Elsevier

Resuscitation

Volume 143, October 2019, Pages 42-49
Resuscitation

Clinical paper
Modulating effects of immediate neuroprognosis on early coronary angiography and targeted temperature management following out-of-hospital cardiac arrest: A retrospective cohort study

https://doi.org/10.1016/j.resuscitation.2019.08.014Get rights and content

Abstract

Aim

The simplified cardiac arrest hospital prognosis (sCAHP) score is a validated tool for predicting neurological outcomes after out-of-hospital cardiac arrest (OHCA). We used the sCAHP score to evaluate whether the effects of early coronary angiography (CAG) and targeted temperature management (TTM) for OHCA were modulated by immediate neuroprognosis.

Methods

This was a single-centre retrospective observational study. Consecutive OHCA patients were screened between 2011 and 2017. Multivariate logistic regression analysis and generalised additive models (GAMs) were used to examine the associations between independent variables and outcomes. Early CAG was defined as CAG performed within 24 h after return of spontaneous circulation (ROSC).

Results

A total of 412 patients were included in the study, and 94 (22.8%) patients had neurologically intact survival. The GAM plot identified a sCAHP score of 185 as the cut-off point to differentiate high-risk (sCAHP score ≧185) from low-risk (sCAHP score <185) patients. Regression models indicated that early CAG was significantly associated with favourable neurological [odds ratio (OR) 4.43, 95% confidence interval (CI) 2.28–8.60, p < 0.001] and survival outcomes (OR 3.47, 95% CI 1.93–6.25, p < 0.001), independent of the sCAHP score. Although TTM was associated with favourable neurological outcome only in low-risk patients (OR 2.13, 95% CI 1.10–4.13, p = 0.02), TTM was associated with improved survival for all patients (OR 2.66, 95% CI 1.54–4.59, p < 0.001), independent of the sCAHP score.

Conclusions

Early CAG and TTM should be considered for all OHCA patients as suggested by guidelines, irrespective of the immediately predicted neuroprognosis after ROSC.

Introduction

Globally, out-of-hospital cardiac arrest (OHCA) strikes an estimated 28–44 people per 100,000 population annually.1 In Asia, the overall survival rate to hospital discharge after OHCA was 5.4%, and the percentage of those recovering favourable neurological status was 2.7%.2

The post-resuscitation care includes early coronary angiography (CAG) and targeted temperature management (TTM).3, 4 Resuscitation guidelines3, 4 recommend early CAG along with percutaneous coronary interventions (PCI) if indicated for all OHCA patients with ST-segment elevation on post-resuscitation electrocardiogram; the guidelines also advocate early CAG for selected OHCA patients without ST-segment elevation on electrocardiogram.5

Analysis of a large registry6 indicated that, in real-world practice, CAG was only performed in approximately one-third of OHCA patients arriving at PCI-capable centres. Lemiale et al.7 reported that about 65% of OHCA patients died from neurological injuries when treated in intensive care units. This perceived medical futility may discourage clinicians or families from implementing early invasive procedures despite the fact that guidelines recommend patient selection for these procedures irrespective of neurological status.3, 4

The cardiac arrest hospital prognosis (CAHP)8 score uses variables that are immediately available on hospital admission, and displays excellent discriminatory performance in predicting neurological outcomes of OHCA patients. The CAHP score stratifies patients into three groups based on their risk and predicted outcomes: low risk, 40% of patients with unfavourable outcomes; medium risk, 80% of patients with unfavourable outcomes; and high risk, 95–100% of patients with unfavourable outcomes. Bougouin et al.9 reported that early CAG was associated with better outcomes only in low-risk OHCA patients, and suggested that early CAG should focus on these patients with preserved neurological status.

The simplified CAHP (sCAHP) score removes the no-flow interval [i.e., the time from arrest to initiation of cardiopulmonary resuscitation (CPR)], and was recently validated with excellent discriminatory performance in an East Asian cohort.10 In current analysis, we used the sCAHP score to evaluate whether the therapeutic effects of early CAG and TTM would be modulated by immediate neuroprognosis after OHCA in East Asian patients.

Section snippets

Setting

This observational study was performed by retrospectively analysing the prospectively-collected OHCA database of the National Taiwan University Hospital, which is a tertiary medical centre. Patients or their surrogates gave written informed consent to be include into the database. Our hospital has 2600 beds, including 220 beds in intensive care units, and there are approximately 100,000 patient visits to our emergency department each year. The study was conducted in accordance with the

Results

A total of 936 adult non-traumatic OHCA patients were sent to our emergency department during the study period, and resuscitation efforts resulted in sustained ROSC in 412 patients who were included in the analysis. As shown in Table 1, the mean age of the patients was 65.2 years (standard deviation: 16.8 years). The majority (74.0%) of the arrests were witnessed, and most of the initial rhythms were non-shockable (69.9%). The mean duration of the low-flow interval was 33.9 min (standard

Main findings

In this study, we first used a validated tool, i.e. sCAHP score, to stratify OHCA patients into different risks of poor neurological outcome. We then used multivariate regression analyses to study the associations between early CAG or TTM and OHCA outcomes. The results indicated that early CAG was associated with improved neurological and survival outcomes across different risk strata. By contrast, TTM seemed to be more effective only in low-risk patients for improving neurological outcome but

Conclusions

Early CAG was associated with improved neurological and survival outcomes of OHCA, irrespective of the immediate neuroprognosis predicted by sCAHP score. By contrast, when OHCA patients were stratified by sCAHP score, TTM appeared to be more effective in improving neurological outcome only for low-risk OHCA patients (patients with sCAHP score <185). The beneficial effects of TTM for survival were consistent for all OHCA patients, independent of the sCAHP score. Therefore, early CAG, PCI and TTM

Conflicts of interests

The authors declare that they have no conflict of interest.

Acknowledgments

We thank Centre of Quality Management of National Taiwan University Hospital for providing the list of patients sustaining in-hospital cardiac arrest. We thank the staff of the 3rd Core Lab, Department of Medical Research, National Taiwan University Hospital for technical support. Author Chih-Hung Wang recieved a grant (108-S4091) from the National Taiwan University Hospital. Author Chien-Hua Huang recieved a grant (108-S4237) from the National Taiwan University Hospital. National Taiwan

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    • Clinical Validation of Cardiac Arrest Hospital Prognosis (CAHP) Score and MIRACLE2 Score to Predict Neurologic Outcomes after Out-of-Hospital Cardiac Arrest

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    1

    The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

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