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Clinical outcomes following out-of-hospital cardiac arrest: The minute-by-minute impact of bystander cardiopulmonary resuscitation

      Abstract

      Aims

      The time-dependent prognostic role of bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) patients has not been described with great precision, especially for neurologic outcomes. Our objective was to assess the association between bystander CPR, emergency medical service (EMS) response time, and OHCA patients’ outcomes.

      Methods

      This cohort study used the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registries. Bystander-witnessed adult OHCA treated by EMS were included. The primary outcome was survival to hospital discharge and secondary outcome was survival with a good neurologic outcome (modified Rankin scale 0–2). Multivariable logistic regression models were used to assess the associations and interactions between bystander CPR, EMS response time and clinical outcomes.

      Results

      Out of 229,637 patients, 41,012 were included (18,867 [46.0%] without bystander CPR and 22,145 [54.0%] with bystander CPR). Bystander CPR was independently associated with higher survival (adjusted odds ratio [AOR] = 1.70 [95%CI 1.61–1.80]) and survival with a good neurologic outcome (AOR = 1.87 [95%CI 1.70–2.06]), while longer EMS response times were independently associated with lower survival to hospital discharge (each additional minute of EMS response time: AOR = 0.92 [95%CI 0.91–0.93], p < 0.001) and lower survival with a good neurologic outcome (AOR = 0.88 [95%CI 0.86–0.89], p < 0.001). There was no interaction between bystander CPR and EMS response time’s association with survival (p = 0.12) and neurologic outcomes (p = 0.65).

      Conclusions

      Although bystander CPR is associated with an immediate increase in odds of survival and of good neurologic outcome for OHCA patients, it does not influence the negative association between longer EMS response time and survival and good neurologic outcome.

