Development of video tutorials to help parents manage children with acute illnesses using a modified Delphi method

AIM

Children often fall sick, which causes concern among parents. Online health information can be confusing and difficult to understand. We aimed to produce simple, informative video tutorials on the symptoms ill children present.

METHODS

We used a modified Delphi method to produce video tutorials on the symptoms fever, vomiting & diarrhea, abdominal pain, breathing difficulties, sore throat, red eyes, earache, and rash. We identified the most common symptoms in acutely ill children. During the first consensus round, experts rated statements on out-of-hospital management from existing health information. Video tutorials were produced from statements rated to be included. Second consensus involved video showings and editing. Two videos were evaluated in focus groups by parents.

RESULTS

During the first round, experts rated median 79 (40-154) statements for each symptom. Panels consisted of median seven (6-11) experts, primarily. Panels reached consensus on inclusion, neutral, or exclusion in 83% of statements. Second round led to adjustments to the videos and final approval by experts. Most parents evaluated the videos as "informative, easy to understand, and calming".

CONCLUSION

We produced video tutorials on the common symptoms ill children present using a modified Delphi method. Feedback from parents in focus groups was positive.

Termination of resuscitation in out-of-hospital cardiac arrest in women and men: An ESCAPE-NET project

AIM

Women have less favorable resuscitation characteristics than men. We investigated whether the Advanced Life Support Termination of Resuscitation rule (ALS-TOR) performs equally in women and men. Additionally, we studied whether adding or removing criteria from the ALS-TOR improved classification into survivors and non-survivors.

METHODS

We analyzed 6,931 female and 14,548 male out-of-hospital cardiac arrest (OHCA) patients from Dutch and Swedish registries, and validated in 10,772 female and 21,808 male Danish OHCA patients. Performance measures were calculated for ALS-TOR in relation to 30-day survival. Recursive partitioning analysis was performed with the ALS-TOR criteria, as well as age, comorbidities, and additional resuscitation characteristics (e.g. initial rhythm, OHCA location). Finally, we explored if we could reduce the number of ALS-TOR criteria without loss of prognostic value.

RESULTS

The ALS-TOR had a specificity and positive predictive value (PPV) of ≥99% in both women and men (e.g. PPV 99.9 in men). Classification by recursive partitioning analysis showed a high sensitivity but a PPV below 99%, thereby exceeding the acceptable miss rate of 1%. A combination of no return of spontaneous circulation (ROSC) before transport to the hospital and unwitnessed OHCA resulted in nearly equal specificity and PPV, higher sensitivity, and a lower transport rate to the hospital than the ALS-TOR.

CONCLUSION

For both women and men, the ALS-TOR has high specificity and low miss rate for predicting 30-day OHCA survival. We could not improve the classification with additional characteristics. Employing a simplified version may decrease the number of futile transports to the hospital.

Half of all out-of-hospital cardiac arrests in public occur in residential areas with lower rates of bystander intervention and survival

Background

Impressive survival rates have been achieved for public out-of-hospital cardiac arrest (OHCA) in selected areas (airports and similar places), but residential areas as a location for public OHCA remain unexplored. This study aimed to investigate incidence, survival, and bystander intervention when public OHCA occurs in residential areas.

Methods

Residential and non-residential areas were defined using Urban Atlas, an open-source database that categorizes urban area surface in the European Union based on land cover use. Residential and non-residential areas were defined based on prespecified Urban Atlas classification. Nature and agricultural areas were excluded. All public OHCAs from 2016–2020 registered with the Danish Cardiac Arrest Registry were included and divided into residential and non-residential areas, excluding OHCAs in nursing homes and medical facilities. The variables have been compared between residential and non-residential areas using the Kruskal Wallis test for non-parametric continuous data and Fischer's exact test for categorical data. A logistic regression model adjusting for age and sex was used to compare bystander cardiopulmonary resuscitation (CPR), bystander defibrillation, and 30-day survival between residential and non-residential areas. A sub-analysis included bystander witnessed OHCAs only.

Results

A total of 1,939 public OHCAs were included, evenly distributed between residential (969 [0.17 OHCA/km2/year]) and non-residential areas (970 [0.21 OHCA/km2/year]). OHCAs in residential areas differed from those in non-residential areas by having a lower proportion of bystander CPR (84.7% [95% CI: 82.3–86.9%] vs. 88.9% [95% CI: 86.7–90.8%], p-value = 0.007), bystander defibrillation (17.2% [95% CI: 14.9–19.8%] vs. 29.5% [95% CI: 26.6–32.4%], p-value <0.001), and 30-day survival (30.1% [95% CI: 27.2–33.1%] vs. 39.8% [95% CI: 36.7–42.9%], p-value <0.001), respectively. The two groups had similar proportions of shockable rhythm and defibrillation by emergency medical services. Patients with public OHCA in residential areas were older, more likely to be female, have an unwitnessed OHCA, and have a short response time (Table 1). The odds for bystander defibrillation were 50% lower in residential areas than non-residential areas, and the odds for bystander CPR and survival were 30% lower. When only including witnessed public OHCA, the odds remain similar, and the odds of receiving bystander defibrillation and surviving were still significantly lower than non-residential areas (Figure 1).

Conclusion

Half of all OHCAs in public occur in residential areas. They are less likely to receive bystander interventions and have a lower likelihood of 30-day survival compared to public OHCAs in non-residential areas.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Tryg Foundation

Increased risk of out-of-hospital cardiac arrest in patients with congenital heart disease: a nationwide study

Background

The last four decades witnessed substantial improvements in treatment of congenital heart disease (CHD) leading to most children surviving into adulthood. Currently, the number of adults with CHD surpasses that of children. The shift in the CHD population's age composition necessitates focusing on long-term problems. A significant, but not well-investigated, issue is the risk of out-of-hospital cardiac arrest (OHCA) in adults with CHD.

