Historical neighborhood redlining and bystander CPR disparities in out-of-hospital cardiac arrest.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is associated with low survival rates. Bystander cardiopulmonary resuscitation (CPR) is essential for improving outcomes, but its utilization remains limited, particularly among racial and ethnic minorities. Historical redlining, a practice that classified neighborhoods for mortgage risk in 1930s, may have lasting implications for social and health outcomes. This study sought to investigate the influence of redlining on the provision of bystander CPR during witnessed OHCA. METHODS: We conducted an analysis using data from the comprehensive Cardiac Arrest Registry to Enhance Survival (CARES), encompassing 736,066 non-traumatic OHCA cases across the United States. The Home Owners' Loan Corporation (HOLC) map shapefiles were utilized to categorize census tracts of arrests into four grades (A signifying "best", B "still desirable", C "declining", and D "hazardous"). Multivariable hierarchical logistic regression models were employed to predict the likelihood of CPR provision, adjusting for various factors including age, sex, race/ethnicity, arrest location, calendar year, and state of occurrence. Additionally, we accounted for the percentage of Black residents and residents below poverty levels at the census tract level. RESULTS: Among the 43,186 witnessed cases of OHCA in graded HOLC census tracts, 37.2% received bystander CPR. The rates of bystander CPR exhibited a gradual decline across HOLC grades, ranging from 41.8% in HOLC grade A to 35.8% in HOLC grade D. In fully adjusted model, we observed significantly lower odds of receiving bystander CPR in HOLC grades C (OR 0.89, 95% CI 0.81-0.98, p = 0.016) and D (OR 0.86, 95% CI 0.78-0.95, p = 0.002) compared to HOLC grade A. CONCLUSION: Redlining, a historical segregation practice, is associated with reduced contemporary rates of bystander CPR during OHCA. Targeted CPR training in redlined neighborhoods may be imperative to enhance survival outcomes.

Out-of-hospital cardiac arrest in children in Norway: A national cohort study, 2016-2021.

Aim: Children constitute an important and distinct subgroup of out-of-hospital cardiac arrest (OHCA) patients. This population-based cohort study aims to establish current age-specific population incidence, precipitating causes, circumstances, and outcome of paediatric OHCA, to guide a focused approach to prevention and intervention to improve outcomes. Methods: Data from the national Norwegian Cardiac Arrest Registry was extracted for the six-year period 2016-21 for persons aged <18 years. We present descriptive statistics for the population, resuscitation events, presumed causes, treatment, and outcomes, alongside age-specific incidence and total paediatric mortality rates. Results: Three hundred and eight children were included. The incidence of OHCA was 4.6 per 100 000 child-years and markedly higher in children <1 year at 20.9 child-years. Leading causes were choking, cardiac and respiratory disease, and sudden infant death syndrome. Overall, 21% survived to 30 days and 18% to one year. Conclusion: A registry-based approach enabled this study to delineate the characteristics and trajectories of OHCA events in a national cohort of children. Precipitating causes of paediatric OHCA are diverse compared to adults. Infants aged <1 year are at particularly high risk. Mortality is high, albeit lower than for adults in Norway. A rational community approach to prevention and treatment may focus on general infant care, immediate first aid by caretakers, and identification of vulnerable children by primary health providers. Cardiac arrest registries are a key source of knowledge essential for quality improvement and research into cardiac arrest in childhood.

Statewide implementation of the cardiac arrest registry to enhance survival in Ohio.

Objective: Public health surveillance is essential for improving community health. The Cardiac Arrest Registry to Enhance Survival (CARES) is a surveillance system for out-of-hospital cardiac arrest (OHCA). We describe results of the organized statewide implementation of Ohio CARES. Methods: We performed a retrospective analysis of CARES enactment in Ohio. Key elements included: establishment of statewide leadership, appointment of a dedicated coordinator, conversion to a statewide subscription, statewide dissemination of information, fundraising from internal and external stakeholders, and conduct of resuscitation academies. We identified all adult (≥18 years) OHCA reported in the registry during 2013-2020. We evaluated OHCA characteristics before (2013-2015) and after (2016-2019) statewide implementation using chi-square test. We evaluated trends in OHCA outcomes using the Cochran-Armitage test of trend. Results: Statewide CARES promotion increased participation from 2 (urban) to 136 (129 urban, 7 rural) EMS agencies. Covered population increased from 1.2 M (10% of state) to 4.8 M (41% of state). After statewide implementation, OHCA populations increased male (58.1% vs 60.8%, p < 0.01), white (50.1% vs 63.7%, p < 0.01), bystander witnessed (26.9% vs 32.9%, p < 0.01) OHCAs. Bystander CPR (34.7% vs 33.2%, p = 0.22), bystander AED (13.5% vs 12.3%, p = 0.55) and initial rhythm (shockable 18.0% vs 18.3%, p = 0.32) did not change. From 2013 to 2019 there were temporal increases in ROSC (29.7% to 31.9%, p-trend = 0.028), survival (7.4% to 12.3%, p-trend < 0.001) and survival with good neurologic outcome (5.6% to 8.6%, p-trend = 0.047). Conclusion: The organized statewide implementation of CARES in Ohio was associated with marked increases in community uptake and concurrent observed improvements in patient outcomes. These results highlight key lessons for community-wide fostering of OHCA surveillance.