      Keywords

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      References

        • Mozaffarian D.
        • Benjamin E.J.
        • Go A.S.
        • et al.
        American Heart Association Statistics C and Stroke Statistics S. Heart disease and stroke statistics--2015 update: a report from the American Heart Association.
        Circulation. 2015; 131: e29-e322
        • Gardner M.J.
        • Leather R.
        • Teo K.
        Prevention of sudden death from ventricular arrhythmia.
        Epidemiol Can J Cardiol. 2000; : 10C-12C
        • Benjamin E.J.
        • Muntner P.
        • Alonso A.
        • et al.
        American Heart Association Council on E, Prevention Statistics C and Stroke Statistics S. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association.
        Circulation. 2019; 139: e56-e528
        • Virani S.S.
        • Alonso A.
        • Aparicio H.J.
        • et al.
        American Heart Association Council on E, Prevention Statistics C and Stroke Statistics S. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association.
        Circulation. 2021; 143: e254-e743
        • Weisfeldt M.L.
        • Sitlani C.M.
        • Ornato J.P.
        • et al.
        Survival after application of automatic external defibrillators before arrival of the emergency medical system: evaluation in the resuscitation outcomes consortium population of 21 million.
        J Am Coll Cardiol. 2010; 55: 1713-1720
        • Berdowski J.
        • Berg R.A.
        • Tijssen J.G.
        • Koster R.W.
        Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies.
        Resuscitation. 2010; 81: 1479-1487
        • Kronick S.L.
        • Kurz M.C.
        • Lin S.
        • et al.
        Part 4: Systems of Care and Continuous Quality Improvement: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
        Circulation. 2015; 132: S397-S413
        • 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.
        Resuscitation. 2015; 96: 328-340
        • Cournoyer A.
        • Notebaert E.
        • Iseppon M.
        • et al.
        Prehospital advanced cardiac life support for out-of-hospital cardiac arrest: a cohort study.
        Acad Emerg Med. 2017;
        • Adnet F.
        • Triba M.N.
        • Borron S.W.
        • et al.
        Cardiopulmonary resuscitation duration and survival in out-of-hospital cardiac arrest patients.
        Resuscitation. 2017; 111: 74-81
        • Neumar R.W.
        • Nolan J.P.
        • Adrie C.
        • et al.
        Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council.
        Circulation. 2008; 118: 2452-2483
        • Lurie K.G.
        • Nemergut E.C.
        • Yannopoulos D.
        • Sweeney M.
        The physiology of cardiopulmonary resuscitation.
        Anesth Analg. 2016; 122: 767-783
        • Hasselqvist-Ax I.
        • Riva G.
        • Herlitz J.
        • et al.
        Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest.
        N Engl J Med. 2015; 372: 2307-2315
        • Rea T.D.
        • Cook A.J.
        • Stiell I.G.
        • et al.
        Predicting survival after out-of-hospital cardiac arrest: role of the Utstein data elements.
        Ann Emerg Med. 2010; 55: 249-257
        • Georgiou M.
        • Papathanassoglou E.
        • Xanthos T.
        Systematic review of the mechanisms driving effective blood flow during adult CPR.
        Resuscitation. 2014; 85: 1586-1593
        • 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
        • Larsen M.P.
        • Eisenberg M.S.
        • Cummins R.O.
        • Hallstrom A.P.
        Predicting survival from out-of-hospital cardiac arrest: a graphic model.
        Ann Emerg Med. 1993; 22: 1652-1658
        • Cournoyer A.
        • Chauny J.M.
        • Paquet J.
        • et al.
        Electrical rhythm degeneration in adults with out-of-hospital cardiac arrest according to the no-flow and bystander low-flow time.
        Resuscitation. 2021;
        • D'Arrigo S.
        • Cacciola S.
        • Dennis M.
        • et al.
        Predictors of favourable outcome after in-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation: A systematic review and meta-analysis.
        Resuscitation. 2017; 121: 62-70
        • Cournoyer A.
        • de Montigny L.
        • Potter B.J.
        • et al.
        Can a Shockable Initial Rhythm Identify Out-of-Hospital Cardiac Arrest Patients with a Short No-flow Time?.
        Resuscitation. 2020; 158: 57-63
        • Maupain C.
        • Bougouin W.
        • Lamhaut L.
        • et al.
        The CAHP (Cardiac Arrest Hospital Prognosis) score: a tool for risk stratification after out-of-hospital cardiac arrest.
        Eur Heart J. 2016; 37: 3222-3228
        • Cournoyer A.
        • Notebaert E.
        • de Montigny L.
        • et al.
        Impact of the direct transfer to percutaneous coronary intervention-capable hospitals on survival to hospital discharge for patients with out-of-hospital cardiac arrest.
        Resuscitation. 2018; 125: 28-33
        • Morrison L.J.
        • Nichol G.
        • Rea T.D.
        • et al.
        Rationale, development and implementation of the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest.
