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Patient characteristics and survival outcomes of cardiac arrest in the cardiac catheterization laboratory: Insights from get with the Guidelines®-Resuscitation registry

  • Ahmed Elkaryoni
    Correspondence
    Corresponding author at: Cardiovascular Disease Fellow, Division of Cardiovascular Disease, Loyola University Medical Center, United States.
    Affiliations
    Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, IL, United States
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  • Andy T. Tran
    Affiliations
    Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, MO, United States

    University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States

    Department of Medicine, University of California, Irvine School of Medicine, Orange, CA, United States
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  • Marwan Saad
    Affiliations
    Lifespan Cardiovascular Institute Providence, RI, United States

    Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, RI, United States
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  • Amir Darki
    Affiliations
    Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, IL, United States
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  • John J. Lopez
    Affiliations
    Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, IL, United States
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  • J. Dawn Abbott
    Affiliations
    Lifespan Cardiovascular Institute Providence, RI, United States

    Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, RI, United States
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  • Paul S. Chan
    Affiliations
    Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, MO, United States

    University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
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  • for the American Heart Association's Get With the Guidelines®-Resuscitation Investigators
    Author Footnotes
    1 The members of the American Heart Association's Get With the Guidelines®-Resuscitation Investigators are listed in Appendix A at the end of the article.
  • Author Footnotes
    1 The members of the American Heart Association's Get With the Guidelines®-Resuscitation Investigators are listed in Appendix A at the end of the article.

      Abstract

      Background

      Characteristics and outcomes of patients with in-hospital cardiac arrest (IHCA) in the cardiac catheterization laboratory (CCL) have not been well-described. Thus, we compared the outcomes of patients with an IHCA in the CCL versus those in the intensive care unit (ICU) and operating rooms (OR).

      Methods

      Within the American Heart Association’s Get With the Guidelines®-Resuscitation registry, we identified patients ≥ 18 years old with IHCA in the CCL, ICU, or OR between 2000–2019. Using hierarchical multivariable logistic regression, we compared rates of survival to discharge for patients with IHCA in the CCL versus ICU and OR.

      Results

      Across 428 hospitals, 193,950 patients had IHCA, of whom 6865, 181,905 and 5180 were in the CCL, ICU and OR, respectively. Overall, 2614 (38.1%) patients with IHCA in the CCL survived to discharge, whereas 30,830 (16.9%) and 2096 (40.5%) survived to discharge from the ICU and OR, respectively. After adjustment, patients with IHCA in CCL were more likely to survive to discharge as compared to those with IHCA in the ICU (odds ratio, 1.37 [95%CI: 1.29–1.46], p < 0.001). In contrast, those who had IHCA in the CCL were less likely to survive to discharge as compared to patients with IHCA in the OR (odds ratio, 0.81 [95%CI: 0.69–0.94], p = 0.006).

      Conclusion

      IHCA in the CCL is not uncommon and has a lower survival rate when compared with IHCA in the OR. The reasons for this difference deserve further study given that cardiac arrest in both settings is witnessed and response time should be similar.

      Keywords

      Introduction

      Cardiac arrest in the cardiac catheterization laboratory (CCL) has substantially increased over the last decade due to the increase in complex coronary and non-coronary interventions for high-risk patients.
      • Yadav K.
      • Truong H.T.
      Cardiac Arrest in the Catheterization Laboratory.
      • Webb J.G.
      • Solankhi N.K.
      • Chugh S.K.
      • et al.
      Incidence, correlates, and outcome of cardiac arrest associated with percutaneous coronary intervention.
      • Brennan J.M.
      • Curtis J.P.
      • Dai D.
      • et al.
      Enhanced mortality risk prediction with a focus on high-risk percutaneous coronary intervention: Results from 1,208,137 procedures in the NCDR (national cardiovascular data registry).
      Previous reports from the Get with the Guidelines®—Resuscitation (GWTG-R) registry showed variation in survival outcomes based on the location of the IHCA in intensive care, telemetry or unmonitored units.

      Perman SM, Stanton E, Soar J, et al., American Heart Association's Get With the Guidelines®—Resuscitation (formerly the National Registry of Cardiopulmonary Resuscitation) Investigators. Location of In-Hospital Cardiac Arrest in the United States-Variability in Event Rate and Outcomes. J Am Heart Assoc. 2016;5:e003638. https://doi.org/10.1161/JAHA.116.003638.

