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Jorge-Perez P, Nikolaou N, Donadello K, Khoury A, Behringer W, Hassager C, Boettiger B, Sionis A, Nolan J, Combes A, Quinn T, Price S, Grand J. Management of comatose survivors of out-of-hospital cardiac arrest in Europe: current treatment practice and adherence to guidelines. A joint survey by the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Resuscitation Council (ERC), the European Society for Emergency Medicine (EUSEM), and the European Society of Intensive Care Medicine (ESICM). Eur Heart J Acute Cardiovasc Care 2023; 12:96-105. [PMID: 36454812 DOI: 10.1093/ehjacc/zuac153] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 10/15/2022] [Accepted: 11/30/2022] [Indexed: 12/03/2022]
Abstract
AIMS International guidelines give recommendations for the management of comatose out-of-hospital cardiac arrest (OHCA) survivors. We aimed to investigate adherence to guidelines and disparities in the treatment of OHCA in hospitals in Europe. METHODS AND RESULTS A web-based, multi-institutional, multinational survey in Europe was conducted using an electronic platform with a predefined questionnaire developed by experts in post-resuscitation care. The survey was disseminated to all members of the societies via email, social media, websites, and newsletters in June 2021. Of 252 answers received, 237 responses from different units were included and 166 (70%) were from cardiac arrest centres. First-line vasopressor used was noradrenaline in 195 (83%) and the first-line inotrope was dobutamine in 148 (64%) of the responses. Echocardiography is available 24/7 in 204 (87%) institutions. Targeted temperature management was used in 160 (75%) institutions for adult comatose survivors of OHCA with an initial shockable rhythm. Invasive or external cooling methods with feedback were used in 72 cardiac arrest centres (44%) and 17 (24%) non-cardiac arrest centres (P < 0.0003). A target temperature between 32 and 34°C was preferred by 46 centres (21%); a target between 34 and 36°C by 103 centres (52%); and <37.5°C by 35 (16%). Multimodal neuroprognostication was poorly implemented and a follow-up at 3 months after discharge was done in 71 (30%) institutions. CONCLUSION Post-resuscitation care is not well established and varies among centres in European hospitals. Cardiac arrest centres have a higher coherence with guidelines compared with respondents from non-cardiac arrest centres. The overall inconsistency in approaches and deviation from recommendations could be a focus for improvement.
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Affiliation(s)
- Pablo Jorge-Perez
- Department of Cardiology, Canary Islands University Hospital, La Laguna, 38320 Santa Cruz de Tenerife, Spain
| | - Nikolaos Nikolaou
- Intensive Cardiac Care Unit, Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Katia Donadello
- Department of Anesthesia and Intensive Care B, Department of Surgery, Dentistry, Gynaecology and Paediatrics, University of Verona, AOUI-University Hospital Integrated Trust of Verona, Policlinico G.B. Rossi, P.le L. Scuro, Verone, Italy
| | - Abdo Khoury
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon, France.,INSERM CIC 1431, Besançon University Hospital, Besançon, France
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University Vienna, Vienna, Austria
| | - Christian Hassager
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, The Heart Center, Copenhagen, Denmark
| | - Bernd Boettiger
- Medical Faculty and University Hospital, University of Cologne, Cologne, Germany.,European Resuscitation Council (ERC), Niel, Belgium.,German Resuscitation Council (GRC), Ulm, Germany
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Jerry Nolan
- Warwick Medical School, University of Warwick, Coventry, UK.,Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Alain Combes
- Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France.,Service de Médecine Intensive-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Tom Quinn
- Kingston University and St. Georges, University of London, London, UK
| | - Susanna Price
- Departments of Cardiology and Critical Care, Royal Brompton & Harefield Hospitals, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Johannes Grand
- Department of Cardiology, Amager-Hvidovre Hospital, University Hospital of Copenhagen, Copenhagen, Denmark
