underwent nationwide health check-ups in 2009 and 2011 were analyzed. A total of 2,801,153 individuals were evaluated for 8100 SCA events during the 17, 740, 420 person-years of follow-up. In a multivariate analysis, there were linear association between the degree of temporal elevation of systolic blood pressure (SBP) and the risk of SCA: (i) adjusted-hazard ratio (HR) 1.11 (p = 0.001) in 10 ≤ ΔSBP < 20 (mmHg) group; (ii) adjusted-HR 1.40 (p < 0.001) in 20 ≤ ΔSBP < 40 group; and (iii) adjusted-HR 1.88 (p < 0.001) in 40 ≤ ΔSBP group as compared with the reference group (- 10 ≤ ΔSBP < 10). Temporal increase in diastolic blood pressure (DBP) also a showed significant association with SCA risk with the highest risk observed in ∆DBP ≥ 25 group (adjusted-HR 1.61; p < 0.001) as compared with the reference group (- 5 ≤ ΔDBP < 5). The association between SBP and SCA was not affected by age, sex, presence of diabetes mellitus, or baseline SBP. In conclusion, a temporal increase in blood pressure was significantly associated with the occurrence of SCA, and this association was consistent across all subgroups. However, a temporary decrease in blood pressure does not reduce the risk of SCA. Prevention of elevated blood pressure may play an important role in preventing SCA.

Design and Execution of Clinical Trials in the Cardiac Intensive Care Unit

Clinical practice in the contemporary cardiac intensive care unit (CICU) has evolved significantly over the last several decades. With more frequent multisystem organ failure, increasing use of advanced respiratory support, and the advent of new mechanical circulatory support platforms, clinicians in the CICU are increasingly managing patients with complex comorbid disease in addition to their high-acuity cardiovascular illnesses. Here, the authors discuss challenges associated with traditional trial design in the CICU setting and review novel clinical trial designs that may facilitate better evidence generation in the CICU.

Lidocaine as an anti-arrhythmic drug: Are there any indications left?

Lidocaine is classified as a class Ib anti-arrhythmic that blocks voltage- and pH-dependent sodium channels. It exhibits well investigated anti-arrhythmic effects and has been the anti-arrhythmic of choice for the treatment of ventricular arrhythmias for several decades. Lidocaine binds primarily to inactivated sodium channels, decreases the action potential duration, and increases the refractory period. It increases the ventricular fibrillatory threshold and can interrupt life-threatening tachycardias caused by re-entrant mechanisms, especially in ischemic tissue. Its use was pushed into the background in the era of amiodarone and modern electric device therapy. Recently, lidocaine has come back into focus for the treatment of acute sustained ventricular tachyarrhythmias. In this brief overview, we review the clinical pharmacology including possible side effects, the historical course, possible indications, and current Guideline recommendations for the use of lidocaine.

Positive single-center randomized trials and subsequent multicenter randomized trials in critically ill patients: a systematic review

BACKGROUND

It is unclear how often survival benefits observed in single-center randomized controlled trials (sRCTs) involving critically ill patients are confirmed by subsequent multicenter randomized controlled trials (mRCTs). We aimed to perform a systemic literature review of sRCTs with a statistically significant mortality reduction and to evaluate whether subsequent mRCTs confirmed such reduction.

METHODS

We searched PubMed for sRCTs published in the New England Journal of Medicine, JAMA, or Lancet, from inception until December 31, 2016. We selected studies reporting a statistically significant mortality decrease using any intervention (drug, technique, or strategy) in adult critically ill patients. We then searched for subsequent mRCTs addressing the same research question tested by the sRCT. We compared the concordance of results between sRCTs and mRCTs when any mRCT was available. We registered this systematic review in the PROSPERO International Prospective Register of Systematic Reviews (CRD42023455362).

RESULTS

We identified 19 sRCTs reporting a significant mortality reduction in adult critically ill patients. For 16 sRCTs, we identified at least one subsequent mRCT (24 trials in total), while the interventions from three sRCTs have not yet been addressed in a subsequent mRCT. Only one out of 16 sRCTs (6%) was followed by a mRCT replicating a significant mortality reduction; 14 (88%) were followed by mRCTs with no mortality difference. The positive finding of one sRCT (6%) on intensive glycemic control was contradicted by a subsequent mRCT showing a significant mortality increase. Of the 14 sRCTs referenced at least once in international guidelines, six (43%) have since been either removed or suggested against in the most recent versions of relevant guidelines.

CONCLUSION

Mortality reduction shown by sRCTs is typically not replicated by mRCTs. The findings of sRCTs should be considered hypothesis-generating and should not contribute to guidelines.

