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Grand J, Wiberg S, Kjaergaard J, Hassager C, Schmidt H, Møller JE, Mølstrøm S, Granholm A. Lower versus higher blood pressure targets in comatose patients resuscitated from out-of-hospital cardiac arrest-Protocol for a secondary Bayesian analysis of the box trial. Acta Anaesthesiol Scand 2024; 68:702-707. [PMID: 38380494 DOI: 10.1111/aas.14392] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/06/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND The management of blood pressure targets during intensive care after out-of-hospital cardiac arrest (OHCA) remains a topic of debate. The blood Pressure and Oxygenation Targets After OHCA (BOX) trial explored the efficacy of two different blood pressure targets in 789 patients during intensive care after OHCA. In the primary frequentist analysis, no statistically significant differences were found for neurological outcome after 90 days. METHODS This protocol outlines secondary Bayesian analyses of 365-day all-cause mortality and two secondary outcomes: neurological outcome after 365 days, and plasma neuron-specific enolase, a biomarker of brain injury, after 48 h. We will employ adjusted Bayesian logistic and linear regressions, presenting results as relative and absolute differences with 95% confidence intervals. We will use weakly informative priors for the primary analyses, and skeptical and evidence-based priors (where available) in sensitivity analyses. Exact probabilities for any benefit/harm will be presented for all outcomes, along with probabilities of clinically important benefit/harm (risk differences larger than 2%-points absolute) and no clinically important differences for the binary outcomes. We will assess whether heterogeneity of treatment effects on mortality is present according to lactate at admission, time to return of spontaneous circulation, primary shockable rhythm, age, hypertension, and presence of ST-elevation myocardial infarction. DISCUSSION This secondary analysis of the BOX trial aim to complement the primary frequentist analysis by quantifying the probabilities of beneficial or harmful effects of different blood pressure targets. This approach seeks to provide clearer insights for researchers and clinicians into the effectiveness of these blood pressure management strategies in acute medical conditions, particularly focusing on mortality, neurological outcomes, and neuron-specific enolase.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital, Hvidovre and Amager Hospital, Copenhagen, Denmark
| | - Sebastian Wiberg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, Odense University Hospital, Denmark and Clinical Institute University of Southern Denmark, Odense, Denmark
| | - Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
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Meyer MAS, Hassager C, Mølstrøm S, Borregaard B, Grand J, Nyholm B, Obling LER, Beske RP, Meyer ASP, Bekker-Jensen D, Winther-Jensen M, Jørgensen VL, Schmidt H, Møller JE, Kjaergaard J. Combined effects of targeted blood pressure, oxygenation, and duration of device-based fever prevention after out-of-hospital cardiac arrest on 1-year survival: post hoc analysis of a randomized controlled trial. Crit Care 2024; 28:20. [PMID: 38216985 PMCID: PMC10785348 DOI: 10.1186/s13054-023-04794-y] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/29/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND The "Blood Pressure and Oxygenation Targets in Post Resuscitation Care" (BOX) trial investigated whether a low versus high blood pressure target, a restrictive versus liberal oxygenation target, and a shorter versus longer duration of device-based fever prevention in comatose patients could improve outcomes. No differences in rates of discharge from hospital with severe disability or 90-day mortality were found. However, long-term effects and potential interaction of the interventions are unknown. Accordingly, the objective of this study is to investigate both individual and combined effects of the interventions on 1-year mortality rates. METHODS The BOX trial was a randomized controlled two-center trial that assigned comatose resuscitated out-of-hospital cardiac arrest patients to the following three interventions at admission: A blood pressure target of either 63 mmHg or 77 mmHg; An arterial oxygenation target of 9-10 kPa or 13-14 kPa; Device-based fever prevention administered as an initial 24 h at 36 °C and then either 12 or 48 h at 37 °C; totaling 36 or 72 h of temperature control. Randomization occurred in parallel and simultaneously to all interventions. Patients were followed for the occurrence of death from all causes for 1 year. Analyzes were performed by Cox proportional models, and assessment of interactions was performed with the interventions stated as an interaction term. RESULTS Analysis for all three interventions included 789 patients. For the intervention of low compared to high blood pressure targets, 1-year mortality rates were 35% (138 of 396) and 36% (143 of 393), respectively, hazard ratio (HR) 0.92 (0.73-1.16) p = 0.47. For the restrictive compared to liberal oxygenation targets, 1-year mortality rates were 34% (135 of 394) and 37% (146 of 395), respectively, HR 0.92 (0.73-1.16) p = 0.46. For device-based fever prevention for a total of 36 compared to 72 h, 1-year mortality rates were 35% (139 of 393) and 36% (142 of 396), respectively, HR 0.98 (0.78-1.24) p = 0.89. There was no sign of interaction between the interventions, and accordingly, no combination of randomizations indicated differentiated treatment effects. CONCLUSIONS There was no difference in 1-year mortality rates for a low compared to high blood pressure target, a liberal compared to restrictive oxygenation target, or a longer compared to shorter duration of device-based fever prevention after cardiac arrest. No combination of the interventions affected these findings. Trial registration ClinicalTrials.gov NCT03141099, Registered 30 April 2017.
