External validation of a risk classification at the emergency department of post-cardiac arrest syndrome patients undergoing targeted temperature management



      There are no established risk classification for post-cardiac arrest syndrome (PCAS) patients at the Emergency Department (ED) undergoing targeted temperature management (TTM). The aim of this study was to externally validate a simplified version of our prognostic score, the “post-Cardiac Arrest Syndrome for Therapeutic hypothermia score” (revised CAST [rCAST]) and estimate the predictive accuracy of the risk classification based on it.


      For the external validation, we used data from an out-of-hospital cardiac arrest (OHCA) registry of the Japanese Association for Acute Medicine (JAAM), which is a multicenter, prospective registry of OHCA patients across Japan. Eligible patients were PCAS patients treated with TTM at 33–36 °C between June 2014 and December 2015. We validated the accuracy of rCAST for predicting the neurological outcomes at 30 and 90 days.


      Among the 12,024 OHCA patients, the data of 460 PCAS patients treated by TTM were eligible for the validation. The areas under the curve of rCAST for predicting the neurological outcomes at 30 and 90 days were 0.892 and 0.895, respectively. The estimated sensitivity and specificity of the risk categories for the outcomes were as follows: 0.95 (95% CI: 0.92–0.98) and 0.47 (0.40–0.55) for the low (rCAST: ≤5.5), 0.62 (0.56–0.68) and 0.48 (0.40–0.55) for the moderate (rCAST: 6.0–14.0), and 0.57 (0.51–0.63) and 0.95 (0.91–0.98) for the high severity category (rCAST: ≥14.5).


