Clinical paperTime in therapeutic range for targeted temperature management and outcomes following out-of-hospital cardiac arrest
Section snippets
Background
Only 1 in 10 patients with an out-of-hospital cardiac arrest (OHCA) survives to hospital discharge, and 1 in 5 of those have a poor neurological outcome.1 Targeted temperature management (TTM) is recommended by international guidelines to reduce hypoxic-ischemic brain injury in patients who remain unable to follow commands post-arrest.2, 3 This recommendation is based on initial randomized clinical trials which found that maintaining a target temperature of 33 °C was associated with higher
Data source
The ROC-CCC was a large, randomized controlled trial that included 8 regional sites and 114 emergency medical services (EMS) agencies across North America which enrolled patients with a non-traumatic OHCA from 2011-2015.9 The sites and EMS services were divided into 49 clusters for randomization, representing a set of EMS agencies serving the same set of hospitals in a regional site. Detailed methods regarding these data are described elsewhere.9, 10 Briefly, exclusion criteria included
Results
There were 3,457 patients in ROC-CCC who underwent TTM and had at least one recorded temperature. Of these, 2,637 patients underwent TTM at least 12 h and had at least four temperature measurements (eFig. 2 in the Online Supplement). The mean age of patients was 62.3 (SD ± 15.2) years, 784 (29.7 %) were women, 1,468 (55.7 %) had VF/VT as the first recorded pulseless rhythm, and the other 1,158 (43.9 %) had PEA, asystole, or an undefined non-shockable rhythm (n = 11 had no documented rhythm).
Discussion
In a post-hoc secondary analysis of a large clinical trial that enrolled patients with OHCA at multiple sites across North America, we found adherence to current TTM guideline recommendations was generally high. However, over a third of participants spent more than 10 % of the time outside the therapeutic range for the recommended temperature target of 32 °C–36 °C, with only modest difference if the target temperature ranges were defined at different thresholds (>32 °C, >33 °C, 33 °C–36 °C, or
Conclusion
Among patients with OHCA who underwent TTM, we found variability in adherence to guideline-recommended treatment targets. Higher TTR was not associated with overall survival, but for certain temperature thresholds, TTR was associated with favorable neurologic outcome.
Funding
This study was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under the award K23HL153775. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Conflict of Interest
Dr Khera receives support from the Doris Duke Charitable Foundation (under award, 2022060). He also receives research support, through Yale, from Bristol-Myers Squibb. He is a coinventor of U.S. Provisional Patent Applications 63/177,117 and 63/346,610, unrelated to current work. He is also a founder of Evidence2Health, a precision health platform to improve evidence-based cardiovascular care. The other authors have no relevant disclosures.
CRediT authorship contribution statement
Kevin M Wheelock: Methodology, Software, Formal analysis, Writing – original draft, Writing – review & editing, Visualization. Paul S Chan: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. Lian Chen: Methodology, Software, Formal analysis, Visualization. James A de Lemos: Conceptualization, Methodology, Writing – review & editing. P Elliott Miller: Methodology, Writing – review & editing. Brahmajee K Nallamothu: Conceptualization, Methodology, Writing –
Acknowledgements
None
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