Targeted Temperature Management in Cardiac Arrest Patients With an Initial Non-Shockable Rhythm: A Systematic Review and Meta-Analysis

Barbarawi, Mahmoud; Al‐Abdouh, Ahmad; Barbarawi, Owais; Lakshman, Harini; Alkasasbeh, Mariam; Rizk, Fatima; Bachuwa, Ghassan; Alkotob, Mohammad Luay

doi:10.1097/shk.0000000000001550

Cited by 6 publications

(7 citation statements)

References 44 publications

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“…Previous frequentist meta-analyses of TTM have reported an overall (considering all studies regardless of initial rhythm, TTM characteristics and times for outcome assessment) non-significant effect on survival and a variable but mostly favourable effect on neurological outcomes by TTM 32–34 [ 6 , 7 , 9 , 10 , 45 ]. Reviews of TTM in post-cardiac arrest care using expanded inclusion criteria and including retrospective, observational cohort studies, while unsuitable to inform clinical practice, have reported a benefit of TTM 32–34 [ 4 , 46 ]. Two recent meta-analyses including the TTM2 trial concluded that various levels of hypothermic TTM may not improve survival or neurological outcome compared to normothermia [ 47 , 48 ] while associated with higher incidence of arrhythmias [ 48 ].…”

Section: Discussionmentioning

confidence: 99%

“…Study heterogeneity in previous [ 4 – 10 ] and recent [ 47 – 50 ] systematic reviews and meta-analyses has been moderate to high [ 51 ] and largely related to studies where hypothermia was compared to no temperature control including a proportion of patients with febrile temperatures. The addition of the recent study by Dankiewicz et al [ 17 ] to the cumulative evidence has reduced heterogeneity given its sample size and protocolised avoidance of fever, similar to the original study by Nielsen et al [ 40 ].…”

Section: Discussionmentioning

confidence: 99%

“…Temperature control with target temperature management (TTM) after cardiac arrest has been endorsed by expert societies and adopted in international clinical practice guidelines [ 1 – 3 ] based on several randomised controlled trials (RCTs), systematic reviews and meta-analyses [ 4 – 10 ]. The original studies and systematic reviews have exclusively used frequentist methods for statistical inference.…”

Section: Introductionmentioning

confidence: 99%

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Target temperature management following cardiac arrest: a systematic review and Bayesian meta-analysis

et al. 2022

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Background Temperature control with target temperature management (TTM) after cardiac arrest has been endorsed by expert societies and adopted in international clinical practice guidelines but recent evidence challenges the use of hypothermic TTM. Methods Systematic review and Bayesian meta-analysis of clinical trials on adult survivors from cardiac arrest undergoing TTM for at least 12 h comparing TTM versus no TTM or with a separation > 2 °C between intervention and control groups using the PubMed/MEDLINE, EMBASE, CENTRAL databases from inception to 1 September 2021 (PROSPERO CRD42021248140). All randomised and quasi-randomised controlled trials were considered. The risk ratio and 95% confidence interval for death (primary outcome) and unfavourable neurological recovery (secondary outcome) were captured using the original study definitions censored up to 180 days after cardiac arrest. Bias was assessed using the updated Cochrane risk-of-bias for randomised trials tool and certainty of evidence assessed using the Grading of Recommendation Assessment, Development and Evaluation methodology. A hierarchical robust Bayesian model-averaged meta-analysis was performed using both minimally informative and data-driven priors and reported by mean risk ratio (RR) and its 95% credible interval (95% CrI). Results In seven studies (three low bias, three intermediate bias, one high bias, very low to low certainty) recruiting 3792 patients the RR by TTM 32–34 °C was 0.95 [95% CrI 0.78—1.09] for death and RR 0.93 [95% CrI 0.84—1.02] for unfavourable neurological outcome. The posterior probability for no benefit (RR ≥ 1) by TTM 32–34 °C was 24% for death and 12% for unfavourable neurological outcome. The posterior probabilities for favourable treatment effects of TTM 32–34 °C were the highest for an absolute risk reduction of 2–4% for death (28–53% chance) and unfavourable neurological outcome (63–78% chance). Excluding four studies without active avoidance of fever in the control arm reduced the probability to achieve an absolute risk reduction > 2% for death or unfavourable neurological outcome to ≤ 50%. Conclusions The posterior probability distributions did not support the use of TTM at 32–34 °C compared to 36 °C also including active control of fever to reduce the risk of death and unfavourable neurological outcome at 90–180 days. Any likely benefit of hypothermic TTM is smaller than targeted in RCTs to date.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Target temperature management following cardiac arrest: a systematic review and Bayesian meta-analysis

et al. 2022

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“…However, it is still a weak recommendation and is from very low-quality evidence. So far, there have been 3 meta-analyses published on this topic with inconsistent results (7)(8)(9). However, the main problem of these articles was the inclusion of most observational studies but only a small number of RCTs, leading to a high risk of bias and random error in these studies.…”