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Affiliation(s)
- Martin A S Meyer
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Christian Hassager
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Britt Borregaard
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Johannes Grand
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Benjamin Nyholm
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Laust E R Obling
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Rasmus P Beske
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Anna Sina P Meyer
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Ditte Bekker-Jensen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Matilde Winther-Jensen
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Data, Biostatistics and Pharmacoepidemiology, Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Vibeke L Jørgensen
- Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jacob E Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Beske RP, Søndergaard FT, Møller JE, Schmidt H, Kjaergaard J, Obling L, Meyer MAS, Mølstrøm S, Winther-Jensen M, Højgaard HF, Jeppesen KK, Sarkisian L, Grand J, Hassager C. Treatment effects of blood pressure targets and hemodynamics according to initial blood lactate levels in comatose out-of-hospital cardiac arrest patients - A sub study of the BOX trial. Resuscitation 2024; 194:110007. [PMID: 37863419 DOI: 10.1016/j.resuscitation.2023.110007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) survivors remaining comatose are often circulatory unstable with high mortality in the first days following resuscitation. Elevated lactate will reflect the severity and duration of hypoperfusion in cardiac arrest. Further, the severity of hypoperfusion could modify the effect on survival of different mean arterial blood pressure (MAP) targets. METHODS In this sub-study of the BOX trial, adult successfully resuscitated comatose OHCA patients (n = 789) with a presumed cardiac cause were randomized to a MAP target of 63 mmHg vs. 77 mmHg. Patients were arbitrarily grouped in low-lactate: <25% of sample, medium-lactate: 25%-75%, and high >75 percentile according to blood lactate levels at hospital arrival as a surrogate of the severity of hypoperfusion. Invasive hemodynamic evaluations were performed using an arterial catheter and pulmonary artery catheter (PAC), and data from admission to 48 hours (h) were recorded. Logistic regression analysis evaluated whether lactate levels (as continuous and categorical) modify the effect of MAP targets on mortality at 365 days. RESULTS The three lactate groups had initial lactate levels of low-lactate: <2.9 mmol/L, medium-lactate: 2.9-7.9 mmol/L, and high-lactate > 7.9 mmol/L. All patients were randomized to a 63 mmHg or 77 mmHg MAP target. The proportion of patients in the high-MAP target group was 100/201 (50%), 178/388 (46%), and 114/197 (58%) for low, medium, and high-lactate groups respectively. At admission, the high-lactate groups had a lower MAP compared to the medium-lactate (2.6 mmHg (95% CI: 0.1-5.0 mmHg, p = 0.02), and the low-lactate group, (3.6 mmHg (95% CI: 0.8-6.5 mmHg, p < 0.01). Accordingly, the vasoactive inotropic score was 79% (95%CI: 42%-124%%) higher with increasing initial lactate level (High-lactate vs. low-lactate) with the largest difference at 6 hours (110.6% (95%CI: 54.4%-187.2%) higher in high-lactate patients). No difference in the cardiac index or systemic vascular resistance was observed between lactate groups. The initial lactate level (continuous) modified the effect of the two MAP targets (p = 0.04). In the highest lactate group, the mortality was 100/197 (51%), and with an odds ratio (OR): 1.7 (95%CI: 0.9-3.0) if randomized to MAP 77 mmHg compared to MAP 63 mmHg. In the lowest lactate group, the mortality was 35/201(17%) and similar if randomized to a MAP target of 77 mmHg (OR: 1.1 (95% CI: 0.5-2.3)). CONCLUSION Comatose OHCA patients with high initial lactate levels required more vasoactive drugs on the first two days of ICU admission to meet the blood pressure target and had a poorer prognosis. No indication that aiming for a higher MAP target is beneficial in patients with an initial high lactate level was found, however, given the post-hoc nature of this study, these results should be considered hypothesis-generating.
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Affiliation(s)
- Rasmus P Beske
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Denmark.
| | - Frederik T Søndergaard
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Denmark; Department of Clinical Research, University of Southern, Denmark
| | - Henrik Schmidt
- Odense University Hospital, Department of Cardiology - B, Odense, Denmark; Department of Clinical Research, University of Southern, Denmark; Odense University Hospital, Cardiothoracic Intensive Care Unit, Odense, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Laust Obling
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Martin A S Meyer
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Simon Mølstrøm
- Odense University Hospital, Cardiothoracic Intensive Care Unit, Odense, Denmark
| | - Matilde Winther-Jensen
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | | | - Laura Sarkisian
- Odense University Hospital, Department of Cardiology - B, Odense, Denmark
| | - Johannes Grand
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Christian Hassager
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Denmark; Department of Clinical Research, University of Southern, Denmark
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Grand J, Møller JE, Hassager C, Schmidt H, Mølstrøm S, Boesgaard S, Meyer MAS, Josiassen J, Højgaard HF, Frydland M, Dahl JS, Obling LER, Bak M, Lind Jørgensen V, Thomsen JH, Wiberg S, Madsen SA, Nyholm B, Kjaergaard J. Impact of blood pressure targets on central hemodynamics during intensive care after out-of-hospital cardiac arrest. Resuscitation 2024; 194:110094. [PMID: 38103857 DOI: 10.1016/j.resuscitation.2023.110094] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/11/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVES The aim was to investigate the advanced hemodynamic effects of the two MAP-targets during intensive care on systemic hemodynamics in comatose patients after cardiac arrest. DESIGN Secondary analysis of a randomized controlled trial. SETTING Primary vasopressor used was per protocol norepinephrine. Hemodynamic monitoring was done with pulmonary artery catheters (PAC) and measurements were made on predefined time points. The primary endpoint of this substudy was the difference in cardiac index within 48 h from a repeated measurements-mixed model. Secondary endpoints included systemic vascular resistance index (SVRI), heart rate, and stroke volume index. PATIENTS Comatose survivors after out-of-hospital cardiac arrest. INTERVENTIONS The "Blood pressure and oxygenations targets after out-of-hospital cardiac arrest (BOX)"-trial was a randomized, controlled, double-blinded, multicenter-study comparing targeted mean arterial pressure (MAP) of 63 mmHg (MAP63) vs 77 mmHg (MAP77). MEASUREMENTS AND MAIN RESULTS Among 789 randomized patients, 730 (93%) patients were included in the hemodynamic substudy. From PAC-insertion (median 1 hours after ICU-admission) and the next 48 hours, the MAP77-group received significantly higher doses of norepinephrine (mean difference 0.09 µg/kg/min, 95% confidence interval (CI) 0.07-0.11, pgroup < 0.0001). Cardiac index was significantly increased (0.20 L/min/m2 (CI 0.12-0.28), pgroup < 0.0001) as was SVRI with an overall difference of (43 dynes m2/s/cm5 (CI 7-79); pgroup = 0.02). Heart rate was increased in the MAP77-group (4 beats/minute; CI 2-6, pgroup < 0.003), but stroke volume index was not (pgroup = 0.10). CONCLUSIONS Targeted MAP at 77 mmHg compared to 63 mmHg resulted in a higher dose of norepinephrine, increased cardiac index and SVRI. Heart rate was also increased, but stroke volume index was not affected by a higher blood pressure target.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Cardiology, Copenhagen University Hospital, Amager-Hvidovre, Copenhagen, Denmark.
