Coronary artery disease
Usefulness of Cooling and Coronary Catheterization to Improve Survival in Out-of-Hospital Cardiac Arrest

https://doi.org/10.1016/j.amjcard.2010.10.011Get rights and content

Survival rates after out-of-hospital cardiac arrest (OHCA) continue to be poor. Recent evidence suggests that a more aggressive approach to postresuscitation care, in particular combining therapeutic hypothermia with early coronary intervention, can improve prognosis. We performed a single-center review of 125 patients who were resuscitated from OHCA in 2 distinct treatment periods, from 2002 to 2003 (control group) and from 2007 to 2009 (contemporary group). Patients in the contemporary group had a higher prevalence of cardiovascular risk factors but similar cardiac arrest duration and prehospital treatment (adrenaline administration and direct cardioversion). Rates of cardiogenic shock (48% vs 41%, p = 0.2) and decreased conscious state on arrival (77% vs 86%, p = 0.2) were similar in the 2 cohorts, as was the incidence of ST-elevation myocardial infarction (33% vs 43%, p = 0.1). The contemporary cohort was more likely to receive therapeutic hypothermia (75% vs 0%, p <0.01), coronary angiography (77% vs 45%, p <0.01), and percutaneous coronary intervention (38% vs 23%, p = 0.03). This contemporary therapeutic strategy was associated with better survival to discharge (64% vs 39%, p <0.01) and improved neurologic recovery (57% vs 29%, p <0.01) and was the only independent predictor of survival (odds ratio 5.5, 95% confidence interval 1.2 to 26.2, p = 0.03). Longer resuscitation time, presence of cardiogenic shock, and decreased conscious state were independent predictors of poor outcomes. In conclusion, modern management of OHCA, including therapeutic hypothermia and early coronary angiography is associated with significant improvement in survival to hospital discharge and neurologic recovery.

Section snippets

Methods

Melbourne has approximately 3.9 million inhabitants, which is served by a comprehensive centrally co-ordinated ambulance system, which is described elsewhere.1 The Alfred Hospital (Melbourne, Victoria, Australia) is a large tertiary-/quaternary-care referral center that provides 24-hour emergency coronary and cardiac surgical interventions for patients with acute coronary syndromes.

In this retrospective analysis we evaluated clinical characteristics and outcomes of all patients who had an

Results

Baseline characteristics of the study population are presented in Table 1. Important prehospital factors including rates of witnessed cardiac arrest, bystander cardiopulmonary resuscitation, time until ROSC, and adrenaline administration by paramedics were similar in the control and contemporary cohorts. On arrival to the emergency department the incidence of cardiogenic shock, defined as systolic blood pressure <90 mm Hg or requiring inotropic support, did not differ significantly between

Discussion

This study has demonstrated that a contemporary treatment paradigm with focused co-ordinated postresuscitative care combining therapeutic hypothermia with coronary angiography is associated with significant improvements in short-term clinical outcomes. The 64% survival to discharge rate is significantly better than other registry data of patients with OHCA and favorably compares to other institutions with similar treatment protocols.7, 8

In the contemporary treatment group, 98% of comatose

References (30)

  • I. Lund-Kordahl et al.

    Improving outcome after out-of-hospital cardiac arrest by strengthening weak links of the local chain of survival; quality of advanced life support and post-resuscitation care

    Resuscitation

    (2010)
  • P.A. Jennings et al.

    Out-of-hospital cardiac arrest in Victoria: rural and urban outcomes

    Med J Aust

    (2006)
  • K.L. Smith et al.

    Cardiac arrests treated by ambulance paramedics and fire fighters

    Med J Aust

    (2002)
  • S. Timerman et al.

    Roll in guidelines 2005–2010 for cardiopulmonary resuscitation and emergency cardiovascular care

    Arq Bras Cardiol

    (2006)
  • American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care

    Circulation

    (2005)
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    Dr. Stub is supported by a scholarship from the Cardiac Society of Australia & New Zealand, Sydney, NSW and an award from Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.

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