Evaluation of the cognitive outcome after out-of-hospital cardiac arrest: The role of thalamus.

Cardiac arrest survivors develop a variety of neuropsychological impairments and neuroanatomical lesions. The goal of this study is to evaluate if brain voxel-based morphometry and lesional Magnetic Resonance Imaging (MRI) analyses performed in the acute phase of an Out-of-Hospital Cardiac Arrest (OHCA) can be sensitive enough to predict the persistence of neuropsychological disorders beyond 3 months. Survivors underwent a prospective brain MRI during the first month after an OHCA and performed neuropsychological assessments at 1 and 3 months. According to the second neuropsychological assessment, survivors were separated into two subgroups, a deficit subgroup with persistent memory, executive functions, attention and/or praxis disorders (n = 11) and a preserved subgroup, disorders free (n = 14). Brain vascular lesion images were investigated, and volumetric changes were compared with healthy controls. Correlations were discussed between brain MRI results, OHCA data and the second neuropsychological assessment. Analyses of acute ischemic lesions did not reveal significant differences between the two subgroups (p = .35), and correlations with cognitive impairments could not be assessed. voxel-based morphometry analyses revealed a global cerebral volume reduction for the two subgroups and a clear decrease of the right thalamic volume for the deficit subgroup. It was associated with a cognitive dysexecutive syndrome represented by four executive indexes according to the 'Groupe de Réflexion pour l'Evaluation des Fonctions EXécutives' criteria. The right thalamus atrophy seems to be more predictive than the vascular lesions and more specific than a global cerebral volume reduction of post-OHCA neuropsychological executive disorders.

Association between the extent of diffusion restriction on brain diffusion-weighted imaging and neurological outcomes after an out-of-hospital cardiac arrest.

BACKGROUND: This study evaluated the association between the extent of diffusion restriction on brain diffusion-weighted imaging (DWI) and neurological outcomes in patients who underwent targeted temperature management (TTM) after an out-of-hospital cardiac arrest (OHCA). METHODS: Patients who underwent brain magnetic resonance imaging within 10 days of OHCA between 2012 and 2021 were analysed. The extent of diffusion restriction was described according to the modified DWI Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS). The 35 predefined brain regions were assigned a score if diffuse signal changes were concordantly present in DWI scans and apparent diffusion coefficient maps. The primary outcome was an unfavourable neurological outcome at 6 months. The sensitivity, specificity, and receiver operating characteristic (ROC) curves for the measured parameters were analysed. Cut-off values were determined to predict the primary outcome. The predictive cut-off DWI-ASPECTS was internally validated using five-fold cross-validation. RESULTS: Of the 301 patients, 108 (35.9%) had 6-month favourable neurological outcomes. Patients with unfavourable outcomes had higher whole-brain DWI-ASPECTS (median, 31 [26-33] vs. 0 [0-1], P < 0.001) than those with favourable outcomes. The area under the ROC curve (AUROC) of whole-brain DWI-ASPECTS was 0.957 (95% confidence interval [CI] 0.928-0.977). A cut-off value of ≥8 for unfavourable neurological outcomes had specificity and sensitivity of 100% (95% CI 96.6-100) and 89.6% (95% CI 84.4-93.6), respectively. The mean AUROC was 0.956. CONCLUSION: More extensive diffusion restriction on DWI-ASPECTS in patients with OHCA who underwent TTM was associated with 6-month unfavourable neurological outcomes. Running title: Diffusion restriction and neurological outcomes after cardiac arrest.

Comparison of the prognostic value of early-phase proton magnetic resonance spectroscopy and diffusion tensor imaging with serum neuron-specific enolase at 72 h in comatose survivors of out-of-hospital cardiac arrest-a substudy of the XeHypotheca trial.

