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Association between sex and survival after non-traumatic out of hospital cardiac arrest: A systematic review and meta-analysis

      Abstract

      Background

      Existing studies have shown conflicting results regarding the relationship of sex with survival after out of hospital cardiac arrest (OHCA). This systematic review evaluates the association of female sex with survival to discharge and survival to 30 days after non-traumatic OHCA.

      Methods

      We searched Medline, Embase, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception through June 2021 for studies evaluating female sex as a predictor of survival in adult patients with non-traumatic cardiac arrest. Random-effects inverse variance meta-analyses were performed to calculate pooled odds ratios (ORs) with 95% confidence intervals (CI). The GRADE approach was used to assess evidence quality.

      Results

      Thirty studies including 1,068,788 patients had female proportion of 41%. There was no association for female sex with survival to discharge (OR 1.03, 95% CI 0.95–1.12; I2 = 89%). Subgroup analysis of low risk of bias studies demonstrated increased survival to discharge for female sex (OR 1.20, 95% CI 1.18–1.23; I2 = 0%) and with high certainty, the absolute increase in survival was 2.2% (95% CI 0.1–3.6%). Female sex was not associated with survival to 30 days post-OHCA (OR 1.02, 95% CI 0.92–1.14; I2 = 79%).

      Conclusions

      In adult patients experiencing OHCA, with high certainty in the evidence from studies with low risk of bias, female sex had a small absolute difference for the outcome survival to discharge and no difference in survival at 30 days. Future models that aim to stratify risk of survival post-OHCA should focus on sex-specific factors as opposed to sex as an isolated prognostic factor.

      Keywords

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      References

        • Tsao C.W.
        • Aday A.W.
        • Almarzooq Z.I.
        • Alonso A.
        • Beaton A.Z.
        • Bittencourt M.S.
        • et al.
        Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association.
        Circulation. 2022; 145: e153-e639
        • Morrison L.J.
        • Schmicker R.H.
        • Weisfeldt M.L.
        • Bigham B.L.
        • Berg R.A.
        • Topjian A.A.
        • et al.
        Effect of Gender on Outcome of Out of Hospital Cardiac Arrest in the Resuscitation Outcomes Consortium.
        Resuscitation. 2016; 100: 76-81
        • Ng Y.Y.
        • Wah W.
        • Liu N.
        • Zhou S.A.
        • Ho A.F.W.
        • Pek P.P.
        • et al.
        Associations between gender and cardiac arrest outcomes in Pan-Asian out-of-hospital cardiac arrest patients.
        Resuscitation. 2016; 102: 116-121
        • Feng D.
        • Li C.
        • Yang X.
        • Wang L.
        Gender differences and survival after an out-of-hospital cardiac arrest: a systematic review and meta-analysis.
        Intern Emerg Med. 2020;
        • Lei H.
        • Hu J.
        • Liu L.
        • Xu D.
        Sex differences in survival after out-of-hospital cardiac arrest: a meta-analysis.
        Crit Care. 2020; 24: 613
        • Bougouin W.
        • Mustafic H.
        • Marijon E.
        • Murad M.H.
        • Dumas F.
        • Barbouttis A.
        • et al.
        Gender and survival after sudden cardiac arrest: A systematic review and meta-analysis.
        Resuscitation. 2015; 94: 55-60
      1. Gewarges M, Allan K, Dorian P. Sex differences in survival outcome after out-of-hospital cardiac arrest: a systematic literature review and meta-analysis. PROSPERO 2018 CRD42018088259.