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Grand J, Schiele F, Hassager C, Nolan JP, Khoury A, Sionis A, Nikolaou N, Donadello K, Behringer W, Böttiger BW, Combes A, Quinn T, Price S, Jorge-Perez P. Quality indicators for post-resuscitation care after out-of-hospital cardiac arrest: A Joint statement from the Association for Acute CardioVascular Care (ACVC) of the European Society of Cardiology, the European Resuscitation Council (ERC), the European Society of Intensive Care Medicine (ESICM), and the European Society for Emergency Medicine (EUSEM). Eur Heart J Acute Cardiovasc Care 2023; 12:197-210. [PMID: 36738295 DOI: 10.1093/ehjacc/zuad006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023]
Abstract
Quality of care (QoC) is a fundamental tenet of modern healthcare and has become an important assessment-tool for healthcare authorities, stakeholders and the public. However, QoC is difficult to measure and quantify because it is a multifactorial and multidimensional concept. Comparison of clinical institutions can be challenging when QoC is estimated solely based on clinical outcomes. Thus, measuring quality through quality indicators (QIs) can provide a foundation for quality assessment and has become widely used in this context. QIs for the evaluation of QoC in acute myocardial infarction are now well-established, but no such indicators exist for the process from resuscitation of cardiac arrest and post-resuscitation care in Europe. In this context, the Association of Acute Cardiovascular Care of the European Society Cardiology, the European Resuscitation Council, European Society of Intensive Care Medicine and the European Society for Emergency Medicine, have reflected on the measurement of QoC in cardiac arrest. A set of QIs have been proposed, with the scope to unify and evolve QoC for the management of cardiac arrest across Europe. We present here the list of QIs (6 primary QIs and 12 secondary Qis), with descriptions of the methodology used, scientific justification and motives for the choice for each measure with the aim that this set of QIs will enable assessment of the quality of post-out-of-hospital cardiac arrest management across Europe.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Amager-Hvidovre Hospital, University Hospital of Copenhagen, Copenhagen, Denmark.,Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, the heart center, Copenhagen, Denmark
| | - Francois Schiele
- Cardiology Department, Besançon University Hospital, BesançonFrance
| | - Christian Hassager
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, the heart center, Copenhagen, Denmark
| | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK.,Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Abdo Khoury
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon, France.,INSERM CIC 1431, Besançon University Hospital, Besançon, France
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Nikolaos Nikolaou
- Intensive Cardiac Care Unit, Cardiology Department, Konstantopouleio General Hopsital, Athens, Greece
| | - Katia Donadello
- Department of Anesthesia and Intensive Care Medicine B, Department of Surgery, Dentistry, Gynaecology and Paediatrics, University of Verona, AOUI-University Hospital Integrated Trust of Verona, Policlinico G.B. Rossi, P.le L. Scuro, Verona, Italy
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University Vienna, Vienna, Austria
| | - Bernd W Böttiger
- Medical Faculty and University Hospital, University of Cologne, Cologne, Germany; European Resuscitation Council (ERC), Niel, Belgium; German Resuscitation Council (GRC), Ulm, Germany
| | - Alain Combes
- Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France.,Service de Médecine Intensive-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition
| | - Tom Quinn
- Kingston University and St. Georges, University of London, London, United Kingdom
| | - Susanna Price
- Departments of Cardiology and Critical Care, Royal Brompton & Harefield Hospitals, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Pablo Jorge-Perez
- Department of Cardiology, Canary Islands University Hospital, La Laguna, 38320 Santa Cruz de Tenerife, Spain
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Fortuny Frau E, Raposeiras-Roubin S, Andreu-Cayuelas J, Garcia-Egido A, Ortiz-Cortes C, Camacho-Freire S, Alonso P, Jorge-Perez P, Lopez-Pais J, Bravo-Marques R, Palacios-Rubio J, Benezet-Mazuecos J, Cosin-Sales J. Differential effect of anticoagulation therapy in patients older versus younger than 80 years with atrial fibrillation and severe chronic kidney disease. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
In non-valvular atrial fibrillation (NVAF) patients, advanced age and chronic kidney disease (CKD) raise the thrombotic and bleeding rates, making the decision of antithrombotic therapy a challenge. Therefore, we conducted an analysis to explore the efficacy and safety of anticoagulation therapy in this population (AF patients ≥80 years) in comparison with younger AF patients (<80 years).