Association of intraosseous and intravenous access with patient outcome in out-of-hospital cardiac arrest

Here we report the results of a study on the association between drug delivery via intravenous route or intraosseous route in out-of-hospital cardiac arrest. Intraosseous drug delivery is considered an alternative option in resuscitation if intravenous access is difficult or impossible. Intraosseous uptake of drugs may, however, be compromised. We have performed a retrospective cohort study of all Danish patients with out-of-hospital cardiac arrest in the years 2016-2020 to investigate whether mortality is associated with the route of drug delivery. Outcome was 30-day mortality, death at the scene, no prehospital return of spontaneous circulation, and 7- and 90-days mortality. 17,250 patients had out-of-hospital cardiac arrest. 6243 patients received no treatment and were excluded. 1908 patients had sustained return of spontaneous circulation before access to the vascular bed was obtained. 2061 patients were unidentified, and 286 cases were erroneously registered. Thus, this report consist of results from 6752 patients. Drug delivery by intraosseous route is associated with increased OR of: No spontaneous circulation at any time (OR 1.51), Death at 7 days (OR 1.94), 30 days (2.02), and 90 days (OR 2.29). Intraosseous drug delivery in out-of-hospital cardiac arrest is associated with overall poorer outcomes than intravenous drug delivery.

The effects of methylene blue during and after cardiac arrest in a porcine model; a randomized, blinded, placebo-controlled study

PURPOSE

To evaluate the effect of methylene blue administered as a bolus on return of spontaneous circulation (ROSC), lactate levels, vasopressor requirements, and markers of neurological injury in a clinically relevant pig model of cardiac arrest.

MATERIALS AND METHODS

40 anesthetized pigs were subjected to acute myocardial infarction and 7 min of untreated cardiac arrest. Animals were randomized into three groups: one group received saline only (controls), one group received 2 mg/kg methylene blue and saline (MB + saline), and one group received two doses of 2 mg/kg methylene blue (MB + MB). The first intervention was given after the 3rd rhythm analysis, while the second dose was administered one hour after achieving ROSC. Animals underwent intensive care and observation for six hours, followed by cerebral magnetic resonance imaging (MRI). The primary outcome for this study was development in lactate levels after cardiac arrest. Categorical data were compared using Fisher's exact test and pointwise data were analyzed using one-way analysis of variance (ANOVA) or equivalent non-parametric test. Continuous data collected over time were analyzed using a linear mixed effects model. A value of p < .05 was considered statistically significant.

RESULTS

Lactate levels increased in all groups after cardiac arrest and resuscitation, however lactate levels in the MB + MB group decreased significantly faster compared with the control group (p = .007) and the MB + saline group (p = .02). The proportion of animals achieving initial ROSC was similar across groups: 11/13 (85%) in the control group, 10/13 (77%) in the MB + saline group, and 12/14 (86%) in the MB + MB group (p = .81). Time to ROSC did not differ between groups (p = .67). There was no significant difference in accumulated norepinephrine dose between groups (p = .15). Cerebral glycerol levels were significantly lower in the MB + MB group after resuscitation compared with control group (p = .03). However, MRI data revealed no difference in apparent diffusion coefficient, cerebral blood flow, or dynamic contrast enhanced MR perfusion between groups.

CONCLUSION

Treatment with a bolus of methylene blue during cardiac arrest and after resuscitation did not significantly improve hemodynamic function. A bolus of methylene blue did not yield the neuroprotective effects that have previously been described in animals receiving methylene blue as an infusion.

Hospital-administered ECPR for out-of-hospital cardiac arrest: an observational cohort study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is a treatment method for refractory out-of-hospital cardiac arrest (OHCA) requiring a complex chain of care.

METHODS

All cases of OHCA between 1 January 2016 and 31 December 2021 in the Helsinki University Hospital catchment area in which the ECPR protocol was activated were included in the study. The protocol involved patient transport from the emergency site with ongoing mechanical cardiopulmonary resuscitation (CPR) directly to the cardiac catheterisation laboratory where the implementation of extracorporeal membrane oxygenation (ECMO) was considered. Cases of hypothermic cardiac arrest were excluded. The main outcomes were the number of ECPR protocol activations, duration of prehospital and in-hospital time intervals, and whether the ECPR candidates were treated using ECMO or not.

RESULTS

The prehospital ECPR protocol was activated in 73 cases of normothermic OHCA. The mean patient age (SD) was 54 (±11) years and 67 (91.8%) of them were male. The arrest was witnessed in 67 (91.8%) and initial rhythm was shockable in 61 (83.6%) cases. The median ambulance response time (IQR) was 9 (7-11) min. All patients received mechanical CPR, epinephrine and/or amiodarone. Seventy (95.9%) patients were endotracheally intubated. The median (IQR) highest prehospital end-tidal CO2 was 5.5 (4.0-6.9) kPa.A total of 37 (50.7%) patients were treated with venoarterial ECMO within a median (IQR) of 84 (71-105) min after the arrest. Thirteen (35.1%) of them survived to discharge and 11 (29.7%) with a cerebral performance category (CPC) 1-2. In those ECPR candidates who did not receive ECMO, 8 (22.2%) received permanent return of spontaneuous circulation during transport or immediately after hospital arrival and 6 (16.7%) survived to discharge with a CPC 1-2.

CONCLUSIONS

Half of the ECPR protocol activations did not lead to ECMO treatment. However, every fourth ECPR candidate and every third patient who received ECMO-facilitated resuscitation at the hospital survived with a good neurological outcome.

