RESUMEN
Importance: Ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) are the most treatable causes of out-of-hospital cardiac arrest (OHCA). Yet, it remains unknown if defibrillator pad position, placement in the anterior-posterior (AP) or anterior-lateral (AL) locations, impacts patient outcomes in VF or pVT OHCA. Objective: To determine the association between initial defibrillator pad placement position and OHCA outcomes for patients presenting with VF or pVT. Design, Setting, and Participants: This prospective cohort study included patients with OHCA and VF or pVT treated by a single North American emergency medical services (EMS) agency from July 1, 2019, through June 30, 2023. The study included patients with OHCA treated by a large suburban fire-based EMS agency that covers a population of 550â¯000. Consecutive patients with an initial EMS-assessed rhythm of VF or pVT receiving EMS defibrillation were included. Pediatric patients (younger than 18 years), interfacility transfers, arrests of obvious traumatic etiology, and patients with preexisting do-not-resuscitate status were excluded. Exposure: AP or AL pad placement. Main Outcomes and Measures: Return of spontaneous circulation (ROSC) at any time with secondary outcomes of pulses present at emergency department (ED) arrival, survival to hospital admission, survival to hospital discharge, and functional survival at hospital discharge (cerebral performance category score of 2 or less). Measures included adjusted odds ratios (aOR), multivariable logistic regressions, and Fine-Gray competing risks regression. Results: A total of 255 patients with OHCA were included (median [IQR] age, 66 [55-74] years; 63 females [24.7%]), with initial pad positioning documented as either AP (158 patients [62.0%]; median [IQR] age, 65 [54-74] years; 37 females [23.4%]) or AL (97 patients [38.0%]; median [IQR] age, 66 [57-74] years; 26 females [26.8%]). Patients with AP placement had higher adjusted odds ratio (aOR) of ROSC at any time (aOR, 2.64 [95% CI, 1.50-4.65]), but not significantly different odds of pulses present at ED arrival (1.34 [95% CI, 0.78-2.30]), survival to hospital admission (1.41 [0.82-2.43]), survival to hospital discharge (1.55 [95% CI, 0.83-2.90]), or functional survival at hospital discharge (1.86 [95% CI, 0.98-3.51]). Competing risk analysis found significantly greater cumulative incidence of ROSC among those at risk with initial AP placement compared with AL (subdistribution hazard ratio, 1.81 [95% CI, 1.23-2.67]; P = .003). Conclusions and Relevance: In this cohort study of patients with OHCA and VF or pVT, AP defibrillator pad placement was associated with higher ROSC compared with AL placement.
Asunto(s)
Desfibriladores , Paro Cardíaco Extrahospitalario , Humanos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Femenino , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Anciano , Desfibriladores/estadística & datos numéricos , Servicios Médicos de Urgencia/métodos , Servicios Médicos de Urgencia/estadística & datos numéricos , Fibrilación Ventricular/terapia , Resultado del Tratamiento , Cardioversión Eléctrica/estadística & datos numéricos , Cardioversión Eléctrica/métodos , Cardioversión Eléctrica/instrumentación , Taquicardia Ventricular/terapia , Reanimación Cardiopulmonar/métodosRESUMEN
AIMS: During out-of-hospital cardiac arrest (OHCA), an automatic external defibrillator (AED) analyzes the cardiac rhythm every two minutes; however, 80% of refibrillations occur within the first minute post-shock. We have implemented an algorithm for Analyzing cardiac rhythm While performing chest Compression (AWC). When AWC detects a shockable rhythm, it shortens the time between analyses to one minute. We investigated the effect of AWC on cardiopulmonary resuscitation quality. METHOD: In this cross-sectional study, we compared patients treated in 2022 with AWC, to a historical cohort from 2017. Inclusion criteria were OHCA patients with a shockable rhythm at the first analysis. Primary endpoint was the chest compression fraction (CCF). Secondary endpoints were cardiac rhythm evolution and survival, including survival analysis of non-prespecified subgroups. RESULTS: In 2017 and 2022, 355 and 377 OHCAs met the inclusion criteria, from which we analyzed the 285 first consecutive cases in each cohort. CCF increased in 2022 compared to 2017 (77% [72-80] vs 72% [67-76]; P < 0.001) and VF recurrences were shocked more promptly (53 s [32-69] vs 117 s [90-132]). Survival did not differ between 2017 and 2022 (adjusted hazard-ratio 0.96 [95% CI, 0.78-1.18]), but was higher in 2022 within the sub-group of OHCAs that occurred in a public place and within a short time from call to AED switch-on (adjusted hazard ratio 0.85[0.76-0.96]). CONCLUSIONS: OHCA patients treated with AWC had higher CCF, shorter time spent in ventricular fibrillation, but no survival difference, except for OHCA that occurred in public places with short intervention time.
