Factors Associated With Pulseless Electric Activity Versus Ventricular Fibrillation

Abstract

Background— Corresponding with a continuing decline in the prevalence of sudden cardiac arrest cases presenting with ventricular fibrillation (VF), there has been a significant rise in the prevalence of pulseless electrical activity (PEA). Given significantly lower survival from PEA versus VF, we comprehensively investigated PEA correlates by incorporating first-responder data with lifetime clinical history information. Methods and Results— In the Portland, Ore, metropolitan area (population ≈1 million), cases of out-of-hospital sudden cardiac arrest who underwent attempted resuscitation were identified prospectively (2002–2007). Those presenting with PEA versus VF and asystole were compared with χ 2 tests, ANOVA, and logistic regression. A total of 1277 cases aged ≥18 years underwent resuscitation by first responders (mean age, 65±16 years; 67% male). Presenting arrhythmia was VF in 48%, PEA in 25%, and asystole/other in the remainder. Compared with VF cases, PEA cases were older (mean age, 68 versus 63 years; P =0.0002), more likely to be female (37% versus 26%; P =0.0008), and less likely to survive to hospital discharge (6% versus 25%; P <0.0001). A history of syncope was strongly associated with PEA (odds ratio, 2.6; confidence interval, 1.3 to 5.3) after adjustment for age, gender, response time, and arrest circumstances. Black race was also independently associated with PEA (odds ratio, 2.6; confidence interval, 1.3 to 5.4). Pulmonary disease and female gender were significant factors associated with PEA ( P for interaction=0.04). In a subgroup analysis of resting ECGs (n=391), there were no differences in cardiac clinical history or prevalence of cardiac conduction system disease (PEA, 31.6% versus VF, 32.2%; P =0.48). Conclusions— PEA cases had a significantly higher prevalence of syncope in their lifetime, with other correlates, including black race, that were distinct from VF cases. Potential mechanistic links between syncope and future manifestation with PEA warrant further exploration.

Pulseless Electric Activity

“…Several studies have shown that women are significantly more likely than men to manifest PEA. [45][46][47] In the Oregon SUDS, approximately one third of women presented with PEA, 45 and after adjustment for demographics, Utstein data elements, and disease burden, female sex remained a significant predictor of PEA (OR, 1.48; 95% CI, 1.05-2.09). 48 However, women appear to have a survival advantage over men for SCA resuscitation outcomes.…”

“…44 In addition, an analysis from the Oregon Sudden Unexpected Death Study (Oregon SUDS) showed that older age was a significant predictor of future PEA after adjustment for other demographic variables, arrest circumstances, and comorbidities. 45 Sex is also associated with the presenting arrhythmia during SCA. Several studies have shown that women are significantly more likely than men to manifest PEA.…”

“…48 Several studies report an association between black race and the propensity to present with PEA. 45,48,49 In 3 suburban counties in Michigan, 21% of blacks versus 14% of whites presented with PEA. 50 In the Oregon SUDS, black race was strongly associated with PEA as opposed to VF (OR, 2.64; 95% CI, 1.29-5.38) after adjustment for age, sex, resuscitation variables, and comorbidities.…”

Causes of sudden unexpected death of adult hospital patients

“…In other studies, there has been an unexplained continuing decline in the prevalence of sudden cardiac arrest cases presenting with ventricular fibrillation and corresponding rise in the prevalence of pulseless electrical activity (PEA) arrests. 4 The 7 patients who had an initial cardiac rhythm of PEA and were judged to have died of an arrhythmia were all, except 1, off cardiac monitoring. Four had myocardial infarctions, 3 heart block pre-arrest, 1 postoperative intramyocardial hematoma, 1 myocardial metastatic melanoma, 1 acute heart transplant rejection, and 3 ventricular tachycardia or fibrillation following PEA, suggesting that PEA was a phase in the evolution of an arrhythmogenic death.…”

Discordant Alternans as a Mechanism for Initiation of Ventricular Fibrillation In Vitro

“…A substantial proportion of sudden cardiac arrests, approximately half in a recent study,2 are associated with ventricular tachycardia (VT) or ventricular fibrillation (VF). It has been observed clinically that sustained VT and VF are often preceded by several irregularly timed premature complexes,3, 4 and studies conducted to explore this phenomenon have shown that specific coupling interval patterns of premature complexes, such as short‐long‐short5 and short‐short‐short,6 tend to lead to reentry and VT.…”