Outcomes of out-of-hospital cardiac arrest in Ireland 2012-2020: Protocol for an observational study

Background

Out-of-hospital cardiac arrest (OHCA) is a leading cause of preventable mortality that now affects almost 3,000 people each year in Ireland. Survival is low at 6-7%, compared to a European average of 8%. The Irish Out-of-Hospital Cardiac Registry (OHCAR) prospectively gathers data on all OHCA in Ireland where emergency medical services attempted resuscitation.The Irish health system has undergone several developments that are relevant to OHCA care in the period 2012-2020. OHCAR data provides a means of exploring temporal trends in OHCA incidence, care, and outcomes over time. It also provides a means of exploring whether system developments were associated with a change in key outcomes.This research aims to summarise key trends in available OHCAR data from the period 2012 - 2020, to explore and model predictors of bystander CPR, bystander defibrillation, and survival, and to explore the hypothesis that significant system level temporal developments were associated with improvements in these outcomes.

Methods

The following protocol sets out the relevant background and research approach for an observational study that will address the above aims. Key trends in available OHCAR data (2012 - 2020) will be described and evaluated using descriptive summaries and graphical displays. Multivariable logistic regression will be used to model predictors of 'bystander CPR', 'bystander defibrillation' and 'survival to hospital discharge' and to explore the effects (if any) of system level developments in 2015/2016 and the COVID-19 pandemic (2020) on these outcomes.

Discussion

The findings of this research will be used to understand temporal trends in the care processes and outcomes for OHCA in Ireland over the period 2012-2020. The results can further be used to optimise future health system developments for OHCA in both Ireland and internationally.

Clinical Features and Outcomes Among Patients With Refractory Out-of-Hospital Cardiac Arrest and an Initial Shockable Rhythm

BACKGROUND

Clinical features among patients with refractory out-of-hospital cardiac arrest (OHCA) and initial shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia are not well-characterized.

METHODS

We compared clinical characteristics and coronary angiographic findings between patients with refractory OHCA (incessant ventricular fibrillation/pulseless ventricular tachycardia after ≥3 direct-current shocks) and those without refractory OHCA.

RESULTS

Between 2014 and 2018, a total of 204 patients with ventricular fibrillation/pulseless ventricular tachycardia OHCA (median age 62; males 78%) were divided into groups with (36%, 74/204) and without refractory arrest (64%, 130/204). Refractory OHCA patients had longer cardiopulmonary resuscitation (23 versus 15 minutes), more frequently required ≥450 mg amiodarone (34% versus 3.8%), and had cardiogenic shock (80% versus 55%) necessitating higher adrenaline dose (4.0 versus 1.0 mg) and higher rates of mechanical ventilation (92% versus 74%; all P<0.01). Of 167 patients (82%) selected for coronary angiography, 33% (n=55) had refractory OHCA (P=0.035). Significant coronary artery disease (≥1 major vessel with >70% stenosis) was present in >70% of patients. Refractory OHCA patients frequently had acute coronary occlusion (64% versus 47%), especially left circumflex (20% versus 6.4%) and graft vessel (7.3% versus 0.9%; all P<0.05) compared with those without refractory OHCA. Refractory OHCA group had higher in-hospital mortality (45% versus 30%, P=0.036) and greater new requirement for dialysis (18% versus 6.3%, P=0.011). After adjustment, refractory OHCA was associated with over 2-fold higher odds of in-hospital mortality (odds ratio, 2.28 [95% CI, 1.06-4.89]; P=0.034).

CONCLUSIONS

Refractory ventricular fibrillation/pulseless ventricular tachycardia OHCA was associated with more intensive resuscitation, higher rates of acute coronary occlusion, and poorer in-hospital outcomes, underscoring the need for future studies in this extreme-risk subgroup.

Trends in use of intraosseous and intravenous access in out-of-hospital cardiac arrest across English ambulance services: A registry-based, cohort study

INTRODUCTION

The optimum route for drug administration in cardiac arrest is unclear. Recent data suggest that use of the intraosseous route may be increasing. This study aimed to explore changes over time in use of the intraosseous and intravenous drug routes in out-of-hospital cardiac arrest in England.

METHODS

We extracted data from the UK Out-of-Hospital Cardiac Arrest Outcomes registry. We included adult out-of-hospital cardiac arrest patients between 2015-2020 who were treated by an English Emergency Medical Service that submitted vascular access route data to the registry. The primary outcome was any use of the intraosseous route during cardiac arrest. We used logistic regression models to describe the association between time (calendar month) and intraosseous use.

RESULTS

We identified 75,343 adults in cardiac arrest treated by seven Emergency Medical Service systems between January 2015 and December 2020. The median age was 72 years, 64% were male and 23% presented in a shockable rhythm. Over the study period, the percentage of patients receiving intraosseous access increased from 22.8% in 2015 to 42.5% in 2020. For each study-month, the odds of receiving any intraosseous access increased by 1.019 (95% confidence interval 1.019 to 1.020, p < 0.001). This observed effect was consistent across sensitivity analyses. We observed a corresponding decrease in use of intravenous access.

CONCLUSION

In England, the use of intraosseous access in out-of-hospital cardiac arrest has progressively increased over time. There is an urgent need for randomised controlled trials to evaluate the clinical effectiveness of the different vascular access routes in cardiac arrest.

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action

Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents' families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.