Purpose

To investigate overall and temporal changes in the rate of OHCA associated with CHD compared with the general population.

Method

We conducted a nested case-control study matching all adult patients with OHCA of presumed cardiac cause between 2001 and 2015 with up to five controls from the entire Danish population on age, sex, date of OHCA and cardiac comorbidities status (at least one among ischemic heart disease, heart failure and presence of implantable cardioverter-defibrillator). Patients with CHD were identified using in- and out-patient hospital diagnoses any time prior to OHCA and divided into two mutually exclusive subgroups, either non-severe or severe CHD. The subclassification of CHD is based on a hierarchical approach previously used, where at least one severe CHD diagnosis is required to be classified as severe.

We used Cox regression models to compute hazard ratios (HRs) and 95% confidence intervals (CI) of OHCA. We stratified on CHD status (non-severe, severe or control), sex and OHCA year group (2001–2008 vs 2009–2015).

Results

We included 35,005 OHCA cases and 175,025 controls: the median age was 72 years, 66.9% were male and 34.6% had cardiac comorbidities. In total, among cases, we identified 103 patients with non-severe CHD and 51 with severe CHD, while, among controls, 247 with non-severe CHD and 69 with severe CHD. Both non-severe and severe CHD were overall associated with higher rates of OHCA compared with the general population: HR 2.11 (95% CI, 1.68–2.66) and HR 3.93 (95% CI, 2.71–5.69), respectively (Figure A). We found similar results when we stratified the analyses according to the presence of cardiac comorbidities at date of OHCA (Figure B) and sex.

When stratified by OHCA year group, we observed stable rates of OHCA associated with non-severe CHD: from HR 2.03 (95% CI, 1.36–3.03) in the period 2001–2008 to HR 2.15 (95% CI, 1.62–2.86) in the period 2009–2015. Conversely, we observed a trend towards decreasing rates of OHCA associated with severe CHD: from HR 5.04 (95% CI, 2.79–9.11) in the period 2001–2008 to HR 3.10 (95% CI, 1.80–5.19) in the period 2009–2015

Conclusions

Non-severe and severe CHD were both associated with higher rates of OHCA compared with the general population. While we observed decreasing rates of OHCA over calendar year for severe CHD, they remained stable for non-severe CHD.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Gentofte University Hospital, Hellerup, Denmark

External validation of the simple NULL-PLEASE clinical score in predicting outcomes in men and women with out-of-hospital cardiac arrest

Background

The NULL-PLEASE score (Nonshockable rhythm, Unwitnessed arrest, Long no-flow or Long low-flow period, blood pH <7.2, Lactate >7.0 mmol/L, End-stage renal disease on dialysis, Age ≥85 years, Still resuscitation, and Extracardiac cause) was developed to help identify patients with out-of-hospital cardiac arrest (OHCA) who are unlikely to survive. Although survival after OHCA differs between sexes, the performance of the NULL-PLEASE score according to sex has not been tested previously.

Purpose

To validate the NULL-PLEASE score separately in men and women in a nationwide setting.

Methods

Using Danish nationwide registry data from 2001–2019, we retrospectively identified male and female OHCA survivors with return of spontaneous circulation (ROSC) or ongoing cardiopulmonary resuscitation at hospital arrival. The primary outcome was 1-day mortality. Secondary outcomes were defined as 30-day mortality and the combination of 1-year mortality or anoxic brain damage. Logistic regression with a NULL-PLEASE score of 0 as reference was used for outcome risk estimation. The predictive ability of the score was assessed using area under the receiver operating characteristics (AUCROC) curves.

Results

A total of 2,601 men (median age 67 years (interquartile range (IQR) 56–76 years), and 1,280 women (median age 69 years (IQR 58–79 years) were included. One-day mortality was 31% in men and 42% in women; 30-day mortality was 56% and 71% in men and women, respectively; and 63% of men and 78% of women experienced the combined outcome. For patients with a NULL-PLEASE score ≥9, absolute risks were: 1-day mortality: 82.0% (95% confidence interval [CI]: 75.6–88.4%) for men and 79.1% (95% CI: 71.3–86.8%) for women; 30-day mortality: 98.6% (95% CI: 96.6–100.0) for men and 97.1% (95% CI: 94.0–100.0%) for women; and the combined outcome: 99.3% (95% CI: 97.9–100.0%) for men and 97.1% (95% CI: 94.0–100.0%) for women. AUCROC values for 1-day mortality were 0.827 (95% CI: 0.811–0.844) for men and 0.736 (95% CI: 0.710–0.763) for women. Results were similar for 30-day mortality and for the combined outcome. ROC curves for all outcomes are shown in Figure 1 (men) and Figure 2 (women). For a NULL-PLEASE score cut-point ≥3 to predict 1-day mortality, the positive predictive value was 91.8% in men and 91.1% in women, with a sensitivity of detecting patients who die of 47.3% in men and 51.8% in women. The corresponding negative predictive value for surviving more than 1 day was 54.6% in men and 37.7% in women, and the specificity of detecting patients who survive was 93.7% in men and 85.3% in women.

Conclusions

In a nationwide OHCA-cohort, the NULL-PLEASE score consistently appeared to perform better in men than in women for all outcomes. Nevertheless, its predictive ability was high among both sexes. Sex-specific differences should not be overlooked in clinical decision-making in patients surviving OHCA.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Danish Heart FoundationThe Danish Foundation TrygFonden

Risk of worsening heart failure and all-cause mortality following mRNA COVID-19 vaccination in patients with heart failure: a Danish nationwide real-world safety study

Background

The studies investigating the safety and efficacy of the SARS-COV2 mRNA vaccines only included a limited number of heart failure patients and no separate analyses were performed regarding the safety of the vaccines in this patient population.

Purpose

The aims of this study were to investigate the risk of worsening heart failure and all-cause mortality associated with the SARS-COV-2 mRNA vaccines in a nationwide cohort of patients with heart failure.

