Elsevier

Resuscitation

Volume 187, June 2023, 109798
Resuscitation

Clinical paper
Determinants of survival in sudden cardiac arrest manifesting with pulseless electrical activity

https://doi.org/10.1016/j.resuscitation.2023.109798Get rights and content

Abstract

Objective

The proportion of sudden cardiac arrests (SCA) manifesting with pulseless electrical activity (PEA) has increased significantly, and the survival rate remains lower than ventricular fibrillation (VF). However, a subgroup of PEA-SCA cases does survive and may yield key predictors of improved outcomes when compared to non-survivors. We aimed to identify key predictors of survival from PEA-SCA.

Methods

Our study sample is drawn from two ongoing community-based, prospective studies of out-of-hospital SCA: Oregon SUDS from the Portland, OR metro area (Pop. approx. 1 million; 2002–2017) and Ventura PRESTO from Ventura County, CA (Pop. approx. 850,000, 2015–2021). For the present sub-study, we included SCA cases with PEA as the presenting rhythm where emergency medical services (EMS) personnel attempted resuscitation.

Results

We identified 1,704 PEA-SCA cases, of which 173 (10.2%) were survivors and 1,531 (89.8%) non-survivors. Patients whose PEA-SCA occurred in a healthcare unit (16.9%) or public location (18.1%) had higher survival than those whose PEA-SCA occurred at home (9.3%) or in a care facility (5.7%). Young age, witness status, PEA-SCA location and pre-existing COPD/asthma were independent predictors of survival. Among witnessed cases the survival rate was 10% even if EMS response time was >10 minutes.

Conclusions

Key determinants for survival from PEA-SCA were young age, witnessed status, public location and pre-existing COPD/asthma. Survival outcomes in witnessed PEA cases were better than expected, even with delayed EMS response.

Introduction

Despite the recent progress in the prevention and treatment of cardiac disease, out-of-hospital sudden cardiac arrest (SCA) is a major cause of mortality worldwide, resulting in more years of potential life lost than any individual cancer.1 SCAs can manifest with either shockable (ventricular fibrillation [VF] and ventricular tachycardia [VT]) or non-shockable (pulseless electrical activity [PEA] and asystole) rhythms. A significant amount of effort has been put into treating and preventing shockable SCAs, while non-shockable SCAs have received less attention. Shockable rhythms were dominant forty years ago, but the proportion of shockable SCAs has declined in recent decades, and currently the majority of SCAs (70–80%) present with non-shockable rhythms.2, 3

Thirty years ago, asystole and PEA were addressed separately in advanced life support guidelines.4 More recently, asystole and PEA have been treated collectively as non-shockable SCA in the current resuscitation guidelines.5, 6 Similarly, outcomes from PEA and asystole have often been reported collectively as non-shockable SCA,7, 8 but some studies have reported that PEA has a better prognosis than asystole.9, 10 Moreover, PEA and asystole are likely to have distinct etiologies and pathophysiologies.11, 12, 13, 14, 15, 16. Given the wide spectrum of clinical profiles and hemodynamic states in cardiac PEA,17, 18 survival rates among PEA-SCA cases are also likely to vary. A better understanding of key predictors of survival may have the potential to translate into improved resuscitation success and better PEA-SCA survival outcomes. In the present study, we utilized data from two large prospective and community-based SCA cohorts to identify key predictors of survival from PEA-SCA.

Section snippets

Population cohorts (Oregon SUDS and Ventura PRESTO)

Our study population is drawn from two different studies in the United States: the Oregon Sudden Unexpected Death Study (Oregon SUDS, since 2002) and the Ventura Prediction of Sudden Death in Multi-Ethnic Communities study (Ventura PRESTO, since 2015). Both studies use an identical design, and previous studies have described the study protocols in more detail.1, 19, 20 Both Oregon SUDS and Ventura PRESTO are prospective and ongoing community-based studies that have ascertained all

Results

In total, we identified 1,704 PEA-SCA cases, of which 173 (10.2%) were survivors and 1,531 (89.8%) were non-survivors. Ninety-one PEA-SCA survivors (53%) and 1,290 non-survivors (84%) had available prearrest clinical records. Of all cases, 70.7% occurred at home, while 13.5% occurred in care facilities, 11.3% in public locations, and 4.5% in healthcare units. Survival to hospital discharge rates was significantly higher if PEA-SCA occurred in a public location (18.1%) or healthcare units

Discussion

In this study, we aimed to identify key predictors of survival from PEA-SCA from two prospective, community-based studies of out-of-hospital SCAs. At least 10% of PEA-SCA cases survived to hospital discharge. Cases that were witnessed or occurred in a public location or healthcare unit had the highest chance of survival. Young age and pre-existing COPD/asthma were independent predictors of survival. Among witnessed PEA-SCA cases, the survival rate remained 10% even if the EMS response time was

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

This work is funded, in part, by the National Institutes of Health, National Heart Lung and Blood Institute Grants R01HL145675 and R01HL147358 to SSC. SSC holds the Pauline and Harold Price Chair in Cardiac Electrophysiology at Cedars-Sinai. LH is a postdoctoral fellow visiting from the Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland, and is funded by Sigrid Juselius Foundation, The Finnish Cultural Foundation,

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