Predicting survival post-cardiac arrest: An observational cohort study

Introduction

Over 400,000 out-of-hospital cardiac arrest (OHCA) occur each year in Canada and the United States with less than 10% survival to hospital discharge. Cardiac arrest is a heterogenous condition and patient outcomes are impacted by a multitude of factors. Prognostication is recommended at 72 hours after return of spontaneous circulation (ROSC), however there may be other factors that could predict patient outcome earlier in the post-arrest period. The objective of our study was to develop and internally validate a novel clinical prediction rule to risk stratify patients early in the post-cardiac arrest period.

Methods

We performed a retrospective cohort study of adult (≥18 years) post-cardiac arrest patients between 2010 and 2015 from the Epistry Cardiac Arrest database in Toronto. Our primary analysis used ordinal logistic regression to examine neurologic outcome at discharge using the modified Rankin Scale (mRS). Our secondary analysis used logistic regression for neurologic outcome and survival to hospital discharge. Models were internally validated using bootstrap validation.

Results

A total of 3432 patients met our inclusion criteria. Our clinical prediction model was able to predict neurologic outcome on an ordinal scale using our predefined variables with an AUC of 0.89 after internal validation. The predictive performance was maintained when examining neurologic outcome as a binary variable and survival to hospital discharge.

Conclusion

We were able to develop a model to accurately risk stratify adult cardiac arrest patients early in the post-cardiac arrest period. Future steps are needed to externally validate this model in other healthcare settings.

Intravenous vs. intraosseous vascular access during out-of-hospital cardiac arrest - protocol for a randomised clinical trial

Objective

During cardiac arrest, current guidelines recommend attempting intravenous access first and to consider intraosseous access if intravenous access is unsuccessful or impossible. However, these recommendations are only based on very low-certainty evidence. Therefore, the "Intravenous vs Intraosseous Vascular Access During Out-of-Hospital Cardiac Arrest" (IVIO) trial aims to determine whether there is a difference in patient outcomes depending on the type of vascular access attempted during out-of-hospital cardiac arrest. This current article describes the clinical IVIO trial.

Methods

The IVIO trial is an investigator-initiated, randomised trial of intravenous vs. intraosseous vascular access during adult non-traumatic out-of-hospital cardiac arrest in Denmark. The intervention will consist of minimum two attempts (if unsuccessful on the first attempt) to successfully establish intravenous or intraosseous vascular access during cardiac arrest. The intraosseous group will be further randomised to the humeral or tibial site. The primary outcome is sustained return of spontaneous circulation and key secondary outcomes include survival and survival with a favourable neurological outcome at 30 days. A total of 1,470 patients will be included.

Results

The trial started in March 2022 and the last patient is anticipated to be included in the spring of 2024. The primary results will be reported after 90-day follow-up and are anticipated in mid-2024.

Conclusion

The current article describes the design of the Danish IVIO trial. The findings of this trial will help inform future guidelines for selecting the optimal vascular access route during out-of-hospital cardiac arrest.

Survival by time-to-administration of amiodarone, lidocaine, or placebo in shock-refractory out-of-hospital cardiac arrest

BACKGROUND

Amiodarone and lidocaine have not been shown to have a clear survival benefit compared to placebo for out-of-hospital cardiac arrest (OHCA). However, randomized trials may have been impacted by delayed administration of the study drugs. We sought to evaluate how timing from emergency medical services (EMS) arrival on scene to drug administration affects the efficacy of amiodarone and lidocaine compared to placebo.

METHOD

This is a secondary analysis of the 10-site, 55-EMS-agency double-blind randomized controlled amiodarone, lidocaine, or placebo in OHCA study. We included patients with initial shockable rhythms who received the study drugs of amiodarone, lidocaine, or placebo before achieving return of spontaneous circulation. We performed logistic regression analyses evaluating survival to hospital discharge and secondary outcomes of survival to admission and functional survival (modified Rankin scale score ≤ 3). We evaluated the samples stratified by early (<8 min) and late administration groups (≥8 min). We compared outcomes for amiodarone and lidocaine compared to placebo and adjust for potential confounders.

RESULTS

There were 2802 patients meeting inclusion criteria, with 879 (31.4%) in the early (<8 min) and 1923 (68.6%) in the late (≥8 min) groups. In the early group, patients receiving amiodarone, compared to placebo, had significantly higher survival to admission (62.0% vs. 48.5%, p = 0.001; adjusted OR [95% CI] 1.76 [1.24-2.50]), survival to discharge (37.1% vs. 28.0%, p = 0.021; 1.56 [1.07-2.29]), and functional survival (31.6% vs. 23.3%, p = 0.029; 1.55 [1.04-2.32]). There were no significant differences with early lidocaine compared to early placebo (p > 0.05). Patients in the late group who received amiodarone or lidocaine had no significant differences in outcomes at discharge compared to placebo (p > 0.05).

CONCLUSIONS

The early administration of amiodarone, particularly within 8 min, is associated with greater survival to admission, survival to discharge, and functional survival compared to placebo in patients with an initial shockable rhythm.

Pathophysiology and treatment of adults with arrhythmias in the emergency department, part 2: Ventricular and bradyarrhythmias

PURPOSE

This is the second article in a 2-part series reviewing the pathophysiology and treatment considerations for arrhythmias. Part 1 of the series discussed aspects related to treating atrial arrhythmias. Here in part 2, the pathophysiology of ventricular arrhythmias and bradyarrhythmias and current evidence on treatment approaches are reviewed.

