C60 12–LEAD POST–ROSC ELECTROCARDIOGRAM DISCRIMINATES SURVIVAL TO HOSPITAL DISCHARGE. A SUB–ANALYSIS OF THE PEACE STUDY

Background

Once the return of spontaneous circulation (ROSC) after an out–of–hospital cardiac arrest (OHCA) is achieved in patients with an ST–elevation myocardial infarction, the acquisition of a 12–lead electrocardiogram (ECG) is strongly recommended in order to determine candidates for urgent coronary angiography. However, little is known so far about the association of ECG features and survival to hospital discharge in OHCA patients.

Methods

We analysed all the post–ROSC ECGs collected from January 2015 to December 2018 in three European centres (Pavia, Lugano and Vienna). For every ECG, the main features were analysed and filed in the database together with the pre–hospital data collected for every patient according to the Utstein style.

Results

We collected 370 ECGs: 287 males (77.6%); median age 62 years old (IQR 53–70 years); 121 from Pavia (32.7%), 38 from Lugano (10.3%) and 211 from Vienna (57.0%). In Cox univariable regression, age older than 62 years [HR 1.7 (95% IC 1.1–2.4), p = 0.007], QRS wider than 120 msec [HR 1.87 (95% IC 1.3–2.7), p < 0.001], ST elevation in more than one segment [HR 1.7(95% IC 1.2–2.5),p=0.003], the presence of left bundle branch block (LBBB) [HR 1.7 (95% IC 1.1–2.9), p = 0.03] and a right bundle branch block [HR 1.8 (95% IC 1.1–2.8), p = 0.01] were all associated with death before hospital discharge. In multivariable Cox regression, adjusted for the ROSC–to–ECG time, age older than 62 years [HR 1.6 (95% IC 1.1–2.3), p = 0.01], QRS wider than 120 msec [HR 1.7 (95%IC 1.2–2.5), p = 0.004] and the presence of ST elevation in more than one segment [HR 1.7 (95%IC 1.2–2.5), p = 0.004] were independently associated with death before hospital discharge. By considering these latter three risk factors, the rate of survival to hospital discharge was significantly influenced by their number [no risk factor: 80.8%; 1 factor: 71.2%; 2 factors: 61.9%; 3 factors: 34.4%; p < 0.001, p for trend <0.001]. With a Cox regression model, considering the absence of risk factor as a reference, we confirmed that having 2 or 3 risk factors was significantly associated with death before hospital discharge [HR 1.9 (95%IC 1–3.5), p = 0.037 e HR 5.1(95%IC 2.6–10.1), p < 0.001 respectively].

Conclusions

Our study confirms the central role of ECG in STEMI patients resuscitated after an OHCA and proves that post–ROSC ECG features can be used for both the selection of patients who may benefit from urgent coronary angiography as well as for prognostic stratifications.

Arterial stiffness in acute COVID-19 and potential associations with clinical outcome

BACKGROUND

Coronavirus disease 2019 (COVID-19) interferes with the vascular endothelium. It is not known whether COVID-19 additionally affects arterial stiffness.

METHODS

This case-control study compared brachial-ankle pulse wave (baPWV) and carotid-femoral pulse wave velocities (cfPWV) of acutely ill patients with and without COVID-19.

RESULTS

Twenty-two COVID-19 patients (50% females, 77 [67-84] years) were compared with 22 age- and sex-matched controls. In COVID-19 patients, baPWV (19.9 [18.4-21.0] vs. 16.0 [14.2-20.4], P = 0.02) and cfPWV (14.3 [13.4-16.0] vs. 11.0 [9.5-14.6], P = 0.01) were higher than in the controls. In multiple regression analysis, COVID-19 was independently associated with higher cfPWV (β = 3.164, P = 0.004) and baPWV (β = 3.532, P = 0.003). PWV values were higher in nonsurvivors. In survivors, PWV correlated with length of hospital stay.

CONCLUSION

COVID-19 appears to be related to an enhanced PWV reflecting an increase in arterial stiffness. Higher PWV might be related to an increased length of hospital stay and mortality.