Methods

Using the Danish nationwide registries, two cohorts were constructed; 1) all prevalent heart failure patients in 2019 and 2) all prevalent heart failure patients in 2021 who were vaccinated with either of the two mRNA vaccines (BNT162B2 or mRNA-1273). The patients in the two cohorts were matched 1:1 using exact exposure matching on age, sex, and duration of heart failure (intervals). For patients in the 2021 cohort, the index date was defined as the date of the patients' second vaccination. Patients in the 2019 cohort were assigned the index day and month of their 1:1 match in the 2021 cohort, but used the pre-vaccination index year 2019. The primary outcomes were worsening heart failure and all-cause mortality and secondary outcomes were myocarditis and venous thromboembolism. Standardized risks were estimated based on outcome-specific Cox regression analyses, and all models were standardized to age, sex, duration of heart failure, use of SGLT2 inhibitors or Entresto, ischemic heart disease, cancer, diabetes, atrial fibrillation, and admission with heart failure <90 days before index.

Results

The total study population comprised 101,786 patients, with 50,893 patients in each cohort. The median age of the study population was 74 (interquartile range (IQR); 66,81), and duration of heart failure was 4.1 (IQR: 2.0,6.7) years. The standardized risk of all-cause mortality within 90 days was 2.2% (95% CI: 2.1% to 2.4%) in the 2021 cohort and 2.6% (95% CI: 2.4% to 2.7%) in the 2019 cohort, showing a significantly lower risk difference for all-cause mortality in 2021 versus 2019 (risk difference: −0.3% (95% CI: −0.5% to −0.1%)) Figure 1)). The standardized risk of worsening heart failure within 90 days was 1.1% (95% CI: −1.0% to 1.2%) in the 2021 cohort and 1.1% (95% CI: 1.0% to 1.2%) in the 2019 cohort showing no significant difference in the risk of worsening heart failure between the two cohorts (risk difference: 0% (95% CI: −0.1% to 0.1%)). No significant differences were found for venous thromboembolism or myocarditis.

Conclusion

This study showed that the SARS-COV2 mRNA vaccines were not associated with an increased risk of worsening heart failure, venous thromboembolism or myocarditis, but was associated with a decreased risk of all-cause mortality. Our study may suggest that these vaccines are safe in heart failure patients.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Danish Heart FoundationLæge Sofus Carl Emil Friis og hustrus legat

Patient reported symptoms in emergency health care service in patients with complete atrioventricular block

Aim

To examine initial symptoms in emergency and medical helpline calls of patients prior to hospital admission and pacemaker implantation due to recent onset of complete atrioventricular block.

Methods

In the capital region of Denmark, Copenhagen, citizens who require medical assistance can contact either the regional 24h non-urgent medical helpline 1813 or the emergency number 1–1-2 (equivalent to 9–1–1). In both services, the symptoms/purposes of the calls are registered by health professionals. We identified calls from patients who received a pacemaker due to recent onset complete AV block. Prior to analysis, symptoms were categorized as fainting, dizziness, other CNS symptoms, chest pain, other cardiac symptoms, breathing problems, trauma/exposure, unconsciousness, unclear problems, and other atypical symptoms.

Results

We identified 451 calls (261 emergency calls and 190 non-emergency calls) which included information on symptom presentation prior to hospital admission due to first time diagnosis of complete atrioventricular block, that resulted in pacemaker implantation (Figure). Typical symptoms such as fainting and dizziness accounted for only 12.6% (57/451) and 13.3% (60/451), respectively. Chest pain (13.6%, 61/451) and other cardiac symptoms (5.3%, 24/451) accounted for roughly one in five patient complaints. Across both service types, patients >80 years (median age) was more likely to call for help due to trauma/exposure, while complaints of fainting trended towards younger patients and the 1-1-2 emergency number. Median time from first call to pacemaker implantation was 2–3 days for fainting, dizziness, and chest pain, compared to 6–8 days for other CNS symptoms and other atypical symptoms (Table).

Conclusion

Typical symptoms such as fainting and dizziness accounted for only 13% in patients with complete atrioventricular block. Instead, these patients presented with a wide variety of initial symptoms, including chest pain, breathing problems, unclear problems, or trauma. Finally, symptom presentation seemed to affect the time to pacemaker implantation.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Danish Heart Foundation

Opioid administered prior to onset of myocardial infarction is associated with atypical symptoms of acute coronary ischemia in emergency calls

Background

Acute identification and treatment of myocardial infarction (MI) is crucial for survival. MI symptom presentation is typically characterized by chest pain. Regular use of opioids to relief pain of chronic diseases is common. However, it has not been investigated whether opioid administered prior to onset of MI is associated more with atypical presentation of ischemia compared to non-opioid users.

Purpose

To investigate if opioid therapy is associated with atypical symptoms of MI.

Methods

The study is registry-based. MI is defined as patients with the ICD-10 discharge diagnoses I20.0 and I21 as primary diagnosis <24 hours after a call to the Capital Emergency Medical Services, including the Emergency Number (1–1-2) and Out-of-hours Service (OOHS). MI patients with opioid treatment prior to onset of MI are compared with a control group of MI patients without opioid treatment. The primary symptom of MI is registered in calls to the Capital Emergency Medical Services, from 2014 to 2018. Opioid treatment includes opioid prescribed and picked up <30 days prior to onset of MI.

Results

In total, 866 MI patients with opioid treatment and 10,061 MI patients without opioid treatment were included. The median age was 72.0 vs 67.8 years, 50.5% vs 34.5% were women, 61.0% vs 54.7% called the Emergency Number (1–1-2), ischemic heart disease was present in 48.5% vs 34.3% and type 2 diabetes in 23.1% vs. 16.2%. Atypical symptoms of MI were associated with opioid treatment and most prevalent in calls to OOHS, in women and by higher age. Acute symptoms of MI are visualized in Figure 1 and 2.

