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Initial rhythm and survival in refractory out-of-hospital cardiac arrest. Post-hoc analysis of the Prague OHCA randomized trial

  • Stepan Havranek
    Correspondence
    Corresponding author at: 2nd Department of Medicine – Department of Cardiovascular Medicine, General University Hospital and First Faculty of Medicine, Charles University, U Nemocnice 2, Prague 2 128 00, Czech Republic.
    Affiliations
    2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
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  • Zdenka Fingrova
    Correspondence
    Corresponding author at: 2nd Department of Medicine – Department of Cardiovascular Medicine, General University Hospital and First Faculty of Medicine, Charles University, U Nemocnice 2, Prague 2 128 00, Czech Republic.
    Affiliations
    2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
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  • Daniel Rob
    Affiliations
    2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
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  • Jana Smalcova
    Affiliations
    2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
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  • Petra Kavalkova
    Affiliations
    2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
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  • Ondrej Franek
    Affiliations
    Emergency Medical Service Prague, Czech Republic
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  • Ondrej Smid
    Affiliations
    2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
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  • Michal Huptych
    Affiliations
    Czech Institute of Informatics, Robotics and Cybernetics (CIIRC), Czech Technical University in Prague, Czech Republic
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  • Milan Dusik
    Affiliations
    2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
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  • Ales Linhart
    Affiliations
    2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
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  • Jan Belohlavek
    Affiliations
    2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
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      Abstract

      Background

      The prognosis of refractory out-of-hospital cardiac arrest (OHCA) is generally poor. A recent Prague OHCA study has demonstrated that an invasive approach (including extracorporeal cardiopulmonary resuscitation, ECPR) is a feasible and effective treatment strategy in refractory OHCA. Here we present a post-hoc analysis of the role of initial rhythm on patient outcomes.

      Methods

      The study enrolled patients who had a witnessed OHCA of presumed cardiac cause without early recovery of spontaneous circulation. The initial rhythm was classified as either a shockable or a non-shockable rhythm. The primary outcome was a composite of 180 day-survival with Cerebral Performance in Category 1 or 2.

      Results

      256 (median age 58y, 17% females) patients were enrolled. The median (IQR) duration of resuscitation was 52 (33–68) minutes. 156 (61%) and 100 (39%) of patients manifested a shockable and non-shockable rhythm, respectively. The primary outcome was achieved in 63 (40%) patients with a shockable rhythm and in 5 (5%) patients with a non-shockable rhythm (p < 0.001). When patients were analyzed separately based on whether the treatment was invasive (n = 124) or standard (n = 132), the difference in the primary endpoint between shockable and non-shockable initial rhythms remained significant (35/72 (49%) vs 4/52 (8%) in the invasive arm and 28/84 (33%) vs 1/48 (2%) in the standard arm; p < 0.001).

      Conclusion

      An initial shockable rhythm and treatment with an invasive approach is associated with a reasonable neurologically favorable survival for 180 days despite refractory OHCA. Non-shockable initial rhythms bear a poor prognosis in refractory OHCA even when ECPR is readily available.

      Keywords

      Abbreviations:

      OHCA (out-of-hospital cardiac arrest), ECPR (extracorporeal cardiopulmonary resuscitation), VF (ventricular fibrillation), PEA (pulseless electrical activity), ROSC (recovery of spontaneous circulation), CPR (cardiopulmonary resuscitation), CA (cardiac arrest), ECR (European Resuscitation Council), LUCAS (Lund University Cardiac Arrest System), S (standard), I (invasive), CPC (Cerebral Performance Category), IQR (interquartile range), ICD (impantable cardioverter-defibrilator), EMS (emergency medical service), ACLS (advanced cardiac life support), TTM (target temperature management), MODS (multiorgan dysfunction syndrome), WLST (withdrawal of life-sustaining therapy), HR (hazard ratio), CI (confidence interval)
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      References