      However, these insights were focused on patients on hospital wards and may not reflect procedural cardiac arrests such as in the CCL.

      Perman SM, Stanton E, Soar J, et al., American Heart Association's Get With the Guidelines®—Resuscitation (formerly the National Registry of Cardiopulmonary Resuscitation) Investigators. Location of In-Hospital Cardiac Arrest in the United States-Variability in Event Rate and Outcomes. J Am Heart Assoc. 2016;5:e003638. https://doi.org/10.1161/JAHA.116.003638.

      Although some data exists for IHCA in the operating rooms and perioperative procedural areas, these results have not been directly compared to other procedural areas such as the CCL.
      • Ramachandran S.K.
      • Mhyre J.
      • Kheterpal S.
      • et al.
      American Heart Association’s Get With The Guidelines-Resuscitation Investigators. Predictors of survival from perioperative cardiopulmonary arrests: a retrospective analysis of 2,524 events from the Get With The Guidelines-Resuscitation registry.
      In addition, the characteristics and outcomes of IHCA in the CCL have not been well-described with some limited data suggesting good prognosis.
      • Sprung J.
      • Ritter M.J.
      • Rihal C.S.
      • et al.
      Outcomes of cardiopulmonary resuscitation and predictors of survival in patients undergoing coronary angiography including percutaneous coronary interventions.
      Although it is known that a witnessed IHCA is associated with better outcomes due to prompt time to advanced cardiac life support,
      • Morrison L.J.
      • Neumar R.W.
      • Zimmerman J.L.
      • et al.
      American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on P. Strategies for improving survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations: a consensus statement from the American Heart Association.
      IHCA in the CCL remains challenging due to the need to address the underlying cause while simultaneously providing advanced cardiac life support during an invasive procedure. Due to the lack of systematic contemporary data on IHCA in the CCL, we leveraged the GWTG-R registry to describe the characteristics of patients with an IHCA in the CCL and compared their survival outcomes versus those with IHCA in the intensive care unit (ICU), and in operating rooms (OR).

      Methods

      Data source

      GWTG-R is a large, prospective, national quality-improvement registry of IHCA. Its design has been previously described.
      • Morrison L.J.
      • Neumar R.W.
      • Zimmerman J.L.
      • et al.
      American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on P. Strategies for improving survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations: a consensus statement from the American Heart Association.
      In brief, trained hospital personnel identify all patients without do-not-resuscitate orders with a cardiac arrest (defined as absence of a palpable central pulse, apnea, and unresponsiveness) who undergo cardiopulmonary resuscitation. Cases are identified through multiple methods, including centralized collection of cardiac arrest flow sheets, reviews of hospital paging system logs, and routine checks of code carts and pharmacy tracer drug records.
      • Morrison L.J.
      • Neumar R.W.
      • Zimmerman J.L.
      • et al.
      American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on P. Strategies for improving survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations: a consensus statement from the American Heart Association.
      Standardized Utstein-style definitions are used for all patient variables and outcomes to facilitate uniform reporting across hospitals.
      • Peberdy M.A.
      • Kaye W.
      • Ornato J.P.
      • et al.
      Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation.
      • Cummins R.O.
      • Chamberlain D.
      • Hazinski M.F.
      • et al.
      Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital 'Utstein style'. American Heart Association.
      Data accuracy in GWTG-R is supported by certification of data abstractors and use of standardized software with data checks for completeness and accuracy. Due to the de-identified nature of the data, this study was deemed exempt by the institutional review board.

      Study population

      We identified patients who were 18 years of age or older enrolled in GWTG-R between 2000 and 2019 with an IHCA in the CCL, ICU or OR. We excluded 187,733 patients with IHCA in other hospital locations, 8988 IHCAs related to trauma, and 1527 IHCAs with missing data on survival to discharge. Furthermore, a total of 21,597 IHCA cases from hospitals without an IHCA event in the CCL, and 1819 IHCAs from hospitals with fewer than 25 IHCA events were excluded. The final cohort was comprised of 193,950 IHCAs from 428 hospitals in the CCL, ICU and OR (Fig. 1).
      Figure thumbnail gr1
      Fig. 1Diagram of the study cohort. ICU indicates intensive care unit; IHCA, in-hospital cardiac arrest; OR, operating room.