PURPOSE: We compared the predictive accuracy of early-phase brain diffusion tensor imaging (DTI), proton magnetic resonance spectroscopy (1H-MRS), and serum neuron-specific enolase (NSE) against the motor score and epileptic seizures (ES) for poor neurological outcome after out-of-hospital cardiac arrest (OHCA). METHODS: The predictive accuracy of DTI, 1H-MRS, and NSE along with motor score at 72 h and ES for the poor neurological outcome (modified Rankin Scale, mRS, 3 - 6) in 92 comatose OHCA patients at 6 months was assessed by area under the receiver operating characteristic curve (AUROC). Combined models of the variables were included as exploratory. RESULTS: The predictive accuracy of fractional anisotropy (FA) of DTI (AUROC 0.73, 95% CI 0.62-0.84), total N-acetyl aspartate/total creatine (tNAA/tCr) of 1H-MRS (0.78 (0.68 - 0.88)), or NSE at 72 h (0.85 (0.76 - 0.93)) was not significantly better than motor score at 72 h (0.88 (95% CI 0.80-0.96)). The addition of FA and tNAA/tCr to a combination of NSE, motor score, and ES provided a small but statistically significant improvement in predictive accuracy (AUROC 0.92 (0.85-0.98) vs 0.98 (0.96-1.00), p = 0.037). CONCLUSION: None of the variables (FA, tNAA/tCr, ES, NSE at 72 h, and motor score at 72 h) differed significantly in predicting poor outcomes in this patient group. Early-phase quantitative neuroimaging provided a statistically significant improvement for the predictive value when combined with ES and motor score with or without NSE. However, in clinical practice, the additional value is small, and considering the costs and challenges of imaging in this patient group, early-phase DTI/MRS cannot be recommended for routine use. TRIAL REGISTRATION: ClinicalTrials.gov NCT00879892, April 13, 2009.

Machine Learning Models for Survival and Neurological Outcome Prediction of Out-of-Hospital Cardiac Arrest Patients.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a major health problem worldwide, and neurologic injury remains the leading cause of morbidity and mortality among survivors of OHCA. The purpose of this study was to investigate whether a machine learning algorithm could detect complex dependencies between clinical variables in emergency departments in OHCA survivors and perform reliable predictions of favorable neurologic outcomes. METHODS: This study included adults (≥18 years of age) with a sustained return of spontaneous circulation after successful resuscitation from OHCA between 1 January 2004 and 31 December 2014. We applied three machine learning algorithms, including logistic regression (LR), support vector machine (SVM), and extreme gradient boosting (XGB). The primary outcome was a favorable neurological outcome at hospital discharge, defined as a Glasgow-Pittsburgh cerebral performance category of 1 to 2. The secondary outcome was a 30-day survival rate and survival-to-discharge rate. RESULTS: The final analysis included 1071 participants from the study period. For neurologic outcome prediction, the area under the receiver operating curve (AUC) was 0.819, 0.771, and 0.956 in LR, SVM, and XGB, respectively. The sensitivity and specificity were 0.875 and 0.751 in LR, 0.687 and 0.793 in SVM, and 0.875 and 0.904 in XGB. The AUC was 0.766 and 0.732 in LR, 0.749 and 0.725 in SVM, and 0.866 and 0.831 in XGB, for survival-to-discharge and 30-day survival, respectively. CONCLUSIONS: Prognostic models trained with ML technique showed appropriate calibration and high discrimination for survival and neurologic outcome of OHCA without using prehospital data, with XGB exhibiting the best performance.

Admission C-reactive protein concentrations are associated with unfavourable neurological outcome after out-of-hospital cardiac arrest.

Whether admission C-reactive protein (aCRP) concentrations are associated with neurological outcome after out-of-hospital cardiac arrest (OHCA) is controversial. Based on established kinetics of CRP, we hypothesized that aCRP may reflect the pre-arrest state of health and investigated associations with neurological outcome. Prospectively collected data from the Vienna Clinical Cardiac Arrest Registry of the Department of Emergency Medicine were analysed. Adults (≥ 18 years) who suffered a non-traumatic OHCA between January 2013 and December 2018, without return of spontaneous circulation or extracorporeal cardiopulmonary resuscitation therapy were eligible. The primary endpoint was a composite of unfavourable neurologic function or death (defined as Cerebral Performance Category 3-5) at 30 days. Associations of CRP levels drawn within 30 min of hospital admission were assessed using binary logistic regression. ACRP concentrations were overall low in our population (n = 832), but higher in the unfavourable outcome group [median: 0.44 (quartiles 0.15-1.44) mg/dL vs. 0.26 (0.11-0.62) mg/dL, p < 0.001]. The crude odds ratio for higher aCRP concentrations was 1.19 (95% CI 1.10-1.28, p < 0.001, per mg/dL) to have unfavourable neurological outcome. After multivariate adjustment for traditional prognostication markers the odds ratio of higher aCRP concentrations was 1.13 (95% CI 1.04-1.22, p = 0.002). Sensitivity of aCRP was low, but specificity for unfavourable neurological outcome was 90% for the cut-off at 1.5 mg/dL and 97.5% for 5 mg/dL CRP. In conclusion, high aCRP levels are associated with unfavourable neurological outcome at day 30 after OHCA.