Asunto(s)
Reanimación Cardiopulmonar , Paro Cardíaco Extrahospitalario , Humanos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Estudios Transversales , Masculino , Femenino , Reanimación Cardiopulmonar/métodos , Reanimación Cardiopulmonar/estadística & datos numéricos , Persona de Mediana Edad , Anciano , Masaje Cardíaco/métodos , Desfibriladores/estadística & datos numéricos , Cardioversión Eléctrica/métodos , Cardioversión Eléctrica/estadística & datos numéricos , Fibrilación Ventricular/terapia , Fibrilación Ventricular/complicaciones , Factores de Tiempo , Servicios Médicos de Urgencia/métodos , Servicios Médicos de Urgencia/estadística & datos numéricos , AlgoritmosRESUMEN
BACKGROUND: We aimed to evaluate the association between atrial fibrillation (AF) burden, duration and number of episodes with healthcare utilisation and quality of life in patients with early paroxysmal AF without a history of AF. METHODS: In this observational cohort study, we included 417 patients with paroxysmal AF from the Reappraisal of Atrial Fibrillation: interaction between hyperCoagulability, Electrical remodelling and Vascular destabilisation in the progression of AF (RACE V) Study. Patients were monitored with an insertable cardiac monitor for 1 year. Outcomes collected were healthcare utilisation, and quality of life assessed using the Atrial Fibrillation Severity Scale and EuroQol EQ-5D-5L questionnaires. RESULTS: During 1 year of follow-up, 63 973 AF episodes were detected in 353 (85%) patients. The median AF burden was 0.7% (IQR 0.1-4.0%). AF ablation was performed more frequently in patients with intermediate-to-high AF burdens (>0.2%) (16.2% vs 5.9%, p=0.01) and longer AF episode duration (>1 hour) (15.8% vs 2.0%, p=0.01), whereas cardioversions were more frequent in patients with longer episode duration (>1 hour) (9.5% vs 0%, p=0.04) and intermediate (0.2-1.9%) (but not high) AF burdens (13.6% vs 4.2%, p=0.01). Patients with many episodes (>147) reported higher symptom severity (p=0.001). No differences in symptom severity nor in EQ-5D-5L scores according to AF burden or duration were observed. CONCLUSION: In patients with early paroxysmal AF, higher AF burden and longer episode duration were associated with increased rates of healthcare utilisation but not with symptoms and quality of life. Patients with a higher number of episodes experienced more severe symptoms. TRIAL REGISTRATION NUMBER: NCT02726698.
Asunto(s)
Fibrilación Atrial , Calidad de Vida , Humanos , Fibrilación Atrial/terapia , Femenino , Masculino , Persona de Mediana Edad , Anciano , Factores de Tiempo , Ablación por Catéter/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Aceptación de la Atención de Salud/estadística & datos numéricos , Cardioversión Eléctrica/estadística & datos numéricos , Encuestas y CuestionariosRESUMEN
OBJECTIVE: Optimal timing for subsequent defibrillation attempts for Out-of-hospital cardiac arrest (OHCA) patients with recurrent VF/pVT is uncertain. We investigated the relationship between VF/pVT duration and return of spontaneous circulation (ROSC) in OHCA patients with recurrent shockable rhythms. METHODS: We analyzed data from the Salt Lake City Fire Department (SLCFD) spanning from 2012 to 2023. The implementation of rhythm-filtering technology since 2011 enabled real-time rhythm interpretation during CPR, with local protocols allowing early defibrillation for recurrent/refractory VF/pVT cases. We included patients experiencing four or five episodes of VF and pVT rhythms and employed generalized estimating equation (GEE) regression analysis to examine the association between VF/pVT durations preceding recurrent defibrillation and return of spontaneous circulation (ROSC). RESULTS: Analysis of 622 appropriate shocks showed that patients achieving ROSC had significantly shorter median VF/pVT duration than those who did not achieve ROSC (0.83 minutes vs. 1.2 minutes, p = 0.004). Adjusted analysis of those with 4 VF/pVT episodes (N = 142) revealed that longer VF/pVT durations were associated with lower odds of achieving ROSC (odds ratio: 0.81, 95% CI: 0.72-0.93, p = 0.005). Every one-minute delay in intra-arrest defibrillation is predicted to decrease the likelihood of achieving ROSC by 19%. CONCLUSION: Every one-minute increase in intra-arrest VF/pVT duration was associated with a statistically significant 19% decrease in the chance of achieving ROSC. This highlights the importance of reducing time to shock in managing recurrent VF/pVT. The findings suggest reevaluating the current recommendations of two minutes intervals for rhythm check and shock delivery.
Asunto(s)
Reanimación Cardiopulmonar , Cardioversión Eléctrica , Paro Cardíaco Extrahospitalario , Retorno de la Circulación Espontánea , Tiempo de Tratamiento , Humanos , Paro Cardíaco Extrahospitalario/terapia , Cardioversión Eléctrica/métodos , Cardioversión Eléctrica/estadística & datos numéricos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Reanimación Cardiopulmonar/métodos , Fibrilación Ventricular/terapia , Fibrilación Ventricular/complicaciones , Fibrilación Ventricular/fisiopatología , Taquicardia Ventricular/terapia , Taquicardia Ventricular/fisiopatología , Factores de Tiempo , Estudios Retrospectivos , RecurrenciaAsunto(s)
Desfibriladores , Humanos , Desfibriladores/provisión & distribución , Desfibriladores/estadística & datos numéricos , Encuestas y Cuestionarios , Masculino , Reanimación Cardiopulmonar/métodos , Cardioversión Eléctrica/métodos , Cardioversión Eléctrica/estadística & datos numéricos , Paro Cardíaco Extrahospitalario/terapiaRESUMEN
BACKGROUND: Out-of-hospital cardiac arrest (OHCA) patients from minoritized communities have lower rates of initial shockable rhythm, which is linked to favorable outcomes. We sought to evaluate the importance of initial shockable rhythm on OHCA outcomes and factors that mediate differences in initial shockable rhythm. METHODS: We performed a retrospective study of the 2013-2022 Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES). Using census tract data, we stratified OHCAs into majority race/ethnicity communities: >50% White, >50% Black, and >50% Hispanic/Latino. We compared logistic regression models between community race/ethnicity and OHCA outcome: (1) unadjusted, (2) adjusting for bystander CPR (bCPR), and (3) adjusting for initial rhythm. Using structural equation modeling, we performed mediation analyses between community race/ethnicity, OHCA characteristics, and initial shockable rhythm. RESULTS: We included 22,730 OHCAs from majority White (21.1% initial shockable rhythm), 4,749 from majority Black (15.3% shockable), and 16,054 majority Hispanic/Latino (16.1% shockable) communities. Odds of favorable neurologic outcome were lower for majority Black (0.4 [0.3-0.5]) and Hispanic/Latino (0.6 [0.6-0.7]). While adjusting for bCPR minimally changed outcome odds, adjusting for shockable rhythm increased odds for Black (0.5 [0.4-0.5]) and Hispanic/Latino (0.7 [0.6-0.8]) communities. On mediation analysis for majority Black, the top mediators of initial shockable rhythm were public location (14.6%), bystander witnessed OHCA (11.6%), and female gender (5.7%). The top mediators for majority Hispanic/Latino were bystander-witnessed OHCA (10.2%), public location (3.52%), and bystander CPR (3.49%), CONCLUSION: Bystander-witnessed OHCA and public location were the largest mediators of shockable rhythm for OHCAs from minoritized communities.