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark; Clinical Institute University of Southern Denmark, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark
| | - Simon Mølstrøm
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark
| | - Søren Boesgaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Jakob Josiassen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Martin Frydland
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark; Clinical Institute University of Southern Denmark, Denmark
| | | | - Mikkel Bak
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark
| | - Vibeke Lind Jørgensen
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Hartvig Thomsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Sebastian Wiberg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Søren Aalbæk Madsen
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Benjamin Nyholm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Rasmussen SB, Jeppesen KK, Kjaergaard J, Hassager C, Schmidt H, Mølstrøm S, Beske RP, Grand J, Ravn HB, Winther-Jensen M, Meyer MAS, Møller JE. Blood Pressure and Oxygen Targets on Kidney Injury After Cardiac Arrest. Circulation 2023; 148:1860-1869. [PMID: 37791480 DOI: 10.1161/circulationaha.123.066012] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 09/06/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) represents a common and serious complication to out-of-hospital cardiac arrest. The importance of post-resuscitation care targets for blood pressure and oxygenation for the development of AKI is unknown. METHODS This is a substudy of a randomized 2-by-2 factorial trial, in which 789 comatose adult patients who had out-of-hospital cardiac arrest with presumed cardiac cause and sustained return of spontaneous circulation were randomly assigned to a target mean arterial blood pressure of either 63 or 77 mm Hg. Patients were simultaneously randomly assigned to either a restrictive oxygen target of a partial pressure of arterial oxygen (Pao2) of 9 to 10 kPa or a liberal oxygenation target of a Pao2 of 13 to 14 kPa. The primary outcome for this study was AKI according to KDIGO (Kidney Disease: Improving Global Outcomes) classification in patients surviving at least 48 hours (N=759). Adjusted logistic regression was performed for patients allocated to high blood pressure and liberal oxygen target as reference. RESULTS The main population characteristics at admission were: age, 64 (54-73) years; 80% male; 90% shockable rhythm; and time to return of spontaneous circulation, 18 (12-26) minutes. Patients allocated to a low blood pressure and liberal oxygen target had an increased risk of developing AKI compared with patients with high blood pressure and liberal oxygen target (84/193 [44%] versus 56/187 [30%]; adjusted odds ratio, 1.87 [95% CI, 1.21-2.89]). Multinomial logistic regression revealed that the increased risk of AKI was only related to mild-stage AKI (KDIGO stage 1). There was no difference in risk of AKI in the other groups. Plasma creatinine remained high during hospitalization in the low blood pressure and liberal oxygen target group but did not differ between groups at 6- and 12-month follow-up. CONCLUSIONS In comatose patients who had been resuscitated after out-of-hospital cardiac arrest, patients allocated to a combination of a low mean arterial blood pressure and a liberal oxygen target had a significantly increased risk of mild-stage AKI. No difference was found in terms of more severe AKI stages or other kidney-related adverse outcomes, and creatinine had normalized at 1 year after discharge. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03141099.
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Affiliation(s)
- Sebastian Buhl Rasmussen
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
| | | | - Jesper Kjaergaard
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
- Department of Clinical Medicine, University of Copenhagen, Denmark (J.K., C.H.)
| | - Christian Hassager
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
- Department of Clinical Medicine, University of Copenhagen, Denmark (J.K., C.H.)
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense (H.S., H.B.R., J.E.M.)
| | - Simon Mølstrøm
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
| | - Rasmus Paulin Beske
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
| | - Johannes Grand
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
| | - Hanne Berg Ravn
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense (H.S., H.B.R., J.E.M.)
| | - Matilde Winther-Jensen
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
| | - Martin Abild Stengaard Meyer
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology (K.K.J., J.E.M.), Odense University Hospital, Denmark
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
- Department of Clinical Research, University of Southern Denmark, Odense (H.S., H.B.R., J.E.M.)
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6
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Grand J, Hassager C, Schmidt H, Mølstrøm S, Nyholm B, Høigaard HF, Dahl JS, Meyer M, Beske RP, Obling L, Kjaergaard J, Møller JE. Serial assessments of cardiac output and mixed venous oxygen saturation in comatose patients after out-of-hospital cardiac arrest. Crit Care 2023; 27:410. [PMID: 37891623 PMCID: PMC10612339 DOI: 10.1186/s13054-023-04704-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/22/2023] [Indexed: 10/29/2023] Open
Abstract
AIM To assess the association with outcomes of cardiac index (CI) and mixed venous oxygen saturation (SvO2) in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). METHODS In the cohort study of 789 patients included in the "BOX"-trial, 565 (77%) patients were included in this hemodynamic substudy (age 62 ± 13 years, male sex 81%). Pulmonary artery catheters were inserted shortly after ICU admission. CI and SvO2 were measured as soon as possible in the ICU and until awakening or death. The endpoints were all-cause mortality at 1 year and renal failure defined as need for renal replacement therapy. RESULTS First measured CI was median 1.7 (1.4-2.1) l/min/m2, and first measured SvO2 was median 67 (61-73) %. CI < median with SvO2 > median was present in 222 (39%), and low SvO2 with CI < median was present in 59 (11%). Spline analysis indicated that SvO2 value < 55% was associated with poor outcome. Low CI at admission was not significantly associated with mortality in multivariable analysis (p = 0.14). SvO2 was significantly inversely associated with mortality (hazard ratioadjusted: 0.91 (0.84-0.98) per 5% increase in SvO2, p = 0.01). SvO2 was significantly inversely associated with renal failure after adjusting for confounders (ORadjusted: 0.73 [0.62-0.86] per 5% increase in SvO2, p = 0.001). The combination of lower CI and lower SvO2 was associated with higher risk of mortality (hazard ratioadjusted: 1.54 (1.06-2.23) and renal failure (ORadjusted: 5.87 [2.34-14.73]. CONCLUSION First measured SvO2 after resuscitation from OHCA was inversely associated with mortality and renal failure. If SvO2 and CI were below median, the risk of poor outcomes increased significantly. REGISTRATION The BOX-trial is registered at clinicaltrials.gov (NCT03141099, date 2017-30-04, retrospectively registered).