        • Perkins G.D.
        • Graesner J.T.
        • Semeraro F.
        • et al.
        European Resuscitation Council Guidelines 2021: Executive summary.
        Resuscitation. 2021; 161: 1-60
        • Nichol G.
        • Thomas E.
        • Callaway C.W.
        • et al.
        Regional variation in out-of-hospital cardiac arrest incidence and outcome.
        JAMA. 2008; 300: 1423-1431
        • Grunau B.
        • Reynolds J.C.
        • Scheuermeyer F.X.
        • et al.
        Comparing the prognosis of those with initial shockable and non-shockable rhythms with increasing durations of CPR: Informing minimum durations of resuscitation.
        Resuscitation. 2016; 101: 50-56
        • Hollenberg J.
        • Herlitz J.
        • Lindqvist J.
        • et al.
        Improved survival after out-of-hospital cardiac arrest is associated with an increase in proportion of emergency crew–witnessed cases and bystander cardiopulmonary resuscitation.
        Circulation. 2008; 118: 389-396
        • Iwami T.
        • Nichol G.
        • Hiraide A.
        • et al.
        Continuous improvements in “chain of survival” increased survival after out-of-hospital cardiac arrests: a large-scale population-based study.
        Circulation. 2009; 119: 728-734
        • Stiell I.G.
        • Wells G.A.
        • DeMaio V.J.
        • et al.
        Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS Study Phase I results. Ontario Prehospital Advanced Life Support.
        Ann Emerg Med. 1999; 33: 44-50
        • 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
        • Drennan I.R.
        • Lin S.
        • Sidalak D.E.
        • Morrison L.J.
        Survival rates in out-of-hospital cardiac arrest patients transported without prehospital return of spontaneous circulation: an observational cohort study.
        Resuscitation. 2014; 85: 1488-1493
        • Wampler D.A.
        • Collett L.
        • Manifold C.A.
        • Velasquez C.
        • McMullan J.T.
        Cardiac arrest survival is rare without prehospital return of spontaneous circulation.
        Prehosp Emerg Care. 2012; 16: 451-455
        • Haas N.L.
        • Coute R.A.
        • Hsu C.H.
        • Cranford J.A.
        • Neumar R.W.
        Descriptive analysis of extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest-An ELSO registry study.
        Resuscitation. 2017; 119: 56-62
        • Kagawa E.
        • Dote K.
        • Kato M.
        • et al.
        Should we emergently revascularize occluded coronaries for cardiac arrest?: rapid-response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention.
        Circulation. 2012; 126: 1605-1613
        • Ortega-Deballon I.
        • Hornby L.
        • Shemie S.D.
        • Bhanji F.
        • Guadagno E.
        Extracorporeal resuscitation for refractory out-of-hospital cardiac arrest in adults: A systematic review of international practices and outcomes.
        Resuscitation. 2016; 101: 12-20
        • Schober A.
        • Sterz F.
        • Herkner H.
        • et al.
        Emergency extracorporeal life support and ongoing resuscitation: a retrospective comparison for refractory out-of-hospital cardiac arrest.
        Emerg Med J. 2017; 34: 277-281
        • Wallmuller C.
        • Sterz F.
        • Testori C.
        • et al.
        Emergency cardio-pulmonary bypass in cardiac arrest: seventeen years of experience.
        Resuscitation. 2013; 84: 326-330
        • Belohlavek J.
        • Smalcova J.
        • Rob D.
        • et al.
        Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.
        JAMA. 2022; 327: 737-747
        • Belohlavek J.
        • Kucera K.
        • Jarkovsky J.
        • et al.
        Hyperinvasive approach to out-of hospital cardiac arrest using mechanical chest compression device, prehospital intraarrest cooling, extracorporeal life support and early invasive assessment compared to standard of care. A randomized parallel groups comparative study proposal. “Prague OHCA study”.
        J Transl Med. 2012; 10: 163
        • Monsieurs K.G.
        • Nolan J.P.
        • Bossaert L.L.
        • et al.