Asunto(s)
Reanimación Cardiopulmonar , Paro Cardíaco Extrahospitalario , Sistema de Registros , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reanimación Cardiopulmonar/estadística & datos numéricos , Cardioversión Eléctrica/estadística & datos numéricos , Servicios Médicos de Urgencia/estadística & datos numéricos , Etnicidad/estadística & datos numéricos , Hispánicos o Latinos/estadística & datos numéricos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/etnología , Estudios Retrospectivos , Texas/epidemiología , Población Blanca/estadística & datos numéricos , Negro o Afroamericano , BlancoRESUMEN
BACKGROUND: Rhythm control, either with antiarrhythmic drugs or catheter ablation, and rate control strategies are the cornerstones of atrial fibrillation (AF) management. Despite the increasing role of rhythm control over the past few years, it remains inconclusive which strategy is superior in improving clinical outcomes. OBJECTIVES: This study summarizes the total and time-varying evidence regarding the efficacy of rhythm- vs rate-control strategies in the management of AF. METHODS: We systematically perused the MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials), and Web of Science databases for randomized controlled trials from inception to November 2023. We included studies that compared the efficacy of rhythm control (ie, antiarrhythmic drugs classes Ia, Ic, or III, AF catheter ablation, and electrical cardioversion) and rate control (ie, beta-blocker, digitalis, or calcium antagonist) strategies among patients with nonvalvular AF. The primary outcome was cardiovascular (CV) death, whereas secondary outcomes included all-cause death, stroke, hospitalization for heart failure (HF), sinus rhythm at the end of the follow-up, and rhythm control-related adverse events. A cumulative meta-analysis to assess temporal trends and a meta-regression analysis using the percentage of ablation use was performed. RESULTS: We identified 18 studies with a total of 17,536 patients (mean age: 68.6 ± 9.7 years, 37.9% females) and a mean follow-up of 28.5 months. Of those, 31.9% had paroxysmal AF. A rhythm control strategy reduced CV death (HR: 0.78; 95% CI: 0.62-0.96), stroke (HR: 0.801; 95% CI: 0.643-0.998), and hospitalization for HF (HR: 0.80; 95% CI: 0.69-0.94) but not all-cause death (HR: 0.86; 95% CI: 0.73-1.02) compared with a rate control strategy. This benefit was driven by contemporary studies, whereas more ablation use within the rhythm control arm was associated with improved outcomes, except stroke. CONCLUSIONS: In patients with AF, a contemporary rhythm control strategy leads to reduced CV mortality, HF events, and stroke compared with a rate control strategy.
Asunto(s)
Antiarrítmicos , Fibrilación Atrial , Ablación por Catéter , Ensayos Clínicos Controlados Aleatorios como Asunto , Anciano , Femenino , Humanos , Masculino , Antiarrítmicos/uso terapéutico , Fibrilación Atrial/terapia , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Cardioversión Eléctrica/estadística & datos numéricos , Cardioversión Eléctrica/métodos , Frecuencia Cardíaca/fisiología , Persona de Mediana EdadRESUMEN
Out-of-hospital cardiac arrest (OHCA) is a major cause of mortality worldwide, with a high incidence and low survival rate. Prompt cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use are major contributors in the "chain of survival" for OHCA. the response of a community plays a key role in determining the outcomes in OHCA. The outcomes of OHCA are affected by health inequalities in bystander CPR and AED use, due to factors such as differences in sex, ethnicity, and socioeconomic status amongst others. Literature shows patients from lower socio-economic backgrounds are more likely to have risk factors for a cardiac arrest and are therefore more likely to have OHCA. Studies have also reported lower rates of bystander AED use in females compared to males. Targeting deprived areas with tailored training and access to AEDs can be beneficial in improving CPR outcomes in communities. Due to the physical nature of CPR maneuvers, age and frailty of the patient can both impact the outcome of the resuscitation. Environmental factors affecting AED use include availability, visibility, accessibility, support, extra equipment, training materials, staffing, and awareness. Education should focus on areas such as conducting BLS on both male and female patients, recognizing cardiac arrest, tailoring BLS to difference ages as well as provision for training in different languages, including sign language. Like some other countries, CPR training is now being implemented in the school curriculum.