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Affiliation(s)
- Johannes Grand
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Cardiology, Copenhagen University Hospital Amager-Hvidovre, Copenhagen, Denmark.
| | - Christian Hassager
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, 5000, Odense, Denmark
| | - Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, 5000, Odense, Denmark
| | - Benjamin Nyholm
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | | | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, 5000, Odense, Denmark
- Clinical Institute University of Southern Denmark, Odense, Denmark
| | - Martin Meyer
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Rasmus P Beske
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Laust Obling
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob E Møller
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Cardiology, Odense University Hospital, 5000, Odense, Denmark
- Clinical Institute University of Southern Denmark, Odense, Denmark
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Hassager C, Schmidt H, Møller JE, Grand J, Mølstrøm S, Beske RP, Boesgaard S, Borregaard B, Bekker-Jensen D, Dahl JS, Frydland MS, Høfsten DE, Isse YA, Josiassen J, Lind Jørgensen VR, Kondziella D, Lindholm MG, Moser E, Nyholm BC, Obling LER, Sarkisian L, Søndergaard FT, Thomsen JH, Thune JJ, Venø S, Wiberg SC, Winther-Jensen M, Meyer MAS, Kjaergaard J. Duration of Device-Based Fever Prevention after Cardiac Arrest. N Engl J Med 2023; 388:888-897. [PMID: 36342119 DOI: 10.1056/nejmoa2212528] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Guidelines recommend active fever prevention for 72 hours after cardiac arrest. Data from randomized clinical trials of this intervention have been lacking. METHODS We randomly assigned comatose patients who had been resuscitated after an out-of-hospital cardiac arrest of presumed cardiac cause to device-based temperature control targeting 36°C for 24 hours followed by targeting of 37°C for either 12 or 48 hours (for total intervention times of 36 and 72 hours, respectively) or until the patient regained consciousness. The primary outcome was a composite of death from any cause or hospital discharge with a Cerebral Performance Category of 3 or 4 (range, 1 to 5, with higher scores indicating more severe disability; a category of 3 or 4 indicates severe cerebral disability or coma) within 90 days after randomization. Secondary outcomes included death from any cause and the Montreal Cognitive Assessment score (range, 0 to 30, with higher scores indicating better cognitive ability) at 3 months. RESULTS A total of 393 patients were randomly assigned to temperature control for 36 hours, and 396 patients were assigned to temperature control for 72 hours. At 90 days after randomization, a primary end-point event had occurred in 127 of 393 patients (32.3%) in the 36-hour group and in 133 of 396 patients (33.6%) in the 72-hour group (hazard ratio, 0.99; 95% confidence interval, 0.77 to 1.26; P = 0.70) and mortality was 29.5% in the 36-hour group and 30.3% in the 72-hour group. At 3 months, the median Montreal Cognitive Assessment score was 26 (interquartile range, 24 to 29) and 27 (interquartile range, 24 to 28), respectively. There was no significant between-group difference in the incidence of adverse events. CONCLUSIONS Active device-based fever prevention for 36 or 72 hours after cardiac arrest did not result in significantly different percentages of patients dying or having severe disability or coma. (Funded by the Novo Nordisk Foundation; BOX ClinicalTrials.gov number, NCT03141099.).
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Affiliation(s)
- Christian Hassager
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Henrik Schmidt
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jacob E Møller
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Johannes Grand
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Simon Mølstrøm
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Rasmus P Beske
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Søren Boesgaard
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Britt Borregaard
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Ditte Bekker-Jensen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jordi S Dahl
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Martin S Frydland
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Dan E Høfsten
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Yusuf A Isse
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jakob Josiassen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Vibeke R Lind Jørgensen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Daniel Kondziella
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Matias G Lindholm
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Emil Moser
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Benjamin C Nyholm
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Laust E R Obling
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Laura Sarkisian
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Frederik T Søndergaard
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jakob H Thomsen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jens J Thune
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Søren Venø
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Sebastian C Wiberg
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Matilde Winther-Jensen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Martin A S Meyer
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jesper Kjaergaard
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
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Mølstrøm S, Nielsen TH, Nordstrøm CH, Forsse A, Møller S, Venø S, Mamaev D, Tencer T, Theódórsdóttir Á, Krøigård T, Møller J, Hassager C, Kjærgaard J, Schmidt H, Toft P. A randomized, double-blind trial comparing the effect of two blood pressure targets on global brain metabolism after out-of-hospital cardiac arrest. Crit Care 2023; 27:73. [PMID: 36823636 PMCID: PMC9951410 DOI: 10.1186/s13054-023-04376-y] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
PURPOSE This study aimed to assess the effect of different blood pressure levels on global cerebral metabolism in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). METHODS In a double-blinded trial, we randomly assigned 60 comatose patients following OHCA to low (63 mmHg) or high (77 mmHg) mean arterial blood pressure (MAP). The trial was a sub-study in the Blood Pressure and Oxygenation Targets after Out-of-Hospital Cardiac Arrest-trial (BOX). Global cerebral metabolism utilizing jugular bulb microdialysis (JBM) and cerebral oxygenation (rSO2) was monitored continuously for 96 h. The lactate-to-pyruvate (LP) ratio is a marker of cellular redox status and increases during deficient oxygen delivery (ischemia, hypoxia) and mitochondrial dysfunction. The primary outcome was to compare time-averaged means of cerebral energy metabolites between MAP groups during post-resuscitation care. Secondary outcomes included metabolic patterns of cerebral ischemia, rSO2, plasma neuron-specific enolase level at 48 h and neurological outcome at hospital discharge (cerebral performance category). RESULTS We found a clear separation in MAP between the groups (15 mmHg, p < 0.001). Cerebral biochemical variables were not significantly different between MAP groups (LPR low MAP 19 (16-31) vs. high MAP 23 (16-33), p = 0.64). However, the LP ratio remained high (> 16) in both groups during the first 30 h. During the first 24 h, cerebral lactate > 2.5 mM, pyruvate levels > 110 µM, LP ratio > 30, and glycerol > 260 µM were highly predictive for poor neurological outcome and death with AUC 0.80. The median (IQR) rSO2 during the first 48 h was 69.5% (62.0-75.0%) in the low MAP group and 69.0% (61.3-75.5%) in the high MAP group, p = 0.16. CONCLUSIONS Among comatose patients resuscitated from OHCA, targeting a higher MAP 180 min after ROSC did not significantly improve cerebral energy metabolism within 96 h of post-resuscitation care. Patients with a poor clinical outcome exhibited significantly worse biochemical patterns, probably illustrating that insufficient tissue oxygenation and recirculation during the initial hours after ROSC were essential factors determining neurological outcome.