Association between serum lactate level during cardiopulmonary resuscitation and survival in adult out-of-hospital cardiac arrest: a multicenter cohort study.

We aimed to investigate the association between serum lactate levels during cardiopulmonary resuscitation (CPR) and survival in patients with out-of-hospital cardiac arrest (OHCA). From the database of a multicenter registry on OHCA patients, we included adult nontraumatic OHCA patients transported to the hospital with ongoing CPR. Based on the serum lactate levels during CPR, the patients were divided into four quartiles: Q1 (≤ 10.6 mEq/L), Q2 (10.6-14.1 mEq/L), Q3 (14.1-18.0 mEq/L), and Q4 (> 18.0 mEq/L). The primary outcome was 1-month survival. Among 5226 eligible patients, the Q1 group had the highest 1-month survival (5.6% [74/1311]), followed by Q2 (3.6% [47/1316]), Q3 (1.7% [22/1292]), and Q4 (1.0% [13/1307]) groups. In the multivariable logistic regression analysis, the adjusted odds ratio of Q4 compared with Q1 for 1-month survival was 0.24 (95% CI 0.13-0.46). 1-month survival decreased in a stepwise manner as the quartiles increased (p for trend < 0.001). In subgroup analysis, there was an interaction between initial rhythm and survival (p for interaction < 0.001); 1-month survival of patients with a non-shockable rhythm decreased when the lactate levels increased (p for trend < 0.001), but not in patients with a shockable rhythm (p for trend = 0.72). In conclusion, high serum lactate level during CPR was associated with poor 1-month survival in OHCA patients, especially in patients with non-shockable rhythm.

Optimal paramedic numbers in resuscitation of patients with out-of-hospital cardiac arrest: A randomized controlled study in a simulation setting.

BACKGROUND: The effect of paramedic crew size in the resuscitation of patients with out-of-hospital cardiac arrest (OHCA) remains inconclusive. We hypothesised that teams with a larger crew size have better resuscitation performance including chest compression fraction (CCF), advanced life support (ALS), and teamwork performance than those with a smaller crew size. METHODS: We conducted a randomized controlled study in a simulation setting. A total of 140 paramedics from New Taipei City were obtained by stratified sampling and were randomly allocated to 35 teams with crew sizes of 2, 3, 4, 5, and 6 (i.e. 7 teams in every paramedic crew size). A scenario involving an OHCA patient who experienced ventricular fibrillation and was attached to a cardiopulmonary resuscitation (CPR) machine was simulated. The primary outcome was the overall CCF; the secondary outcomes were the CCF in manual CPR periods, time from the first dose of epinephrine until the accomplishment of intubation, and teamwork performance. Tasks affecting the hands-off time during CPR were also analysed. RESULTS: In all 35 teams with crew sizes of 2, 3, 4, 5, and 6, the overall CCFs were 65.1%, 64.4%, 70.7%, 72.8%, and 71.5%, respectively (P = 0.148). Teams with a crew size of 5 (58.4%, 61.8%, 68.9%, 72.4%, and 68.7%, P<0.05) had higher CCF in manual CPR periods and better team dynamics. Time to the first dose of epinephrine was significantly shorter in teams with 4 paramedics, while time to completion of intubation was shortest in teams with 6 paramedics. Troubleshooting of M-CPR machine decreased the hands-off time during resuscitation (39 s), with teams comprising 2 paramedics having the longest hands-off time (63s). CONCLUSION: Larger paramedic crew size (≧4 paramedics) did not significantly increase the overall CCF in OHCA resuscitation but showed higher CCF in manual CPR period before the setup of the CPR machine. A crew size of ≧4 paramedics can also shorten the time of ALS interventions, while teams with 5 paramedics will have the best teamwork performance. Paramedic teams with a smaller crew size should focus more on the quality of manual CPR, teamwork, and training how to troubleshoot a M-CPR machine.