Asunto(s)
Reanimación Cardiopulmonar , Desfibriladores , Disparidades en Atención de Salud , Paro Cardíaco Extrahospitalario , Humanos , Reanimación Cardiopulmonar/métodos , Desfibriladores/estadística & datos numéricos , Cardioversión Eléctrica/estadística & datos numéricos , Cardioversión Eléctrica/instrumentación , Cardioversión Eléctrica/métodos , Servicios Médicos de Urgencia/estadística & datos numéricos , Servicios Médicos de Urgencia/métodos , Salud Global , Disparidades en el Estado de Salud , Disparidades en Atención de Salud/estadística & datos numéricos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/epidemiología , Factores de Riesgo , Factores SocioeconómicosRESUMEN
BACKGROUND: Annually 15,200 children suffer an in-hospital cardiac arrest (IHCA) in the US. Ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) is the initial rhythm in 10-15% of these arrests. We sought to evaluate the association of number of shocks and early dose escalation with survival for initial VF/pVT in pediatric IHCA. METHODS: Using 2000-2020 data from the American Heart Association's (AHA) Get with the Guidelines®-Resuscitation (GWTG-R) registry, we identified children >48 hours of life and ≤18 years who had an IHCA from initial VF/pVT and received defibrillation. RESULTS: There were 251 subjects (37.7%) who received a single shock and 415 subjects (62.3%) who received multiple shocks. Baseline and cardiac arrest characteristics did not differ between those who received a single shock versus multiple shocks except for duration of arrest and calendar year. The median first shock dose was consistent with AHA dosing recommendations and not different between those who received a single shock versus multiple shocks. Survival was improved for those who received a single shock compared to multiple shocks. However, no difference in survival was noted between those who received 2, 3, or ≥4 shocks. Of those receiving multiple shocks, no difference was observed with early dose escalation. CONCLUSIONS: In pediatric IHCA, most patients with initial VF/pVT require more than one shock. No distinctions in patient or pre-arrest characteristics were identified between those who received a single shock versus multiple shocks. Subjects who received a single shock were more likely to survive to hospital discharge even after adjusting for duration of resuscitation.
Asunto(s)
Reanimación Cardiopulmonar , Cardioversión Eléctrica , Paro Cardíaco , Sistema de Registros , Taquicardia Ventricular , Fibrilación Ventricular , Humanos , Masculino , Femenino , Niño , Cardioversión Eléctrica/métodos , Cardioversión Eléctrica/estadística & datos numéricos , Paro Cardíaco/terapia , Paro Cardíaco/mortalidad , Paro Cardíaco/complicaciones , Preescolar , Taquicardia Ventricular/terapia , Taquicardia Ventricular/mortalidad , Taquicardia Ventricular/complicaciones , Taquicardia Ventricular/epidemiología , Adolescente , Fibrilación Ventricular/complicaciones , Fibrilación Ventricular/terapia , Fibrilación Ventricular/mortalidad , Reanimación Cardiopulmonar/métodos , Reanimación Cardiopulmonar/estadística & datos numéricos , Lactante , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Refractory ventricular fibrillation or pulseless ventricular tachycardia (rVF/pVT) during out-of-hospital cardiac arrest (OHCA) is associated with poor survival. Double sequential defibrillation (DSED) and vector change (VC) improved survival for rVF/pVT in the DOSE-VF RCT. However, the role of angiography and percutaneous coronary intervention (angiography/PCI) during the trial is unknown. OBJECTIVES: To determine the incidence of ST-elevation (STE) and no ST-elevation (NO-STE) on post-arrest ECG and the use of angiography/PCI in patients with rVF/pVT during the DOSE-VF RCT. METHOD: Adults (≥18-years) with rVF/pVT OHCA randomized in the DOSE-VF RCT who survived to hospital admission were included. The primary analysis compared the proportion of angiography in STE and NO-STE. We performed regression modelling to examine association between STE, the interaction with defibrillation strategy, and survival to discharge controlling for known covariates. RESULTS: We included 151 patients, 74 (49%) with STE and 77 (51%) with NO-STE. The proportion of angiography was higher in the STE cohort than NO-STE (87.8% vs 44.2%, pâ¯<â¯0.001); similarly the proportion of PCI was also higher (75.7% vs 9.1%, pâ¯<â¯0.001). Survival to discharge was similar between STE and NO-STE (63.5% vs 51.9%, pâ¯=â¯0.15). Use of angiography/PCI did not differ between defibrillation strategies. Decreased age (OR 0.95, 95% CI 0.92-0.98; pâ¯=â¯0.001) and angiography (OR 9.33, 95% CI 3.60-26.94; pâ¯<â¯0.001) were predictors of survival; however, STE was not. CONCLUSION: We found high rates of angiography/PCI in patients with STE compared to NO-STE, however similar rates of survival. Angiography was an independent predictor of survival. Improved rates of survival employing DSED and VC were independent of angiography/PCI.
Asunto(s)
Angiografía Coronaria , Cardioversión Eléctrica , Electrocardiografía , Paro Cardíaco Extrahospitalario , Intervención Coronaria Percutánea , Fibrilación Ventricular , Humanos , Angiografía Coronaria/estadística & datos numéricos , Angiografía Coronaria/métodos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Fibrilación Ventricular/terapia , Fibrilación Ventricular/complicaciones , Masculino , Femenino , Cardioversión Eléctrica/métodos , Cardioversión Eléctrica/estadística & datos numéricos , Persona de Mediana Edad , Intervención Coronaria Percutánea/métodos , Electrocardiografía/métodos , Anciano , Reanimación Cardiopulmonar/métodos , Infarto del Miocardio con Elevación del ST/complicaciones , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/diagnósticoRESUMEN
OBJECTIVES: Contrary to advanced cardiac life support guidelines that recommend immediate defibrillation for shockable in-hospital cardiac arrest (IHCA), epinephrine administration before first defibrillation is common and associated with lower survival at a "patient-level." Whether this practice varies across hospitals and its association with "hospital-level" IHCA survival remains unknown. The purpose of this study was to determine hospital variation in rates of epinephrine administration before defibrillation for shockable IHCA and its association with IHCA survival. DESIGN: Observational cohort study. SETTING: Five hundred thirteen hospitals participating in the Get With The Guidelines Resuscitation Registry. PATIENTS: A total of 37,668 adult patients with IHCA due to an initial shockable rhythm from 2000 to 2019. INTERVENTIONS: Epinephrine before first defibrillation. MEASUREMENTS AND MAIN RESULTS: Using multivariable hierarchical regression, we examined hospital variation in epinephrine administration before first defibrillation and its association with hospital-level rates of risk-adjusted survival. The median hospital rate of epinephrine administration before defibrillation was 18.8%, with large variation across sites (range, 0-68.8%; median odds ratio: 1.54; 95% CI, 1.47-1.61). Major teaching status and annual IHCA volume were associated with hospital rate of epinephrine administration before defibrillation. Compared with hospitals with the lowest rate of epinephrine administration before defibrillation (Q1), there was a stepwise decline in risk-adjusted survival at hospitals with higher rates of epinephrine administration before defibrillation (Q1: 44.3%, Q2: 43.4%; Q3: 41.9%; Q4: 40.3%; p for trend < 0.001). CONCLUSIONS: Administration of epinephrine before defibrillation in shockable IHCA is common and varies markedly across U.S. hospitals. Hospital rates of epinephrine administration before defibrillation were associated with a significant stepwise decrease in hospital rates of risk-adjusted survival. Efforts to prioritize immediate defibrillation for patients with shockable IHCA and avoid early epinephrine administration are urgently needed.