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Affiliation(s)
- Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark.
| | - Troels Halfeld Nielsen
- grid.7143.10000 0004 0512 5013Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Carl-Henrik Nordstrøm
- grid.7143.10000 0004 0512 5013Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Axel Forsse
- grid.4973.90000 0004 0646 7373Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Møller
- grid.7143.10000 0004 0512 5013OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Søren Venø
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Dmitry Mamaev
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Tomas Tencer
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Ásta Theódórsdóttir
- grid.7143.10000 0004 0512 5013Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Thomas Krøigård
- grid.7143.10000 0004 0512 5013Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Jacob Møller
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark ,grid.7143.10000 0004 0512 5013Department of Cardiology, Odense University Hospital, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Clinical Medicine, University of Southern, Odense, Denmark
| | - Christian Hassager
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Kjærgaard
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Schmidt
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Palle Toft
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
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Schmidt H, Kjaergaard J, Hassager C, Mølstrøm S, Grand J, Borregaard B, Roelsgaard Obling LE, Venø S, Sarkisian L, Mamaev D, Jensen LO, Nyholm B, Høfsten DE, Josiassen J, Thomsen JH, Thune JJ, Lindholm MG, Stengaard Meyer MA, Winther-Jensen M, Sørensen M, Frydland M, Beske RP, Frikke-Schmidt R, Wiberg S, Boesgaard S, Lind Jørgensen V, Møller JE. Oxygen Targets in Comatose Survivors of Cardiac Arrest. N Engl J Med 2022; 387:1467-1476. [PMID: 36027567 DOI: 10.1056/nejmoa2208686] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The appropriate oxygenation target for mechanical ventilation in comatose survivors of out-of-hospital cardiac arrest is unknown. METHODS In this randomized trial with a 2-by-2 factorial design, we randomly assigned comatose adults with out-of-hospital cardiac arrest in a 1:1 ratio to either a restrictive oxygen target of a partial pressure of arterial oxygen (Pao2) of 9 to 10 kPa (68 to 75 mm Hg) or a liberal oxygen target of a Pao2 of 13 to 14 kPa (98 to 105 mm Hg); patients were also assigned to one of two blood-pressure targets (reported separately). The primary outcome was a composite of death from any cause or hospital discharge with severe disability or coma (Cerebral Performance Category [CPC] of 3 or 4; categories range from 1 to 5, with higher values indicating more severe disability), whichever occurred first within 90 days after randomization. Secondary outcomes were neuron-specific enolase levels at 48 hours, death from any cause, the score on the Montreal Cognitive Assessment (ranging from 0 to 30, with higher scores indicating better cognitive ability), the score on the modified Rankin scale (ranging from 0 to 6, with higher scores indicating greater disability), and the CPC at 90 days. RESULTS A total of 789 patients underwent randomization. A primary-outcome event occurred in 126 of 394 patients (32.0%) in the restrictive-target group and in 134 of 395 patients (33.9%) in the liberal-target group (hazard ratio, 0.95; 95% confidence interval, 0.75 to 1.21; P = 0.69). At 90 days, death had occurred in 113 patients (28.7%) in the restrictive-target group and in 123 (31.1%) in the liberal-target group. On the CPC, the median category was 1 in the two groups; on the modified Rankin scale, the median score was 2 in the restrictive-target group and 1 in the liberal-target group; and on the Montreal Cognitive Assessment, the median score was 27 in the two groups. At 48 hours, the median neuron-specific enolase level was 17 μg per liter in the restrictive-target group and 18 μg per liter in the liberal-target group. The incidence of adverse events was similar in the two groups. CONCLUSIONS Targeting of a restrictive or liberal oxygenation strategy in comatose patients after resuscitation for cardiac arrest resulted in a similar incidence of death or severe disability or coma. (Funded by the Novo Nordisk Foundation; BOX ClinicalTrials.gov number, NCT03141099.).
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Affiliation(s)
- Henrik Schmidt
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Jesper Kjaergaard
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Christian Hassager
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Simon Mølstrøm
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Johannes Grand
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Britt Borregaard
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Laust E Roelsgaard Obling
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Søren Venø
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Laura Sarkisian
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Dmitry Mamaev
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Lisette O Jensen
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Benjamin Nyholm
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Dan E Høfsten
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Jakob Josiassen
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Jakob H Thomsen
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Jens J Thune
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Matias G Lindholm
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Martin A Stengaard Meyer
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Matilde Winther-Jensen
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Marc Sørensen
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Martin Frydland
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Rasmus P Beske
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Ruth Frikke-Schmidt
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Sebastian Wiberg
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Søren Boesgaard
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Vibeke Lind Jørgensen
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Jacob E Møller
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
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Kjaergaard J, Møller JE, Schmidt H, Grand J, Mølstrøm S, Borregaard B, Venø S, Sarkisian L, Mamaev D, Jensen LO, Nyholm B, Høfsten DE, Josiassen J, Thomsen JH, Thune JJ, Obling LER, Lindholm MG, Frydland M, Meyer MAS, Winther-Jensen M, Beske RP, Frikke-Schmidt R, Wiberg S, Boesgaard S, Madsen SA, Jørgensen VL, Hassager C. Blood-Pressure Targets in Comatose Survivors of Cardiac Arrest. N Engl J Med 2022; 387:1456-1466. [PMID: 36027564 DOI: 10.1056/nejmoa2208687] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Evidence to support the choice of blood-pressure targets for the treatment of comatose survivors of out-of-hospital cardiac arrest who are receiving intensive care is limited. METHODS In a double-blind, randomized trial with a 2-by-2 factorial design, we evaluated a mean arterial blood-pressure target of 63 mm Hg as compared with 77 mm Hg in comatose adults who had been resuscitated after an out-of-hospital cardiac arrest of presumed cardiac cause; patients were also assigned to one of two oxygen targets (reported separately). The primary outcome was a composite of death from any cause or hospital discharge with a Cerebral Performance Category (CPC) of 3 or 4 within 90 days (range, 0 to 5, with higher categories indicating more severe disability; a category of 3 or 4 indicates severe disability or coma). Secondary outcomes included neuron-specific enolase levels at 48 hours, death from any cause, scores on the Montreal Cognitive Assessment (range, 0 to 30, with higher scores indicating better cognitive ability) and the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability) at 3 months, and the CPC at 3 months. RESULTS A total of 789 patients were included in the analysis (393 in the high-target group and 396 in the low-target group). A primary-outcome event occurred in 133 patients (34%) in the high-target group and in 127 patients (32%) in the low-target group (hazard ratio, 1.08; 95% confidence interval [CI], 0.84 to 1.37; P = 0.56). At 90 days, 122 patients (31%) in the high-target group and 114 patients (29%) in the low-target group had died (hazard ratio, 1.13; 95% CI, 0.88 to 1.46). The median CPC was 1 (interquartile range, 1 to 5) in both the high-target group and the low-target group; the corresponding median modified Rankin scale scores were 1 (interquartile range, 0 to 6) and 1 (interquartile range, 0 to 6), and the corresponding median Montreal Cognitive Assessment scores were 27 (interquartile range, 24 to 29) and 26 (interquartile range, 24 to 29). The median neuron-specific enolase level at 48 hours was also similar in the two groups. The percentages of patients with adverse events did not differ significantly between the groups. CONCLUSIONS Targeting a mean arterial blood pressure of 77 mm Hg or 63 mm Hg in patients who had been resuscitated from cardiac arrest did not result in significantly different percentages of patients dying or having severe disability or coma. (Funded by the Novo Nordisk Foundation; BOX ClinicalTrials.gov number, NCT03141099.).