The prognostic impact of therapeutic anticoagulation after biological aortic valve replacement

Background

Recent guidelines state that in patients with surgical biological aortic valve replacement (AVR), the use of anti-platelet therapy is as a valid alternative to postoperative anticoagulation (AC) in the absence of a further indication for AC. However, the prognostic impact of different anti-thrombotic strategies after biological AVR has not clearly been investigated so far and outcome data remain scare and inconclusive. Moreover, the AC strategy of patients presenting with post-operative atrial fibrillation (POAF), has not been investigated so far. Therefore, we aim to picture the therapeutic AC approach after biological AVR and whether the presence of POAF effects decision making with regard to anti-thrombotic management.

Methods

Within this prospective observational study 515 patients undergoing elective cardiac valve and or coronary artery bypass graft (CABG) surgery were enrolled. All patients were continuously screened for the development of POAF and followed until the primary endpoint (mortality) was reached. Logistic regression analysis was performed to elucidate the effect of AC on outcome.

Results

A total of 200 individuals underwent biological AVR (including 81 [40.3%] combined AVR+CABG surgeries, median age: 77 years [IQR: 71–80 years]; 133 [66.3%] male gender). 97 (48.3%) patients received therapeutic AC at the time of discharge, including 42 (43.4%) on vitamin K antagonists (VKA), 53 (54.6%) on low-dose low-molecular weight heparin (LMWH) and 2 (2.0%) non-vitamin K antagonist oral anticoagulants (NOACs). 103 (51.2%) patients received another anti-thrombotic approach including 23 (22.3%) on dual anti-platelet therapy (DAPT) and 72 (69.9%) with prophylactic LMWH. Interestingly, the fraction of patients that received AC were comparable between POAF (CHA2DS2-Vasc score 4, IQR: 3–5) and non-POAF individuals (51.9% vs. 44.6%; p=0.304). After a median follow-up time of 1069 days (IQR: 673–1475 days) 21 patients (10.4%) died, referring to 9 (8.3%) non-POAF and 12 (13.0%) POAF individuals. We found that a therapeutic AC after surgery showed a strong and inverse association with 3-year mortality with a crude odds ratio (OR) of 0.31 (95% CI 0.12–0.79; p=0.015). The prognostic potential remained stable after adjustment for potential confounders (p=0.029).

Conclusion

Therapeutic AC showed a strong and independent inverse association with 3-year mortality, mirroring a potential benefit on outcome compared to anti-platelet therapy or low-dose LMWH. However, the fraction of patients receiving therapeutic AC was considerably low – especially NOACs were not commonly used. Despite its association with fatal cardiac adverse events, the presence of POAF was not a relevant value for decision making for the initiation of AC. Further prognostic data on both thromboembolic and bleeding events are needed to elucidate a net-benefit of therapeutic AC in patients with surgical biological AVR who have an indication for AC or present with POAF.

Kaplan-Meier Survival plot

Funding Acknowledgement

Type of funding source: None

Post-ROSC electrocardiogram timing in the management of out-of-hospital cardiac arrest: results of an international multicentric study (PEACE study)

Background

Electrocardiogram (ECG) is a key tool to triage out-of-hospital cardiac arrest (OHCA) patients after achieving a sustained return of spontaneous circulation (ROSC). According to current guidelines, an immediate coronary angiography is indicated only when the post-ROSC ECG discloses a ST-elevation myocardial Infarction (STEMI). Moreover, the 12-lead ECG should be recorded as soon as possible after ROSC, although it is reasonable that in the early post-ROSC stages ECG could reflect the ischemia secondary to cardiac arrest besides that of coronary origin possibly causing an overdiagnosis of STEMI (false positive).

Purpose

To assess whether the time from ROSC to ECG acquisition could affect the percentage of false positive ECG for STEMI.

Methods

We performed a retrospective, international, multicenter study (PEACE Study - NCT04096079). We included all patients over 18 years of age hospitalized after an OHCA due to medical cause at one of the three participating high-volume hospitals of three different European countries between 2015, 1st January and 2018, 31st December. We considered for the present study only patients who underwent coronary angiography and in whom a post-ROSC ECG was available. For the electrocardiographic diagnosis of STEMI the criteria established by the ESC 2017 guidelines were used, while the execution of a percutaneous coronary angioplasty (PTCA) was evaluated as an angiographic endpoint. We used logistic regression to evaluate the association of time to acquisition and the endpoint. We computed odds ratios and 95% confidence intervals (OR, 95% CI).