Asunto(s)
Cardioversión Eléctrica , Epinefrina , Paro Cardíaco , Epinefrina/administración & dosificación , Epinefrina/uso terapéutico , Humanos , Paro Cardíaco/terapia , Paro Cardíaco/mortalidad , Paro Cardíaco/tratamiento farmacológico , Femenino , Masculino , Anciano , Persona de Mediana Edad , Cardioversión Eléctrica/estadística & datos numéricos , Cardioversión Eléctrica/métodos , Hospitales/estadística & datos numéricos , Estudios de Cohortes , Vasoconstrictores/administración & dosificación , Vasoconstrictores/uso terapéuticoAsunto(s)
Reanimación Cardiopulmonar , Desfibriladores , Paro Cardíaco Extrahospitalario , Humanos , Reanimación Cardiopulmonar/instrumentación , Reanimación Cardiopulmonar/métodos , Reanimación Cardiopulmonar/estadística & datos numéricos , Desfibriladores/estadística & datos numéricos , Cardioversión Eléctrica/instrumentación , Cardioversión Eléctrica/estadística & datos numéricos , Servicios Médicos de Urgencia/legislación & jurisprudencia , Servicios Médicos de Urgencia/métodos , Servicios Médicos de Urgencia/estadística & datos numéricos , Paro Cardíaco Extrahospitalario/epidemiología , Paro Cardíaco Extrahospitalario/terapia , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVES: The optimal targeted temperature in patients with shockable rhythm is unclear, and current guidelines recommend targeted temperature management with a correspondingly wide range between 32°C and 36°C. Our aim was to study survival and neurologic outcome associated with targeted temperature management strategy in postarrest patients with initial shockable rhythm. DESIGN: Observational substudy of the Coronary Angiography after Cardiac Arrest without ST-segment Elevation trial. SETTING: Nineteen hospitals in The Netherlands. PATIENTS: The Coronary Angiography after Cardiac Arrest trial randomized successfully resuscitated patients with shockable rhythm and absence of ST-segment elevation to a strategy of immediate or delayed coronary angiography. In this substudy, 459 patients treated with mild therapeutic hypothermia (32.0-34.0°C) or targeted normothermia (36.0-37.0°C) were included. Allocation to targeted temperature management strategy was at the discretion of the physician. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After 90 days, 171 patients (63.6%) in the mild therapeutic hypothermia group and 129 (67.9%) in the targeted normothermia group were alive (hazard ratio, 0.86 [95% CI, 0.62-1.18]; log-rank p = 0.35; adjusted odds ratio, 0.89; 95% CI, 0.45-1.72). Patients in the mild therapeutic hypothermia group had longer ICU stay (4 d [3-7 d] vs 3 d [2-5 d]; ratio of geometric means, 1.32; 95% CI, 1.15-1.51), lower blood pressures, higher lactate levels, and increased need for inotropic support. Cerebral Performance Category scores at ICU discharge and 90-day follow-up and patient-reported Mental and Physical Health Scores at 1 year were similar in the two groups. CONCLUSIONS: In the context of out-of-hospital cardiac arrest with shockable rhythm and no ST-elevation, treatment with mild therapeutic hypothermia was not associated with improved 90-day survival compared with targeted normothermia. Neurologic outcomes at 90 days as well as patient-reported Mental and Physical Health Scores at 1 year did not differ between the groups.
Asunto(s)
Angiografía Coronaria/métodos , Cardioversión Eléctrica/estadística & datos numéricos , Hipotermia Inducida/normas , Paro Cardíaco Extrahospitalario/terapia , Anciano , Angiografía Coronaria/estadística & datos numéricos , Femenino , Humanos , Hipotermia Inducida/métodos , Hipotermia Inducida/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Países Bajos , Paro Cardíaco Extrahospitalario/epidemiología , Resucitación/métodos , Resucitación/estadística & datos numéricos , Resultado del TratamientoRESUMEN
Importance: Ventricular tachycardia (VT) is associated with high mortality in patients with cardiac sarcoidosis (CS), and medical management of CS-associated VT is limited by high failure rates. The role of catheter ablation has been investigated in small, single-center studies. Objective: To investigate outcomes associated with VT ablation in patients with CS. Design, Setting, and Participants: This cohort study from the Cardiac Sarcoidosis Consortium registry (2003-2019) included 16 tertiary referral centers in the US, Europe, and Asia. A total of 158 consecutive patients with CS and VT were included (33% female; mean [SD] age, 52 [11] years; 53% with ejection fraction [EF] <50%). Exposures: Catheter ablation of CS-associated VT and, as appropriate, medical treatment. Main Outcomes and Measures: Immediate and short-term outcomes included procedural success, elimination of VT storm, and reduction in defibrillator shocks. The primary long-term outcome was the composite of VT recurrence, heart transplant (HT), or death. Results: Complete procedural success (no inducible VT postablation) was achieved in 85 patients (54%). Sixty-five patients (41%) had preablation VT storm that did not recur postablation in 53 (82%). Defibrillator shocks were significantly reduced from a median (IQR) of 2 (1-5) to 0 (0-0) in the 30 days before and after ablation (P < .001). During median (IQR) follow-up of 2.5 (1.1-4.9) years, 73 patients (46%) experienced VT recurrence and 81 (51%) experienced the composite primary outcome. One- and 2-year rates of survival free of VT recurrence, HT, or death were 60% and 52%, respectively. EF less than 50% and myocardial inflammation on preprocedural 18F-fluorodeoxyglucose positron emission tomography were significantly associated with adverse prognosis in multivariable analysis for the primary outcome (HR, 2.24; 95% CI, 1.37-3.64; P = .001 and HR, 2.93; 95% CI, 1.31-6.55; P = .009, respectively). History of hypertension was associated with a favorable long-term outcome (adjusted HR, 0.51; 95% CI, 0.28-0.92; P = .02). Conclusions and Relevance: In this observational study of selected patients with CS and VT, catheter ablation was associated with reductions in defibrillator shocks and recurrent VT storm. Preablation LV dysfunction and myocardial inflammation were associated with adverse long-term prognosis. These data support the role of catheter ablation in conjunction with medical therapy in the management of CS-associated VT.