Vasospasm-related Sudden Cardiac Death Has Outcomes Comparable with Coronary Stenosis in Out-of-Hospital Cardiac Arrest.

BACKGROUND: Characteristics of coronary vasospasm-related sudden cardiac death are not well understood. We aimed to compare the characteristics and clinical outcomes between coronary vasospasm and stenosis, in out-of-hospital cardiac arrest (OHCA) survivors, who underwent coronary angiogram (CAG). METHODS: We conducted a multicenter retrospective observational registry-based study at 8 Korean tertiary care centers. Data of OHCA survivors undergoing CAG between 2010 and 2015 were extracted. Patients were divided into vasospasm and stenosis (stenosis > 50%) groups based on CAG findings. The primary and the secondary outcomes were survival and a good neurologic outcome at 30 days after OHCA. Patients in the vasospasm and stenosis groups were propensity score matched. RESULTS: Of the 413 included patients, vasospasm and stenosis groups comprised 87 and 326 patients, respectively. There were 279 (66.7%) survivors and 206 (49.3%) patients with good neurologic outcomes. The vasospasm group had better clinical characteristics for outcome (younger age, less diabetes and hypertension, more prehospital restoration of spontaneous circulation, higher Glasgow Coma Scale, less ST segment elevation, and less requirement of circulatory support). The vasospasm group had better survival (75/87 vs. 204/326, P < 0.001) and good neurologic outcomes (62/87 vs. 144/326, P < 0.001). However, vasospasm was not independently associated with survival (odds ratio [OR], 0.980; 95% confidence interval [CI], 0.400-2.406) or neurologic outcomes (OR, 0.870; 95% CI, 0.359-2.108) after adjustment and vasospasm was not associated with survival and neurologic outcome in propensity score-matched cohorts. CONCLUSION: Our analysis of propensity score-matched cohorts finds that vasospasm OHCA survivors have survival and neurologic outcomes comparable with those of stenotic OHCA survivors.

Myocardial infarction type 1 is frequent in refractory out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR).

Extracorporeal cardiopulmonary resuscitation (ECPR) is a last resort treatment option for refractory cardiac arrest performed in specialized centers. Following consensus recommendations, ECPR is mostly offered to younger patients with witnessed collapse but without return of spontaneous circulation (ROSC). We report findings from a large single-center registry with 252 all-comers who received ECPR from 2011-2019. It took a median of 52 min to establish stable circulation by ECPR. Eighty-five percent of 112 patients with out-of-hospital cardiac arrest (OHCA) underwent coronary angiography, revealing myocardial infarction (MI) type 1 with atherothrombotic vessel obstruction in 70 patients (63% of all OHCA patients, 74% of OHCA patients undergoing coronary angiography). Sixty-six percent of 140 patients with intra-hospital cardiac arrest (IHCA) underwent coronary angiography, which showed MI type 1 in 77 patients (55% of all IHCA patients, 83% of IHCA patients undergoing coronary angiography). These results suggest that MI type 1 is a frequent finding and - most likely - cause of cardiac arrest (CA) in patients without ROSC, especially in OHCA. Hospital survival rates were 30% and 29% in patients with OHCA and IHCA, respectively. According to these findings, rapid coronary angiography may be advisable in patients with OHCA receiving ECPR without obvious non-cardiac cause of arrest, irrespective of electrocardiogram analysis. Almost every third patient treated with ECPR survived to hospital discharge, supporting previous data suggesting that ECPR may be beneficial in CA without ROSC. In conclusion, interventional cardiology is of paramount importance for ECPR programs.

Association between Cardiac Arrest Time and Favorable Neurological Outcomes in Witnessed Out-of-Hospital Cardiac Arrest Patients Treated with Targeted Temperature Management.