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Affiliation(s)
- Jesper Kjaergaard
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Jacob E Møller
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Henrik Schmidt
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Johannes Grand
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Simon Mølstrøm
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Britt Borregaard
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Søren Venø
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Laura Sarkisian
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Dmitry Mamaev
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Lisette O Jensen
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Benjamin Nyholm
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Dan E Høfsten
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Jakob Josiassen
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Jakob H Thomsen
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Jens J Thune
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Laust E R Obling
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Matias G Lindholm
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Martin Frydland
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Martin A S Meyer
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Matilde Winther-Jensen
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Rasmus P Beske
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Ruth Frikke-Schmidt
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Sebastian Wiberg
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Søren Boesgaard
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Søren A Madsen
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Vibeke L Jørgensen
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
| | - Christian Hassager
- From the Departments of Cardiology (J.K., J.E.M., J.G., B.N., D.E.H., J.J., J.H.T., L.E.R.O., M.G.L., M.F., M.A.S.M., M.W.-J., R.P.B., S.W., S.B., C.H.) and Cardiothoracic Anesthesiology (S.A.M., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., R.F.-S., C.H.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Departments of Cardiology (J.E.M., B.B., L.S., L.O.J.) and Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.), Odense University Hospital, and the Department of Clinical Medicine, University of Southern Denmark (J.E.M., B.B., L.O.J., C.H.), Odense - all in Denmark
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Grand J, Hassager C, Schmidt H, Møller JE, Mølstrøm S, Nyholm B, Kjaergaard J. Hemodynamic evaluation by serial right heart catheterizations after cardiac arrest; protocol of a sub-study from the Blood Pressure and Oxygenation Targets after Out-of-Hospital Cardiac Arrest-trial (BOX). Resusc Plus 2021; 8:100188. [PMID: 34950913 PMCID: PMC8671111 DOI: 10.1016/j.resplu.2021.100188] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 01/20/2023] Open
Abstract
Background Neurological injury and mortality remain high in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). Hypotension and hypoxia during post-resuscitation care have been associated with poor outcome, but the optimal oxygenation- and blood pressure-targets are unknown. The impact of different doses of norepinephrine on advanced hemodynamic after OHCA and the impact of different oxygenation-targets on pulmonary circulation and resistance (PVR), are unknown. The aims of this substudy of the "Blood pressure and oxygenations targets after out-of-hospital cardiac arrest (BOX)"-trial are to investigate the effect of two different MAP- and oxygenation-targets on advanced systemic and pulmonary hemodynamics measured by pulmonary artery catheters (PAC). Methods The BOX-trial is an investigator-initiated, randomized, controlled study comparing targeted MAP of 63 mmHg vs 77 mmHg (double-blinded intervention) and 9-10 kPa versus PaO2 of 13-14 kPa oxygenation-targets (open-label). Per protocol, all patients will be monitored systematically with PACs. The primary endpoint of the hemodynamic-substudy is cardiac output for the MAP-intervention, and PVR for the oxygenation-intervention. For both endpoints, the difference within 48 h between groups are assessed. Secondary endpoints are pulmonary capillary wedge pressure and pulmonary arterial pressure and association between advanced hemodynamic variables and mortality and biomarkers of inflammation and brain injury. Discussion In the BOX-trial, patients will be randomly allocated to two levels of MAP and oxygenation, which are central parts of post-resuscitation care and where evidence is sparse. The advanced-hemodynamic substudy will give valuable knowledge of the hemodynamic consequences of changing blood pressure and oxygen-levels of the critical cardiac patient. It will be one of the largest clinical, prospective trials of advanced hemodynamics measured by serial PACs in consecutive comatose patients, resuscitated after OHCA. The randomized and placebo-controlled trialdesign of the MAP-intervention minimizes risk of selection bias and confounders. Furthermore, hemodynamic characteristics and associations with outcome will be investigated. Trial registration ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT03141099). Registered March 30, 2017.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark.,Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark
| | - Simon Mølstrøm
- Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark
| | - Benjamin Nyholm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
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Forsse A, Nielsen TH, Mølstrøm S, Hjelmborg J, Nielsen KS, Nygaard KH, Yilmaz S, Nordström CH, Poulsen FR. A Prospective Observational Feasibility Study of Jugular Bulb Microdialysis in Subarachnoid Hemorrhage. Neurocrit Care 2021; 33:241-255. [PMID: 31845174 DOI: 10.1007/s12028-019-00888-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Cerebral metabolic perturbations are common in aneurysmal subarachnoid hemorrhage (aSAH). Monitoring cerebral metabolism with intracerebral microdialysis (CMD) allows early detection of secondary injury and may guide decisions on neurocritical care interventions, affecting outcome. However, CMD is a regional measuring technique that is influenced by proximity to focal lesions. Continuous microdialysis of the cerebral venous drainage may provide information on global cerebral metabolism relevant for the care of aSAH patients. This observational study aimed to explore the feasibility of jugular bulb microdialysis (JBMD) in aSAH and describe the output characteristics in relation to conventional multimodal monitoring. METHODS Patients with severe aSAH were