Conclusion

Opioid treatment prior to onset of MI was associated with increased atypical symptoms of MI, especially dyspnea, and increased in calls to the OOHS, in women and by higher age. This might challenge the clinician in early diagnose of MI in patients with opioid treatment and thereby delay acute lifesaving treatment.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation

Psychiatric Admissions, Referrals, and Suicidal Behavior Before and During the COVID-19 Pandemic in Denmark: A Time-Trend Study

Introduction

The COVID-19 pandemic has affected mental health globally, but the impact on referrals and admissions to mental health services remains understudied.

Objectives

To assess patterns in psychiatric admissions, referrals, and suicidal behavior before and during the COVID-19 pandemic in Denmark.

Methods

Utilizing hospital and Emergency Medical Services (EMS) health records covering 46% of the Danish population, we compared psychiatric in-patients, referrals to mental health services and suicidal behavior in years prior to the COVID-19 pandemic to levels during the first lockdown (March 11 – May 17, 2020), inter-lockdown period (May 18 – December 15, 2020), and second lockdown (December 16, 2020 – February 28, 2021) using negative binomial models.

Results

The rate of psychiatric in-patients declined compared to pre-pandemic levels (RR = 0.95, 95% CI = 0.94 – 0.96, p < 0.01). Referrals were not significantly different (RR = 1.01, 95% CI = 0.92 – 1.10, p = 0.91) during the pandemic; neither was suicidal behavior among hospital contacts (RR = 1.04, 95% CI = 0.94 – 1.14, p = 0.48) nor EMS contacts (RR = 1.08, 95% CI = 1.00 – 1.18, p = 0.06). In the age group <18, an increase in the rate of psychiatric in-patients (RR = 1.11, 95% CI = 1.07 – 1.15, p < 0.01) was observed during the pandemic; however, this did not exceed the pre-pandemic, upwards trend in psychiatric hospitalizations in the age group <18 (p = 0.78).

Conclusions

The pandemic was associated with a decrease in psychiatric hospitalizations. No significant change was observed in referrals and suicidal behavior.

Disclosure

No significant relationships.

Prodromal symptoms of out-of-hospital cardiac arrest among patients calling emergency and non-emergency medical help services

Background

Early identification of individuals at risk of out-of-hospital cardiac arrest (OHCA) remains difficult. Little is known about symptoms presented when contacting a medical helpline prior to OHCA.

Aim

To examine the registered prodromal symptoms when patients phoned to seek medical help prior to OHCA.

Methods

OHCA patients (≥18 years) were identified from the Danish Cardiac Arrest Registry (2014–2018) and linked with calls to the non-emergency (1813-Medical Helpline) and Emergency Medical Services 1–1-2 (112). We examined (1) symptoms registered within 30 days before OHCA, categorized into eight groups and stratified by time-period and call-type; (2) hospital diagnoses and medical prescriptions according to symptom groups within 180 days before these calls.

Results

Among 974 OHCA patients who called in total within 30 days before OHCA, 816 OHCA patients (males 57%, median age 76 years [Q1-Q3: 65–84]) had a registered symptom and some of them called more than once (1,145 calls by 816 patients). Overall, the most reported group of symptoms was “Other” (29%), containing a diverse group of prodromal symptoms registered by the caregiver that did not fit into the other categories (Figure), followed by breathing problems (15%). When stratified by time-period (Figure) the most common symptom group remained “Other”. This was followed by symptoms related to the Central Nervous System (CNS)/Unconsciousness (17%) for the time-period within 0–7 days before OHCA, and by breathing problems (19%) and trauma/exposure (17%) for the time-period within 8–30 days before OHCA (Figure). When stratified by call-type, most patients (60.8%) called the 1813-Medical Helpline, where “Other” (35%) and abdominal/back/urinary (14%) symptom groups were the most common. While breathing problems (24%) and CNS/Unconsciousness (21%) were highly reported among calls to 112. Within 180-days before contact with the medical helpline, independently of the symptom group presented, respiratory-related hospital diagnoses and antibiotic medications were common.

Conclusions

Patients with OHCA who called emergency and non-emergency medical helpline 30 days before OHCA had diverse prodromal symptoms; the largest category were “Other” symptoms, followed by breathing-related symptoms.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 under the ESCAPE-NET program;Helsefonden Figure 1. Classification of the prodromal symptoms among patients that called for medical assistance. Stratified by the time-period within 0–7 days and 8–30 days before OHCA. The number of calls within 0–7 days before OHCA = 471 (399 patients), and the number of calls within 8–30 days before OHCA = 674 (500 patients).

Duration of resuscitation efforts and long-term prognosis following in-hospital cardiac arrest (IHCA)

Background

The decision to terminate resuscitation efforts can be challenging. Notably, the association between duration of resuscitation and long-term survival and functional outcomes after in-hospital cardiac arrest (IHCA) is unknown.

Purpose

To examine 30-day and 1-year survival stratified by duration of resuscitation efforts. Further, to report long term outcome (1-year survival) without anoxic brain damage or nursing home admission among 30-day IHCA survivors.

Methods

We included all patients with IHCA from 13 Danish hospitals between January 1st, 2013 to December 31st, 2015. Patients were only included if there was clinical indication for a resuscitation attempt. Data on IHCA was obtained from the DANARREST database, which was linked to national registries to retrieve information on patient characteristics, survival, anoxic brain damage and nursing home admission. Patients were stratified into four groups (A-D) according to quartiles of duration of resuscitation efforts: Group A (&lt;5 minutes), group B (5–11 minutes), group C (12–20 minutes) and group D (≥21 minutes).

Using multivariable regression analysis, outcomes were standardized for patient age, sex, Charlson Comorbidity Index, witnessed arrest, monitored arrest, cardiopulmonary resuscitation (CPR) prior to arrival of the in-hospital cardiac arrest team and defibrillation.