BACKGROUND: Patients who achieve a return of spontaneous circulation (ROSC) with prolonged cardiac arrest have been recognized to have a poor prognosis. This might lead to reluctance in the provision of post-resuscitation care. Hence, we evaluated the impact of cardiac arrest time on neurologic outcomes in out-of-hospital cardiac arrest (OHCA) patients. METHODS: This cross-sectional study used a hospital-based nationwide registry of OHCAs in Korea between 2012 and 2016. All witnessed OHCA patients aged ≥ 15 years and treated with targeted temperature management were included. We collected the time from collapse to sustained ROSC, which was defined as the downtime. The primary outcome was a favorable neurological outcome at hospital discharge. A multiple logistic regression analysis was conducted to determine independent factors for primary outcome in patients with downtime > 30 minutes. RESULTS: Overall, neurologically favorable outcome rates were 30.5% in 1,963 patients. When the downtime was stratified into categories of 0-10, 11-20, 21-30, 31-40, 41-50, 51-60, and > 60 minutes according to 10-minute intervals, neurologically favorable outcome rates were 58.2%, 52.3%, 37.3%, 24.6%, 14.1%, 17.4%, and 16.7%, respectively (P < 0.001). In patients with downtime > 30 minutes, age 51-70 years (odds ratio [OR], 5.35; 95% confidence interval [CI], 2.50-11.49), age ≤ 50 years (OR, 13.16; 95% CI, 6.06-28.57), shockable rhythm (OR, 3.92; 95% CI, 2.71-5.68), bystander resuscitation (OR, 1.80; 95% CI, 1.27-2.55), cardiac cause (OR, 3.50; 95% CI, 1.69-7.25), percutaneous coronary intervention (OR, 1.82; 95% CI, 1.18-2.81), and downtime ≤ 40 minutes (OR, 2.02; 95% CI, 1.42-2.88) were associated with favorable neurological outcomes. CONCLUSION: In patients with prolonged downtime, predicting favorable neurologic outcome may be multifactorial. The cutoff value for downtime is not the only determining factor to provide post-resuscitation care.

Prognostic value of OHCA, C-GRApH and CAHP scores with initial neurologic examinations to predict neurologic outcomes in cardiac arrest patients treated with targeted temperature management.

OBJECTIVE: The aim of this study in out-of-hospital cardiac arrest (OHCA) patients treated with targeted temperature management (TTM) was to evaluate the prognostic value of OHCA, C-GRApH, and CAHP scores with initial neurologic examinations for predicting neurologic outcomes. METHODS: This retrospective study included OHCA patients treated with TTM from 2009 to 2017. We calculated three cardiac arrest (CA)-specific risk scores (OHCA, C-GRApH, and CAHP) at the time of admission. The initial neurologic examination included an evaluation of the Full Outline of UnResponsiveness brainstem reflexes (FOUR_B) and Glasgow Coma Scale motor (GCS_M) scores. The primary outcome was the neurologic outcome at hospital discharge. RESULTS: Of 311 subjects, 99 (31.8%) had a good neurologic outcome at hospital discharge. The OHCA score had an area under the receiver operating characteristic curve (AUROC) of 0.844 (95% confidence interval (CI): 0.798-0.884), the C-GRApH score had an AUROC of 0.779 (95% CI: 0.728-0.824), and the CAHP score had an AUROC of 0.872 (95% CI: 0.830-0.907). The addition of the FOUR_B or GCS_M score to the OHCA score improved the prediction of poor neurologic outcome (with FOUR_B: AUROC = 0.899, p = 0.001; with GCS_M: AUROC = 0.880, p = 0.004). The results were similar with the C-GRApH and CAHP scores in predicting poor neurologic outcome. CONCLUSIONS: This study confirms the good prognostic performance of CA-specific scores to predict neurologic outcomes in OHCA patients treated with TTM. By adding new variables associated with the initial neurologic examinations, the prognoses of neurologic outcomes improved compared to the existing scoring models.

Usefulness of F2-isoprostanes in early prognostication after cardiac arrest: a topical review of the literature and meta-analysis of preclinical data.

