Temporal Trends in the Use of Therapeutic Hypothermia for Out-of-Hospital Cardiac Arrest

Abstract

Importance Despite evidence that therapeutic hypothermia improves patient outcomes for out-of-hospital cardiac arrest, use of this therapy remains low. Objective To determine whether the use of therapeutic hypothermia and patient outcomes have changed after publication of the Targeted Temperature Management trial on December 5, 2013, which supported more lenient temperature management for out-of-hospital cardiac arrest. Design, Setting, and Participants A retrospective cohort was conducted between January 1, 2013, and December 31, 2016, of 45 935 US patients in the Cardiac Arrest Registry to Enhance Survival who experienced out-of-hospital cardiac arrest and survived to hospital admission. Exposures Calendar time by quarter year. Main Outcomes and Measures Use of therapeutic hypothermia and patient survival to hospital discharge. Results Among 45 935 patients (17 515 women and 28 420 men; mean [SD] age, 59.3 [18.3] years) who experienced out-of-hospital cardiac arrest and survived to admission at 649 US hospitals, overall use of therapeutic hypothermia during the study period was 46.4%. In unadjusted analyses, the use of therapeutic hypothermia dropped from 52.5% in the last quarter of 2013 to 46.0% in the first quarter of 2014 after the December 2013 publication of the Targeted Temperature Management trial. Use of therapeutic hypothermia remained at or below 46.5% through 2016. In segmented hierarchical logistic regression analysis, the risk-adjusted odds of use of therapeutic hypothermia was 18% lower in the first quarter of 2014 compared with the last quarter of 2013 (odds ratio, 0.82; 95% CI, 0.71-0.94; P = .006). Similar point-estimate changes over time were observed in analyses stratified by presenting rhythm of ventricular tachycardia or ventricular fibrillation (odds ratio, 0.89; 95% CI, 0.71-1.13, P = .35) and pulseless electrical activity or asystole (odds ratio, 0.75; 95% CI, 0.63-0.89; P = .001). Overall risk-adjusted patient survival was 36.9% in 2013, 37.5% in 2014, 34.8% in 2015, and 34.3% in 2016 ( P < .001 for trend). In mediation analysis, temporal trends in use of hypothermia did not consistently explain trends in patient survival. Conclusions and Relevance In a US registry of patients who experienced out-of-hospital cardiac arrest, the use of guideline-recommended therapeutic hypothermia decreased after publication of the Targeted Temperature Management trial, which supported more lenient temperature thresholds. Concurrent with this change, survival among patients admitted to the hospital decreased, but was not mediated by use of hypothermia.

Temporal trends in the use of targeted temperature management after cardiac arrest and association with outcome: insights from the Paris Sudden Death Expertise Centre

“…The existence of an association between changes in TTM policies and outcome is debated as previous authors reported conflicting results [20,21]. Our results are in accordance with those from a recent North-American study [8], which explored a quite similar population of post-cardiac arrest patients. On the opposite, our results are discordant with those from Salter et al [5], who reported an association between the progressive switch from 33 to 36°C and an increase in both the proportion with fever in ICU and hospital mortality.…”

“…In a recent retrospective study performed in Australia and New Zealand, similar changes in clinicians' attitude regarding target temperature after CA, which occurred in up to one third of ICU, were associated with an increased proportion of patients with fever [5]. In the USA, where this treatment was historically less employed as compared with European countries, TTM use was shown to further decrease in many centers, as revealed by recent administrative data [8]. In parallel, Khera et al found that TTM use dropped in all subgroups of CA survivors (both shockable and non-shockable) [9].…”

“…7 Medical Intensive Care Unit, European University Hospital, Paris, France. 8 Medical Intensive Care Unit, Lariboisière University Hospital, Paris, France. 9 SAMU de Paris, DAR Necker University Hospital-Assistance, Paris, France.…”

Higenamine exerts an antispasmodic effect on cold‑induced vasoconstriction by regulating the PI3K/Akt, ROS/α2C‑AR and PTK9 pathways independently of the AMPK/eNOS/NO axis

“…Studies indicate that clinical-induction of hypothermia can improve the neurological function of unconscious subjects following unexpected cardiac arrest by preserving heart and brain stability (50)(51)(52)(53). Recently, it has been reported that early application of mild hypothermia therapy not only improves the neurological outcome, but also increases the survival probability of patients postdischarge (54). The present study's findings indicated that higenamine and its regulated pathways could play a significant role in the mild hypothermia therapy.…”

Célhőmérséklet a tartós újraélesztés utáni komplex intenzív kezelés során. Állásfoglalás az enyhe terápiás hypothermia mellett

“…A vizsgálat eredménye nagy vihart kavart a PCAS kezelésében, sok centrum szinte azonnal áttért a THTról a 36 °C-os testhőmérséklet-tartásra, mely az összes fiziológiai szervezeti választ és mellékhatást "kiveszi" a monitorozandó és kezelendő változók közül. A hűtési eljárás gyakorlatának csökkenése 2013 óta több vizsgálattal, regiszterrel alátámasztottan folyamatos, még az igen fejlett intenzív terápiás lehetőségekkel bíró országokban is (CARESS, ROC) [17]. Mindemellett úgy tűnik, hogy ezzel együtt a mortalitás enyhe emelkedést mutathat, mivel a 36 °C-os csoportokban több a hyperthermiás kiugrás, ami ugyanúgy káros a központi idegrendszernek, mint a THT leállításakor észlelt hyperpyrexia, amit a 2002-es tanulmányokban igazoltak.…”