Etiological diagnoses of out-of-hospital cardiac arrest survivors admitted to the intensive care unit: Insights from a French registry

doi:10.1016/j.resuscitation.2017.06.006

Resuscitation

Volume 117, August 2017, Pages 66-72

https://doi.org/10.1016/j.resuscitation.2017.06.006 Get rights and content

Abstract

Background

Respective proportions of final etiologies are disparate in cohorts of cardiac arrest patients, depending on examined population and diagnostic algorithms. In particular, prevalence and characteristics of sudden unexplained death syndrome (SUDS) are debated. We aimed at describing etiologies in a large cohort of aborted out-of-hospital cardiac arrest (OHCA) patients, in order to assess prevalence and outcome of SUDS.

Patients and methods

We analyzed data from our prospective registry of successfully resuscitated OHCA patients admitted to a cardiac arrest centre between January 2002 and December 2014. The in-ICU diagnostic strategy included early coronary angiogram, brain and chest CT scan. This was completed by an extensive diagnostic strategy, encompassing biological and toxicological tests, repeated electrocardiograms and echocardiography, MRI and pharmacologic tests. Two independent investigators reviewed each final diagnosis. Baseline characteristics were compared between subgroups of patients. Three-month mortality was compared between subgroups using univariate Kaplan-Meier curves.

Results

Over the study period, 1657 patients were admitted to our unit after an aborted OHCA. The event was attributed to a non-cardiac and a cardiac cause in 478 (32.0%) and 978 (65.5%) patients, respectively. The main cause of cardiac related OHCA was ischemic heart disease (76.7%) while primary electrical diseases accounted for only 2.5%. Sudden unexplained deaths (SUDS) were observed in 37 (2.5%) patients.

Conclusion

We observed that ischemic heart disease was by far the most common cause of cardiac arrest, while primary electrical diseases were much less frequent. SUDS accounted for a very small proportion of patients who suffered an aborted OHCA.

Introduction

Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death in industrialized countries, with an incidence of more than 359,000 new cases per year in the United States [1] and nearly 40,000 in France [2]. Besides the activation of the “chain of survival”, identifying and treating the cause is currently a major issue, involving hospital and prehospital teams, as underlined in recent guidelines from the International Liaison Committee On Resuscitation (ILCOR) [3].

Among the causes of aborted OHCA, many high quality studies have reported a high prevalence of coronary artery disease (CAD) [4], [5], but there is a lack of knowledge regarding the other causes. An undetermined proportion of events are the consequence of a non-ischemic cardiac disease, which can be structural or primary electrical diseases (such as a channelopathies). The real proportion of patients with these etiologies is difficult to assess, as most published studies included selected populations such as survivors in whom diagnosis was already made as part of a previous family investigation [6], [7]. On the whole, respective proportions of final etiologies are disparate in cohorts of cardiac arrest patients, depending on examined population and diagnostic algorithms. In particular, prevalence and characteristics of sudden unexplained death syndrome (SUDS) and idiopathic ventricular fibrillation (IVF) are debated. In these patients in whom no diagnosis was possible despite extensive exploration, the management strategy of both patients and relatives is not well clarified. To date, knowledge about these SUDS patients regarding their characteristics and outcome is considered to be insufficient for many experts [8].

We aimed at describing etiologies in a large cohort of aborted out-of-hospital cardiac arrest (OHCA) patients, in order to better characterize SUDS victims.

Section snippets

Pre-hospital management

We have previously described pre-hospital management of OHCA patients in the geographic area of south Great Paris, France [9]. Briefly, out-of-hospital resuscitation is delivered by an emergency team, which includes at least one physician trained in emergency medicine according to standard procedure based on the ILCOR recommendations [10]. Patients in whom return of spontaneous circulation (ROSC) is achieved are then referred to our academic tertiary hospital.

Diagnostic strategy

In all aborted OHCA patients

Results

From January 2002 to December 2014, 1563 successfully resuscitated OHCA patients were admitted to our center. Among them, 70 patients were not analysed: major hemodynamic instability precluding any diagnostic explorations (n = 60) and immediate withdrawal of care in 10 cases related to the underlying comorbidities (Fig. 1). Thus, 1493 OHCA patients were retained in the final analysis.

Patients were mostly male (72.4%), 60 years old in median and suffered an OHCA related to an initial shockable

Discussion

In the present study, we analyzed aetiologies in a large cohort of aborted OHCA patients. We identified ischemic heart disease as being by far the main cause of aborted OHCA while primary electrical diseases accounted for a very small proportion of final diagnosis. Only three percent of OHCA were considered as unexplained.

In the present study, ischemic heart disease accounted for nearly 80% of cardiac related OHCA. In this subgroup an acute coronary occlusion was the main etiology, accounting

Conclusion

We observed that ischemic heart disease was by far the most common cause of aborted cardiac arrest, while primary electrical diseases accounted for a very low part of identified diagnosis. SUDS accounted for a very small proportion of patients who suffered an aborted OHCA. Focusing on this subgroup of patients for further investigations and follow-up may improve management of these patients and their relatives.

Conflict of interest statement

None

Acknowledgment

We thank Nancy Kentish-Barnes for her help in preparing the manuscript.

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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/[email protected]”

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Clinical paperEtiological diagnoses of out-of-hospital cardiac arrest survivors admitted to the intensive care unit: Insights from a French registry☆

Abstract

Background

Patients and methods

Results

Conclusion

Introduction

Section snippets

Pre-hospital management

Diagnostic strategy

Results

Discussion

Conclusion

Conflict of interest statement

Acknowledgment

Resuscitation

Resuscitation

AJC

AJC

Resuscitation

Heart Rhythm

Heart disease and stroke statistics-2017 update: a report from the american heart association

Circulation

Characteristics and prognosis of sudden cardiac death in Greater Paris

Intensive Care Med

Part 8: post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care

Circulation

Sudden cardiac death

Circulation

Sudden cardiac death in the United States, 1989–1998

Circulation

Sudden arrhythmic death syndrome: familial evaluation identifies inheritable heart disease in the majority of families

Eur Heart J

Risk of cardiovascular disease in family members of young sudden cardiac death victims

Eur Heart J

Eur Heart J

Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry

Circ: Cardiovasc Interventions

Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the utstein resuscitation registry templates for out-of-hospital cardiac arrest

Circulation

Should we perform a coronary angiography in all cardiac arrest survivors?

Curr Opin Crit Care

Clinical paper
Etiological diagnoses of out-of-hospital cardiac arrest survivors admitted to the intensive care unit: Insights from a French registry☆