SUMMARY

Ventricular arrhythmias can arise suddenly and are a common cause of sudden cardiac death. Several antiarrhythmics may be effective in management of ventricular arrhythmias, but there is robust evidence to support the use of only a few of these agents, and such evidence was largely derived from trials involving patients with out-of-hospital cardiac arrest. Bradyarrhythmias range from asymptomatic mild prolongation of nodal conduction to severe conduction delays and impending cardiac arrest. Vasopressors, chronotropes, and pacing strategies require careful attention and titration to minimize adverse effects and patient harm.

CONCLUSION

Ventricular arrhythmias and bradyarrhythmias can be consequential and require acute intervention. As experts in pharmacotherapy, acute care pharmacists can participate in providing high-level intervention by aiding in diagnostic workup and medication selection.

Resuscitation Strategies for Maximizing Survival

There is no single resuscitation strategy that will uniformly improve cardiac arrest outcomes. Traditional vital signs cannot be relied on in cardiac arrest, and the use of continuous capnography, regional cerebral tissue oxygenation, and continuous arterial monitoring are options for use early defibrillation are critical elements of resuscitation. Cardio-cerebral perfusion may be improved with the use of active compression-decompression CPR, an impedance threshold device, and head-up CPR. In refractory shockable arrest, if ECPR is not an option, consider changing defibrillator pad placement and/or double defibrillation, additional medication options, and possibly stellate ganglion block.

Out-of-Hospital Cardiac Arrest

Survival from out-of-hospital cardiac arrest (OHCA) is predicated on a community and system-wide approach that includes rapid recognition of cardiac arrest, capable bystander CPR, effective basic and advanced life support (BLS and ALS) by EMS providers, and coordinated postresuscitation care. Management of these critically ill patients continues to evolve. This article focuses on the management of OHCA by EMS providers.

The Pharmacologic Management of Cardiac Arrest

The effectiveness of pharmacologic management of cardiac arrest patients is widely debated; however, several studies published in the past 5 years have begun to clarify some of these issues. This article covers the current state of evidence for the effectiveness of the vasopressor epinephrine and the combination of vasopressin-steroids-epinephrine and antiarrhythmic medications amiodarone and lidocaine and reviews the role of other medications such as calcium, sodium bicarbonate, magnesium, and atropine in cardiac arrest care. We additionally review the role of β-blockers for refractory pulseless ventricular tachycardia/ventricular fibrillation and thrombolytics in undifferentiated cardiac arrest and suspected fatal pulmonary embolism.

Defibrillation in the Cardiac Arrest Patient

Defibrillation is one of the few interventions known to favorably impact survival in cardiac arrest. In witnessed arrest, survival improves with defibrillation as early as possible, whereas it may improve outcomes to administer high-quality chest compressions for 90 seconds before defibrillation in unwitnessed arrest. Minimizing pre-, peri-, and post-shock pauses has been shown to have mortality benefits. Refractory ventricular fibrillation has high mortality rates, and there is ongoing research into promising adjunctive treatment modalities. There remains no consensus on optimal pad positioning and defibrillation energy level, however, recent data suggest anteroposterior pad placement may be superior to anterolateral placement.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Management of the Underlying Etiologies and Comorbidities of Heart Failure

Most patients with heart failure (HF) have multiple comorbidities, which impact their quality of life, aggravate HF, and increase mortality. Cardiovascular comorbidities include systemic and pulmonary hypertension, ischemic and valvular heart diseases, and atrial fibrillation. Non-cardiovascular comorbidities include diabetes mellitus (DM), chronic kidney and pulmonary diseases, iron deficiency and anemia, and sleep apnea. In patients with HF with hypertension and left ventricular hypertrophy, renin-angiotensin system inhibitors combined with calcium channel blockers and/or diuretics is an effective treatment regimen. Measurement of pulmonary vascular resistance via right heart catheterization is recommended for patients with HF considered suitable for implantation of mechanical circulatory support devices or as heart transplantation candidates. Coronary angiography remains the gold standard for the diagnosis and reperfusion in patients with HF and angina pectoris refractory to antianginal medications. In patients with HF and atrial fibrillation, long-term anticoagulants are recommended according to the CHA2DS2-VASc scores. Valvular heart diseases should be treated medically and/or surgically. In patients with HF and DM, metformin is relatively safer; thiazolidinediones cause fluid retention and should be avoided in patients with HF and dyspnea. In renal insufficiency, both volume status and cardiac performance are important for therapy guidance. In patients with HF and pulmonary disease, beta-blockers are underused, which may be related to increased mortality. In patients with HF and anemia, iron supplementation can help improve symptoms. In obstructive sleep apnea, continuous positive airway pressure therapy helps avoid severe nocturnal hypoxia. Appropriate management of comorbidities is important for improving clinical outcomes in patients with HF.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Management of the Underlying Etiologies and Comorbidities of Heart Failure