Asunto(s)
Antiarrítmicos/uso terapéutico , Cardiomiopatías/terapia , Ablación por Catéter , Muerte Súbita Cardíaca/prevención & control , Sarcoidosis/terapia , Taquicardia Ventricular/cirugía , Adulto , Cardiomiopatías/complicaciones , Cardiomiopatías/diagnóstico por imagen , Cardiomiopatías/fisiopatología , Desfibriladores Implantables , Cardioversión Eléctrica/estadística & datos numéricos , Femenino , Fluorodesoxiglucosa F18 , Corazón/diagnóstico por imagen , Trasplante de Corazón/estadística & datos numéricos , Humanos , Inflamación/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Mortalidad , Análisis Multivariante , Miocardio , Tomografía de Emisión de Positrones , Radiofármacos , Recurrencia , Sarcoidosis/complicaciones , Sarcoidosis/diagnóstico por imagen , Sarcoidosis/fisiopatología , Volumen Sistólico , Taquicardia Ventricular/etiología , Taquicardia Ventricular/fisiopatología , Resultado del TratamientoRESUMEN
BACKGROUND: To date, only a few comparisons between subcutaneous implantable cardioverter-defibrillator (S-ICD) patients undergoing and those not undergoing defibrillation testing (DT) at implantation (DT+ vs DT-) have been reported. OBJECTIVE: The purpose of this study was to compare long-term clinical outcomes of 2 propensity-matched cohorts of DT+ and DT- patients. METHODS: Among consecutive S-ICD patients implanted across 17 centers from January 2015 to October 2020, DT- patients were 1:1 propensity-matched for baseline characteristics with DT+ patients. The primary outcome was a composite of ineffective shocks and cardiovascular mortality. Appropriate and inappropriate shock rates were deemed secondary outcomes. RESULTS: Among 1290 patients, a total of 566 propensity-matched patients (283 DT+; 283 DT-) served as study population. Over median follow-up of 25.3 months, no significant differences in primary outcome event rates were found (10 DT+ vs 14 DT-; P = .404) as well as for ineffective shocks (5 DT- vs 3 DT+; P = .725). At multivariable Cox regression analysis, DT performance was associated with a reduction of neither the primary combined outcome nor ineffective shocks at follow-up. A high PRAETORIAN score was positively associated with both the primary outcome (hazard ratio 3.976; confidence interval 1.339-11.802; P = .013) and ineffective shocks alone at follow-up (hazard ratio 19.030; confidence interval 4.752-76.203; P = .003). CONCLUSION: In 2 cohorts of strictly propensity-matched patients, DT performance was not associated with significant differences in cardiovascular mortality and ineffective shocks. The PRAETORIAN score is capable of correctly identifying a large percentage of patients at risk for ineffective shock conversion in both cohorts.
Asunto(s)
Desfibriladores Implantables , Cardioversión Eléctrica/estadística & datos numéricos , Análisis de Falla de Equipo , Falla de Equipo/estadística & datos numéricos , Taquicardia Ventricular , Investigación sobre la Eficacia Comparativa , Muerte Súbita Cardíaca/epidemiología , Muerte Súbita Cardíaca/prevención & control , Desfibriladores Implantables/efectos adversos , Desfibriladores Implantables/estadística & datos numéricos , Análisis de Falla de Equipo/métodos , Análisis de Falla de Equipo/estadística & datos numéricos , Europa (Continente)/epidemiología , Femenino , Humanos , Masculino , Ensayo de Materiales/métodos , Ensayo de Materiales/estadística & datos numéricos , Persona de Mediana Edad , Puntaje de Propensión , Medición de Riesgo/métodos , Taquicardia Ventricular/mortalidad , Taquicardia Ventricular/terapiaRESUMEN
Since the first report of an association between cardiac troponin (cTn) and adverse outcome in hypertrophic cardiomyopathy (HD), there is a paucity in confirmative data. We performed a prospective, prespecified 5-year follow-up cohort study of 135 HC patients who participated in a national multicenter project and underwent clinical evaluation, MRI (cine, LGE and T2-weighted imaging) and biomarker assessment (high-sensitivity cTnT (hs-cTnT), N-terminal pro-B-type natriuretic peptide, soluble tumorgenicity suppressor-2, Galectin-3, Growth differentiation factor-15, C-terminal Propeptide of Type I Collagen (CICP)). An elevated hs-cTnT concentration was defined as ≥14ng/L. Follow-up was systematically performed for the primary endpoint: a composite of sudden cardiac death, heart failure related death, stroke-related death, heart failure hospitalization, hospitalization for stroke, spontaneous sustained ventricular tachycardia (VT) or appropriate ICD discharge, and progression to NYHA class III-IV. Elevated hs-cTnT was present in 33 of 135 (24%) HC patients. During a median follow-up of 5.0 years (IQR: 4.9-5.1) 18 patients reached the primary endpoint. Using Cox regression analysis, elevated hs-cTnT was univariately associated with the primary endpoint (HR: 3.4 (95%CI: 1.4-8.7, p=0.009). Also female sex, previous syncope, previous non-sustained VT, reduced LV ejection fraction (<50%) and CICP were associated with the primary endpoint. In multivariable analysis, elevated hs-cTnT remained independently associated with outcome (aHR: 4.7 (95%CI: 1.8-12.6, p = 0.002). In conclusion, this 5-year follow-up study is the first to prospectively confirm the association of elevated hs-cTnT and adverse outcomes. In addition to established clinical variables, cTn seems the biomarker of interest to further improve risk prediction in HC, which should be evaluated in larger prospective registries.