included at admission or after in-house deterioration when local clinical guidelines prompted extended multimodal monitoring. Non-dominant frontal CMD, intracranial pressure (ICP), partial brain tissue oxygenation pressure (PbtO2), and cerebral perfusion pressure (CPP) were recorded every hour. The dominant jugular vein was accessed by retrograde insertion of a microdialysis catheter with the tip placed in the jugular bulb under ultrasound guidance. Glucose, lactate, pyruvate, lactate/pyruvate ratio, glycerol, and glutamate were studied for correlation to intracranial measurements. Modified Rankin scale was assessed at 6 months. RESULTS Twelve adult aSAH patients were monitored during a mean 4.2 ± 2.6 days yielding 22,041 data points for analysis. No complications related to JBMD were observed. Moderate or strong significant monotonic CMD-to-JBMD correlations were observed most often for glucose (7 patients), followed by lactate (5 patients), and pyruvate, glycerol, and glutamate (3 patients). Moderate correlation for lactate/pyruvate ratio was only seen in one patient. Analysis of critical periods defined by ICP > 20, CPP < 65, or PbtO2 < 15 revealed a tendency toward stronger CMD-to-JBMD associations in patients with many or long critical periods. Possible time lags between CMD and JBMD measurements were only identified in 6 out of 60 patient variables. With the exception of pyruvate, a dichotomized outcome was associated with similar metabolite patterns in JBMD and CMD. A nonsignificant tendency toward greater differences between outcome groups was seen in JBMD. CONCLUSIONS Continuous microdialysis monitoring of the cerebral drainage in the jugular bulb is feasible and safe. JBMD-to-CMD correlation is influenced by the type of metabolite measured, with glucose and lactate displaying the strongest associations. JBMD lactate correlated more often than CMD lactate to CPP, implying utility for detection of global cerebral metabolic perturbations. Studies comparing JBMD to other global measures of cerebral metabolism, e.g., PET CT or Xenon CT, are warranted.
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Affiliation(s)
- Axel Forsse
- Department of Neurosurgery, Odense University Hospital, Sønder Boulevard 29, 5000, Odense, Denmark. .,BRIDGE - Brain Research - Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Troels Halfeld Nielsen
- Department of Neurosurgery, Odense University Hospital, Sønder Boulevard 29, 5000, Odense, Denmark.,BRIDGE - Brain Research - Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Jacob Hjelmborg
- Department of Biostatistics and Epidemiology, University of Southern Denmark, Odense, Denmark
| | - Kasper Stokbro Nielsen
- Department of Oral and Maxillofacial Surgery, Odense University Hospital, Odense, Denmark
| | - Kevin Hebøll Nygaard
- Department of Neurosurgery, Odense University Hospital, Sønder Boulevard 29, 5000, Odense, Denmark.,BRIDGE - Brain Research - Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sibel Yilmaz
- Department of Neurosurgery, Odense University Hospital, Sønder Boulevard 29, 5000, Odense, Denmark
| | - Carl-Henrik Nordström
- Department of Neurosurgery, Odense University Hospital, Sønder Boulevard 29, 5000, Odense, Denmark.,BRIDGE - Brain Research - Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Frantz Rom Poulsen
- Department of Neurosurgery, Odense University Hospital, Sønder Boulevard 29, 5000, Odense, Denmark.,BRIDGE - Brain Research - Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Nordström CH, Jakobsen R, Mølstrøm S, Nielsen TH. Cerebral venous blood is not drained via the internal jugular vein in the pig. Resuscitation 2021; 162:437-438. [PMID: 33582253 DOI: 10.1016/j.resuscitation.2021.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Affiliation(s)
| | - Rasmus Jakobsen
- Department of Anesthesia and Intensive Care, Odense University Hospital, Denmark
| | - Simon Mølstrøm
- Department of Anesthesia and Intensive Care, Odense University Hospital, Odense C, Denmark
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Jakobsen RP, Nielsen TH, Mølstrøm S, Nordström CH, Granfeldt A, Toft P. Moderately prolonged permissive hypotension results in reversible metabolic perturbation evaluated by intracerebral microdialysis - an experimental animal study. Intensive Care Med Exp 2019; 7:67. [PMID: 31802303 PMCID: PMC6892994 DOI: 10.1186/s40635-019-0282-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/13/2019] [Indexed: 12/28/2022] Open
Abstract
Background Damage control resuscitation (DCR) and damage control surgery (DCS) is the main strategy in patients with uncontrollable hemorrhagic shock. One aspect of DCR is permissive hypotension. However, the duration of hypotension that can be tolerated without affecting the brain is unknown. In the present study we investigate the effect of 60 min severe hypotension on the brain’s energy metabolism and seek to verify earlier findings that venous cerebral blood can be used as a marker of global cerebral energy state. Material and methods Ten pigs were anaesthetized, and vital parameters recorded. Microdialysis catheters were placed in the left parietal lobe, femoral artery, and superior sagittal sinus for analysis of lactate, pyruvate, glucose, glycerol, and glutamate. Hemorrhagic shock was induced by bleeding the animal until mean arterial pressure (MAP) of 40 mmHg was achieved. After 60 min the pigs were resuscitated with autologous blood and observed for 3 h. Results At baseline the lactate to pyruvate ratios (LP ratio) in the hemisphere, artery, and sagittal sinus were (median (interquartile range)) 13 (8–16), 21 (18–24), and 9 (6–22), respectively. After induction of hemorrhagic shock, the LP ratio from the left hemisphere in 9 pigs increased to levels indicating a reversible perturbation of cerebral energy metabolism 19 (12–30). The same pattern was seen in LP measurements from the femoral artery 28 (20–35) and sagittal sinus 22 (19–26). At the end of the experiment hemisphere, artery and sinus LP ratios were 16 (10–23), 17 (15–25), and 17 (10–27), respectively. Although hemisphere and sinus LP ratios decreased, they did not reach baseline levels (p < 0.05). In one pig hemisphere LP ratio increased to a level indicating irreversible metabolic perturbation (LP ratio > 200). Conclusion During 60 min of severe hypotension intracerebral microdialysis shows signs of perturbations of cerebral energy metabolism, and these changes trend towards baseline values after resuscitation. Sagittal sinus microdialysis values followed hemisphere values but were not distinguishable from systemic arterial values. Venous (jugular bulb) microdialysis might have a place in monitoring conditions where global cerebral ischemia is a risk.