Most patients with heart failure (HF) have multiple comorbidities, which impact their quality of life, aggravate HF, and increase mortality. Cardiovascular comorbidities include systemic and pulmonary hypertension, ischemic and valvular heart diseases, and atrial fibrillation. Non-cardiovascular comorbidities include diabetes mellitus (DM), chronic kidney and pulmonary diseases, iron deficiency and anemia, and sleep apnea. In patients with HF with hypertension and left ventricular hypertrophy, renin-angiotensin system inhibitors combined with calcium channel blockers and/or diuretics is an effective treatment regimen. Measurement of pulmonary vascular resistance via right heart catheterization is recommended for patients with HF considered suitable for implantation of mechanical circulatory support devices or as heart transplantation candidates. Coronary angiography remains the gold standard for the diagnosis and reperfusion in patients with HF and angina pectoris refractory to antianginal medications. In patients with HF and atrial fibrillation, long-term anticoagulants are recommended according to the CHA2DS2-VASc scores. Valvular heart diseases should be treated medically and/or surgically. In patients with HF and DM, metformin is relatively safer; thiazolidinediones cause fluid retention and should be avoided in patients with HF and dyspnea. In renal insufficiency, both volume status and cardiac performance are important for therapy guidance. In patients with HF and pulmonary disease, beta-blockers are underused, which may be related to increased mortality. In patients with HF and anemia, iron supplementation can help improve symptoms. In obstructive sleep apnea, continuous positive airway pressure therapy helps avoid severe nocturnal hypoxia. Appropriate management of comorbidities is important for improving clinical outcomes in patients with HF.

The Effect of Time to Treatment With Antiarrhythmic Drugs on Survival and Neurological Outcomes in Shock Refractory Out-of-Hospital Cardiac Arrest

OBJECTIVES

Examining the association of time to treatment (drug or placebo) with survival to hospital discharge and neurologic outcome.

DESIGN

Post hoc analysis of the Resuscitation Outcomes Consortium Amiodarone, Lidocaine, Placebo randomized controlled trial.

SETTING

Emergency medical services enrolled patients with out-of-hospital cardiac arrest (OHCA) at multiple North American sites.

PATIENTS

Adults with nontraumatic OHCA and an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia refractory to at least one defibrillation attempt were included.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We used logistic regression to examine the association of time to treatment with survival to hospital discharge and favorable neurologic status at discharge (modified Rankin Scale ≤ 3) for the three treatment groups including an interaction term between treatment and time to treatment to determine the effect of time on treatment effects. Time to treatment data were available for 2,994 out of 3,026 patients (99%). The proportion of patients who survived to hospital discharge decreased as time to drug administration increased, in amiodarone (odds ratio [OR], 0.91; 95% CI, 0.90-0.93 per min), lidocaine (OR, 0.93; 95% CI, 0.91-0.96), and placebo (OR, 0.91; 95% CI, 0.90-0.93). Comparing amiodarone to placebo, there was improved survival at all times of drug administration (OR, 1.32; 95% CI, 1.05-1.65). Comparing lidocaine to placebo, survival was not different with shorter times to drug administration (< 11 min), whereas survival was higher with lidocaine at longer times to drug administration with an interaction between treatment effect and time to treatment (p = 0.048). Survival with good neurologic outcome showed similar results for all analyses.

CONCLUSIONS

Survival and favorable neurologic outcomes decreased with longer times to drug administration. Amiodarone improved survival at all time points whereas lidocaine improved survival only at later time points, compared with placebo.

The impact of time to amiodarone administration on survival from out-of-hospital cardiac arrest

Aim

To examine the impact of time to amiodarone administration on survival from shock-refractory Ventricular Fibrillation/pulseless Ventricular Tachycardia (VF/pVT) following out-of-hospital cardiac arrest (OHCA).

Methods

A retrospective cohort study of adult (≥16 years) OHCA patients in shock-refractory VF/pVT (after 3 consecutive defibrillation attempts) of medical aetiology who arrested between January 2010 and December 2019. Time-dependent propensity score matching was used to sequentially match patients who received amiodarone at any given minute of resuscitation with patients eligible to receive amiodarone during the same minute. Log-binomial regression models were used to assess the association between time of amiodarone administration (by quartiles of time-to-matching) and survival outcomes.

Results

A total of 2,026 patients were included, 1,393 (68.8%) of whom received amiodarone with a median (interquartile range) time to administration of 22.0 (18.0-27.0) minutes. Propensity score matching yielded 1,360 matched pairs. Amiodarone administration within 28 minutes of the emergency call was associated with a higher likelihood of return of spontaneous circulation (ROSC) (≤18minutes: RR = 1.03 (95%CI 1.02, 1.04); 19-22minutes: RR = 1.02 (95%CI 1.01, 1.03); 23-27minutes: RR = 1.01 (95%CI 1.00, 1.02)) and event survival (pulse on hospital arrival) (≤18 minutes: RR = 1.05 (95%CI 1.03, 1.07); 19-22 minutes: RR = 1.03 (95%CI 1.01, 1.05); 23-27 minutes: RR = 1.02 (95%CI 1.00, 1.03). Amiodarone administration within 23 minutes of the emergency call was associated with a higher likelihood of survival to hospital discharge (≤18minutes: RR = 1.17 (95%CI 1.09, 1.24; 19-22 minutes: RR = 1.10 (95%CI 1.04, 1.17).

