Dr. Søholm: The background of the current study is that previous studies have found higher survival rates after out-of-hospital cardiac arrest and admission to tertiary heart centres for post-resuscitaton care compared with nontertiary hospitals, however the reasons for this difference has only been speculative. The aim of the study was to examine the level-of post-resuscitation care at tertiary heart centers compared with nontertiary hospitals and to associate this with outcome. Only patients without ST-segment elevation myocardial infarction was examined to avoid referral bias.
Medical Research: What are the main findings?
Dr. Søholm: The main findings of the study of 1.078 patients was that the survival in patients admitted to tertiary heart centers was significantly higher compared with survival in patients admitted to nontertiary hospitals even after adjustment for known risk markers including pre-arrest co-morbidity. We found that the adjusted odds of predefined markers of level-of-care differed in both the acute phase after admission, during the intensive care admission and in the workup prior to hospital discharge. The odds of admission to an intensive care unit was 1.8 for patients admitted to a tertiary heart centre. During the intensive care admission the odds of a temporay pacemaker was 6.4, use of vasoactive agents 1.5, acute and late coronary angiography was 10 and 3.8 respectively, neurophysiological examination 1.8, brain computed tomography 1.9, whereas no difference in the odds of therapeutic hypothermia was found. Prior to hospital discharge the odds of a consultation by a cardiologist was 8.6, having an echocardiography was 2.9, and survivors more often had an implantable cardioverter defibrillator implanted (odds 2.1) as compared with patients admitted to nontertiary hospitals.
Medical Research: What should clinicians and patients take away from your report?
Dr. Søholm: This study is an observational study of consecutive patients with out-of-hospital cardiac arrest during nine years (2002 through 2011), and therefore we find associations and we cannot draw causalities from the current study. We do however find that level-of-care after admission to a tertiary heart center seems higher as compared with nontertiary hospitals in both the early phase after resuscitation, during the intensive care admission, and in the general workup prior to hospital discharge. The varying level-of-care may therefore have contributed to the marked survival difference noted. It is increasingly recognized that post-resuscitation is of major importance after the pre-hospital treatment and return of spontaneous circulation. Clinicians should therefore pay more attention to give the appropriate level-of-care to resuscitated cardiac arrest patients, and to use the recommended examinations for prognostication before giving up on a patient.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Søholm: Future studies should focus on the impact of the different treatments for post-resuscitation care. The post-resuscitation care should be focused on preserving the brain (therapeutic hypothermia for how long, and is avoiding fever enough?), minimizing cardiac damage (acute coronary angiography in all patients?), stabilize the hemodynamics (for example the Impella pump), and treating the cause of the cardiac arrest (placement of implantable cardiac defibrillators, are we choosing the right patients?). The survival after cardiac arrest has increased in recent years, but we believe that it can be further increased by improving both the pre-hospital but also the in-hospital treatments after resuscitation.
Søholm H, Kjaergaard J, Bro-Jeppesen J, Hartvig-Thomsen J, Lippert F, Køber L, Nielsen N, Engsig M, Steensen M, Wanscher M, Karlsen FM, Hassager C.
Circ Cardiovasc Qual Outcomes. 2015 May;8(3):268-76. doi: 10.1161/CIRCOUTCOMES.115.001767. Epub 2015 May 5.
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Helle Søholm, MD, PhD (2015). Cardiac Arrest Survival Better At Tertiary Care Hospitals