        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • Mulrow C.
        • Gøtzsche P.C.
        • Ioannidis J.P.A.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
        BMJ. 2009; 339b2700
        • Hayden J.A.
        • van der Windt D.A.
        • Cartwright J.L.
        • Cote P.
        • Bombardier C.
        Assessing bias in studies of prognostic factors.
        Ann Intern Med. 2013; 158: 280-286
        • Sun X.
        • Briel M.
        • Walter S.D.
        • Guyatt G.H.
        Is a subgroup effect believable? Updating criteria to evaluate the credibility of subgroup analyses.
        BMJ. 2010; 340c117
        • Lau K.
        • Malik A.
        • Foroutan F.
        • Buchan T.A.
        • Daza J.F.
        • Sekercioglu N.
        • et al.
        Resting Heart Rate as an Important Predictor of Mortality and Morbidity in Ambulatory Patients With Heart Failure: A Systematic Review and Meta-Analysis.
        J Card Fail. 2021; 27: 349-363
        • Foroutan F.
        • Iorio A.
        • Thabane L.
        • Guyatt G.
        Calculation of absolute risk for important outcomes in patients with and without a prognostic factor of interest.
        J Clin Epidemiol. 2020; 117: 46-51
        • Iorio A.
        • Spencer F.A.
        • Falavigna M.
        • Alba C.
        • Lang E.
        • Burnand B.
        • et al.
        Use of GRADE for assessment of evidence about prognosis: rating confidence in estimates of event rates in broad categories of patients.
        BMJ. 2015; 350h870
        • Nichol G.
        • Brown S.P.
        • Perkins G.D.
        • Kim F.
        • Sterz F.
        • Broeckel Elrod J.A.
        • et al.
        What change in outcomes after cardiac arrest is necessary to change practice? Results of an international survey.
        Resuscitation. 2016; 107: 115-120
        • Foroutan F.
        • Guyatt G.
        • Zuk V.
        • Vandvik P.O.
        • Alba A.C.
        • Mustafa R.
        • et al.
        Use of GRADE for assessment of evidence about prognostic factors: rating certainty in identification of groups of patients with different absolute risks.
        J Clin Epidemiol. 2020; (S089543561930873X)
        • Adielsson A.
        • Hollenberg J.
        • Karlsson T.
        • Lindqvist J.
        • Lundin S.
        • Silfverstolpe J.
        • et al.
        Increase in survival and bystander CPR in out-of-hospital shockable arrhythmia: Bystander CPR and female gender are predictors of improved outcome. Experiences from Sweden in an 18-year perspective.
        Heart. 2011; 97: 1391-1396
        • Albizreh B.
        • Arabi A.
        • Al Suwaidi J.
        • Patel A.
        • Singh R.
        • Albinali H.
        Out-of-Hospital cardiac arrest in the young: A 23-year middle Eastern experience.
        Heart Views. 2021; 22: 3-7
        • Arunachalam K.
        • Zhang Z.
        • Chu A.
        • Maan A.
        Impact of Racial and Gender Variations in Patients With Out-of-hospital Cardiac Arrest: A Nation-Wide Study.
        Crit Pathw Cardiol. 2021; 20: 25-30
        • Arrich J.
        • Sterz F.
        • Fleischhackl R.
        • Uray T.
        • Losert H.
        • Kliegel A.
        • et al.
        Gender Modifies the Influence of Age on Outcome After Successfully Resuscitated Cardiac Arrest: A Retrospective Cohort Study.
        Medicine. 2006; 85: 288-294
        • Bărcan A.
        • Chițu M.
        • Benedek E.
        • Rat N.
        • Korodi S.
        • Morariu M.
        • et al.
        Predictors of Mortality in Patients with ST-Segment Elevation Acute Myocardial Infarction and Resuscitated Out-of-Hospital Cardiac Arrest.
        J Crit Care Med. 2016; 2: 22-29
        • Bonnin M.J.
        • Pepe P.E.
        • Kimball K.T.
        • Clark P.S.
        Distinct criteria for termination of resuscitation in the out-of-hospital setting.
        JAMA. 1993; 270: 1457-1462
        • Bray J.E.
        • Stub D.
        • Bernard S.
        • Smith K.
        Exploring gender differences and the “oestrogen effect” in an Australian out-of-hospital cardiac arrest population.
        Resuscitation. 2013; 84: 957-963
        • Cournoyer A.
        • Notebaert É.
        • Cossette S.
        • Londei-Leduc L.
        • de Montigny L.
        • Ross D.
        • et al.
        The prognostic significance of repeated prehospital shocks for out-of-hospital cardiac arrest survival.
        Cjem. 2019; 21: 330-338
        • Daya M.R.
        • Schmicker R.H.
        • Zive D.M.
        • Rea T.D.
        • Nichol G.
        • Buick J.E.
        • et al.
        Out-of-hospital cardiac arrest survival improving over time: Results from the Resuscitation Outcomes Consortium (ROC).
        Resuscitation. 2015; 91: 108-115
        • de Vreede-Swagemakers J.J.
        • Gorgels A.P.
        • Dubois-Arbouw W.I.
        • Dalstra J.
        • Daemen M.J.
        • van Ree J.W.
        • et al.