Conclusion

Amiodarone administered within 23 minutes of the emergency call is associated with improved survival outcomes in shock-refractory VF/pVT, although prospective trials are required to confirm these findings.

aMplitude spectral area of ventricular fibrillation and amiOdarone Study in patients with out-of-hospital cArdIaC arrest. The MOSAIC study

Objective

Antiarrhythmic drugs are recommended for out of hospital cardiac arrest (OHCA) with shock-refractory ventricular fibrillation (VF). Amplitude Spectral Area (AMSA) of VF is a quantitative waveform measure that describes the amplitude-weighted mean frequency of VF, it correlates with intramyocardial adenosine triphosphate (ATP) concentration, it is a predictor of shock efficacy and an emerging indicator to guide defibrillation and resuscitation efforts. How AMSA might be influenced by amiodarone administration is unknown.

Methods

In this international multicentre observational study, all OHCAs receiving at least one shock were included. AMSA values were calculated by retrospectively analysing the pre-shock ECG interval of 2 s. Multivariable models were run and a propensity score based on the probability of receiving amiodarone was created to compare two randomly matched samples.

Results

2,077 shocks were included: 1,407 in the amiodarone group and 670 in the non-amiodarone group. AMSA values were lower in the amiodarone group [8.8 (6-12.7) mV·Hz vs. 9.8 (6-14) mV·Hz, p = 0.035]. In two randomly matched propensity score-based groups of 261 shocks, AMSA was lower in the amiodarone group [8.2 (5.8-13.5) mV·Hz vs. 9.6 (5.6-11.6), p = 0.042]. AMSA was a predictor of shock success in both groups but the predictive power was lower in the amiodarone group [Area Under the Curve (AUC) non-amiodarone group 0.812, 95%CI: 0.78-0.841 vs. AUC amiodarone group 0.706, 95%CI: 0.68-0.73; p < 0.001].

Conclusions

Amiodarone administration was independently associated with the probability of recording lower values of AMSA. In patients who have received amiodarone during cardiac arrest the predictive value of AMSA for shock success is significantly lower, but still statistically significant.

Comparison the efficacy of amiodarone and lidocaine for cardiac arrest: A network meta-analysis

BACKGROUND

There is no evidence that antiarrhythmic drugs can improve long-term survival or survival with favorable neurological outcomes in cardiac arrest patients. We did this network meta-analysis to comprehensively compare the efficacy of various antiarrhythmic drugs for cardiac arrest patients.

METHODS

We searched studies from inception until Nov 11, 2022 through PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP Database, and Wanfang database. All studies comparing different antiarrhythmic drugs for cardiac arrest were included in this meta-analysis. Outcomes were survival to hospital discharge in cardiac arrest, survival to hospital admission/24 h and favorable neurological outcome. This network meta-analysis was performed by R software.

RESULTS

Finally, a total of 9 studies (10,980 patients) were finally included in this network meta-analysis. Amiodarone (odd ratio [OR] 2.28, 95% credibility interval [CrI] 1.61-3.27) and lidocaine (OR 1.53, 95% CrI 1.05-2.25) was superior than placebo in terms of the survival to hospital admission/24 h with statistically significant. Amiodarone (OR 2.19, 95% CrI 1.54-3.14) and lidocaine (OR 1.58, 95% CrI 1.09-2.32) was superior than placebo in terms of the survival to hospital discharge with statistically significant. Amiodarone (OR 2.43, 95% CrI 1.61-3.68) and lidocaine (OR 1.62, 95% CrI 1.04-2.53) was superior than placebo in terms of the favorable neurological outcome with statistically significant. The surface under the cumulative ranking (SUCRA) shows that amiodarone ranked first (SUCRA, 99.6%), lidocaine ranked second (SUCRA, 49.6%), placebo ranked the last (SUCRA, 0.86%). Inverted funnel plot is essentially symmetrical, it is possible that this study has a small sample effect or a small publication bias.

CONCLUSIONS

Amiodarone had the best effect on both survival to hospital admission, discharge and more favorable neurological outcome. Thus, amiodarone should be listed as first line drug for cardiac arrest. However, the quality of available evidence limits the formation of powerful conclusions regarding the comparative efficacy or safety of amiodarone or lidocaine used to treat cardiac arrest. Higher-quality randomized controlled trials are required for further research in future.

Evaluation of the effectiveness of potassium chloride in the management of out-of hospital cardiac arrest by refractory ventricular fibrillation: Study protocol of the POTACREH study

PURPOSE

Out-of-hospital cardiac arrest (OHCA) has a poor prognosis, with an overall survival rate of about 5% at discharge. Shockable rhythm cardiac arrests (ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)) have a better prognosis. In case of shockable rhythm, treatment is based on defibrillation, and thereafter, in case of failure of 3 external electric shocks (EES), on direct intravenous administration of 300 mg amiodarone, or lidocaine when amiodarone is unavailable or inefficient. During surgical procedures under extracorporeal circulation, a high potassium cardioplegia solution is administered to interrupt cardiac activity and facilitate surgical procedure. By extension, direct intravenous administration of potassium chloride (KCl) has been shown to convert VF, resulting in return to a hemodynamically efficient organized heart rate within a few minutes. The aim of this study is to provide clinical evidence that direct intravenous injection of KCl, into a patient presenting with OHCA due to refractory VF although 3 EES, should interrupt this VF and then allow rapid restauration of an organized heart rhythm, and thus return of spontaneous circulation (ROSC).