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Affiliation(s)
- Rasmus Peter Jakobsen
- Department of Anesthesia and Intensive Care, Odense University Hospital, J.B. Winsløws Vej 4, Indgang 8, 20, 201, 5000, Odense C, Denmark.
| | - Troels Halfeld Nielsen
- Department of Neurosurgery, Odense University Hospital, Kløvervænget 47, Indgang 44, 1. etage, 5000, Odense C, Denmark
| | - Simon Mølstrøm
- Department of Anesthesia and Intensive Care, Odense University Hospital, J.B. Winsløws Vej 4, Indgang 8, 20, 201, 5000, Odense C, Denmark
| | - Carl-Henrik Nordström
- Department of Neurosurgery, Odense University Hospital, Kløvervænget 47, Indgang 44, 1. etage, 5000, Odense C, Denmark
| | - Asger Granfeldt
- Department of Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99 G304, 8200, Aarhus, Denmark
| | - Palle Toft
- Department of Anesthesia and Intensive Care, Odense University Hospital, J.B. Winsløws Vej 4, Indgang 8, 20, 201, 5000, Odense C, Denmark
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Bie P, Mølstrøm S, Wamberg S. Normotensive sodium loading in conscious dogs: regulation of renin secretion during β-receptor blockade. Am J Physiol Regul Integr Comp Physiol 2009; 296:R428-35. [DOI: 10.1152/ajpregu.90753.2008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Renin secretion is regulated in part by renal nerves operating through β1-receptors of the renal juxtaglomerular cells. Slow sodium loading may decrease plasma renin concentration (PRC) and cause natriuresis at constant mean arterial blood pressure (MAP) and glomerular filtration rate (GFR). We hypothesized that in this setting, renin secretion and renin-dependent sodium excretion are controlled by via the renal nerves and therefore are eliminated or reduced by blocking the action of norepinephrine on the juxtaglomerular cells with the β1-receptor antagonist metoprolol. This was tested in conscious dogs by infusion of NaCl (20 μmol·kg−1·min−1for 180 min, NaLoad) during regular or low-sodium diet (0.03 mmol·kg−1·day−1, LowNa) with and without metoprolol (2 mg/kg plus 0.9 mg·kg−1·h−1). Vasopressin V2receptors were blocked by Otsuka compound OPC31260 to facilitate clearance measurements. Body fluid volume was maintained by servocontrolled fluid infusion. Metoprolol per se did not affect MAP, heart rate, or sodium excretion significantly, but reduced PRC and ANG II by 30–40%, increased plasma atrial natriuretic peptide (ANP), and tripled potassium excretion. LowNa per se increased PRC (+53%), ANG II (+93%), and aldosterone (+660%), and shifted the vasopressin function curve to the left. NaLoad elevated plasma [Na+] by 4.5% and vasopressin by threefold, but MAP and plasma ANP remained unchanged. NaLoad decreased PRC by ∼30%, ANG II by ∼40%, and aldosterone by ∼60%, regardless of diet and metoprolol. The natriuretic response to NaLoad was augmented during metoprolol regardless of diet. In conclusion, PRC depended on dietary sodium and β1-adrenergic control as expected; however, the acute sodium-driven decrease in PRC at constant MAP and GFR was unaffected by β1-receptor blockade demonstrating that renin may be regulated without changes in MAP, GFR, or β1-mediated effects of norepinephrine. Low-sodium diet augments vasopressin secretion, whereas ANP secretion is reduced.
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Mølstrøm S, Larsen NH, Simonsen JA, Washington R, Bie P. Normotensive sodium loading in normal man: regulation of renin secretion during beta-receptor blockade. Am J Physiol Regul Integr Comp Physiol 2008; 296:R436-45. [PMID: 19073901 DOI: 10.1152/ajpregu.90754.2008] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Saline administration may change renin-angiotensin-aldosterone system (RAAS) activity and sodium excretion at constant mean arterial pressure (MAP). We hypothesized that such responses are elicited mainly by renal sympathetic nerve activity by beta1-receptors (beta1-RSNA), and tested the hypothesis by studying RAAS and renal excretion during slow saline loading at constant plasma sodium concentration (Na+ loading; 12 micromol Na+.kg(-1).min(-1) for 4 h). Normal subjects were studied on low-sodium intake with and without beta1-adrenergic blockade by metoprolol. Metoprolol per se reduced RAAS activity as expected. Na+ loading decreased plasma renin concentration (PRC) by one-third, plasma ANG II by one-half, and plasma aldosterone by two-thirds (all P < 0.05); surprisingly, these changes were found without, as well as during, acute metoprolol administration. Concomitantly, sodium excretion increased indistinguishably with and without metoprolol (16 +/- 2 to 71 +/- 14 micromol/min; 13 +/- 2 to 55 +/- 13 micromol/min, respectively). Na+ loading did not increase plasma atrial natriuretic peptide, glomerular filtration rate (GFR by 51Cr-EDTA), MAP, or cardiac output (CO by impedance cardiography), but increased central venous pressure (CVP) by approximately 2.0 mmHg (P < 0.05). During Na+ loading, sodium excretion increased with CVP at an average slope of 7 micromol.min(-1).mmHg(-1). Concomitantly, plasma vasopressin decreased by 30-40% (P < 0.05). In conclusion, beta1-adrenoceptor blockade affects neither the acute saline-mediated deactivation of RAAS nor the associated natriuretic response, and the RAAS response to modest saline loading seems independent of changes in MAP, CO, GFR, beta1-mediated effects of norepinephrine, and ANP. Unexpectedly, the results do not allow assessment of the relative importance of RAAS-dependent and -independent regulation of renal sodium excretion. The results are compatible with the notion that at constant arterial pressure, a volume receptor elicited reduction in RSNA via receptors other than beta1-adrenoceptors, decreases renal tubular sodium reabsorption proximal to the macula densa leading to increased NaCl concentration at the macula densa, and subsequent inhibition of renin secretion.
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Affiliation(s)
- Simon Mølstrøm
- Department of Physiology and Pharmacology, Institute of Medical Biology, University of Southern Denmark, 21 Winslowparken, Odense, DK-5000, Denmark
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