Out-of-hospital cardiac arrest: Survival in children and young adults over 30 years, a nationwide registry-based cohort study.

OBJECTIVES: We studied short-term (30-day) and long-term (up to ten-year) survival among children and young adults following out-of-hospital cardiac arrest (OHCA) in Sweden over the course of the past 30 years. We also studied the causes of OHCA in children and examined predictors of survival. SETTING: This was a nationwide, registry-based cohort study, using the Swedish Registry of Cardiopulmonary Resuscitation. Our study comprised a cohort of 4,804 individuals aged 0 to 30 years who suffered OHCA between 1990 and 2020, in whom cardiopulmonary resuscitation (CPR) was initiated. We stratified the study cohort to distinct age groups and time periods. RESULTS: We found an increase in 30-day survival from 7% to 20% over the span of 30 years. In those under 1 year of age, survival increased from 2% to 19%. Time to CPR decreased from 14 to 2 min. The 10-year survival was high among those who survived 30 days. The etiology of cardiac arrests exhibited significant variations across different age groups but remained relatively consistent over time. Causes linked to mental illness constituted a substantial percentage of these cases. Compared to the reference period (1990-1994), the odds of survival in 2015-2020 was 3.00 (95% CI: 1.43, 6.94; p = 0.006). CONCLUSION: Survival rate after OHCA in children and young adults has increased three-fold over the past 30 years. Still overall mortality is high underscoring the need for continued efforts to mitigate risk factors and optimize survival.

Trends in EMS-attended out-of-hospital cardiac arrest survival, United States 2015-2019.

AIM: Everyday, nearly 1000 U.S. adults experience out-of-hospital cardiac arrest (OHCA). Survival to hospital discharge varies across many factors, including sociodemographics, location of arrest, and whether bystander intervention was provided. The current study examines recent trends in OHCA survival by location of arrest using a cohort of emergency medical service (EMS) agencies that contributed data to the Cardiac Arrest Registry to Enhance Survival. METHODS: The 2015 CARES cohort (N = 122,613) includes EMS agencies contributing data across five consecutive years, 2015-2019. We assessed trends in EMS-attended OHCA survival for the 2015 CARES cohort by location of arrest - public, residential, nursing home. Unadjusted and adjusted percentages were estimated using 3-level hierarchical logistic regression models among cases aged 18-65 years. RESULTS: Overall, survival from EMS-attended OHCA significantly increased from 12.5% in 2015 to 13.8% in 2019 (p = 0.001). Survival from bystander witnessed arrests also increased significantly from 17.8% in 2015 to 19.7% in 2019 (p = 0.004). The trend for survival increased overall and for bystander witnessed OHCAs occurring in public places and nursing homes. CONCLUSION: Increasing trends for EMS-attended OHCA survival were observed in the overall and bystander witnessed groups. No change in the trend for survival was observed among OHCAs in the groups most likely to have a desirable outcome - bystander witnessed, with a shockable rhythm, and receiving bystander intervention. Reporting and monitoring of OHCA may be an important first step in improving outcomes. Additional community interventions focused on bystander CPR and AED use may be warranted.

The research progress on the registration database of out-of-hospital cardiac arrest / 中华危重病急救医学

Out-of-hospital cardiac arrest (OHCA) with high mortality and disable rate is a public health problem of common concern all over the world. In order to improve the survival rate of OHCA, developed countries such as Europe and the United States have established regional and even national OHCA registration database for continuous monitoring and quality improvement of OHCA, identifying the weaknesses in each link of the survival chain, and evaluating effective measures to enhance the survival rate. At present, China still lacks of registration database that can comprehensively collect the information of OHCA and effectively reflect the treatment status and research direction of OHCA. In order to shorten the huge gap of OHCA survival rate between China and developed countries such as Europe and the United States, we should learn from the experience of foreign registration databases and establish OHCA registration database suitable for China's national conditions, so as to promote the improvement of OHCA survival rate in China. This paper presents several major OHCA registry databases of the internationally recognized, such as cardiac arrest registry to enhance survival (CARES), resuscitation outcomes consortium (ROC), European registry of cardiac arrest (EuReCa), Pan-Asian resuscitation outcomes registry (PAROS), and Australian resuscitation outcome consortium (Aus-ROC), aims to provide a reference for promoting the construction of the cardiac arrest registration database in China.