        Circumstances and causes of out-of-hospital cardiac arrest in sudden death survivors.
        Heart (Brit Cardiac Soc). 1998; 79: 356-361
        • Goto Y.
        • Funada A.
        • Maeda T.
        • Okada H.
        • Goto Y.
        Sex-specific differences in survival after out-of-hospital cardiac arrest: a nationwide, population-based observational study.
        Crit Care. 2019; 23: 263
        • Heller R.F.
        • Steele P.L.
        • Fisher J.D.
        • Alexander H.M.
        • Dobson A.J.
        Success of cardiopulmonary resuscitation after heart attack in hospital and outside hospital.
        BMJ (Clinical research ed). 1995; 311: 1332-1336
        • Irfan F.B.
        • Bhutta Z.A.
        • Castren M.
        • Straney L.
        • Djarv T.
        • Tariq T.
        • et al.
        Epidemiology and outcomes of out-of-hospital cardiac arrest in Qatar: A nationwide observational study.
        Int J Cardiol. 2016; 223: 1007-1013
        • Jeong J.S.
        • Kong S.Y.
        • Shin S.D.
        • Ro Y.S.
        • Song K.J.
        • Hong K.J.
        • et al.
        Gender disparities in percutaneous coronary intervention in out-of-hospital cardiac arrest.
        Am J Emerg Med. 2019; 37: 632-638
        • Johnson M.A.
        • Haukoos J.S.
        • Larabee T.M.
        • Daugherty S.
        • Chan P.S.
        • McNally B.
        • et al.
        Females of childbearing age have a survival benefit after out-of-hospital cardiac arrest.
        Resuscitation. 2013; 84: 639-644
        • Kim C.
        • Fahrenbruch C.E.
        • Cobb L.A.
        • Eisenberg M.S.
        Out-of-hospital cardiac arrest in men and women.
        Circulation. 2001; 104: 2699-2703
        • Kim J.
        • Kim K.
        • Lee J.H.
        • Jo Y.H.
        • Rhee J.E.
        • Kim T.Y.
        • et al.
        Red blood cell distribution width as an independent predictor of all-cause mortality in out of hospital cardiac arrest.
        Resuscitation. 2012; 83: 1248-1252
        • Kotini-Shah P.
        • Del Rios M.
        • Khosla S.
        • Pugach O.
        • Vellano K.
        • McNally B.
        • et al.
        Sex differences in outcomes for out-of-hospital cardiac arrest in the United States.
        Resuscitation. 2021; 163: 6-13
        • Ma M.-H.-M.
        • Chiang W.-C.
        • Ko P.-C.-I.
        • Huang J.-C.-C.
        • Lin C.-H.
        • Wang H.-C.
        • et al.
        Outcomes from out-of-hospital cardiac arrest in Metropolitan Taipei: does an advanced life support service make a difference?.
        Resuscitation. 2007; 74: 461-469
        • Nakanishi N.
        • Nishizawa S.
        • Kitamura Y.
        • Nakamura T.
        • Matsumuro A.
        • Sawada T.
        • et al.
        The increased mortality from witnessed out-of-hospital cardiac arrest in the home.
        Prehospital Emergency Care: Official Journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2011; 15: 271-277
        • Nishiuchi T.
        • Hayashino Y.
        • Fukuhara S.
        • Iwami T.
        • Hayashi Y.
        • Hiraide A.
        • et al.
        Survival rate and factors associated with 1-month survival of witnessed out-of-hospital cardiac arrest of cardiac origin with ventricular fibrillation and pulseless ventricular tachycardia: The Utstein Osaka project.
        Resuscitation. 2008; 78: 307-313
        • Olasveengen T.M.
        • Wik L.
        • Sunde K.
        • Steen P.A.
        Outcome when adrenaline (epinephrine) was actually given vs. not given - post hoc analysis of a randomized clinical trial.
        Resuscitation. 2012; 83: 327-332
        • Patterson T.
        • Perkins G.D.
        • Hassan Y.
        • Moschonas K.
        • Gray H.
        • Curzen N.
        • et al.
        Temporal Trends in Identification, Management, and Clinical Outcomes After Out-of-Hospital Cardiac Arrest: Insights From the Myocardial Ischaemia National Audit Project Database.
        Circul Cardiovasc Intervent. 2018; 11: e005346
        • Pechmajou L.
        • Sharifzadehgan A.
        • Bougouin W.
        • Dumas F.
        • Beganton F.
        • Jost D.
        • et al.
        Does occurrence during sports affect sudden cardiac arrest survival?.
        Resuscitation. 2019; 141: 121-127
        • Pell J.P.
        • Sirel J.
        • Marsden A.K.
        • Cobbe S.M.
        Sex differences in outcome following community-based cardiopulmonary arrest.
        Eur Heart J. 2000; 21: 239-244
        • Redpath C.
        • Sambell C.
        • Stiell I.
        • Johansen H.
        • Williams K.
        • Samie R.
        • et al.
        In-hospital mortality in 13,263 survivors of out-of-hospital cardiac arrest in Canada.
        Am Heart J. 2010; 159 (577–83.e1)
        • Winther-Jensen M.
        • Kjaergaard J.
        • Wanscher M.
        • Nielsen N.
        • Wetterslev J.
        • Cronberg T.
        • et al.