Prognostication after cardiac arrest (CA) represents a challenging issue, and several biomarkers have been proposed in the attempt to predict outcome. Among these, F2-isoprostanes stand out as potential biomarkers for early prognostication, providing information on the magnitude of global oxidative injury after return of spontaneous circulation (ROSC). We performed a topical review searching PubMed and Scopus databases to identify studies evaluating the modifications of F2-isoprostanes in the early period after CA, and a meta-analysis of studies providing curves of F2-isoprostanes plasma levels seeking to describe the biomarker's kinetics after CA. Evidence suggests that plasma levels of F2-isoprostanes increase in the early post-resuscitation period and seem well correlated with the burden of ischaemia-reperfusion injury. Our meta-analysis shows a possible increase as early as 5 minutes after ROSC, which persists at 2 hours and is attenuated at 4 hours. Clinical studies are warranted to evaluate the utility of this biomarker for prognostication purposes in CA survivors.

Differences in the performance of resuscitation according to the resuscitation guideline terminology during infant cardiopulmonary resuscitation: "Approximately 4 cm" versus "at least one-third the anterior-posterior diameter of the chest".

AIM: This study was conducted to investigate the effect of resuscitation guideline terminology on the performance of infant cardiopulmonary resuscitation (CPR). METHODS: A total of 40 intern or resident physicians conducted 2-min CPR with the two-finger technique (TFT) and two-thumb technique (TT) on a simulated infant cardiac arrest model with a 1-day interval. They were randomly assigned to Group A or B. The participants of Group A conducted CPR with the chest compression depth (CCD) target of "approximately 4 cm" and those of Group B conducted CPR with the CCD target of "at least one-third the anterior-posterior diameter of the chest". Single rescuer CPR was performed with a 15:2 compression to ventilation ratio on the floor. RESULTS: In both chest compression techniques, the average CCD of Group B was significantly deeper than that of Group A (TFT: 41.0 [range, 39.3-42.0] mm vs. 36.5 [34.0-37.9] mm, P = 0.002; TT: 42.0 [42.0-43.0] mm vs. 37.0 [35.3-38.0] mm, P < 0.001). Adequacy of CCD also showed similar results (Group B vs. A; TFT: 99% [82-100%] vs. 29% [12-58%], P = 0.001; TT: 100% [100-100%] vs. 28% [8-53%], P < 0.001). CONCLUSIONS: Using the CCD target of "at least one-third the anterior-posterior diameter of the chest" resulted in deep and adequate chest compressions during simulated infant CPR in contrast to the CCD target of "approximately 4 cm". Therefore, changes in the terminology used in the guidelines should be considered to improve the quality of CPR. TRIAL REGISTRATION: Clinical Research Information Service; cris.nih.go.kr/cris/en (Registration number: KCT0003486).

Application of a Dual-Dispatch System for Out-of-Hospital Cardiac Arrest Patients: Will More Hands Save More Lives?

BACKGROUND: Recovery after out-of-hospital cardiac arrest (OHCA) is difficult, and emergency medical services (EMS) systems apply various strategies to improve outcomes. Multi-dispatch is one means of providing high-quality cardiopulmonary resuscitation (CPR), but no definitive best-operation guidelines are available. We assessed the effects of a basic life support (BLS)-based dual-dispatch system for OHCA. METHODS: This prospective observational study of 898 enrolled OHCA patients, conducted in Daegu, Korea from March 1, 2015 to June 30, 2016, involved patients > 18 years old with suspected cardiac etiology OHCA. In Daegu, EMS started a BLS-based dual-dispatch system in March 2015, for cases of cardiac arrest recognition by a dispatch center. We assessed the association between dual-dispatch and OHCA outcomes using multivariate logistic regressions. We also analyzed the effect of dual-dispatch according to the stratified on-scene time. RESULTS: Of 898 OHCA patients (median, 69.0 years; 65.5% men), dual-dispatch was applied in 480 (53.5%) patients. There was no difference between the single-dispatch group (SDG) and the dual-dispatch group (DDG) in survival at discharge and neurological outcomes (survival discharge, P = 0.176; neurological outcomes, P = 0.345). In the case of less than 10 minutes of on-scene time, the adjusted odds ratio was 1.749 (95% confidence interval [CI], 0.490-6.246) for survival discharge and 6.058 (95% CI, 1.346-27.277) for favorable neurological outcomes in the DDG compared with the SDG. CONCLUSION: Dual-dispatch was not associated with better OHCA outcomes for the entire study population, but showed favorable neurological outcomes when the on-scene time was less than 10 minutes.