Results

The study population comprised of 1868 patients, median age was 74 (1st-3rd quartile [Q1-Q3] 65–81 years) and 65.0% were men. In total, 52.1% (n=973) of the patients achieved return of spontaneous circulation (ROSC). The overall median duration of resuscitation was 12 min (Q1-Q3 5–21 min).

The standardized absolute chance of 30-day survival was 63.6% (95% CI 58.0%-69.0%) for group A, 34.0% (95% CI 29.7%-38.2%) for group B, 14.1% (95% CI 10.7%-17.5%) for group C and 9.0% (95% CI 6.8%-11.8%) for group D. Similarly, the chance of 1-year survival was highest for group A (51.5%; 95% CI 46.3%-56.7%) gradually decreasing to 7.0% (95% CI 4.5%-9.5%) in group D (Fig. 1).

Among 30-day survivors of an IHCA, the standardized absolute chance of survival without anoxic brain damage or nursing home admission within one-year post-arrest was highest for patients resuscitated in group A (83.2%; 95% CI 78.4%-88.1%), decreasing to 72.3% (95% CI 64.5%-80.0%) in group B, 68.3% (95% CI 55.3%-81.2%) in group C and 71.1% (95% CI 54.2%-88.0%) in group D (Fig. 2).

Conclusion

Short time to ROSC after in-hospital cardiac arrest is associated with better long-term prognosis. However, the majority of 30-day survivors are alive 1-year post-arrest without anoxic brain damage and without need for nursing home admission despite prolonged resuscitation.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Racial disparities in out-of-hospital cardiac arrest in Denmark

Introduction

American studies have pointed out racial disparities regarding sudden cardiac death occurrence and outcomes. Black individuals have higher sudden cardiac death rates and lower survival compared with white subjects (1). Although income and social status partly explain differences in outcomes (2), sudden cardiac death is 2-fold higher in black individuals after adjustment on these characteristics (3,4).

In Denmark, immigrants account for 9.1% of the population (5) but to date, no data exists regarding Out-of-Hospital Cardiac Arrest (OHCA) incidence.

Purpose

The main objective of this study was to compare the incidence of OHCA among native and immigrant individuals between 2001 and 2014 in Denmark.

Methods

This nationwide study included all patients identified from the Danish Cardiac Arrest Registry with OHCA of presumed cardiac cause between 18 and 80 years from 2001 to 2014 (6).

The primary outcome was OHCA occurrence defined as a clinical condition of cardiac arrest resulting in resuscitation efforts either by bystanders or by EMS personnel. The immigrant status was defined as native or immigrant according to the national database from Statistics Denmark. An immigrant was defined as a person born abroad whose both parents were either foreign citizens or born abroad.

The odds ratio of OHCA between immigrants and native Danes were adjusted according to age, sex, income, and education level.

Results

A total of 33,730 OHCA were recorded between 2001 and 2014. Among them, 1,684 occurred in immigrants and 32,046 in natives. Compared to natives, immigrant victims of OHCA were younger (62.0 [51.0, 71.0] vs. 66.0 [56.0, 74.0], p&lt;0.001), and more often had a history of diabetes (20.5% vs. 14.0; p&lt;0.001), myocardial infarction (11.9% vs. 8.7%; p&lt;0.001) and chronic heart failure (17.0% vs. 14.7%; p&lt;0.01). Female proportion was not statistically different between the two groups (30.2% vs. 31.3% of immigrants and natives respectively; p=0.32).

The incidence of OHCA was 61.0/100,000 person-years in natives and 35.0/100,000 person-years in immigrants (OR=0.57; 95% CI 0.54–0.60; p&lt;0.001). Between 2001 and 2014, the OHCA incidence decreased from 71.4 [67.9–75.0] to 70.9 [68.2–73.6]/100 000 person-years in natives (p=0.99) and from 40.2 [30.8–51.5] to 36.5 [31.1–42.6] /100,000 person-years in immigrants (p=0.91) (Figure).

After logistic regression, compared to natives, the immigrant status was associated with 0.61-fold odds of OHCA when adjusting on age and sex (OR=0.61; 95% CI 0.59–0.65; p&lt;0.001), and 0.65-fold odds of OHCA when adjusting on age, sex, income, and education level (OR=0.66; 95% CI 0.63–0.70; p&lt;0.001).

Conclusion

This is the first study assessing the incidence of OHCA in immigrants versus natives in a European country. Despite higher cardiovascular burden, the incidence of OHCA was lower in immigrants even when adjusted on sex, age, income, and education reflecting a selection of individuals migrating to Denmark.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Fédération Française de Cardiologie

Symptoms reported in calls to emergency medical services 24 hours prior to out-of-hospital cardiac arrest

Background and purpose

It remains unknown whether patients with out-of-hospital cardiac arrest (OHCA) experience prodromal symptoms. We aimed to investigate symptoms reported by patients with OHCA contacting emergency medical services (EMS) within 24 hours prior to arrest.

Methods

We linked OHCAs occurring from 2016 through 2018 to corresponding emergency calls occurring within 24 hours prior to arrest (defined as “pre-arrest calls”). These calls were included and evenly split and evaluated by authors.

Results

Among 4071 patients with OHCA, 481 patients (11.8%) had pre-arrest calls (59.9% males, median age 74 years) with a total of 539 calls. Figure 1 shows the reported symptoms across calls. The most commonly reported symptoms were breathing problems (59.4%), confusion (23.0%), unconsciousness (20.2%), chest pain (19.5%) and paleness (19.1%). The most common co-occurring symptom pairs were breathing problems in combination with paleness (14.5%), confusion (14.1%), unconsciousness (13.5%), sweating (13.0%) and chest pain (11.9%), respectively. An urgent response was dispatched in 68.7% of calls containing breathing problems compared to 83.0% of calls containing chest pain.