Methods
For these results we have analyzed data from FIBRA, a multicentric Spanish retrospective registry on patients with CKD-EPI <30 ml/min/1.73 m2 and newly diagnosed NVAF. For death, multivariable Cox regression analysis was developed. For embolic and bleeding events, competing-risks regression based on Fine and Gray's proportional subhazards model was performed, being death the competing event
Results
We analyzed 405 patients with CKD-EPI <30 ml/min/1.73 m2. 232 were ≥80 years-old (57.3%). Median of CHA2DS2-VASC and HASBLED scores were 5 and 3 in patients ≥80 years, respectively, and 3 and 2 in patients <80 years, respectively. The prescription of antithrombotic therapies in elderly versus younger patients is shown in Figure 1. During a follow-up of 4.6±2.5 years, 205 died (50.6%), 34 had embolic events (8.4%) and 85 had bleeding outcomes (21.0%). After multivariate analysis, no benefit of anticoagulation therapy was found for mortality in both, older and younger patients. In patients ≥80, anticoagulation was associated with higher rates of bleeding events without a decrease in embolic outcomes.
Conclusion
In our registry, anticoagulation has not shown benefit in NVAF patients ≥80 years with glomerular filtrate rate <30 ml/min/1.73 m2, increasing the risk of bleeding events without reducing embolic outcomes.
Figure 1
Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): BMS-Pfizer alliance unconditional grant
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Affiliation(s)
- E Fortuny Frau
- University Hospital Son Espases, Palma de Mallorca, Spain
| | | | | | - A Garcia-Egido
- Hospital of Leon (Complejo Asistencial Universitario de Leon), Leon, Spain
| | | | | | - P Alonso
- Hospital de Manises, Valencia, Spain
| | - P Jorge-Perez
- University Hospital Insular of Gran Canaria, Las Palmas De Gran Canaria, Spain
| | - J Lopez-Pais
- University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
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Andreu Cayuelas J, Raposeiras-Roubin S, Fortuny Frau E, Garcia Del Egido A, Seller-Moya J, Ortiz Cortes C, Camacho Freire S, Alonso Fernandez P, Jorge-Perez P, Lopez-Pais J, Bravo-Marques R, Palacios-Rubio J, Benezet-Mazuecos J, Cosin-Sales J. Impact of antithrombotic therapy in the prognosis of atrial fibrillation patients with advanced chronic kidney disease. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Chronic kidney disease (CKD) is associated with an elevated thromboembolic and bleeding risk in atrial fibrillation (AF) patients, so the decision of antithrombotic therapy is a challenge.
Purpose
To analyze mortality, embolic and bleeding events in patients with advanced CKD and AF.
Methods
Multicentric retrospective registry on patients with AF and advanced CKD (CKD-EPI <30 mL/min/1.73 m2). For death, multivariable Cox regression analysis was developed. For embolic and bleeding events, competing-risks regression based on Fine and Gray's proportional subhazards model was performed, being death the competing event
Results
We analysed 405 patients with advanced CKD and newly diagnosed AF. 57 patients were not treated with antithrombotic therapy (14.1%), 80 only with antiplatelet/s (19.8%), 211 only with anticoagulation (52.1%), and 57 with anticoagulant plus antiplatelet/s (14.1%). During a follow-up of 4.6±2.5 years, 205 died (50.6%), 34 had embolic events (8.4%) and 85 had bleeding outcomes (21.0%). Bleeding event rate was significantly lower in patients without antithrombotic therapy (Figure). After multivariate analysis, anticoagulant treatment was associated with higher bleeding rates, without differences in mortality or embolic events (Table).
Conclusion
Anticoagulation therapy was associated with a significant increase in bleeding events in patients with advanced CKD and newly diagnosed AF. None of the antithrombotic therapy regimens resulted in lower embolic events rate neither benefit in mortality.
Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): This study was supported by an unconditional grant from BMS-Pfizer
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Affiliation(s)
| | | | - E Fortuny Frau
- University Hospital Son Espases, Cardiology, Palma de Mallorca, Spain
| | - A Garcia Del Egido
- Hospital of Leon (Complejo Asistencial Universitario de Leon), Cardiology, Leon, Spain
| | | | - C Ortiz Cortes
- Hospital San Pedro de Alcantara, Cardiology, Caceres, Spain
| | | | | | - P Jorge-Perez
- INCANIS Hospital Universitario de Canarias, Cardiology, La Laguna, Spain
| | - J Lopez-Pais
- University Hospital of Santiago de Compostela, Cardiology, Santiago de Compostela, Spain
| | | | - J Palacios-Rubio
- University Hospital Son Espases, Cardiology, Palma de Mallorca, Spain
| | | | - J Cosin-Sales
- Hospital Arnau de Vilanova, Cardiology, Valencia, Spain
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