Results

Population consisted of 370 patients (77.6% male, mean age 61±13 years, median ROSC-ECG time 15 minutes). Post-ROSC ECG was positive for STEMI in 198 patients and in 39 of them (10.5%) a PTCA was not performed during urgent coronary angiography, representing the false positive (FP) ECG. Dividing the population in three tertiles according to the time from ROSC to ECG (≤7 mins; 8–33 mins; >33 mins), the percentage of FP-ECG in the first tertile (18.5%) was statistically significantly higher than in the second (7.2%, OR 2.9 (95% CI 1.1–7.5) p=0.025) and third (5.8%, OR 3.7 (95% CI 2.2–6.5) p<0.001) as also shown in the Figure. These differences remained significant when adjusting for sex, age, number of segments involved at ECG (anterior, lateral, posterior, inferior and right), QRS duration >120 msec, ECG heart rate >100 bpm and adrenaline administered >1 mg.

Conclusion

Our study offers the first demonstration that the acquisition of the 12-leads ECG too early after ROSC can misleadingly lead to the diagnosis of STEMI. Despite further validation are required, our data suggest that it may be reasonable to delay the acquisition of the ECG at least 8 minutes after ROSC or to repeat the acquisition if the first ECG, resulting diagnostic for STEMI, was performed very early.

Figure 1

Funding Acknowledgement

Type of funding source: None

Clinical outcomes from out-of-hospital cardiac arrest in low-resource settings - A scoping review

AIM OF THE SCOPING REVIEW

Scientific recommendations on resuscitation are typically formulated from the perspective of an ideal resource environment, with little consideration of applicability in lower-income countries. We aimed to determine clinical outcomes from out-of-hospital cardiac arrest (OHCA) in low-resource countries, to identify shortcomings related to resuscitation in these areas and possible solutions, and to suggest future research priorities.

DATA SOURCES

This scoping review was part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR), and was performed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. We identified low-resource countries as countries with a low- or middle gross national income per capita (World Bank data). We performed a literature search on outcomes after OHCA in these countries, and we extracted data on the outcome. We applied descriptive statistics and conducted a post-hoc correlation analysis of cohort size and ROSC rates.

RESULTS

We defined 24 eligible studies originating from middle-income countries, but none from low-income regions, suggesting a reporting bias. The number of reported patients in these studies ranged from 54 to 3214. Utstein-style reporting was rarely used. Return of spontaneous circulation varied from 0% to 62%. Fifteen studies reported on survival to hospital discharge (between 1.0 and 16.7%) or favourable neurological outcome (between 1.0 and 9.3%). An inverse correlation was found for study cohort size and the rate of return of spontaneous circulation (ρ = -0.48, p = 0.034).

CONCLUSION

Studies of OHCA outcomes in low-resource countries are heterogeneous and may be compromised by reporting bias. Minimum cardiopulmonary resuscitation standards for low-resource settings should be developed collaboratively involving local experts, respecting culture and context while balancing competing health priorities.

Hemodynamic effects of Vernakalant in cardio-surgical ICU-patients treated for recent-onset postoperative atrial fibrillation

Postoperative atrial fibrillation (POAF) is one of the most frequent complications after cardiothoracic surgery and a predictor for postoperative mortality and prolonged ICU-stay. Current guidelines suggest the multi-channel inhibitor Vernakalant as a treatment option for rhythm control. However, rare cases of severe hypotension and cardiogenic shock following drug administration have been reported. To elucidate the impact of Vernakalant on hemodynamics, we included ten ICU patients developing POAF after elective cardiac surgery, all of them awake and breathing spontaneously, in this prospective trial. Patients received the recommended dosage of Vernakalant and were clinically observed and monitored (heart rate, invasive blood pressure, pulse oximetry, central venous pressure) in 1-minute-intervals for 20 minutes before- and 120 minutes after the first dose of Vernakalant. The median time from the end of surgery until occurrence of POAF amounted up to 52.8 [45.9–77.4] hours, it took 3.5 [1.2–10.1] hours from occurrence of POAF until the first application of Vernakalant. All patients received catecholamine support with epinephrine that was held steady and not dynamic throughout the observational phase. We noted stable hemodynamic conditions, with a trend towards a reduction in heart rate throughout the 120 minutes after drug administration. In 7 patients (70%), conversion to sustained sinus rhythm (SR) occurred within 8.0 minutes [6.0–9.0]. No serious adverse events (SAEs) were noted during the observation period. In this prospective trial in ICU-patients showing POAF after cardiac surgery, intravenous Vernakalant did not induce clinically relevant negative effects on patients’ hemodynamics but resulted in conversion to sustained SR after a median of 8.0 minutes in 7 out of ten patients.