      Statistical analysis

      The primary outcome was survival to hospital discharge. The secondary outcome was sustained return of spontaneous circulation (ROSC) for > 20 minutes. Due to the large cohort size, baseline patient characteristics between patients with IHCA in the CCL vs the ICU and CCL vs the OR were compared using standardized differences, with a standardized difference of > 0.10 difference considered clinically relevant.
      • Austin P.C.
      Using the Standardized Difference to Compare the Prevalence of a Binary Variable Between Two Groups in Observational Research.
      .
      To compare rates of survival to discharge between IHCAs in the CCL, OR and the ICU, we constructed separate hierarchical multivariable logistic regression models and evaluated survival rates for patients with an IHCA in the CCL vs ICU and in the CCL vs OR. Hierarchical models were used, with hospital as a random effect to account for clustering of patients within hospitals. Models adjusted as fixed effects for the following patient-level factors: demographics (age, sex, race), initial cardiac arrest rhythm (asystole, pulseless electrical activity, ventricular fibrillation, pulseless ventricular tachycardia), location of cardiac arrest, illness category (medical cardiac, medical non-cardiac, surgical cardiac, surgical non-cardiac, other), comorbid conditions (prior heart failure or myocardial infarction, index admission heart failure or myocardial infarction, diabetes mellitus, baseline depression in central nervous system function, acute stroke, pneumonia, and metastatic or hematologic malignancy), medical conditions present within 24 hours of cardiac arrest (renal insufficiency, hepatic insufficiency, respiratory insufficiency, hypotension, septicemia, and metabolic or electrolyte abnormality), as well as interventions present within 24 hours prior to IHCA (intravenous vasopressor, hemodialysis, and mechanical ventilation). Models also adjusted for calendar year of arrest, as well as the time of day (work hours [7:00 am to 10:59 pm] vs after hours [11:00 pm to 6:59 am]), and day of the week (weekday vs weekend) of the IHCA. Similar models were constructed to compare rates of ROSC between IHCAs in the CCL vs the ICU and in the CCL vs the OR. Furthermore, we examined rates of post-ROSC survival in the cohort by repeating the models above for patients with sustained ROSC and compared rates of survival to hospital discharge for IHCAs in the CCL vs the ICU, and in the CCL vs the OR.
      Finally, among those with an IHCA in the CCL, we examined for independent predictors of survival to discharge among patients who had IHCA in the CCL. We also compared outcomes among patients with an IHCA in the CCL who had probable shock (defined as having both hypotension and being on a continuous intravenous vasoactive agent at the time of their IHCA) and acute myocardial infarction. To accomplish this, we constructed separate multivariable hierarchical logistic regression models to identify predictors of survival to discharge from IHCA in the CCL, and among subgroups of patients with probable shock or acute myocardial infarction using the same model covariates as described above.
      For each analysis, the null hypothesis was evaluated at a 2-sided significance level of 0.05 and calculated 95% confidence intervals (CIs) using robust standard errors. Power analyses were not performed given the large cohort size, and all analyses were conducted using R statistical software version 4.0.5 (R Project for Statistical Computing). The Institutional Review Board for Saint Luke’s Mid America Heart Institute approved the study project as an exempt study as the registry contained only de-identified data.