Exercise-related out-of-hospital cardiac arrest in Victoria, Australia.

BACKGROUND: Characteristics and outcomes of exercise-related out-of-hospital cardiac arrests (OHCA) are not well described in Australia. METHODS: This was a retrospective observational study of non-exercise-related aetiology and exercise-related OHCAs from the Victorian Ambulance Cardiac Arrest Registry between 2008 and 2016, including 12-month quality of life data from 2010 to 2016. Exercise-related OHCA was defined as taking place during or within 1 h of at least moderate intensity exercise. Descriptive statistics and adjusted logistic regression analyses were performed. RESULTS: During the study period there were 482 exercise-related and 33,358 non-exercise-related OHCAs. Jogging/running were the most frequent precipitating sports. The incidence rate of exercise-related OHCA was low (<1 per 100,000 person-years). Compared to non-exercise-related aetiology, exercise-related OHCAs were younger (mean 54 versus 70 years, p < 0.001) and more likely to present in an initial shockable rhythm (85% versus 18%, p < 0.001). Bystander CPR, and bystander or EMS defibrillation at any time, were more common among exercise-related arrests (93% versus 38%, p < 0.001 and 91% versus 24%, p < 0.001, respectively). A public access defibrillator was used in 24% of shockable exercise-related OHCAs compared with 4% of non-exercise-related OHCAs (p < 0.001). After adjustment for arrest characteristics, exercise-related OHCAs were more likely to survive to hospital discharge (50% versus 14%, p < 0.001; adjusted odds ratio [AOR] = 1.56, 95% confidence interval [CI] 1.25-1.96, p < 0.001) and survive to 12-months with good functional recovery (72% versus 62%, p = 0.012; AOR = 1.57, 95% CI 1.08-2.28, p = 0.018). CONCLUSIONS: Exercise-related OHCAs were associated with better short- and long-term prognoses compared to non-exercise-related OHCAs. The underlying factors associated with this survival benefit warrant further investigation.

Passive leg raising in out-of-hospital cardiac arrest.

BACKGROUND: The use of passive leg raising (PLR) in cardiopulmonary resuscitation (CPR) is sometimes discussed and even recommended. The effect of this intervention has never been properly addressed. We planned to determine whether PLR in out-of-hospital cardiac arrest (OHCA) is associated with an improved survival to 30 days. METHODS: In eight districts in western Sweden, we introduced PLR within five minutes after the start of CPR, among patients with OHCA. Patients in whom PLR was not performed, within the same district, served as a control group. Thirty-day survival was the primary endpoint. A propensity score analysis, as well as a standard multivariate analysis, was used to assess possible differences between the two groups. RESULTS: We identified 3554 patients with OHCA from the eight districts. Forty-four percent were treated with PLR during CPR. Patients who received PLR differed from those who did not, by having more risk factors for an adverse outcome (fewer crew-witnessed cases, more OHCA at home, a greater need for medication and prolonged delays to treatment). The overall survival to 30 days was 7.9% among patients who received PLR versus 13.5% among those who did not. A comparison of the groups, using propensity score matching, revealed a 30 -day survival of 8.6% in the PLR group versus 8.2% in the control group (odds ratio 1.07; 95% confidence interval 0.80-1.44). CONCLUSION: In an observational study, we introduced PLR as an addition to standard treatment in patients with OHCA. We did not find any evidence that this treatment improves survival to 30 days.

Impact of Early Vasopressor Administration on Neurological Outcomes after Prolonged Out-of-Hospital Cardiac Arrest.