Clinical Factors Associated with Obstructive Coronary Artery Disease in Patients with Out-of-Hospital Cardiac Arrest: Data from the Korean Cardiac Arrest Research Consortium (KoCARC) Registry.

BACKGROUND: Although coronary artery disease (CAD) is a major cause of out-of-hospital cardiac arrest (OHCA), there has been no convinced data on the necessity of routine invasive coronary angiography (ICA) in OHCA. We investigated clinical factors associated with obstructive CAD in OHCA. METHODS: Data from 516 OHCA patients (mean age 58 years, 83% men) who underwent ICA after resuscitation was obtained from a nation-wide OHCA registry. Obstructive CAD was defined as the lesions with diameter stenosis ≥ 50% on ICA. Independent clinical predictors for obstructive CAD were evaluated using multiple logistic regression analysis, and their prediction performance was compared using area under the receiver operating characteristic curve with 10,000 repeated random permutations. RESULTS: Among study patients, 254 (49%) had obstructive CAD. Those with obstructive CAD were older (61 vs. 55 years, P < 0.001) and had higher prevalence of hypertension (54% vs. 36%, P < 0.001), diabetes mellitus (29% vs. 21%, P = 0.032), positive cardiac enzyme (84% vs. 74%, P = 0.010) and initial shockable rhythm (70% vs. 61%, P = 0.033). In multiple logistic regression analysis, old age (≥ 60 years) (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.36-3.00; P = 0.001), hypertension (OR, 1.74; 95% CI, 1.18-2.57; P = 0.005), positive cardiac enzyme (OR, 1.72; 95% CI, 1.09-2.70; P = 0.019), and initial shockable rhythm (OR, 1.71; 95% CI, 1.16-2.54; P = 0.007) were associated with obstructive CAD. Prediction ability for obstructive CAD increased proportionally when these 4 factors were sequentially combined (P < 0.001). CONCLUSION: In patients with OHCA, those with old age, hypertension, positive cardiac enzyme and initial shockable rhythm were associated with obstructive CAD. Early ICA should be considered in these patients.

Prognostic Value of Neurological Status on Hospital Arrival for Short-Term Outcome in Patients With Cardiovascular Shock　- Sub-analysis of the Japanese Circulation Society Cardiovascular Shock Registry.

BACKGROUND: Consciousness disturbance is one of the major clinical signs associated with shock state, but its prognostic value has not been previously evaluated in cardiovascular shock patients. We aimed to evaluate the prognostic value of neurological status for 30-day mortality in cardiovascular shock patients without out-of-hospital cardiac arrest (OHCA). Methods and Results: Patients with out-of-hospital onset cardiovascular shock were recruited from the Japanese Circulation Society Shock Registry. Neurological status upon hospital arrival was evaluated using the Japan Coma Scale (JCS). Patients were divided into 4 groups according to the JCS: alert, JCS 0; awake, JCS 1-3 (not fully alert but awake without any stimuli); arousable, JCS 10-30 (arousable with stimulation); and coma JCS 100-300 (unarousable). The primary endpoint was 30-day all-cause death. In total, 700 cardiovascular shock patients without OHCA were assessed. The coma group was associated with a higher incidence of 30-day all-cause death compared with other groups (alert, 15.3%; awake, 24.4%; arousable, 36.8%; coma, 48.5%, P<0.001). Similar trends were observed in etiologically divergent subgroups (acute coronary syndrome, non-ischemic arrhythmia, and aortic disease). On multivariate Cox regression analysis, arousable (hazard ratio [HR], 1.82; 95% CI: 1.16-2.85, P=0.009) and coma (HR, 2.72; 95% CI: 1.76-4.22, P<0.001) (reference: alert) independently predicted 30-day mortality. CONCLUSIONS: Neurological status upon hospital arrival was useful to predict 30-day mortality in cardiovascular shock patients without OHCA.

The association between plasma miR-122-5p release pattern at admission and all-cause mortality or shock after out-of-hospital cardiac arrest.