        No difference in mortality between men and women after out-of-hospital cardiac arrest.
        Resuscitation. 2015; 96: 78-84
        • Winther-Jensen M.
        • Hassager C.
        • Kjaergaard J.
        • Bro-Jeppesen J.
        • Thomsen J.H.
        • Lippert F.K.
        • et al.
        Women have a worse prognosis and undergo fewer coronary angiographies after out-of-hospital cardiac arrest than men.
        Eur Heart J Acute Cardiovasc Care. 2018; 7: 414-422
        • Yasunaga H.
        • Miyata H.
        • Horiguchi H.
        • Tanabe S.
        • Akahane M.
        • Ogawa T.
        • et al.
        Population density, call-response interval, and survival of out-of-hospital cardiac arrest.
        Int J Health Geogr. 2011; 10: 26
        • Hermel M.
        • Bosson N.
        • Fang A.
        • French W.J.
        • Niemann J.T.
        • Sung G.
        • et al.
        Implementation of Targeted Temperature Management After Out-of-Hospital Cardiac Arrest: Observations From the Los Angeles County Regional System.
        J Am Heart Assoc. 2020; 9: e016652
        • Inoue A.
        • Hifumi T.
        • Sakamoto T.
        • Kuroda Y.
        Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest in Adult Patients.
        J Am Heart Assoc. 2020; 9: e015291
        • Agerstrom J.
        • Carlsson M.
        • Bremer A.
        • Herlitz J.
        • Israelsson J.
        • Arestedt K.
        Discriminatory cardiac arrest care? Patients with low socioeconomic status receive delayed cardiopulmonary resuscitation and are less likely to survive an in-hospital cardiac arrest.
        Eur Heart J. 2021; 42: 861-869
        • Aschauer S.
        • Dorffner G.
        • Sterz F.
        • Erdogmus A.
        • Laggner A.
        A prediction tool for initial out-of-hospital cardiac arrest survivors.
        Resuscitation. 2014; 85: 1225-1231
        • Balan P.
        • Hsi B.
        • Thangam M.
        • Zhao Y.
        • Monlezun D.
        • Arain S.
        • et al.
        The cardiac arrest survival score: A predictive algorithm for in-hospital mortality after out-of-hospital cardiac arrest.
        Resuscitation. 2019; 144: 46-53
        • Goto Y.
        • Maeda T.
        • Goto Y.
        Decision-tree model for predicting outcomes after out-of-hospital cardiac arrest in the emergency department.
        Crit Care. 2013; 17: R133
        • Ji C.
        • Brown T.P.
        • Booth S.J.
        • Hawkes C.
        • Nolan J.P.
        • Mapstone J.
        • et al.
        Risk prediction models for out-of-hospital cardiac arrest outcomes in England.
        Eur Heart J – Quality Care Clin Outcomes. 2020(qcaa019).;
        • Blewer A.L.
        • McGovern S.K.
        • Schmicker R.H.
        • May S.
        • Morrison L.J.
        • Aufderheide T.P.
        • et al.
        Gender Disparities Among Adult Recipients of Bystander Cardiopulmonary Resuscitation in the Public.
        Circul Cardiovasc Quality Outcomes. 2018; 11: e004710
        • Perman S.M.
        • Shelton S.K.
        • Knoepke C.
        • Rappaport K.
        • Matlock D.D.
        • Adelgais K.
        • et al.
        Public Perceptions on Why Women Receive Less Bystander Cardiopulmonary Resuscitation Than Men in Out-of-Hospital Cardiac Arrest.
        Circulation. 2019; 139: 1060-1068
        • Bosson N.
        • Kaji A.H.
        • Fang A.
        • Thomas J.L.
        • French W.J.
        • Shavelle D.
        • et al.
        Sex Differences in Survival From Out-of-Hospital Cardiac Arrest in the Era of Regionalized Systems and Advanced Post-Resuscitation Care.
        J Am Heart Assoc. 2016; 5: e004131
        • Lascarrou J.-B.
        • Merdji H.
        • Le Gouge A.
        • Colin G.
        • Grillet G.
        • Girardie P.
        • et al.
        Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm.
        N Engl J Med. 2019; 381: 2327-2337

      Linked Article

      • Female sex and prognosis following out-of-hospital cardiac arrest: Does lack of statistical significance equal clinically insignificant?
        ResuscitationVol. 179
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          Sex as a predictor of survival for non-traumatic out-of-hospital cardiac arrest (OHCA) has been an area of interest with conflicting results. Previous studies examining sex-based differences in outcomes showed that women who suffer OHCA have lower likelihood of survival to hospital discharge then their male counterparts.1–3 Contrary to this evidence, women have a higher likelihood of return of spontaneous circulation compared to men.4 Poor outcomes are likely driven by sex disparities in post-resuscitation care; women who suffer OHCA are less likely to receive bystander cardiopulmonary resuscitation (CPR), less frequently experience witnessed cardiac arrest in a public location and have non-shockable initial rhythms.
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