      Results

      Of 193,950 patients in the study cohort, 6865 had an IHCA in the CCL, 181,905 patients in the ICU, and 5180 in the OR. Patients with IHCA in the CCL, as compared to those in the ICU or OR, were generally older, more frequently male and of White race, more likely to have ventricular fibrillation as the initial cardiac arrest rhythm, had higher rates of prior myocardial infarction or index hospitalization for myocardial infarction, and had lower rates of most other comorbidities (Table 1). A medical-cardiac admission diagnosis was the most common cause of hospitalization among patients with an IHCA in the CCL. Patients with IHCA in the CCL vs those in the ICU or OR were also less likely to be on dialysis or on mechanical ventilation at the time of their IHCA.
      Table 1Patient and Arrest Characteristics of IHCA Events by CCL vs ICU and CCL vs OR.
      CCLvs ICUSMD
      The standardized mean difference (SMD) compares the difference in means or proportions in units of the pooled standard deviation; a standardized difference greater than 0.10 considered clinically relevant.
      vs ORSMD
      The standardized mean difference (SMD) compares the difference in means or proportions in units of the pooled standard deviation; a standardized difference greater than 0.10 considered clinically relevant.
      N = 6865N = 181905N = 5180
      Demographics
      Age, year66.4 (13.5)63.9 (15.3)0.16863.3 (16.3)0.204
      Female2590 (37.7)76,604 (42.1)0.0902286 (44.1)0.131
      Race0.3430.169
       White5459 (79.5)119,854 (65.9)3816 (73.7)0.204
       Black781 (11.4)43,195 (23.7)893 (17.2)
       Asian131 (1.9)3556 (2.0)99 (1.9)
       Other/Unknown494 (7.2)15,300 (8.4)372 (7.2)
      Co-existing conditions
      Acute stroke93 (1.4)7424 (4.1)0.168122 (2.4)0.074
      Acute CNS non-stroke event370 (5.4)15,421 (8.5)0.122245 (4.7)0.030
      Baseline depression in CNS function316 (4.6)17,375 (9.6)0.194345 (6.7)0.089
      Congestive heart failure (this admission)986 (14.4)33,640 (18.5)0.112526 (10.2)0.129
      Congestive heart failure (prior admission)1189 (17.3)40,978 (22.5)0.1311033 (19.9)0.067
      Myocardial ischemia/infarction (this admission)4111 (59.9)34,649 (19.0)0.920446 (8.6)1.284
      Myocardial ischemia/infarction (prior admission)1740 (25.3)27,984 (15.4)0.249787 (15.2)0.255
      Pneumonia213 (3.1)30,736 (16.9)0.472229 (4.4)0.069
      Respiratory insufficiency2273 (33.1)105,310 (57.9)0.5142164 (41.8)0.180
      Renal insufficiency1255 (18.3)77,973 (42.9)0.5541521 (29.4)0.262
      Hepatic insufficiency181 (2.6)19,926 (11.0)0.335335 (6.5)0.185
      Diabetes mellitus2077 (30.3)61,554 (33.8)0.0771664 (32.1)0.040
      Metabolic/electrolyte abnormality950 (13.8)51,207 (28.2)0.357950 (18.3)0.123
      Metastatic or hematologic malignancy235 (3.4)20,767 (11.4)0.309548 (10.6)0.283
      Hypotension/hypoperfusion2250 (32.8)72,986 (40.1)0.1531987 (38.4)0.117
      Sepsis157 (2.3)38,199 (21.0)0.610523 (10.1)0.328
      Arrest characteristics
      Initial rhythm0.4870.409
       Asystole1337 (19.5)45,954 (25.3)1704 (32.9)
       PEA2951 (43.0)101,915 (56.0)2271 (43.8)
       Pulseless VT680 (9.9)16,515 (9.1)487 (9.4)
       VF1897 (27.6)17,521 (9.6)718 (13.9)
      Length of hospital stay, day2.0 [0.0, 7.0]5.0 [1.0, 14.0]0.3475.0 [1.0, 13.0]0.316
      Admitting diagnosis0.1280.285
       Medical-Cardiac5813 (84.7)69,661 (38.3)332 (6.4)
       Medical-Noncardiac214 (3.1)77,625 (42.7)554 (10.7)
       Surgical-Cardiac745 (10.9)16,427 (9.0)945 (18.2)
       Surgical-Noncardiac86 (1.3)17,983 (9.9)3259 (62.9)
       Other7 (0.1)209 (0.1)90 (1.7)
      After hours arrest1001 (14.6)60,050 (33.0)0.443500 (9.7)0.151
      Weekend or holiday arrest1610 (23.5)60,722 (33.4)0.221911 (17.6)0.146
      Assisted or mechanical vent already in place2768 (40.3)126,189 (69.4)0.6104242 (81.9)0.943
      Vasoactive agent already in place2662 (38.8)90,353 (49.7)0.2211739 (33.6)0.108
      Dialysis/extracorporeal filtration (ongoing)38 (0.6)9851 (5.4)0.28972 (1.4)0.085
      Values are mean (SD), median [25th – 75th interquartile range] or n (%).
      CCL, cardiac catheterization laboratory; ICU, intensive care unit; IHCA, in-hospital cardiac arrest; OR, operating room; CNS, central nervous system.
      * The standardized mean difference (SMD) compares the difference in means or proportions in units of the pooled standard deviation; a standardized difference greater than 0.10 considered clinically relevant.
