Post-discharge survival following pre-hospital cardiopulmonary arrest due to cardiac aetiology: temporal trends and impact of changes in clinical management

Temporal trends in cardiac arrest incidence and outcome in Finnish intensive care units from 2003 to 2013

PURPOSE

To estimate temporal trends in incidence and hospital mortality after cardiac arrest in Finnish intensive care units.

METHODS

Using a large nationwide intensive care unit (ICU) database we identified patients suffering from cardiac arrest following ICU admission (ICU-CA) during the study period (2003-2013). ICU-CA was defined as need for cardiopulmonary resuscitation and/or defibrillation (non-arrest cardioversions were excluded) according to the Therapeutic Intervention Scoring System-76. Patients admitted with an admission diagnosis of cardiac arrest were excluded. We determined crude incidence and risk-adjusted hospital mortality (based on a customized severity of illness model) for all ICU-CA patients, and for predefined admission diagnosis subgroups. Temporal trends for the observed period were calculated for crude incidence and risk-adjusted hospital mortality.

RESULTS

Crude incidence for all ICU-CA patients was 29/1,000 ICU admissions, with the highest incidence 118/1,000 in the non-operative cardiovascular subgroup. Overall hospital mortality for ICU-CA patients was 55.5% [95% confidence interval (CI) 54-57%]. Hospital mortality was 53.1% (95% CI 50.4-55.8%) for non-operative cardiovascular ICU-CA patients, 32.9% (95% CI 26.9-38.9%) for post cardiac surgery ICU-CA patients, and 56.3% (95% CI 51.2-61.3%) for neurological/neurosurgical ICU-CA patients. There was a significant reduction in the overall ICU-CA incidence and in the risk-adjusted hospital mortality of ICU-CA and non-cardiac arrest cases (non-CA) over the observed study period (p < 0.001).

CONCLUSION

Our data suggest that the incidence of ICU-CA has decreased in Finnish ICUs between 2003 and 2013. Similar reduction in hospital mortality over time was observed for both ICU-CA and non-CA populations.

Trends in survival after in-hospital cardiac arrest

BACKGROUND

Despite advances in resuscitation care in recent years, it is not clear whether survival and neurologic function after in-hospital cardiac arrest have improved over time.

METHODS

We identified all adults who had an in-hospital cardiac arrest at 374 hospitals in the Get with the Guidelines-Resuscitation registry between 2000 and 2009. Using multivariable regression, we examined temporal trends in risk-adjusted rates of survival to discharge. Additional analyses explored whether trends were due to improved survival during acute resuscitation or postresuscitation care and whether they occurred at the expense of greater neurologic disability in survivors.

RESULTS

Among 84,625 hospitalized patients with cardiac arrest, 79.3% had an initial rhythm of asystole or pulseless electrical activity, and 20.7% had ventricular fibrillation or pulseless ventricular tachycardia. The proportion of cardiac arrests due to asystole or pulseless electrical activity increased over time (P<0.001 for trend). Risk-adjusted rates of survival to discharge increased from 13.7% in 2000 to 22.3% in 2009 (adjusted rate ratio per year, 1.04; 95% confidence interval [CI], 1.03 to 1.06; P<0.001 for trend). Survival improvement was similar in the two rhythm groups and was due to improvement in both acute resuscitation survival and postresuscitation survival. Rates of clinically significant neurologic disability among survivors decreased over time, with a risk-adjusted rate of 32.9% in 2000 and 28.1% in 2009 (adjusted rate ratio per year, 0.98; 95% CI, 0.97 to 1.00; P=0.02 for trend).

CONCLUSIONS

Both survival and neurologic outcomes after in-hospital cardiac arrest have improved during the past decade at hospitals participating in a large national quality-improvement registry. (Funded by the American Heart Association.).

Improved Survival After Out-of-Hospital Cardiac Arrest Is Associated With an Increase in Proportion of Emergency Crew–Witnessed Cases and Bystander Cardiopulmonary Resuscitation

Background— Out-of-hospital cardiac arrest (OHCA) is a major public health problem. We sought to describe changes in 1-month survival after OHCA in patients given cardiopulmonary resuscitation (CPR) during the last 14 years in Sweden.

Methods and Results— All patients experiencing OHCA in whom CPR was attempted between 1992 and 2005 and who were reported to the Swedish Cardiac Arrest Register were included in the study. In all, 38 646 patients were included in this survey. The proportion of patients who were admitted alive to a hospital increased from 15.3% in 1992 to 21.7% in 2005 ( P for trend <0.0001). The corresponding values for patients being alive after 1 month were 4.8% and 7.3%, respectively ( P for trend <0.0001). The increase in 1-month survival was particularly evident among patients found with a shockable rhythm (increase from 12.7% in 1992 to 22.3% in 2005; P for trend <0.0001). The corresponding figures for patients found with a nonshockable rhythm were 1.2% in 1992 and 2.3% in 2005 ( P for trend=0.044). Factors that potentially contributed to the improved survival rate were an increase in emergency medical crew–witnessed cases from 9% in 1992 to 15% in 2005 ( P for trend <0.0001) and, to a lesser degree, an increase in bystander CPR from 31% in 1992 to 50% in 2005 ( P for trend <0.0001). After adjustment for potential risk factors, the increase in survival remained significant.

Conclusions— We found a significant increase in survival after OHCA in Sweden over the last 14 years. The increase was particularly marked among patients found with a shockable rhythm and was associated with an increase in the proportion of crew-witnessed cases and, to a lesser degree, an increase in the performance of bystander CPR.

Long-term survival after out-of-hospital cardiac arrest

OBJECTIVE

The purpose of this study was to assess the long-term survival after OHCA.

METHODS

All OHCA-calls where the Copenhagen Mobile Emergency Care Unit (MECU) was involved from 1994 to1998 are included in this study. Data were collected prospectively. Data on long-term survival was obtained from the Danish Causes of Death Registry and the Danish Civil Registration System. We conducted a search to find out whether patients were still alive on 31 January 2005.

RESULTS

Resuscitation was indicated and attempted in 1095 cases and 95 patients (8.7%) survived to discharge. Of these 75% had an initial rhythm of VF, 13% had asystole, 10% had PEA and 2% were unknown. Survival was 87% after one year and survival after 10 years was 46% with a significantly lower survival for patients over 60 years.

CONCLUSION

Long-term survival after out-of-hospital cardiac arrest in a physician-staffed emergency system was comparable to survival after myocardial infarction with 46% being alive after ten years.

Clinical review: beyond immediate survival from resuscitation-long-term outcome considerations after cardiac arrest

A substantial body of literature concerning resuscitation from cardiac arrest now exists. However, not surprisingly, the greater part concerns the cardiac arrest event itself and optimising survival and outcome at relatively proximal time points. The aim of this review is to present the evidence base for interventions and therapeutic strategies that might be offered to patients surviving the immediate aftermath of a cardiac arrest, excluding components of resuscitation itself that may lead to benefits in long-term survival. In addition, this paper reviews the data on long-term impact, physical and neuropsychological, on patients and their families, revealing a burden that is often underestimated and underappreciated. As greater numbers of patients survive cardiac arrest, outcome measures more sophisticated than simple survival are required.