Introduction Vasopressors are associated with return of spontaneous circulation (ROSC), but no long-term benefit has been demonstrated in randomized trials. However, these trials did not control for the timing of vasopressor administration which may influence outcomes. Consequently, the objective of this study was to develop a model describing the likelihood of favorable neurological outcome (cerebral performance category [CPC] 1 or 2) as a function of the public safety answering point call receipt (PSAP)-to-pressor-interval (PPI) in prolonged out-of-hospital cardiac arrest. Hypothesis The likelihood of favorable neurological outcome declines with increasing PPI. METHODS: This investigation was a retrospective study of cardiac arrest using linked data from the Cardiac Arrest Registry to Enhance Survival (CARES) database (Centers for Disease Control and Prevention [Atlanta, Georgia USA]; American Heart Association [Dallas, Texas USA]; and Emory University Department of Emergency Medicine [Atlanta, Georgia USA]) and the North Carolina (USA) Prehospital Medical Information System. Adult patients suffering a bystander-witnessed, non-traumatic cardiac arrest between January 2012 and June 2014 were included. Logistic regression was used to calculate the adjusted odds ratio (OR) of neurological outcome as a function of PPI, while controlling for patient age, gender, and race; endotracheal intubation (ETI); shockable rhythm; layperson cardiopulmonary resuscitation (CPR); and field hypothermia. RESULTS: Of the 2,100 patients meeting inclusion criteria, 913 (43.5%) experienced ROSC, 618 (29.4%) survived to hospital admission, 187 (8.9%) survived to hospital discharge, and 155 (7.4%) were discharged with favorable neurological outcomes (CPC 1 or 2). Favorable neurological outcome was less likely with increasing PPI (OR=0.90; P<.01) and increasing age (OR=0.97; P<.01). Compared to patients with non-shockable rhythms, patients with shockable rhythms were more likely to have favorable neurological outcomes (OR=7.61; P<.01) as were patients receiving field hypothermia (OR=2.13; P<.01). Patient gender, non-Caucasian race, layperson CPR, and ETI were not independent predictors of favorable neurological outcome. CONCLUSION: In this evaluation, time to vasopressor administration was significantly associated with favorable neurological outcome. Among adult, witnessed, non-traumatic arrests, the odds of hospital discharge with CPC 1 or 2 declined by 10% for every one-minute delay between PSAP call-receipt and vasopressor administration. These retrospective observations support the notion of a time-dependent function of vasopressor effectiveness on favorable neurological outcome. Large, prospective studies are needed to verify this relationship. Hubble MW , Tyson C . Impact of early vasopressor administration on neurological outcomes after prolonged out-of-hospital cardiac arrest. Prehosp Disaster Med. 2017; 32(3):297-304.

Outcomes of sudden cardiac arrest in a state-wide integrated resuscitation program: Results from the Minnesota Resuscitation Consortium.

BACKGROUND: Despite many advances in resuscitation science the outcomes of sudden cardiac arrest (SCA) remain poor. The Minnesota Resuscitation Consortium (MRC) is a statewide integrated resuscitation program, established in 2011, to provide standardized, evidence-based resuscitation and post-resuscitation care. The objective of this study is to assess the outcomes of a state-wide integrated resuscitation program. METHODS: We examined the trends in resuscitation metrics and outcomes in Minnesota since 2011 and compared these to the results from the national Cardiac Arrest Registry to Enhance Survival (CARES) program. Since 2011 MRC has expanded significantly providing service to >75% of Minnesota's population. RESULTS: A total of 5192 SCA occurred in counties covered by MRC from 2011 to 2014. In this period, bystander cardiopulmonary resuscitation (CPR) and use of hypothermia, automatic CPR device and impedance threshold device increased significantly (p<0.0001 for all). Compared to CARES, SCA cases in Minnesota were more likely to be ventricular fibrillation (31% vs. 23%, p<0.0001) but less likely to receive bystander CPR (33% vs. 39%, p<0.0001). Survival to hospital discharge with good or moderate cerebral performance (12% vs. 8%, p<0.0001), survival in SCA with a shockable rhythm (Utstein survival) (38% vs. 33%, p=0.0003) and Utstein survival with bystander CPR (44% vs. 37%, p=0.003) were greater in Minnesota than CARES. CONCLUSIONS: State-wide integration of resuscitation services in Minnesota was feasible. Survival rate after cardiac arrest is greater in Minnesota compared to the mean survival rate in CARES.

Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI.

AIM: To determine if early cardiac catheterization (CC) is associated with improved survival in comatose patients who are resuscitated after cardiac arrest when electrocardiographic evidence of ST-elevation myocardial infarction (STEMI) is absent. METHODS: We conducted a retrospective observational study of a prospective cohort of 754 consecutive comatose patients treated with therapeutic hypothermia (TH) following cardiac arrest. RESULTS: A total of 269 (35.7%) patients had cardiac arrest due to a ventricular arrhythmia without STEMI and were treated with TH. Of these, 122 (45.4%) received CC while comatose (early CC). Acute coronary occlusion was discovered in 26.6% of patients treated with early CC compared to 29.3% of patients treated with late CC (p=0.381). Patients treated with early CC were more likely to survive to hospital discharge compared to those not treated with CC (65.6% vs. 48.6%; p=0.017). In a multivariate regression model that included study site, age, bystander CPR, shock on admission, comorbid medical conditions, witnessed arrest, and time to return of spontaneous circulation, early CC was independently associated with a significant reduction in the risk of death (OR 0.35, 95% CI 0.18-0.70, p=0.003). CONCLUSIONS: In comatose survivors of cardiac arrest without STEMI who are treated with TH, early CC is associated with significantly decreased mortality. The incidence of acute coronary occlusion is high, even when STEMI is not present on the postresuscitation electrocardiogram.