      Overall, 2614 (38.1%) patients with IHCA in the CCL survived to discharge, whereas 30,830 (16.9%) and 2096 (40.5%) of those with IHCA survived to discharge from the ICU and OR, respectively (Fig. 2). After adjustment for 27 patient and cardiac arrest factors, patients with IHCA in CCL were more likely to survive to discharge as compared with those with IHCA from the ICU (odds ratio, 1.37 [95% CI: 1.29–1.46], p < 0.001; Fig. 2/Supplemental Table-1). In contrast, patients with IHCA in the CCL were less likely to survive to discharge as compared with those with IHCA in the OR (odds ratio, 0.81 [95% CI: 0.69–0.94], p = 0.006; Fig. 2/Supplemental Table-2). For the secondary outcome, patients with IHCA in the CCL were less likely to achieve sustained ROSC as compared with those with IHCA in ICU (odds ratio, 0.90 [95% CI: 0.85–0.95], p < 0.001; Fig. 2/Supplemental Table-3) and in the OR (odds ratio, 0.84 [95% CI: 0.72–0.98], p = 0.027; Fig. 2/Supplemental Table-4). Finally, when examining post-ROSC survival by limiting the analytic cohort to those patients with sustained ROSC, patients with IHCAs in the CCL were more likely to survive to discharge as compared to IHCAs in the ICU (odds ratio, 1.68 [95% CI: 1.56–1.80], p < 0.001; Supplemental Table-5) and there was a nonsignificant trend in lower post-ROSC survival in patients with IHCA in the CCL vs the OR (odds ratio, 0.86 [95% CI: 0.71–1.03], p = 0.098; Supplemental Table-6).
      Figure thumbnail gr2
      Fig. 2Likelihood of survival to discharge and sustained ROSC among patients with IHCAs in the CCL vs ICU and in the CCL vs OR. ICU, intensive care unit; IHCA, in-hospital cardiac arrest; OR, operating room; ROSC, return of spontaneous circulation; SMD, standardized mean difference. The list of all variables included in each multivariable hierarchical regression model is reported in the .
      Among patients who had IHCA in the CCL, 1395 patients had probable shock of whom 280 (20.1%) survived to discharge, while for those who had acute myocardial infraction (4111 patients), 1,426 (34.7%) survived to discharge. Predictors of survival to discharge among patients with IHCA in the CCL are shown in Table 2. Older age, non-white race, an initial non-shockable rhythm, and IHCA during nighttime hours and on weekends were associated with a lower likelihood of survival to discharge after an IHCA in the CCL. Similarly, patients with prior myocardial infarction, an index myocardial infarction, hypotension, metabolic or electrolyte abnormalities, respiratory insufficiency, and requirement for mechanical ventilation or continuous intravenous vasopressors were less likely to survive to discharge after an IHCA in the CCL. Furthermore, independent predictors of survival to discharge among subgroups of patients with IHCA in the CCL who had probable shock or acute myocardial infarction did not significantly differ from the overall group of patients with CCL IHCA (Supplemental Table-7, and 8, respectively).
      Table 2Multivariable hierarchical model showing predictors of survival to discharge among patients with IHCA in the CCL.
      bDiedSurvivedOR (95% CI)
      Age, year mean (standard deviation)68.1 (13.3)63.6 (13.4)0.97 (0.97–0.98)
      Female gender1685 (39.6)905 (34.6)0.95 (0.85–1.08)
      White race3297 (77.7)2163 (82.9)1.24 (1.06–1.45)
      Acute stroke69 (1.6)24 (0.9)0.68 (0.40–1.16)
      Acute CNS non-stroke event297 (7.0)73 (2.8)0.64 (0.47–0.87)
      Baseline depression in CNS function242 (5.7)74 (2.8)0.79 (0.57–1.09)
      Congestive heart failure (this admission)667 (15.7)319 (12.2)1.04 (0.87–1.25)
      Congestive heart failure (prior admission)789 (18.6)400 (15.3)0.88 (0.74–1.05)
      Myocardial ischemia/infarction (this admission)2684 (63.1)1427 (54.6)0.59 (0.52–0.67)
      Myocardial ischemia/infarction (prior admission)1115 (26.2)625 (23.9)0.82 (0.71–0.95)
      Pneumonia163 (3.8)50 (1.9)0.81 (0.56–1.18)
      Respiratory insufficiency1711 (40.2)562 (21.5)0.86 (0.74–0.99)
      Renal insufficiency913 (21.5)343 (13.1)0.85 (0.72–1.01)
      Hepatic insufficiency135 (3.2)46 (1.8)0.89 (0.59–1.33)
      Diabetes mellitus1338 (31.5)739 (28.3)1.05 (0.92–1.20)
      Metabolic/electrolyte abnormality732 (17.2)218 (8.3)0.75 (0.62–0.92)
      Hypotension/hypoperfusion1689 (39.7)561 (21.5)0.67 (0.58–0.78)
      Sepsis121 (2.8)36 (1.4)0.77 (0.50–1.18)
      Initial rhythm-
      • -
        Pulseless electrical activity
      2241 (52.7)710 (27.2)0.66 (0.56–0.77)
      • -
        Pulseless ventricular tachycardia
      361 (8.5)319 (12.2)1.66 (1.34–2.06)
      • -
        Ventricular fibrillation
      744 (17.5)1154 (44.1)2.69 (2.27–3.18)
      Admitting diagnosis-
      • -
        Medical-Noncardiac
      151 (3.6)63 (2.4)0.67 (0.47–0.95)
      • -
        Surgical-Cardiac
      455 (10.7)290 (11.1)1.02 (0.84–1.25)
      • -
        Surgical-Noncardiac
      55 (1.3)31 (1.2)0.89 (0.53–1.50)
      • -
        Other
      6 (0.1)1 (0.0)0.10 (0.01–1.08)
      After hours arrest688 (16.2)313 (12.0)0.84 (0.70–1.00)
      Weekend or holiday arrest1096 (25.8)514 (19.7)0.85 (0.73–0.98)
      Assisted or mechanical vent already in place2182 (51.3)587 (22.5)0.39 (0.34–0.45)
      Vasoactive agent already in place2031 (47.8)632 (24.2)0.55 (0.49–0.63)
      Dialysis/extracorporeal filtration (ongoing)27 (0.6)11 (0.4)0.83 (0.37–1.82)
      CCL, cardiac catheterization laboratory; CI, confidence interval; CNS, central nervous system;
      IHCA, in-hospital cardiac arrest; OR, odds ration; Asystole is the reference for initial rhythm variable, and medical-cardiac is the reference for admitting diagnosis.

