Postresuscitation care with mild therapeutic hypothermia and coronary intervention after out-of-hospital cardiopulmonary resuscitation: a prospective registry analysis

Abstract

IntroductionMild therapeutic hypothermia (MTH) has been shown to result in better neurological outcome after cardiopulmonary resuscitation. Percutaneous coronary intervention (PCI) may also be beneficial in patients after out-of-hospital cardiac arrest (OHCA).MethodsA selected cohort study of 2,973 prospectively documented adult OHCA patients within the German Resuscitation Registry between 2004 and 2010. Data were analyzed by backwards stepwise binary logistic regression to identify the impact of MTH and PCI on both 24-hour survival and neurological outcome that was based on cerebral performance category (CPC) at hospital discharge. Odds ratios (95% confidence intervals) were calculated adjusted for the following confounding factors: age, location of cardiac arrest, presumed etiology, bystander cardiopulmonary resuscitation, witnessing, first electrocardiogram rhythm, and thrombolysis.ResultsThe Preclinical care dataset included 2,973 OHCA patients with 44% initial return of spontaneous circulation (n = 1,302) and 35% hospital admissions (n = 1,040). Seven hundred and eleven out of these 1,040 OHCA patients (68%) were also registered within the Postresuscitation care dataset. Checking for completeness of datasets required the exclusion of 127 Postresuscitation care cases, leaving 584 patients with complete data for final analysis. In patients without PCI (n = 430), MTH was associated with increased 24-hour survival (8.24 (4.24 to 16.0), P < 0.001) and the proportion of patients with CPC 1 or CPC 2 at hospital discharge (2.13 (1.17 to 3.90), P < 0.05) as an independent factor. In normothermic patients (n = 405), PCI was independently associated with increased 24-hour survival (4.46 (2.26 to 8.81), P < 0.001) and CPC 1 or CPC 2 (10.81 (5.86 to 19.93), P < 0.001). Additional analysis of all patients (n = 584) revealed that 24-hour survival was increased by MTH (7.50 (4.12 to 13.65), P < 0.001) and PCI (3.88 (2.11 to 7.13), P < 0.001), while the proportion of patients with CPC 1 or CPC 2 was significantly increased by PCI (5.66 (3.54 to 9.03), P < 0.001) but not by MTH (1.27 (0.79 to 2.03), P = 0.33), although an unadjusted Fisher exact test suggested a significant effect of MTH (unadjusted odds ratio 1.83 (1.23 to 2.74), P < 0.05).ConclusionsPCI may be an independent predictor for good neurological outcome (CPC 1 or CPC 2) at hospital discharge. MTH was associated with better neurological outcome, although subsequent logistic regression analysis did not show statistical significance for MTH as an independent predictor for good neurological outcome. Thus, postresuscitation care on the basis of standardized protocols including coronary intervention and hypothermia may be beneficial after successful resuscitation. One of the main limitations may be a selection bias for patients subjected to PCI and MTH.

Post–Cardiac Arrest Mortality Is Declining

“…5 In addition, results from observational studies have suggested that some interventions, such as immediate coronary intervention, may improve survival in certain populations. 6,7 Over the past decade, the highest level of evidence for a treatment that improves outcomes came from 2 randomized trials published in 2002 that showed that induced hypothermia reduces mortality and improves neurological outcomes in patients with out-of-hospital ventricular fibrillation cardiac arrest. 8,9 Primarily on the basis of these trials, therapeutic hypothermia (TH) is now considered standard-of-care in the United States for patients who remain comatose after resuscitation for this particular patient population.…”

Major interventions are associated with survival of out of hospital cardiac arrest patients - a population based survey

“…(27) In contrast with urbanization, higher level of hospital care, such as in a medical center, was associated with successful ROSC in our report. Several studies have identified in-hospital factors associated with improved mortality after successful resuscitation from OHCA in patients ad- (36,37) or with no ST elevation on ECG. (38,39) The benefit of ECMO on survival and neurological function in a selected patient group following OHCA had also been documented.…”

Advances in Resuscitation

“…Interestingly, the hypothermia group demonstrated a significant reduction in infarct size as measured by cardiac magnetic resonance imaging and cardiac biomarker measurement. Gräsner et al 134 recently published work on the effect of PCI and TH in OHCA patients who survived to hospital admission. Patients who received TH without PCI demonstrated improved 24-hour survival and neurological outcome.…”