Ahmed A Harhash1, Teresa L May2, Chiu-Hsieh Hsu3, Sachin Agarwal4, David B Seder2, Michael R Mooney5, Nainesh Patel6, John McPherson7, Paul McMullan8, Richard Riker2, Eldar Soreide9, Karen G Hirsch10, Pascal Stammet11, Alison Dupont12, Sten Rubertsson13, Hans Friberg14, Niklas Nielsen14, Tanveer Rab15, Karl B Kern16. 1. University of Arizona Sarver Heart Center, Tucson, Arizona, USA; University of Vermont, Burlington, Vermont, USA. 2. Maine Medical Center, Portland, Maine, USA. 3. University of Arizona College of Public Health, Tucson, Arizona, USA. 4. Columbia Univeristy, New York, New York, USA. 5. Minneapolis Heart Institute, Minneapolis, Minnesota, USA. 6. Lehigh Valley Medical Center, Lehigh, Pennsylvania, USA. 7. Vanderbilt University Medical Center, Nashville, Tennessee, USA. 8. St. Thomas Heart, Nashville, Tennessee, USA. 9. Stavanger University Hospital, Stavanger, Norway. 10. Stanford University, Stanford, California, USA. 11. National Fire and Rescue Corps, Luxembourg, Luxembourg. 12. Northside Hospital, Lawrenceville, Georgia, USA. 13. Uppsala University, Uppsala, Sweden. 14. Lund University, Helsingborg, Sweden. 15. Emory University School of Medicine, Atlanta, Georgia, USA. 16. University of Arizona Sarver Heart Center, Tucson, Arizona, USA. Electronic address: kernk@email.arizona.edu.
Abstract
BACKGROUND: The American College of Cardiology Interventional Council published consensus-based recommendations to help identify resuscitated cardiac arrest patients with unfavorable clinical features in whom invasive procedures are unlikely to improve survival. OBJECTIVES: This study sought to identify how many unfavorable features are required before prognosis is significantly worsened and which features are most impactful in predicting prognosis. METHODS: Using the INTCAR (International Cardiac Arrest Registry), the impact of each proposed "unfavorable feature" on survival to hospital discharge was individually analyzed. Logistic regression was performed to assess the association of such unfavorable features with poor outcomes. RESULTS: Seven unfavorable features (of 10 total) were captured in 2,508 patients successfully resuscitated after cardiac arrest (ongoing cardiopulmonary resuscitation and noncardiac etiology were exclusion criteria in our registry). Chronic kidney disease was used in lieu of end-stage renal disease. In total, 39% survived to hospital discharge. The odds ratio (OR) of survival to hospital discharge for each unfavorable feature was as follows: age >85 years OR: 0.30 (95% CI: 0.15 to 0.61), time-to-ROSC >30 min OR: 0.30 (95% CI: 0.23 to 0.39), nonshockable rhythm OR: 0.39 (95% CI: 0.29 to 0.54), no bystander cardiopulmonary resuscitation OR: 0.49 (95% CI: 0.38 to 0.64), lactate >7 mmol/l OR: 0.50 (95% CI: 0.40 to 0.63), unwitnessed arrest OR: 0.58 (95% CI: 0.44 to 0.78), pH <7.2 OR: 0.78 (95% CI: 0.63 to 0.98), and chronic kidney disease OR: 0.96 (95% CI: 0.70 to 1.33). The presence of any 3 or more unfavorable features predicted <40% survival. Presence of the 3 strongest risk factors (age >85 years, time-to-ROSC >30 min, and non-ventricular tachycardia/ventricular fibrillation) together or ≥6 unfavorable features predicted a ≤10% chance of survival to discharge. CONCLUSIONS: Patients successfully resuscitated from cardiac arrest with 6 or more unfavorable features have a poor long-term prognosis. Delaying or even forgoing invasive procedures in such patients is reasonable.
BACKGROUND: The American College of Cardiology Interventional Council published consensus-based recommendations to help identify resuscitated cardiac arrestpatients with unfavorable clinical features in whom invasive procedures are unlikely to improve survival. OBJECTIVES: This study sought to identify how many unfavorable features are required before prognosis is significantly worsened and which features are most impactful in predicting prognosis. METHODS: Using the INTCAR (International Cardiac Arrest Registry), the impact of each proposed "unfavorable feature" on survival to hospital discharge was individually analyzed. Logistic regression was performed to assess the association of such unfavorable features with poor outcomes. RESULTS: Seven unfavorable features (of 10 total) were captured in 2,508 patients successfully resuscitated after cardiac arrest (ongoing cardiopulmonary resuscitation and noncardiac etiology were exclusion criteria in our registry). Chronic kidney disease was used in lieu of end-stage renal disease. In total, 39% survived to hospital discharge. The odds ratio (OR) of survival to hospital discharge for each unfavorable feature was as follows: age >85 years OR: 0.30 (95% CI: 0.15 to 0.61), time-to-ROSC >30 min OR: 0.30 (95% CI: 0.23 to 0.39), nonshockable rhythm OR: 0.39 (95% CI: 0.29 to 0.54), no bystander cardiopulmonary resuscitation OR: 0.49 (95% CI: 0.38 to 0.64), lactate >7 mmol/l OR: 0.50 (95% CI: 0.40 to 0.63), unwitnessed arrest OR: 0.58 (95% CI: 0.44 to 0.78), pH <7.2 OR: 0.78 (95% CI: 0.63 to 0.98), and chronic kidney disease OR: 0.96 (95% CI: 0.70 to 1.33). The presence of any 3 or more unfavorable features predicted <40% survival. Presence of the 3 strongest risk factors (age >85 years, time-to-ROSC >30 min, and non-ventricular tachycardia/ventricular fibrillation) together or ≥6 unfavorable features predicted a ≤10% chance of survival to discharge. CONCLUSIONS:Patients successfully resuscitated from cardiac arrest with 6 or more unfavorable features have a poor long-term prognosis. Delaying or even forgoing invasive procedures in such patients is reasonable.
Authors: Guy Rozen; Gabby Elbaz-Greener; Ibrahim Marai; E Kevin Heist; Jeremy N Ruskin; Shemy Carasso; Edo Y Birati; Offer Amir Journal: Clin Cardiol Date: 2021-11-16 Impact factor: 2.882