      Discussion

      In the GWTG-R national registry of IHCA, we examined the characteristics and outcomes of patients with an IHCA in the CCL. We found that patients with IHCA in the CCL were more likely to survive to discharge when compared to those with an IHCA in the ICU. In contrast, they were less likely to survival to discharge when compared to patients with an IHCA in the OR. Furthermore, patients who had IHCA in the CCL were less likely to achieve sustained ROSC when compared to those who had IHCA in either the ICU or OR. Among those with sustained ROSC, patients with IHCAs in the CCL had a higher likelihood of survival to discharge when compared to those with IHCA in the ICU, and the relationship for post-ROSC survival for IHCAs in the CCL vs the OR, though borderline nonsignificant, was similar to the main analysis (0.86 vs 0.81, respectively). Among patients with IHCA in the CCL, older age, non-shockable rhythm, IHCA during weekend or afterhours, having myocardial infarction during this index admission or previous hospitalization and treatment with mechanical ventilation or continuous intravenous vasopressors at the time of the cardiac arrest were associated with a lower likelihood with survival to discharge.
      Although IHCAs occurring in the CCL and the OR would be witnessed and have received immediate medical response, we found that patients with an IHCA in the CCL had a lower likelihood of achieving sustained ROSC or survival to discharge than those with an IHCA in the OR. Despite adjustment for measurable differences in patient or cardiac arrest characteristics between both patient groups, this difference in survival may be related to other unmeasured factors like acuity of presentation between both groups (i.e. acute coronary syndrome presentation in the CCL vs more stable patients in the OR) and factors triggering the cardiac arrest in each group (e.g., cardiac arrest in the OR may be due to a reversible cause such as hypovolemia, electrolyte abnormality, drug reaction, or procedure complication in a prior stable patient). Similarly, the higher survival rate for IHCA in the CCL versus in the ICU could reflect unmeasured confounding regarding illness severity of patients as rates of ROSC were lower in the CCL versus that in the ICU.
      • Andersen L.W.
      • Holmberg M.J.
      • Berg K.M.
      • Donnino M.W.
      • Granfeldt A.
      In-Hospital Cardiac Arrest: A Review.
      We did not have hemodynamic information on patients with IHCA in the CCL or the OR, and it is possible that unmeasured factors such as higher rates of cardiogenic shock could have accounted for lower survival rates in the CCL. Indeed, the fact that only 2.3% of patients with IHCA in the CCL had documented sepsis at the time of IHCA while 38.8% of CCL patients were on continuous intravenous vasoactive agents at the time of IHCA supports this (see Table 1). Furthermore, patients with an IHCA in the CCL were more likely to have an initial shockable rhythm when compared to patients with an IHCA in the ICU, which results in higher unadjusted survival rates to discharge. Because an initial shockable rhythm of overall survival, adjusted rates of survival to discharge for patients with IHCA in the CCL compared to those in the OR were ultimately lower. This may be because of unmeasured factors that predispose patients with IHCA in the CCL to have lower survival rates than patients in the OR, after accounting for initial rhythm including issues of cardiogenic shock. Finally, the known difficulty of performing high quality cardiopulmonary resuscitation with manual chest compression while fixing the underlying cause of cardiac arrest in the CCL can also contribute to the lower survival in the CCL vs OR.
      The findings from this study extend the available evidence about different rates of survival among patients with IHCA based on the location of IHCA in the hospital and add a different perspective about a unique group of patients with IHCA in the CCL. Previous reports from GWTG-R found a survival to discharge rate of 19.3% in a monitored ward setting, 10.6% in an unmonitored ward setting, 14% in ICU, and 31.7% in perioperative settings.