Conclusion

Among patients with OHCA, 11.8% had a call to EMS within 24 hours prior to arrest and breathing problems was the most commonly reported symptom occurring in 59.4% of calls.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Danish Heart FoundationResearch Grant from Nordsjællands Hospital Figure 1

Temporal variation in out-of-hospital cardiac arrest occurrence in individuals with or without diabetes

Objective

Out-of-hospital cardiac arrest (OHCA) occurrence has been shown to exhibit a circadian rhythm, following the circadian rhythm of acute myocardial infarction (AMI) occurrence. Diabetes mellitus (DM) is associated with changes in circadian rhythm. We aimed to compare the temporal variation of OHCA occurrence over the day and week between OHCA patients with DM and those without.

Methods

In two population-based OHCA registries (Amsterdam Resuscitation Studies [ARREST] 2010-2016, n = 4163, and Danish Cardiac Arrest Registry [DANCAR], 2010-2014, n = 12,734), adults (≥18y) with presumed cardiac cause of OHCA and available medical history were included. Single and double cosinor analysis was performed to model circadian variation of OHCA occurrence. Stratified analysis of circadian variation was performed in patients with AMI as immediate cause of OHCA.

Results

DM patients (22.8% in ARREST, 24.2% in DANCAR) were older and more frequently had cardiovascular risk factors or previous cardiovascular disease. Both cohorts showed 24 h-rhythmicity, with significant amplitudes in single and double cosinor functions (P-range < 0.001). In both registries, a morning peak (10:00-11:00) and an evening peak (20:00-21:00) was observed in both DM and non-DM patients. No septadian variation was observed in either DM or non-DM patients (P-range 0.13-84).

Conclusions

In these two population-based OHCA registries, we observed a similar circadian rhythm of OHCA occurrence in DM and non-DM patients.

Symptom presentation of acute myocardial infarction – can we correctly identify patients with atypical symptoms of myocardial infarctions over the phone?

Introduction

Acute myocardial infarction (AMI) can manifest itself with a variety of symptoms which can hinder early recognition of the disease, particularly when diagnosis is performed over the phone. It is currently unknown to what extent AMI patients are correctly recognized and quickly referred to treatment when calling for help at the emergency medical services (EMS) and out-of-hours service (OOHS). Therefore, we investigated how the symptom presentation of AMI patients affected their chances of being recognized.

Purpose

This study aimed to describe the symptoms reported by AMI patients when calling the EMS and OOHS and investigate to what extent these patients were correctly recognized and lastly, how the symptom presentation affected the survival.

Methods

All calls to the EMS and OOHS in the Capital Region of Denmark from 1st January 2014 to 31st December 2017 are included in this study resulting in 4,905,318 calls made by 1,313,980 people. A total of 5,526 people were identified with either a hospital admission with an AMI or an AMI as cause of death maximum 72 hours after a call to the EMS or OOHS. The main symptoms were registered by the EMS and OOHS personnel and we grouped the symptoms into symptom categories. Finally, a patient was defined as recognized if an emergency ambulance were dispatched. The unrecognized patients were separated into one group which were not referred to any treatment and another group that received none-urgent treatment.

Results

72% of all AMI patients reported chest pain as their main symptom followed by breathing problems (7%) and unknown problems (5%). A total of 76% of all AMI patients were correctly recognized and received an emergency ambulance. The proportion of recognized AMIs was 88% at the EMS, but only 55% at the OOHS. The symptom presentation was highly associated with the help provided to the patient and less than 14% of patients reporting musculoskeletal pain, infection/fever or pain in stomach/back/intestine received an emergency ambulance. In comparison, 87% of patients with chest pain and 96% of unconscious patients received an emergency ambulance (Figure 1). Results from a multiple logistic regression showed that chest pain patients had the lowest risk of death at 30-days follow-up compared to all other symptom presentation.

Conclusion

24% of AMI patients were not correctly recognized with an acute life-threatening disease when calling for help. Patients presenting without chest pain and unconsciousness had a much lower chance of being recognized. Similarly, patients calling the OOHS were less likely to be recognized compared to patients calling the EMS. Symptom presentations without chest pain had a dramatically increased 30-day mortality indicating that AMI patients with atypical symptoms truly are a high-risk patient group.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Danish Heart Association

Rapid recognition of out-of-hospital cardiac arrest by emergency medical dispatchers is associated with improved survival

Background

Emergency medical dispatchers' (EMD) recognition of out-of-hospital cardiac arrest (OHCA) is an essential part of the first link in the Chain of Survival. However, it is unknown whether the time-to-recognition of OHCA by EMD during an emergency call is associated with survival.

Purpose

To investigate the effect of time-to-recognition on 30-day survival among patients with recognised OHCA.

Methods

We linked data on OHCAs occurring in the Capital Region of Denmark from 2016 through 2017 to records of corresponding emergency calls. We defined recognition as dispatching an ambulance with an appropriate priority level and subsequently defined time-to-recognition as the time from start of the call to the time of dispatching the ambulance. Among patients with recognised OHCA, we performed uni- and multivariate logistic regression to investigate the association of time-to-recognition and 30-day survival and reported odds ratios (OR) with 95% confidence intervals (CI).

Results

Among 2,382 patients with OHCA, 94.2% were recognised, in which median age was 73.6 years, 61.6% were males and median time-to-recognition was 0.8 minutes (interquartile range 0.7 minutes). Patients for whom time-to-recognition was up to (but not including) one minute had more than three-fold higher probability of surviving 30 days (15.5%) compared to patients for whom time-to-recognition was three or more minutes (4.5%) (Figure 1). Time-to-recognition was significantly associated with 30-day survival: OR 0.75 per minute (95% CI 0.62–0.91, P&lt;0.005), and results were similar in the adjusted analysis: OR 0.72 per minute (95% CI 0.58–0.90, P&lt;0.005).