      The rCAST was useful for predicting the neurological outcomes with high accuracy in PCAS patients, and the three grades was developed for a risk classification based on the rCAST.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Resuscitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Adrie C.
        • Cariou A.
        • Mourvillier B.
        • et al.
        Predicting survival with good neurological recovery at hospital admission after successful resuscitation of out-of-hospital cardiac arrest: the OHCA score.
        Eur Heart J. 2006; 27: 2840-2845
        • Rittenberger J.C.
        • Tisherman S.A.
        • Holm M.B.
        • Guyette F.X.
        • Callaway C.W.
        An early, novel illness severity score to predict outcome after cardiac arrest.
        Resuscitation. 2011; 82: 1399-1404
        • Coppler P.J.
        • Elmer J.
        • Calderon L.
        • et al.
        Validation of the Pittsburgh Cardiac Arrest Category illness severity score.
        Resuscitation. 2015; 89: 86-92
        • Oksanen T.
        • Tiainen M.
        • Skrifvars M.B.
        • et al.
        Predictive power of serum NSE and OHCA score regarding 6-month neurologic outcome after out-of-hospital ventricular fibrillation and therapeutic hypothermia.
        Resuscitation. 2009; 80: 165-170
        • Nolan J.P.
        • Soar J.
        • Cariou A.
        • et al.
        European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care.
        Intensive Care Med. 2015; 41: 2039-2056
        • Japan Resuscitation Council
        2015 Japanese guidelines for emergency care and cardiopulmonary resuscitation.
        Igaku-Shoin, Tokyo2016
        • Callaway C.W.
        • Donnino M.W.
        • Fink E.L.
        • et al.
        Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
        Circulation. 2015; 132: S465-S482
        • Nishikimi M.
        • Matsuda N.
        • Matsui K.
        • et al.
        CAST: a new score for early prediction of neurological outcomes after cardiac arrest before therapeutic hypothermia with high accuracy.
        Intensive Care Med. 2016; 42: 2106-2107
        • Nishikimi M.
        • Matsuda N.
        • Matsui K.
        • et al.
        A novel scoring system for predicting the neurologic prognosis prior to the initiation of induced hypothermia in cases of post-cardiac arrest syndrome: the CAST score.
        Scand J Trauma Resusc Emerg Med. 2017; 25: 49
        • Kitamura T.
        • Iwami T.
        • Atsumi T.
        • et al.
        The profile of Japanese Association for Acute Medicine - out-of-hospital cardiac arrest registry in 2014-2015.
        Acute Med Surg. 2018; 5: 249-258
        • Perkins G.D.
        • Jacobs I.G.
        • Nadkarni V.M.
        • et al.
        Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.
        Circulation. 2015; 132: 1286-1300
        • Ajam K.
        • Gold L.S.
        • Beck S.S.
        • Damon S.
        • Phelps R.
        • Rea T.D.
        Reliability of the Cerebral Performance Category to classify neurological status among survivors of ventricular fibrillation arrest: a cohort study.
        Scand J Trauma Resusc Emerg Med. 2011; 19: 38
        • Akobeng A.K.
        Understanding diagnostic tests 3: receiver operating characteristic curves.
        Acta Paediatr. 2007; 96: 644-647
        • Ogura T.
        • Nakano M.
        • Izawa Y.
        • Nakamura M.
        • Fujizuka K.
        • Lefor A.T.
        Analysis of risk classification for massive transfusion in severe trauma using the gray zone approach.
        Am J Emerg Med. 2015; 33: 1146-1151
        • Coste J.
        • Pouchot J.
        A grey zone for quantitative diagnostic and screening tests.
        Int J Epidemiol. 2003; 32: 304-313
        • Sawyer K.N.
        • Kurz M.C.
        • Elswick Jr., R.K.
        Virginia Commonwealth University AI. An investigation of a hypothermic to ischemic ratio in patients following out-of-hospital cardiac arrest presenting with a shockable rhythm.
        Ther Hypothermia Temp Manag. 2014; 4: 72-78
        • Kiehl E.L.
        • Parker A.M.
        • Matar R.M.
        • et al.
        C-GRApH: a validated scoring system for early stratification of neurologic outcome after out-of-hospital cardiac arrest treated with targeted temperature management.
        J Am Heart Assoc. 2017; 6
        • Martinell L.
        • Nielsen N.
        • Herlitz J.
        • et al.
        Early predictors of poor outcome after out-of-hospital cardiac arrest.
        Crit Care. 2017; 21: 96
        • Munshi L.
        • Del Sorbo L.
        • Adhikari N.K.J.
        • et al.
        Prone position for acute respiratory distress syndrome. A systematic review and meta-analysis.
        Ann Am Thorac Soc. 2017; 14: S280-S288
        • Nielsen N.
        • Wetterslev J.
        • Cronberg T.
        • et al.
        Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest.
        N Engl J Med. 2013; 369: 2197-2206
        • Oksanen T.
        • Skrifvars M.B.
        • Varpula T.
        • et al.
        Strict versus moderate glucose control after resuscitation from ventricular fibrillation.
        Intensive Care Med. 2007; 33: 2093-2100
        • Laurent I.
        • Adrie C.
        • Vinsonneau C.
        • et al.
        High-volume hemofiltration after out-of-hospital cardiac arrest: a randomized study.
        J Am Coll Cardiol. 2005; 46: 432-437
        • Argaud L.
        • Cour M.
        • Dubien P.Y.
        • et al.
        Effect of cyclosporine in nonshockable out-of-hospital cardiac arrest: the CYRUS randomized clinical trial.
        JAMA Cardiol. 2016; 1: 557-565
        • Machado C.
        Randomized clinical trial of magnesium, diazepam, or both after out-of-hospital cardiac arrest.
        Neurology. 2003; 60 (author reply -9): 1868
        • Kjaergaard J.
        • Nielsen N.
        • Winther-Jensen M.
        • et al.
        Impact of time to return of spontaneous circulation on neuroprotective effect of targeted temperature management at 33 or 36 degrees in comatose survivors of out-of hospital cardiac arrest.
        Resuscitation. 2015; 96: 310-316
        • Nielsen N.
        Predictive scores, friend or foe for the cardiac arrest patient.
        Resuscitation. 2012; 83 (669-670)