P4736The Prognostic Impact of Volume Substitution on Cardiac Strain and the Development of Postoperative Atrial Fibrillation after Cardiac Surgery

Background

Postoperative atrial fibrillation (POAF) represents a common complication after cardiac valve or coronary artery bypass surgery. Etiologically, multifactorial causes such as the patients' age, weight, comorbidities or local remodeling proved a strong association with this common arrhythmia. While strain of atrial tissue is known to induce atrial fibrillating impulses, less attention has been paid to potentially strain-promoting values during the peri- and post-operative period. Therefore, we aimed to determine the association of peri- and post-operative volume substitution on markers of cardiac strain and subsequently its impact on the promotion and development of POAF.

Methods

In this prospective observational study 271 patients undergoing elective cardiac surgery in our Medical University were enrolled (median age: 69 years [IQR: 60–75 years]; 195 [72%] male gender). Intra- and post-operative data was collected from anesthesiologic and intensive care unit protocols. Multivariate binary logistic regression analysis was used to identify the prognostic value of volume substitution on the development of POAF.

Results

A total of 123 (45.4%) individuals developed POAF. The average intra-operative transfusion volume was significantly elevated in the POAF subgroup (605.6ml [POAF] vs. 227.1ml [non-POAF]; p<0.001). Moreover, the fluid balance within the first 24 hours after surgery was significantly higher in patients developing POAF (+1129.6 ml [POAF] vs. +544.9 ml [non-POAF]; p=0.044). We found that N-terminal pro brain natriuretic peptide (NT-proBNP) values were significantly elevated in patients that received any volume substitution (2860.0 pg/mL [Transfusion] vs. 1486.5 pg/mL [no-Transfusion]; p=0.002). In line with those results, the postoperative fluid balance was also found to have a direct and significant correlation with postoperative NT-ProBNP values (r=0.287, p=0.002). Of note, the amount of substituted volume proved to be a strong and independent predictor for POAF with an adjusted odds-ratio (OR) per one standard deviation (1-SD) of 2.49 (95% CI: 1.25–4.96; p=0.009).

Conclusion

Within the present analysis we were able to demonstrate that substitution of larger transfusion volumes presents a strong and independent predictor for the development of POAF. Via the observed distinct association with NT-proBNP values, it can reasonably be assumed that post-operative atrial fibrillating impulses are triggered via volume-induced cardiac strain.

Regional cerebral oxygen saturation during cardiopulmonary resuscitation as a predictor of return of spontaneous circulation and favourable neurological outcome - A review of the current literature

INTRODUCTION

Regional cerebral oxygen saturation (rSO2) can be measured non-invasively even at no- or low-flow states. It thus allows assessment of brain oxygenation during CPR. Certain rSO2 values had been associated with return of spontaneous circulation (ROSC) and neurological outcome in the past. Clear-cut thresholds for the prediction of beneficial outcome, however, are still lacking.

METHODS

We conducted a database search to extract all available investigations on rSO2 measurement during CPR. Mean, median, and ΔrSO2 values were either taken from the studies or calculated. Thresholds for the outcome "ROSC" and "neurological outcome" were sought.

RESULTS

We retrieved 26 publications for the final review. The averaged mean rSO2 for patients achieving ROSC was 41 ± 12% vs. 30 ± 12% for non-ROSC (p = .009). ROSC was not observed when mean rSO2 remained <26%. In ROSC patients, ΔrSO2 was 22 ± 16% vs. 7 ± 10% in non-ROSC patients (p = .009). A rSO2 threshold of 36% predicted ROSC with a sensitivity of 67% and specificity of 69% while ΔrSO2 of 7% showed a sensitivity of 100% and a specificity of 86% (AUC = 0.733 and 0.893, respectively). Mean rSO2 of 47 ± 11% was associated with favourable and 38 ± 12% with poor neurological outcome. There was, however, a great overlap between groups due to scarce data.

CONCLUSION

Higher rSO2 consistently correlated with increased rates of ROSC. The discriminatory power of rSO2 to prognosticate favourable neurological outcome remains unclear. Measuring rSO2 during CPR could potentially facilitate clinical decision-making.