        Resuscitation. 2008; 78: 161-169
        • Nichol G.
        • Leroux B.
        • Wang H.
        • et al.
        Trial of Continuous or Interrupted Chest Compressions during CPR.
        N Engl J Med. 2015; 373: 2203-2214
        • Kudenchuk P.J.
        • Brown S.P.
        • Daya M.
        • et al.
        Dorian P and Resuscitation Outcomes Consortium I. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest.
        N Engl J Med. 2016; 374: 1711-1722
        • Aufderheide T.P.
        • Nichol G.
        • Rea T.D.
        • et al.
        Sopko G and Resuscitation Outcomes Consortium I. A trial of an impedance threshold device in out-of-hospital cardiac arrest.
        N Engl J Med. 2011; 365: 798-806
        • Stiell I.G.
        • Nichol G.
        • Leroux B.G.
        • et al.
        Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest.
        N Engl J Med. 2011; 365: 787-797
        • van Swieten J.C.
        • Koudstaal P.J.
        • Visser M.C.
        • Schouten H.J.
        • van Gijn J.
        Interobserver agreement for the assessment of handicap in stroke patients.
        Stroke. 1988; 19: 604-607
        • Grissom R.J.
        • Kim J.J.
        Effect sizes for research: Univariate and multivariate applications.
        Routledge, 2012
        • Sawilosky S.S.
        New effect size rule of thumb.
        J Mod Appl Stat Methods. 2009; 8: 597-599
        • Song J.
        • Guo W.
        • Lu X.
        • Kang X.
        • Song Y.
        • Gong D.
        The effect of bystander cardiopulmonary resuscitation on the survival of out-of-hospital cardiac arrests: a systematic review and meta-analysis.
        Scand J Trauma Resusc Emerg Med. 2018; 26: 86
        • Iwami T.
        • Kitamura T.
        • Kiyohara K.
        • Kawamura T.
        Dissemination of chest compression-only cardiopulmonary resuscitation and survival after out-of-hospital cardiac arrest.
        Circulation. 2015; 132: 415-422
        • Chalkias A.
        • Xanthos T.
        Post-cardiac arrest brain injury: Pathophysiology and treatment.
        J Neurol Sci. 2012; 315: 1-8
        • Hightower D.
        • Thomas S.H.
        • Stone C.K.
        • Dunn K.
        • March J.A.
        Decay in quality of closed-chest compressions over time.
        Ann Emerg Med. 1995; 26: 300-303
        • Gallagher E.J.
        • Lombardi G.
        • Gennis P.
        Effectiveness of bystander cardiopulmonary resuscitation and survival following out-of-hospital cardiac arrest.
        JAMA. 1995; 274: 1922-1925
        • Fernando S.M.
        • Vaillancourt C.
        • Morrow S.
        • Stiell I.G.
        Analysis of bystander CPR quality during out-of-hospital cardiac arrest using data derived from automated external defibrillators.
        Resuscitation. 2018; 128: 138-143
        • Tagami T.
        • Hirata K.
        • Takeshige T.
        • et al.
        Implementation of the fifth link of the chain of survival concept for out-of-hospital cardiac arrest.
        Circulation. 2012; 126: 589-597
        • Panchal A.R.
        • Bartos J.A.
        • Cabanas J.G.
        • et al.
        Adult B and Advanced Life Support Writing G. Part 3: Adult Basic and Advanced Life Support: 20220 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
        Circulation. 2020; 142: S366-S468
        • Pachys G.
        • Kaufman N.
        • Bdolah-Abram T.
        • Kark J.D.
        • Einav S.
        Predictors of long-term survival after out-of-hospital cardiac arrest: the impact of Activities of Daily Living and Cerebral Performance Category scores.
        Resuscitation. 2014; 85: 1052-1058
        • Zakhary B.
        • Nanjayya V.B.
        • Sheldrake J.
        • Collins K.
        • Ihle J.F.
        • Pellegrino V.
        Predictors of mortality after extracorporeal cardiopulmonary resuscitation.
        Crit Care Resusc. 2018; 20: 223-230
        • Vaillancourt C.
        • Lui A.
        • De Maio V.J.
        • Wells G.A.
        • Stiell I.G.
        Socioeconomic status influences bystander CPR and survival rates for out-of-hospital cardiac arrest victims.
        Resuscitation. 2008; 79: 417-423
        • Valenzuela T.D.
        • Roe D.J.
        • Cretin S.
        • Spaite D.W.
        • Larsen M.P.
        Estimating effectiveness of cardiac arrest interventions: a logistic regression survival model.
        Circulation. 1997; 96: 3308-3313
        • Guy A.
        • Kawano T.
        • Besserer F.
        • et al.
        The relationship between no-flow interval and survival with favourable neurological outcome in out-of-hospital cardiac arrest: Implications for outcomes and ECPR eligibility.
        Resuscitation. 2020; 155: 219-225
        • Stoesser C.E.
        • Boutilier J.J.
        • Sun C.L.F.
        • et al.
        Moderating effects of out-of-hospital cardiac arrest characteristics on the association between EMS response time and survival.
        Resuscitation. 2021; 169: 31-38
        • Chocron R.
        • Jobe J.
        • Guan S.
        • et al.
        Bystander Cardiopulmonary Resuscitation Quality: Potential for Improvements in Cardiac Arrest Resuscitation.
        J Am Heart Assoc. 2021; 10: e017930