        European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary.
        Resuscitation. 2015; 95: 1-80
        • Nolan J.P.
        • Soar J.
        • Zideman D.A.
        • et al.
        Group ERCGW. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary.
        Resuscitation. 2010; 81: 1219-1276
        • Rubertsson S.
        • Lindgren E.
        • Smekal D.
        • et al.
        Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial.
        JAMA. 2014; 311: 53-61
        • Yannopoulos D.
        • Bartos J.
        • Raveendran G.
        • et al.
        Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial.
        Lancet. 2020; 396: 1807-1816
        • Alm-Kruse K.
        • Sorensen G.
        • Osbakk S.A.
        • et al.
        Outcome in refractory out-of-hospital cardiac arrest before and after implementation of an ECPR protocol.
        Resuscitation. 2021; 162: 35-42
        • Nas J.
        • Thannhauser J.
        • van Dijk E.
        • et al.
        Coronary angiography findings in patients with shock-resistant ventricular fibrillation cardiac arrest.
        Resuscitation. 2021; 164: 54-61
        • Grunau B.
        • Kime N.
        • Leroux B.
        • et al.
        Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest.
        JAMA. 2020; 324: 1058-1067
        • Reynolds J.C.
        • Frisch A.
        • Rittenberger J.C.
        • Callaway C.W.
        Duration of resuscitation efforts and functional outcome after out-of-hospital cardiac arrest: when should we change to novel therapies?.
        Circulation. 2013; 128: 2488-2494
        • Chen Y.S.
        • Lin J.W.
        • Yu H.Y.
        • et al.
        Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis.
        Lancet. 2008; 372: 554-561
        • Chen Y.S.
        • Yu H.Y.
        • Huang S.C.
        • et al.
        Extracorporeal membrane oxygenation support can extend the duration of cardiopulmonary resuscitation.
        Crit Care Med. 2008; 36: 2529-2535
        • Kim S.J.
        • Jung J.S.
        • Park J.H.
        • Park J.S.
        • Hong Y.S.
        • Lee S.W.
        An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study.
        Crit Care. 2014; 18: 535
        • Adabag S.
        • Hodgson L.
        • Garcia S.
        • et al.
        Outcomes of sudden cardiac arrest in a state-wide integrated resuscitation program: Results from the Minnesota Resuscitation Consortium.
        Resuscitation. 2017; 110: 95-100
        • Spaulding C.M.
        • Joly L.M.
        • Rosenberg A.
        • et al.
        Immediate coronary angiography in survivors of out-of-hospital cardiac arrest.
        N Engl J Med. 1997; 336: 1629-1633
        • Yannopoulos D.
        • Bartos J.A.
        • Aufderheide T.P.
        • et al.
        The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association.
        Circulation. 2019; 139: e530-e552
        • Kurkciyan I.
        • Meron G.
        • Sterz F.
        • et al.
        Spontaneous subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest.
        Resuscitation. 2001; 51: 27-32
        • Kurkciyan I.
        • Meron G.
        • Sterz F.
        • et al.
        Pulmonary embolism as a cause of cardiac arrest: presentation and outcome.
        Arch Intern Med. 2000; 160: 1529-1535
        • Meron G.
        • Kurkciyan I.
        • Sterz F.
        • et al.
        Non-traumatic aortic dissection or rupture as cause of cardiac arrest: presentation and outcome.
        Resuscitation. 2004; 60: 143-150
        • Cummins R.O.
        • Eisenberg M.S.
        • Hallstrom A.P.
        • Litwin P.E.
        Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation.
        Am J Emerg Med. 1985; 3: 114-119
        • Wilcox-Gok V.L.
        Survival from out-of-hospital cardiac arrest. A multivariate analysis.
        Med Care. 1991; 29: 104-114
        • Bascom K.E.
        • Dziodzio J.
        • Vasaiwala S.
        • et al.
        Derivation and Validation of the CREST Model for Very Early Prediction of Circulatory Etiology Death in Patients Without ST-Segment-Elevation Myocardial Infarction After Cardiac Arrest.
        Circulation. 2018; 137: 273-282