      Perman SM, Stanton E, Soar J, et al., American Heart Association's Get With the Guidelines®—Resuscitation (formerly the National Registry of Cardiopulmonary Resuscitation) Investigators. Location of In-Hospital Cardiac Arrest in the United States-Variability in Event Rate and Outcomes. J Am Heart Assoc. 2016;5:e003638. https://doi.org/10.1161/JAHA.116.003638.

      • Ramachandran S.K.
      • Mhyre J.
      • Kheterpal S.
      • et al.
      American Heart Association’s Get With The Guidelines-Resuscitation Investigators. Predictors of survival from perioperative cardiopulmonary arrests: a retrospective analysis of 2,524 events from the Get With The Guidelines-Resuscitation registry.
      Those different insights from GWTG-R examining odds of survival to discharge after IHCA based on the location of IHCA demonstrated that patients with witnessed CA (in the CCL or OR) had a relatively higher survival to discharge than IHCA in other locations like the ICU, or monitored/unmonitored wards.
      Previous studies that explored the characteristics of IHCA in the CCL showed a prevalence of initial shockable rhythm rates of only 14.0% and 16.6%.
      • Wagner H.
      • Hardig B.M.
      • Rundgren M.
      • et al.
      Mechanical chest compressions in the coronary catheterization laboratory to facilitate coronary intervention and survival in patients requiring prolonged resuscitation efforts.
      • Wagner H.
      • Terkelsen C.J.
      • Friberg H.
      • et al.
      Cardiac arrest in the catheterisation laboratory: a 5-year experience of using mechanical chest compressions to facilitate PCI during prolonged resuscitation efforts.
      However, these were small studies. In our cohort from a national registry, we found that 37.5% of patients with IHCA in the CCL had an initial shockable rhythm. The difference in analytic cohorts can be the reason for this variation in initial cardiac rhythm at presentation. The overall survival to discharge rates from those studies were ∼25%.
      • Wagner H.
      • Hardig B.M.
      • Rundgren M.
      • et al.
      Mechanical chest compressions in the coronary catheterization laboratory to facilitate coronary intervention and survival in patients requiring prolonged resuscitation efforts.
      • Wagner H.
      • Terkelsen C.J.
      • Friberg H.
      • et al.
      Cardiac arrest in the catheterisation laboratory: a 5-year experience of using mechanical chest compressions to facilitate PCI during prolonged resuscitation efforts.
      In contrast, our study had higher rates of survival to discharge at 38.1%, owing to the fact that a larger proportion of patients with IHCA in the CCL had shockable rhythms.

      Clinical implications

      While our findings are helpful in showing that IHCA in CCL is not uncommon, our model to predict survival in patients with an IHCA in the CCL defined some similar predictors as in the overall IHCA setting. There were differences, though. For instance, a history of myocardial infarction or an index myocardial infarction for IHCA in the CCL were negative predictors, whereas they are usually associated with a neutral or positive association for survival for patients with IHCA on hospital wards. Nonetheless, these predictors may help define patients with higher risk for decompensation to IHCA while undergoing coronary or non-coronary interventions in the CCL. Furthermore, whether using mechanical cardiopulmonary resuscitation devices in the CCL may have an effect on survival outcomes may deserve further investigation.