Section: Comparison With Previous Studiesmentioning

confidence: 99%

“…Currently, the guidelines recommend TTM for CA survivors with SR or NSR (3). However, compared with CA survivors with SR having conclusive evidence of TTM to support their use, studies focusing on TTM for NSR survivors have reported conflicting results (7)(8)(9). Most current clinical recommendations are based on the consensus of expert opinions and extrapolate the potential benefits of TTM in NSR patients from the evidence of SR survivors (3,4).…”

Section: Introductionmentioning

confidence: 99%

Targeted Temperature Management for Cardiac Arrest Due to Non-shockable Rhythm: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

et al. 2022

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BackgroundTargeted temperature management (TTM) is recommended in adult patients following cardiac arrest (CA) with any rhythm. However, as to non-shockable (NSR) CA, high-quality evidence of TTM supporting its practices remains uncertain. Thus, we aimed to conduct a systematic review and meta-analysis with randomized controlled trials (RCTs) to explore the efficacy and safety of TTM in this population.MethodsWe searched PubMed, Embase, and Cochrane library databases for potential trials from inception through Aug 25, 2021. RCTs evaluating TTM for CA adults due to NSR were included, regardless of the timing of cooling initiation. Outcome measurements were mortality and good neurological function. We used the Cochrane bias tools to evaluate the quality of the included studies. Heterogeneity, subgroup analyses, and sensitivity analysis were investigated to test the robustness of the primary outcomes.ResultsA total of 14 RCTs with 4,009 adults were eligible for the final analysis. All trials had a low to moderate risk of bias. Of the included trials, six compared NSR patients with or without TTM, while eight compared pre-hospital to in-hospital TTM. Pooled data showed that TTM was not associated with improved mortality (Risk ratio [RR] 1.00; 95% CI, 0.944–1.05; P = 0.89, I2 = 0%) and good neurological outcome (RR 1.18; 95% CI 0.90–1.55; P = 0.22, I2 = 8%). Similarly, use of pre-hospital TTM resulted in neither an improved mortality (RR 0.99, 95% CI 0.97–1.03; I2 = 0%, P = 0.32) nor favorable neurological outcome (RR 1.13, 95% CI 0.93–1.38; I2 = 0%, P = 0.22). These results were further confirmed in the sensitivity analyses and subgroup analyses.ConclusionsOur results showed that using the TTM strategy did not significantly affect the mortality and neurologic outcomes in CA survival presenting initial NSR.

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Cost-Effectiveness Analysis of Intravascular Targeted Temperature Management after Cardiac Arrest in England

Javanbakht¹,

Mashayekhi²,

Hemami³

et al. 2022

PharmacoEconomics Open

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Background Targeted temperature management (TTM) has been shown to improve neurological outcomes and survival in patients resuscitated from cardiac arrest; however, the cost effectiveness of multiple TTM methods is not well studied. Objective This study aimed to evaluate the cost effectiveness of intravascular temperature management (IVTM) using Thermogard XP compared with surface cooling methods after cardiac arrest in the England from the perspectives of the UK national health service and Personal Social Services. Methods We developed a multi-state Markov model that evaluated IVTM (Thermogard XP) compared with surface cooling using two different devices (Blanketrol III and Arctic Sun 5000) over a short-term and lifetime time horizon. Model input parameters were obtained from the literature and local databases. We assumed a hypothetical cohort of 1000 patients who required TTM after cardiac arrest per year in the England. The outcomes were costs (in £, year 2019 values) and qualityadjusted life-years (QALYs), discounted at 3.5% annually. Deterministic and probabilistic sensitivity analyses were undertaken to examine the effect of alternative assumptions and uncertainty in model parameters on the results. ResultsThe cost-effectiveness analysis determined that Thermogard XP resulted in direct cost savings of £2339 and £2925 (per patient) compared with Blanketrol III and Arctic Sun 5000, respectively, and a gain of 0.98 QALYs over the patient lifetime. The probabilistic sensitivity analysis demonstrated that the probability of Thermogard XP being cost saving would be 69.2% and 65.3% versus the Arctic Sun 5000 and Blanketrol III, respectively. Conclusion Implementation of IVTM using Thermogard XP can lead to cost savings and improved patient quality of life versus surface cooling methods.

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Targeted Temperature Management in Cardiac Arrest Patients With an Initial Non-Shockable Rhythm: A Systematic Review and Meta-Analysis

Cited by 6 publications

References 44 publications

Target temperature management following cardiac arrest: a systematic review and Bayesian meta-analysis

Target temperature management following cardiac arrest: a systematic review and Bayesian meta-analysis

Targeted Temperature Management for Cardiac Arrest Due to Non-shockable Rhythm: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Cost-Effectiveness Analysis of Intravascular Targeted Temperature Management after Cardiac Arrest in England

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