Nation-Wide Observational Study of Cardiac Arrests Occurring in Nursing Homes and Nursing Facilities in Singapore

INTRODUCTION@#Nursing home (NH) residents with out-of-hospital cardiac arrests (OHCA) have unique resuscitation priorities. This study aimed to describe OHCA characteristics in NH residents and identify independent predictors of survival.@*MATERIALS AND METHODS@#OHCA cases between 2010-16 in the Pan-Asian Resuscitation Outcomes Study were retrospectively analysed. Patients aged <18 years old and non-emergency cases were excluded. Primary outcome was survival at discharge or 30 days. Good neurological outcome was defined as a cerebral performance score between 1-2.@*RESULTS@#A total of 12,112 cases were included. Of these, 449 (3.7%) were NH residents who were older (median age 79 years, range 69-87 years) and more likely to have a history of stroke, heart and respiratory diseases. Fewer NH OHCA had presumed cardiac aetiology (62% vs 70%, <0.01) and initial shockable rhythm (8.9% vs 18%, <0.01), but had higher incidence of bystander cardiopulmonary resuscitation (74% vs 43%, <0.01) and defibrillator use (8.5% vs 2.8%, <0.01). Non-NH (2.8%) residents had better neurological outcomes than NH (0.9%) residents ( <0.05). Factors associated with survival for cardiac aetiology included age <65 years old, witnessed arrest, bystander defibrillator use and initial shockable rhythm; for non-cardiac aetiology, these included witnessed arrest (adjusted odds ratio [AOR] 3.8, <0.001) and initial shockable rhythm (AOR 5.7, <0.001).@*CONCLUSION@#Neurological outcomes were poorer in NH survivors of OHCA. These findings should inform health policies on termination of resuscitation, advance care directives and do-not-resuscitate orders in this population.

Ethnic Differences and Trends in ST-Segment Elevation Myocardial Infarction Incidence and Mortality in a Multi-Ethnic Population

INTRODUCTION@#This study aimed to compare the incidence and mortality of ST-segment elevation myocardial infarction (STEMI) across the 3 main ethnic groups in Singapore, determine if there is any improvement in trends over the years and postulate the reasons underlying the ethnic disparity.@*MATERIALS AND METHODS@#This study consisted of 16,983 consecutive STEMI patients who sought treatment from all public hospitals in Singapore from 2007 to 2014.@*RESULTS@#Compared to the Chinese (58 per 100,000 population in 2014), higher STEMI incidence rate was consistently observed in the Malays (114 per 100,000 population) and Indians (126 per 100,000 population). While the incidence rate for the Chinese and Indians remained relatively stable over the years, the incidence rate for the Malays rose slightly. Relative to the Indians (30-day and 1-year all-cause mortality at 9% and 13%, respectively, in 2014), higher 30-day and 1-year all-cause mortality rates were observed in the Chinese (15% and 21%) and Malays (13% and 18%). Besides the Malays having higher adjusted 1-year all-cause mortality, all other ethnic disparities in 30-day and 1-year mortality risk were attenuated after adjusting for demographics, comorbidities and primary percutaneous coronary intervention.@*CONCLUSION@#It is important to continuously evaluate the effectiveness of existing programmes and practices as the aetiology of STEMI evolves with time, and to strike a balance between prevention and management efforts as well as between improving the outcome of "poorer" and "better" STEMI survivors with finite resources.

Outcomes of Patients Presenting with Primary or Secondary Atrial Fibrillation with Rapid Ventricular Rate to the Emergency Department

INTRODUCTION@#Atrial fibrillation (AF) with rapid ventricular rate (RVR) is a common diagnosis in the Emergency Department (ED) requiring evaluation and treatment. We present the characteristics and outcomes of patients presenting with primary or secondary AF in a tertiary hospital ED.@*MATERIALS AND METHODS@#This retrospective cohort study included consecutive patients ≥21 years old, with a primary or secondary diagnosis of AF with RVR in the ED over a 1-year period from 1 January 2016 to 31 December 2016. Primary AF is defined as AF with no precipitating cause and secondary AF as AF secondary to a precipitating cause.@*RESULTS@#A total of 464 patients presented to the ED from 1 January to 31 December 2016 with primary and secondary diagnosis of AF with RVR; 44.8% had primary diagnosis of AF whereas 55.2% had secondary AF. Overall admission rate from ED was high at 91.8% (primary 84.6% vs secondary 97.7%). Patients with primary AF were younger (68 vs 74 years, <0.001), had lower rates of cardiovascular risk factors, and shorter length of stay (median 4 vs 5 days). Within 30 days of discharge, they had lower ED reattendance (16.3% vs 25.8%, <0.001) and lower readmission (16.3% vs 25.8%, <0.001). There was no mortality in the primary AF group (0% vs 9.8%, <0.001).@*CONCLUSION@#Currently, majority of patients with AF with RVR are admitted from the ED. Other study suggests patients with uncomplicated primary AF have lower adverse outcomes and some could potentially be treated as outpatients.

Impact of Direct Cardiovascular Laboratory Activation by Emergency Physicians on False-Positive Activation Rates

<p><b>INTRODUCTION</b>Door-to-balloon (DTB) time is critical to ST elevation myocardial infarction (STEMI) patients' survival. Although DTB time is reduced with direct cardiovascular laboratory (CVL) activation by emergency physicians, concerns regarding false-positive activation remain. We evaluate false-positive rates before and after direct CVL activation and factors associated with false-positive activations.</p><p><b>MATERIALS AND METHODS</b>This is a retrospective single centre study of all emergency CVL activation 3 years before and after introduction of direct activation in July 2007. False-positive activation is defined as either: 1) absence of culprit vessel with coronary artery thrombus or ulceration, or 2) presence of chronic total occlusion of culprit vessel, with no cardiac biomarker elevations and no regional wall abnormalities. All false-positive cases were verified by reviewing their coronary angiograms and patient records.</p><p><b>RESULTS</b>A total of 1809 subjects were recruited; 84 (4.64%) identified as false-positives. Incidence of false-positive before and after direct activation was 4.1% and 5.1% respectively, which was not significant (P = 0.315). In multivariate logistic regression analysis, factors associated with false-positive were: female (odds ratio (OR): 2.104 [1.247-3.548], P = 0.005), absence of chest pain (OR: 5.369 [3.024-9.531], P <0.0001) and presence of only left bundle branch block (LBBB) as indication for activation (OR: 65.691 [19.870-217.179], P <0.0001).</p><p><b>CONCLUSION</b>Improvement in DTB time with direct CVL activation by emergency physicians is not associated with increased false-positive activations. Factors associated with false-positive, especially lack of chest pain or LBBB, can be taken into account to optimise STEMI management.</p>