Conclusion

Rapid recognition of OHCA by EMD resulted in improved survival rate of patients. This was particularly evident when time-to-recognition was three or more minutes.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Hjerteforeningen

Contacts to the healthcare system prior to out-of-hospital cardiac arrests

Background

Patients who suffer a sudden out-of-hospital cardiac arrest (OHCA) may be preceded by warning symptoms and healthcare system contact. Though, is currently difficult early identification of sudden cardiac arrest patients.

Purpose

We aimed to examine contacts with the healthcare system up to two weeks and one year before OHCA.

Methods

OHCA patients were identified from the Danish Cardiac Arrest Registry (2001–2014). The pattern of healthcare contacts (with either general practitioner (GP) or hospital) within the year prior to OHCA of OHCA patients was compared with that of 9 sex- and age-matched controls from the background general population. Additionally, we evaluated characteristics of OHCA patients according to the type of healthcare contact (GP/hospital/both/no-contact) and the including characteristics of contacts, within two weeks prior their OHCA event.

Results

Out of 28,955 OHCA patients (median age of 72 (62–81) years and with 67% male) of presumed cardiac cause, 16,735 (57.8%) contacted the healthcare system (GP and hospital) within two weeks prior to OHCA. From one year before OHCA, the weekly percentages of contacts to GP were relatively constant (26%) until within 2 weeks prior to OHCA where they markedly increased (54%). In comparison, 14% of the general population contacted the GP during the same period (Figure). The weekly percentages of contacts with hospitals gradually increased in OHCA patients from 3.5% to 6.5% within 6 months, peaking at the second week (6.8%), prior to OHCA. In comparison, only 2% of the general population had a hospital contact in that period (Figure). Within 2 weeks of OHCA, patients contacted GP mainly by telephone (71.6%). Hospital diagnoses were heterogenous, where ischemic heart disease (8%) and heart failure (4.5%) were the most frequent.

Conclusions

There is an increase in healthcare contacts prior to “sudden” OHCA and overall, 54% of OHCA-patients had contacted GP within 2 weeks before the event. This could have implications for developing future strategies for early identification of patients prior to their cardiac arrest.

Figure 1. The weekly percentages of contacts to GP (red) and hospital (blue) within one year before OHCA comparing the OHCA cases to the age- and sex-matched control population (N cases = 28,955; N controls = 260,595).

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020

Long-term outcomes after in-hospital cardiac arrest: 30-day survival and 1-year follow-up of mortality, anoxic brain damage, nursing home admission and in-home care

AIMS

Long-term functional outcomes after in-hospital cardiac arrest (IHCA) are scarcely studied. However, survivors are at risk of neurological impairment from anoxic brain damage which could affect quality of life and lead to need of care at home or in a nursing home.

METHODS

We linked data on ICHAs in Denmark with nationwide registries to report 30-day survival as well as factors associated with survival. Furthermore, among 30-day survivors we reported the one-year cumulative risk of anoxic brain damage or nursing home admission with mortality as the competing risk.

RESULTS

In total, 517 patients (27.3%) survived to day 30 out of 1892 eligible patients; 338 (65.9%) were men and median age was 68 (interquartile range 58-76). Lower age, witnessed arrest by health care personnel, monitored arrest and presumed cardiac cause of arrest were associated with 30-day survival. Among 454 30-day survivors without prior anoxic brain damage or nursing home admission, the risk of anoxic brain damage or nursing home admission within the first-year post-arrest was 4.6% (n = 21; 95% CI 2.7-6.6%) with a competing risk of death of 15.6% (n = 71; 95% CI 12.3-19.0%), leaving 79.7% (n = 362) alive without anoxic brain damage or nursing home admission. When adding the risk of need of in-home care among 343 30-day survivors without prior home care needs, 68.8% (n = 236) were alive without any of the composite events one-year post-arrest.

CONCLUSION

The majority of 30-day survivors of IHCA are alive at one-year follow-up without anoxic brain damage, nursing home admission or need of in-home care.

The challenges and possibilities of public access defibrillation

Out-of-hospital cardiac arrest (OHCA) is a major health problem that affects approximately four hundred and thousand patients annually in the United States alone. It is a major challenge for the emergency medical system as decreased survival rates are directly proportional to the time delay from collapse to defibrillation. Historically, defibrillation has only been performed by physicians and in-hospital. With the development of automated external defibrillators (AEDs), rapid defibrillation by nonmedical professionals and subsequently by trained or untrained lay bystanders has become possible. Much hope has been put to the concept of Public Access Defibrillation with a massive dissemination of public available AEDs throughout most Western countries. Accordingly, current guidelines recommend that AEDs should be deployed in places with a high likelihood of OHCA. Despite these efforts, AED use is in most settings anecdotal with little effect on overall OHCA survival. The major reasons for low use of public AEDs are that most OHCAs take place outside high incidence sites of cardiac arrest and that most OHCAs take place in residential settings, currently defined as not suitable for Public Access Defibrillation. However, the use of new technology for identification and recruitment of lay bystanders and nearby AEDs to the scene of the cardiac arrest as well as new methods for strategic AED placement redefines and challenges the current concept and definitions of Public Access Defibrillation. Existing evidence of Public Access Defibrillation and knowledge gaps and future directions to improve outcomes for OHCA are discussed. In addition, a new definition of the different levels of Public Access Defibrillation is offered as well as new strategies for increasing AED use in the society.

Risk of thromboembolism and fatal stroke in patients with psoriasis and nonvalvular atrial fibrillation: a Danish nationwide cohort study

OBJECTIVES

Psoriasis is a chronic inflammatory disease that is associated with a prothrombotic state and cardiovascular disease, including atrial fibrillation and thromboembolism. We therefore evaluated the impact of psoriasis in patients with atrial fibrillation and the performance of the CHA2 DS2 VASc score in these patients.

DESIGN, SETTING AND PARTICIPANTS

The study comprised all Danish patients hospitalized with nonvalvular atrial fibrillation in the period 1997-2011 (n = 99,357). Follow-up started 7 days from discharge and excluded subjects treated with anticoagulation. Poisson regression adjusted for CHA2 DS2 VASc score was used to estimate the incidence rate ratios and 95% confidence intervals.