      Limitations

      Despite that GWTG-R is the largest nationwide multicenter registry describing IHCA in the United States, it only represents ∼15% of all U.S. hospitals; therefore, our findings may not be generalizable to non-participating hospitals.

      Perman SM, Stanton E, Soar J, et al., American Heart Association's Get With the Guidelines®—Resuscitation (formerly the National Registry of Cardiopulmonary Resuscitation) Investigators. Location of In-Hospital Cardiac Arrest in the United States-Variability in Event Rate and Outcomes. J Am Heart Assoc. 2016;5:e003638. https://doi.org/10.1161/JAHA.116.003638.

      We were unable to calculate the incidence rate of IHCA in the CCL or account for the severity of the underlying comorbidities (hepatic, renal, and renal insufficiency, severity of shock or acute cerebrovascular event), ascertain presence of cardiogenic shock, the type of myocardial infarction (ST vs non-ST elevation myocardial infarction), ejection fraction, the type of intervention in the CCL (coronary, valvular, pericardial or right heart catheterization), details about procedural-related complications which may have led to IHCA (acute coronary occlusion, pericardial tamponade, coronary or ventricular perforation, or dissection), and the type of procedure during which IHCA occurred in the OR, as these variables are not collected in GWTG-R. There is the possibility that some brief IHCA events in the CCL (e.g., ventricular fibrillation requiring one defibrillation shock) may not be captured in the GWTG-R and therefore our analyses of IHCA in the CCL reflect sustained IHCA events.

      Conclusion

      In a large national registry, patients with an IHCA in the CCL had a 38% chance of survival to discharge. This survival likelihood was lower than IHCA occurring in the OR but higher than those occurring in the ICU. The lower rate of IHCA survival in the CCL as compared with IHCA survival in the OR deserves further study given that cardiac arrest in both settings is witnessed and response time should be similar.

      Funding/Support

      No extramural funding was used to support this work. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the paper and its final contents.

      Author Disclosures

      Dr. Tran reported receiving grants from the National Heart, Lung, and Blood Institute of the National Institutes of Health T32 training grant T32HL110837 during the conduct of the study. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
      JDA: Research funding MicroPort, Boston Scientific. Advisory Boards Philips, Medtronic. Consulting Abbott, Recor.

      CRediT authorship contribution statement

      Ahmed Elkaryoni: Conceptualization, Methodology, Validation, Investigation, Writing – original draft, Visualization, Project administration. Andy T. Tran: Conceptualization, Methodology, Software, Formal analysis, Resources, Writing – original draft. Marwan Saad: Writing – review & editing, Visualization. Amir Darki: Writing – review & editing, Visualization. John J. Lopez: Writing – review & editing, Visualization. J Dawn Abbott: Writing – review & editing, Visualization. Paul S. Chan: Conceptualization, Methodology, Validation, Investigation, Visualization, Project administration, Writing – review & editing, Supervision, Project administration.

      Appendix A.

      a) “The Get With The Guidelines® programs are provided by the American Heart Association.”
      b) “Hospitals participating in the registry submit clinical information regarding the medical history, hospital care, and outcomes of consecutive patients hospitalized for cardiac arrest using an online, interactive case report form and Patient Management ToolTM (IQVIA, Parsippany, New Jersey).”
      c) “IQVIA (Parsippany, New Jersey) serves as the data collection (through their Patient Management Tool – PMTTM) and coordination center for the American Heart Association/American Stroke Association Get With The Guidelines® programs. The University of Pennsylvania serves as the data analytic center and has an agreement to prepare the data for research purposes.”
      d) AHA Adult Research Task Force members: Anne Grossestreuer PhD; Ari Moskowitz MD; Dana Edelson MD MS; Joseph Ornato MD; Mary Ann Peberdy MD; Matthew Churpek MD MPH PhD; Monique Anderson Starks MD MHS; Paul Chan MD MSc; Saket Girotra MBBS SM; Sarah Perman MD MSCE; Zachary Goldberger MD MS.

      Appendix B. Supplementary material

      The following are the Supplementary data to this article:

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