METHODS

A multicenter, prospective, single group, phase 2 study will be conducted on 81 patients presenting with refractory VF. After failure of 3 EES, each patient will receive direct intravenous injection of 20 mmol KCl instead of amiodarone. The primary outcome will be survival rate at hospital admission. Major secondary outcomes will include ROSC and time to ROSC in the prehospital setting, number of VF recidivism after KCl injection, survival rate at hospital discharge with a good neurologic prognostic, and survival rate 3 months after hospital discharge with a good neurologic prognostic.

RESULTS

No patient is currently included in the study.

DISCUSSION

Conventional guideline strategy based on antiarrhythmic drug administration, i.e. amiodarone or lidocaine, for OHCA due to shockable rhythm, has not yet demonstrated an increase in survival at hospital admission or at hospital discharge. This may be related to the major cardiodepressant effect of those drugs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04316611. Registered on March 2020. AP-HP180577 / N° EUDRACT: 2019-002544-24. Funded by the French Health Ministry. https://clinicaltrials.gov/ct2/show/NCT04316611.

Long-term increase in fasting blood glucose is associated with increased risk of sudden cardiac arrest

BACKGROUND

Diabetes mellitus (DM) is associated with various cardiovascular complications, including sudden cardiac arrest (SCA). Furthermore, the severity of DM, as assessed by fasting blood glucose (FBG), is associated with the risk of SCA. However, whether long-term changes in FBG influence on SCA risk remains to be determined.

METHODS

This study used sequential nationwide health screening data from 2009 and 2011. FBG was measured at each health screening, and ΔFBG was calculated as FBG in 2011-FBG in 2009.

RESULTS

Overall, 2,801,153 people were analyzed, and the mean follow-up duration was 6.33 years. Compared with the euglycemic group (- 20 ≤ ΔFBG < 20), the 20 ≤ ΔFBG < 40, 40 ≤ ΔFBG < 100, and ΔFBG ≥ 100 groups had increased SCA risks of 25% (adjusted hazard ratio [HR] = 1.25; 95% confidence interval [CI] 1.16-1.35; p < 0.001), 66% (adjusted HR = 1.66; 95% CI 1.49-1.86; p < 0.001), and 2.9-fold (adjusted HR = 2.85; 95% CI 2.37-3.44; p < 0.001), respectively. The association between ΔFBG and SCA was maintained in people with DM but not in people without DM. However, sex, age, blood pressure, and presence of heart failure did not affect the association between ΔFBG and SCA. A decrease in ΔFBG over time was not associated with reduced risk of SCA: the adjusted HR was 1.11 (95% CI 0.98-1.27; p = 0.113) for the ΔFBG < -40 group and 1.12 (95% CI 1.03-1.22; p = 0.009) for the - 40 ≤ ∆FBG < - 20 group.

CONCLUSIONS

A long-term increase in ΔFBG can be associated with increased risk of SCA in people with DM. However, a long-term decrease in ΔFBG was not associated with reduced risk of SCA. Actions to prevent increase in FBG can have significant effects on public health in terms of SCA prevention.

Time to Antiarrhythmic and Association with Return of Spontaneous Circulation in the United States

INTRODUCTION

Recent clinical trials have failed to identify a benefit of antiarrhythmic administration during cardiac arrest. However, little is known regarding the time to administration of antiarrhythmic drugs in clinical practice or its impact on return of spontaneous circulation (ROSC). We utilized a national EMS registry to evaluate the time of drug administration and association with ROSC.

METHODS

We utilized the 2018 and 2019 NEMSIS datasets, including all non-traumatic, adult 9-1-1 EMS activations for cardiac arrests with initial shockable rhythm and that received an antiarrhythmic. We calculated the time from 9-1-1 call to administration of antiarrhythmic. We excluded cases with erroneous time stamps. Stratified by initial antiarrhythmic (amiodarone and lidocaine), we created a mixed-effect logistic regression model evaluating the association between every 5-minute increase in time to antiarrhythmic and ROSC. We modeled EMS agency as a random intercept and adjusted for confounders.

RESULTS

There were 449,630 adults, non-traumatic cardiac arrests identified with 11,939 meeting inclusion criteria. 9,236 received amiodarone and 1,327 received lidocaine initially. The median time in minutes to initial dose for amiodarone was 19.9 minutes (IQR 15.8-25.6) and for lidocaine was 19.5 minutes (IQR 15.2-25.4). Increasing time to initial antiarrhythmic was associated with decreased odds of ROSC for both amiodarone (aOR 0.9; 95% CI 0.9-0.94) and lidocaine (aOR 0.9; 95% CI 0.8-0.97).

CONCLUSION

Time to administration of anti-arrhythmic medication varied, but most patients received the first dose of anti-arrhythmic drug more than 19 minutes after the initial 9-1-1 call. Longer time to administration of an antiarrhythmic in patients with an initial shockable rhythm was associated with decreased ROSC rates.