Asunto(s)
Cardiomiopatía Hipertrófica/sangre , Muerte Súbita Cardíaca/epidemiología , Insuficiencia Cardíaca/mortalidad , Taquicardia Ventricular/epidemiología , Troponina T/sangre , Anciano , Proteínas Sanguíneas , Estudios de Cohortes , Desfibriladores Implantables , Cardioversión Eléctrica/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Galectinas/sangre , Factor 15 de Diferenciación de Crecimiento/sangre , Hospitalización/estadística & datos numéricos , Humanos , Proteína 1 Similar al Receptor de Interleucina-1/sangre , Imagen por Resonancia Magnética , Imagen por Resonancia Cinemagnética , Masculino , Persona de Mediana Edad , Péptido Natriurético Encefálico/sangre , Fragmentos de Péptidos/sangre , Procolágeno/sangre , Pronóstico , Estudios Prospectivos , Accidente Cerebrovascular/mortalidad , Taquicardia Ventricular/terapiaRESUMEN
OBJECTIVE: Pulmonary vein isolation (PVI) guided by a standardised CLOSE (contiguous optimised lesions) protocol has been shown to increase clinical success after catheter ablation for paroxysmal atrial fibrillation (PAF). This study analysed healthcare utilisation and quality of life (QOL) outcomes from a large multicentre prospective study, measured association between QOL and atrial fibrillation (AF) burden and identified factors associated with lack of QOL improvement. METHODS: CLOSE-guided ablation was performed in 329 consecutive patients (age 61.4 years, 60.8% male) with drug-refractory PAF in 17 European centres. QOL was measured at baseline and 12 months post-ablation via Atrial Fibrillation Effect on QualiTy of Life Survey (AFEQT) and EuroQoL EQ-5D-5L questionnaires. All-cause and cardiovascular hospitalisations and cardioversions over 12 months pre-ablation and post-ablation were recorded. Rhythm monitoring included weekly and symptom-driven trans-telephonic monitoring, plus ECG and Holter monitoring at 3, 6 and 12 months. AF burden was defined as the percentage of postblanking tracings with an atrial tachyarrhythmia ≥30 s. Continuous measures across multiple time points were analysed using paired t-tests, and associations between various continuous measures were analysed using independent sample t-tests. Each statistical test used two-sided p values with a significance level of 0.05. RESULTS: Both QOL instruments showed significant 12-month improvements across all domains: AFEQT score increased 25.1-37.5 points and 33.3%-50.8% fewer patients reporting any problem across EuroQoL EQ-5D-5L domains. Overall, AFEQT improvement was highly associated with AF burden (p=0.009 for <10% vs ≥10% burden, p<0.001 for <20% vs ≥20% burden). Cardiovascular hospitalisations were significantly decreased after ablation (42%, p=0.001). Patients without substantial improvement in AFEQT (55/301, 18.2%) had higher AFEQT and CHA2DS2-VASc scores at baseline, and higher AF burden following PVI. CONCLUSIONS: QOL improved and healthcare utilisation decreased significantly after ablation with a standardised CLOSE protocol. QOL improvement was significantly associated with impairment at baseline and AF burden after ablation. TRIAL REGISTRATION NUMBER: NCT03062046.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Aceptación de la Atención de Salud/estadística & datos numéricos , Venas Pulmonares/cirugía , Calidad de Vida , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Fibrilación Atrial/psicología , Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Costo de Enfermedad , Cardioversión Eléctrica/estadística & datos numéricos , Electrocardiografía Ambulatoria/métodos , Electrocardiografía Ambulatoria/estadística & datos numéricos , Europa (Continente)/epidemiología , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Periodo Perioperatorio/psicología , Periodo Perioperatorio/estadística & datos numéricos , Encuestas y CuestionariosRESUMEN
Background COVID-19 was temporally associated with an increase in out-of-hospital cardiac arrests, but the underlying mechanisms are unclear. We sought to determine if patients with implantable defibrillators residing in areas with high COVID-19 activity experienced an increase in defibrillator shocks during the COVID-19 outbreak. Methods and Results Using the Medtronic (Mounds View, MN) Carelink database from 2019 and 2020, we retrospectively determined the incidence of implantable defibrillator shock episodes among patients residing in New York City, New Orleans, LA, and Boston, MA. A total of 14 665 patients with a Medtronic implantable defibrillator (age, 66±13 years; and 72% men) were included in the analysis. Comparing analysis time periods coinciding with the COVID-19 outbreak in 2020 with the same periods in 2019, we observed a larger mean rate of defibrillator shock episodes per 1000 patients in New York City (17.8 versus 11.7, respectively), New Orleans (26.4 versus 13.5, respectively), and Boston (30.9 versus 20.6, respectively) during the COVID-19 surge. Age- and sex-adjusted hurdle model showed that the Poisson distribution rate of defibrillator shocks for patients with ≥1 shock was 3.11 times larger (95% CI, 1.08-8.99; P=0.036) in New York City, 3.74 times larger (95% CI, 0.88-15.89; P=0.074) in New Orleans, and 1.97 times larger (95% CI, 0.69-5.61; P=0.202) in Boston in 2020 versus 2019. However, the binomial odds of any given patient having a shock episode was not different in 2020 versus 2019. Conclusions Defibrillator shock episodes increased during the higher COVID-19 activity in New York City, New Orleans, and Boston. These observations may provide insights into COVID-19-related increase in cardiac arrests.