MAIN OUTCOME MEASURE

Hospitalization or death from thromboembolism.

RESULTS

Mean follow-up was 3.5, 3.1, and 2.8 years for patients with no psoriasis, mild psoriasis and severe psoriasis, respectively. Patients with psoriasis were younger compared to patients without psoriasis, but CHA2DS2VASc score did not differ between the three groups. Thromboembolism rates per 100 patient-years (95% confidence intervals) were 4.8 (4.7-4.9), 4.8 (4.2-5.4) and 6.1 (5.0-7.5) for patients with no psoriasis, mild psoriasis and severe psoriasis, respectively. Importantly, the observed thromboembolism rates in patients with severe psoriasis were markedly higher (2.6- to3.4-fold) than predicted by the CHA2 DS2 VASc score. Relative to no psoriasis, incidence rate ratios were 0.99 (0.87-1.11) and 1.27 (1.02-1.57) for mild and severe psoriasis, respectively. Correspondingly, incidence rate ratios for fatal stroke were 0.97 (0.80-1.12) and 1.51 (1.12-2.05).

CONCLUSIONS

In patients with nonvalvular atrial fibrillation not treated with oral anticoagulation, severe psoriasis was associated with increased risk of thromboembolism. In these patients, CHA2 DS2 VASc underestimated the risk of thromboembolism.

Antipsychotics and associated risk of out-of-hospital cardiac arrest

Antipsychotic drugs have been associated with sudden cardiac death, but differences in the risk of out-of-hospital cardiac arrest (OHCA) associated with different antipsychotic drug classes are not clear. We identified all OHCAs in Denmark (2001-2010). The risk of OHCA associated with antipsychotic drug use was evaluated by conditional logistic regression analysis in case-time-control models. In total, 2,205 (7.6%) of 28,947 OHCA patients received treatment with an antipsychotic drug at the time of the event. Overall, treatment with any antipsychotic drug was associated with OHCA (odds ratio (OR) = 1.53, 95% confidence interval (CI): 1.23-1.89), as was use with typical antipsychotics (OR = 1.66, CI: 1.27-2.17). By contrast, overall, atypical antipsychotic drug use was not (OR = 1.29, CI: 0.90-1.85). Two individual typical antipsychotic drugs, haloperidol (OR = 2.43, CI: 1.20-4.93) and levomepromazine (OR = 2.05, CI: 1.18-3.56), were associated with OHCA, as was one atypical antipsychotic drug, quetiapine (OR = 3.64, CI: 1.59-8.30).

Changes in short- and long-term cardiovascular risk of incident diabetes and incident myocardial infarction--a nationwide study

AIMS/HYPOTHESIS

We assessed secular trends of cardiovascular outcomes following first diagnosis of myocardial infarction (MI) or diabetes in an unselected population.

METHODS

All Danish residents aged > or = 30 years without prior diabetes or MI were identified by individual-level linkage of nationwide registers. Individuals hospitalised with MI or claiming a first-time prescription for a glucose-lowering medication (GLM) during the period from 1997 to 2006 were included. Analyses were by Poisson regression models. Primary endpoints were death by all causes, cardiovascular death and MI.

RESULTS

The study included 3,092,580 individuals, of whom 77,147 had incident MI and 118,247 new-onset diabetes. MI patients had an increased short-term risk of all endpoints compared with the general population. The rate ratio (RR) for cardiovascular death within the first year after MI was 11.1 (95% CI 10.8-11.5) in men and 14.8 (14.3-15.3) in women, respectively. The risk rapidly declined and 1 year after the index MI, RR was 2.11 (2.00-2.23) and 2.8 (2.64-2.97) in men and women, respectively. Patients with diabetes carried a constantly elevated risk of all endpoints compared with the general population. The cardiovascular death RR was 1.90 (1.77-2.04) and 1.92 (1.78-2.07) in men and women, respectively during the first year after GLM initiation.

CONCLUSIONS/INTERPRETATION

Incident MI is associated with high short-term risk, which decreases rapidly over time. Incident diabetes is associated with a persistent excessive cardiovascular risk after initiation of GLM therapy. This further strengthens the necessity of early multi-factorial intervention in diabetes patients for long-term benefit.

Clinical consequences of hospital variation in use of oral anticoagulant therapy after first-time admission for atrial fibrillation

OBJECTIVE

To analyse how hospital factors influence the use of oral anticoagulants (OAC) in atrial fibrillation (AF) patients and address the clinical consequences of hospital variation in OAC use.

DESIGN AND SUBJECTS

By linkage of nationwide Danish administrative registers we conducted an observational study including all patients with a first-time hospitalization for AF between 1995 and 2004 as well as prescription claims for OAC. Multivariable logistic regression analysis was used to evaluate hospital factors associated with prescription of OAC therapy. Cox proportional-hazard models were used to estimate the risk of re-hospitalization for thromboembolism and haemorrhagic stroke with respect to discharge from a low, intermediate, or high OAC use hospital.

RESULTS

Overall 40,133 (37%) out of 108,504 patients received OAC; ranging from 17% to 50% between the hospitals with the lowest and highest OAC use, respectively. Cardiology departments had the highest use of OAC, but neither tertiary university hospitals nor high volume hospitals had higher OAC use than local community hospitals and low volume hospitals. Risk of a thromboembolic event was significantly increased amongst patients from hospitals with a low OAC use (hazard ratio 1.16, confidence interval 1.10-1.22). Notably, higher OAC use was not associated with a higher risk of haemorrhagic stroke.

CONCLUSION

In Denmark between 1995 and 2004, there was a major hospital variation in AF patients receiving OAC, and consequently, more thromboembolic events were observed amongst patients from low OAC use hospitals. Our study emphasizes the need for a continued vigilance on implementation of international AF management guidelines.