BACKGROUND: Data suggests that the plasma levels of the liver-specific miR-122-5p might both be a marker of cardiogenic shock and a prognostic marker of out-of-hospital cardiac arrest (OHCA). Our aim was to characterize plasma miR-122-5p at admission after OHCA and to assess the association between miR-122-5p and relevant clinical factors such all-cause mortality and shock at admission after OHCA. METHODS: In the pilot trial, 10 survivors after OHCA were compared to 10 age- and sex-matched controls. In the main trial, 167 unconscious survivors of OHCA from the Targeted Temperature Management (TTM) trial were included. RESULTS: In the pilot trial, plasma miR-122-5p at admission after OHCA was 400-fold elevated compared to controls. In the main trial, plasma miR-122-5p at admission was independently associated with lactate and bystander cardiopulmonary resuscitation. miR-122-5p at admission was not associated with shock at admission (p = 0.14) or all-cause mortality (p = 0.35). Target temperature (33 °C vs 36 °C) was not associated with miR-122-5p levels at any time point. CONCLUSIONS: After OHCA, miR-122-5p demonstrated a marked acute increase in plasma and was independently associated with lactate and bystander resuscitation. However, miR-122-5p at admission was not associated with all-cause mortality or shock at admission.

2018 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This 2018 American Heart Association focused update on pediatric advanced life support guidelines for cardiopulmonary resuscitation and emergency cardiovascular care follows the 2018 evidence review performed by the Pediatric Task Force of the International Liaison Committee on Resuscitation. It aligns with the International Liaison Committee on Resuscitation's continuous evidence review process, and updates are published when the group completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendation for antiarrhythmic drug therapy in pediatric shock-refractory ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. As was the case in the pediatric advanced life support section of the "2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care," only 1 pediatric study was identified. This study reported a statistically significant improvement in return of spontaneous circulation when lidocaine administration was compared with amiodarone for pediatric ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. However, no difference in survival to hospital discharge was observed among patients who received amiodarone, lidocaine, or no antiarrhythmic medication. The writing group reaffirmed the 2015 pediatric advanced life support guideline recommendation that either lidocaine or amiodarone may be used to treat pediatric patients with shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.

Quantitative pupillometry and neuron-specific enolase independently predict return of spontaneous circulation following cardiogenic out-of-hospital cardiac arrest: a prospective pilot study.

This study aimed to identify neurological and pathophysiological factors that predicted return of spontaneous circulation (ROSC) among patients with out-of-hospital cardiac arrest (OHCA). This prospective 1-year observational study evaluated patients with cardiogenic OHCA who were admitted to a tertiary medical center, Nippon Medical School Hospital. Physiological and neurological examinations were performed at admission for quantitative infrared pupillometry (measured with NPi-200, NeurOptics, CA, USA), arterial blood gas, and blood chemistry. Simultaneous blood samples were also collected to determine levels of neuron-specific enolase (NSE), S-100b, phosphorylated neurofilament heavy subunit, and interleukin-6. In-hospital standard advanced cardiac life support was performed for 30 minutes.The ROSC (n = 26) and non-ROSC (n = 26) groups were compared, which a revealed significantly higher pupillary light reflex ratio, which was defined as the percent change between maximum pupil diameter before light stimuli and minimum pupil diameter after light stimuli, in the ROSC group (median: 1.3% [interquartile range (IQR): 0.0-2.0%] vs. non-ROSC: (median: 0%), (Cut-off: 0.63%). Furthermore, NSE provided the great sensitivity and specificity for predicting ROSC, with an area under the receiver operating characteristic curve of 0.86, which was created by plotting sensitivity and 1-specificity. Multivariable logistic regression analyses revealed that the independent predictors of ROSC were maximum pupillary diameter (odds ratio: 0.25, 95% confidence interval: 0.07-0.94, P = 0.04) and NSE at admission (odds ratio: 0.96, 95% confidence interval: 0.93-0.99, P = 0.04). Pupillary diameter was also significantly correlated with NSE concentrations (r = 0.31, P = 0.027). Conclusively, the strongest predictors of ROSC among patients with OHCA were accurate pupillary diameter and a neuronal biomarker, NSE. Quantitative pupillometry may help guide the decision to terminate resuscitation in emergency departments using a neuropathological rationale. Further large-scale studies are needed.