Asunto(s)
COVID-19 , Muerte Súbita Cardíaca , Desfibriladores Implantables , Cardioversión Eléctrica , Paro Cardíaco Extrahospitalario , Anciano , Boston/epidemiología , COVID-19/complicaciones , COVID-19/epidemiología , Muerte Súbita Cardíaca/epidemiología , Muerte Súbita Cardíaca/prevención & control , Cardioversión Eléctrica/instrumentación , Cardioversión Eléctrica/estadística & datos numéricos , Femenino , Humanos , Incidencia , Masculino , Nueva Orleans/epidemiología , Ciudad de Nueva York/epidemiología , Paro Cardíaco Extrahospitalario/epidemiología , Paro Cardíaco Extrahospitalario/etiología , Distribución de Poisson , SARS-CoV-2RESUMEN
AIMS: To evaluate the prevalence and predictors of persistent sinus rhythm in a recent cohort of unselected patients undergoing electrical cardioversion for atrial fibrillation. METHODS: We enrolled all consecutive patients undergoing elective electrical cardioversion for atrial fibrillation between January 2017 and December 2018. We analysed baseline clinical and echocardiographic data as well as pharmacological antiarrhythmic therapy. Primary endpoint was the maintenance of sinus rhythm at 12 months after electrical cardioversion. RESULTS: Of the 300 patients enrolled, 270 (90%) had successful electrical cardioversion and among them, 201 patients have 12-month follow-up data (mean age 70â±â10âyears; 74% men). At 12âmonths, only 45.7% were in sinus rhythm. Patients without sinus rhythm compared with persistent sinus rhythm at 12âmonths had a lower baseline left ventricle ejection fraction (LVEF) (49.1â±â16 vs. 59.7â±â9%, Pâ=â0.02) and had more frequently a history of atrial fibrillation more than 12âmonths (55 vs. 34% Pâ=â0.003). At the multivariate analysis, only the duration of the disease beyond 12âmonths (OR 0.26, 95% CI: 0.08-0.88, Pâ=â0.032), LVEF (OR 1.06, 95% CI: 1.01-1.12, Pâ=â0.012) and the presence of sinus rhythm at 1-month follow-up (OR 18.28, 95% CI: 3.3-100, Pâ=â0.001) were associated with the probability of maintaining sinus rhythm at 12âmonths. CONCLUSION: In unselected patients with atrial fibrillation undergoing elective electrical cardioversion, only 45.7% were in sinus rhythm at 12 months. The presence of sinus rhythm at 1-month follow-up emerged as an independent predictor of maintenance of sinus rhythm. This highlights that early re-evaluation of these patients appears useful for assessing longer term outcomes also from the perspective of a possible selective approach to ablation strategies.
Asunto(s)
Cuidados Posteriores , Fibrilación Atrial/terapia , Cardioversión Eléctrica , Frecuencia Cardíaca , Cuidados Posteriores/métodos , Cuidados Posteriores/estadística & datos numéricos , Anciano , Fibrilación Atrial/diagnóstico , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/métodos , Cardioversión Eléctrica/estadística & datos numéricos , Femenino , Humanos , Masculino , Pronóstico , Recurrencia , Volumen Sistólico , Tiempo , Factores de Tiempo , Resultado del Tratamiento , Función Ventricular IzquierdaRESUMEN
AIMS: The role of the implantable cardioverter defibrillator (ICD) in primary prevention real-world population is debated. We sought to evaluate the incidence, predictors and prognostic impact of ICD shocks in consecutive heart failure patients implanted for primary prevention at our tertiary institution. METHODS AND RESULTS: We retrospectively selected a sample of 497 patients (mean age 64.8 years, 82.1% men, average left ventricular ejection fraction, LVEF, 27.1%). At long-term follow-up (median time 70.4 months), total mortality was 40.8%, and 16.5% of patients had received at least one appropriate shock (3.12%/year). Inappropriate shock [odds ratio (OR) 1.93, 95% confidence interval (95% CI) 1.08-3.47; Pâ=â0.027] and length of follow-up (1 year, OR 1.01, 95% CI 1.00-1.01; Pâ=â0.0031) were associated with the occurrence of appropriate shock, whereas atrial fibrillation (OR 2.65, 95% CI 1.55-4.51, Pâ<â0.001), length of follow-up (1-year OR 1.01, 95% CI 1.00-1.01, Pâ<â0.001) and appropriate shock (OR 1.93, 95% CI 1.08-3.47, Pâ=â0.027) were associated with the occurrence of inappropriate shock. Neither appropriate nor inappropriate shock independently increased mortality risk, whereas older age (hazard ratio 1.05; 95% CI 1.04-1.07; Pâ<â0.001), atrial fibrillation (hazard ratio 2.25; 95% CI 1.67-3.02; Pâ<â0.001) and lower LVEF (hazard ratio 0.97; 95% CI 0.94-0.99; Pâ=â0.004) did. CONCLUSION: Incidence of shocks in real-world primary prevention ICD recipients might be lower than expected, and the association between ICD shocks and prolongation of survival is not as clear-cut as might be perceived. Further investigations from larger real-world samples are warranted.