Elsevier

Resuscitation

Volume 84, Issue 5, May 2013, Pages 558-563
Resuscitation

Clinical Paper
Prodromal symptoms of out-of-hospital cardiac arrests: A report from a large-scale population-based cohort study

https://doi.org/10.1016/j.resuscitation.2012.10.006Get rights and content

Abstract

Objective

Little is known about which symptoms are manifested before out-of-hospital cardiac arrest (OHCA). The objective of this study is to describe the prodromal symptoms of OHCA focusing on the onset of the symptom in relation of etiology of cardiac arrests, and to analyze the association between those symptoms and their outcomes after OHCA.

Methods

This prospective, population-based cohort study enrolled all persons aged 18 years or older who had experienced OHCA of presumed cardiac and non-cardiac origin that were witnessed by bystanders or emergency medical system (EMS) personnel in Osaka from 2003 through 2004.

Results

There were 1042 were presumed to be of cardiac origin and 424 of non-cardiac. Patients with non-cardiac origin were more likely to have prodromal symptoms than those with cardiac etiology (70.0% vs. 61.8%, p = 0.003). Over 40% of OHCA regardless of etiology had displayed symptoms at least several minutes before their arrest (40.2% [259/644] in those of cardiac origin and 45.5% [135/297] in those of non-cardiac origin). As to cardiac origin, the most frequent prodromal symptom was dyspnea (27.6%), followed by chest pain (20.7%) and syncope (12.7%). For non-cardiac origin, the most frequent symptom was also dyspnea (40.7%), but chest pain was rarely presented (3.4%). Although, prodromal symptoms themselves were not associated with better neurological outcomes (adjusted odds ratio [AOR], 2.03; 95% confidence interval [CI], 1.00–4.13), earlier contact to a patient yielded better neurological outcomes (AOR per every one-minute increase, 0.90; 95% CI, 0.82–0.99).

Conclusions

Many of OHCA regardless of etiology have prodromal symptoms before arrest. Prodromal symptoms induced early activation of the EMS system, and may thus improve outcomes after OHCA.

Introduction

Out-of-hospital cardiac arrest (OHCA) is a common public health problem accounting for more than 60% of deaths from cardiovascular diseases.1, 2, 3 Although fatalities from acute myocardial infarction (AMI) have been decreasing mainly due to recent substantial advances in in-hospital treatments, many AMI patients die before arriving at a hospital.4 In Japan, approximately 60,000 OHCAs of cardiac origin occur every year, and the number has been steadily increasing.5, 6 Despite continuous improvements in the “chain of survival”, survival after OHCA remains low.1, 2, 6, 7

Cardiac arrest is the first manifestation in about one third of AMI cases.8 It is well known that most OHCAs occur in persons who have neither past history nor major risk factors of heart disease, which makes it quite difficult to predict the occurrence of OHCAs.8 On the other hand, one study indicated that some OHCA patients had manifested prodromal symptoms before their arrests.9 If we knew specific symptoms suggesting the threat of a cardiac arrest, we could develop preventive measures against OHCA.

The Utstein Osaka Project, launched in 1998, is a large, ongoing, prospective, population-based cohort study of OHCA in Osaka, Japan that covers 8.8 million people.6, 10, 11 Approximately 5000 OHCA patients were newly registered in this project every year. For this study, we collected data on prodromal symptoms in addition to the Utstein-style data. The objective of this study is to describe the prodromal symptoms of OHCA focusing on the onset of the symptom in relation of etiology of cardiac arrests, and to analyze the association between those symptoms and their outcomes after OHCA.

Section snippets

Study design, population, and setting

The present study was carried out within the Utstein Osaka Project, which is a prospective, population-based cohort study of all persons with OHCA who are treated by emergency medical service (EMS) personnel in the city of Osaka, Japan. This study included all OHCA patients aged 18 years or older who were presumed to be of cardiac and non-cardiac origin and who were witnessed by bystanders or EMS personnel from January 1, 2003 through December 31, 2004. Osaka is the third largest city in Japan

Patients’ characteristics and resuscitation situations

A total of 3093 OHCA cases of age 18 years or older were documented during the study period. Among them, resuscitation was attempted in 2999, and 1183 were witnessed by bystanders and 283 were witnessed by EMS (Fig. 1). Of those who were witnessed, 1042 were presumed to be of cardiac origin and 424 of non-cardiac origin.

Table 1 shows patients’ and resuscitation characteristics according to etiology of cardiac arrests. Patients with presumed cardiac origin were more likely to have past history

Discussion

This study clearly demonstrated that many OHCA patients regardless of type of etiology manifested prodromal symptoms prior to their arrests. Although there are some articles on prodromal symptoms in cardiac arrests, most studies focused on specific situations such as younger generation,14 athletes,15 cardiac disease patients,16 or people with family history of cardiac disease,17 and there were few studies like ours. A small study from Germany reported that 50% of OHCA occurred after typical

Conclusions

This large population-based observational study indicated that over 60% of OHCA patients had prior symptoms to their cardiac arrests, and 40% of such symptoms had been manifested at least several minutes before their arrests regardless of etiology.

Early activation of the EMS system by recognizing these prodromal symptoms might improve outcomes after OHCA.

Conflicts of interest

There are no conflicts of interest to declare.

Role of funding source

This work was supported by a grant from the Fire Disaster Management Agency (for studies concerning a strategy for applying the results of the Utstein report to the improvement of emergency service), and by a Japan Heart Foundation Research Grant.

Acknowledgements

We greatly appreciate the dedication of Hiroshi Morita, Hidekazu Yukioka, Hisashi Sugimoto, Toshifumi Uejima, Kikushi Katsurada, Masafumi Kishimoto, Chizuka Shiokawa, Masahiko Nitta, Akihiko Hirakawa, Hiroshi Rinka, Kentaro Kajino, Yasuo Ohishi, Tomoyoshi Mouri, and Hiroyuki Yokoyama, as well as of other members of the Utstein Osaka Project for their contribution to the organization, coordination, and oversight of the steering committee. We wish to thank Masahiko Ando at Center for Advanced

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    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.10.006.

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