Growth differentiation factor 15 and early prognosis after out-of-hospital cardiac arrest

Abstract Background Growth differentiation factor 15 (GDF-15) is an inflammatory cytokine released in response to tissue injury. It has prognostic value in cardiovascular diseases and other acute and chronic conditions. Here, we explored the value of GDF-15 as an early predictor of neurologic outcome after an out-of-hospital cardiac arrest (OHCA). Methods Prospective registry study of patients in coma after an OHCA, admitted in the intensive cardiac care unit from a single university center. Serum levels of GDF-15 were measured on admission. Neurologic status was evaluated according to the cerebral performance category (CPC) scale. The relationship between GDF-15 levels and poor neurologic outcome at 6 months was analyzed. Results Among 62 patients included, 32 (51.6%) presented poor outcome (CPC 3–5). Patients with CPC 3–5 exhibited significantly higher GDF-15 levels (median, 17.1 [IQR, 11.1–20.4] ng/mL) compared to those with CPC 1–2 (7.6 [IQR, 4.1–13.1] ng/mL; p = 0.004). Multivariable logistic regression analyses showed that age (OR, 1.09; 95% CI 1.01–1.17; p = 0.020), home setting arrest (OR, 8.07; 95% CI 1.61–40.42; p = 0.011), no bystander cardiopulmonary resuscitation (OR, 7.91; 95% CI 1.84–34.01; p = 0.005), and GDF-15 levels (OR, 3.74; 95% CI 1.32–10.60; p = 0.013) were independent predictors of poor outcome. The addition of GDF-15 in a dichotomous manner (≥ 10.8 vs. < 10.8 ng/mL) to the resulting clinical model improved discrimination; it increased the area under the curve from 0.867 to 0.917, and the associated continuous net reclassification improvement was 0.90 (95% CI 0.48–1.44), which allowed reclassification of 37.1% of patients. Conclusions After an OHCA, increased GDF-15 levels were an independent, early predictor of poor neurologic outcome. Furthermore, when added to the most common clinical factors, GDF-15 improved discrimination and allowed patient reclassification.

Download Full-text

Promising candidates for extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest

Scientific Reports ◽

10.1038/s41598-020-79283-1 ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Yo Sep Shin ◽

Youn-Jung Kim ◽

Seung Mok Ryoo ◽

Chang Hwan Sohn ◽

Shin Ahn ◽

...

Keyword(s):

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Cerebral Performance Category ◽

Neurologic Outcome ◽

Low Flow ◽

Extracorporeal Cardiopulmonary Resuscitation ◽

Neurologic Status ◽

Good Neurologic Outcome ◽

Hospital Stays ◽

Hospital Cardiac Arrest

AbstractPrecise criteria for extracorporeal cardiopulmonary resuscitation (ECPR) are still lacking in patients with out-of-hospital cardiac arrest (OHCA). We aimed to investigate whether adopting our hypothesized criteria for ECPR to patients with refractory OHCA could benefit. This before-after study compared 4.5 years after implementation of ECPR for refractory OHCA patients who met our criteria (Jan, 2015 to May, 2019) and 4 years of undergoing conventional CPR (CCPR) prior to ECPR with patients who met the criteria (Jan, 2011 to Jan, 2014) in the emergency department. The primary and secondary outcomes were good neurologic outcome at 6-months and 1-month respectively, defined as 1 or 2 on the Cerebral Performance Category score. A total of 70 patients (40 with CCPR and 30 with ECPR) were included. For a good neurologic status at 6-months and 1-month, patients with ECPR (33.3%, 26.7%) were superior to those with CCPR (5.0%, 5.0%) (all Ps < 0.05). Among patients with ECPR, a group with a good neurologic status showed shorter low-flow time, longer extracorporeal membrane oxygenation duration and hospital stays, and lower epinephrine doses used (all Ps < 0.05). The application of the detailed indication before initiating ECPR appears to increase a good neurologic outcome rate.

Download Full-text

A Practical Risk-Score for Early Prediction of Neurological Outcome after Out-of-Hospital Cardiac Arrest –MIRA2CLE2

10.1101/2020.04.12.20045146 ◽

2020 ◽

Author(s):

Nilesh Pareek ◽

Peter Kordis ◽

Nicholas Beckley-Hoelscher ◽

Dominic Pimenta ◽

Spela Tadel Kocjancic ◽

...

Keyword(s):

Cardiac Arrest ◽

Risk Score ◽

Neurological Outcome ◽

Heart Attack ◽

Primary Outcome ◽

Cerebral Performance Category ◽

Epinephrine Administration ◽

Poor Outcome ◽

Poor Neurological Outcome ◽

Hospital Cardiac Arrest

AimsThe purpose of this study was to develop a practical risk−score to predict poor neurological outcome after out−of−hospital cardiac arrest (OOHCA) for use on arrival to a Heart Attack Centre.Methods and ResultsBetween May 2012 and December 2017, 1055 patients had OOHCA in our region, of whom 373 patients were included in the King's Out of Hospital Cardiac Arrest Registry (KOCAR). We performed prediction modelling with multi-variable logistic regression to identify factors independently predictive of the primary outcome in order to derive a risk score. This was externally validated in two independent cohorts comprising 474 patients. The primary outcome was poor neurological function at 6−month follow−up (Cerebral Performance Category 3-−). Seven independent variables for prediction of outcome were identified: Missed (Unwitnessed) arrest, Initial non-shockable rhythm, non-Reactivity of pupils, Age, Changing intra-arrest rhythms, Low pH<;7.20 and Epinephrine administration. From these variables, the MIRA2CLE2 score was developed which had an AUC of 0.90 in the development and 0.85 and 0.89 in the validation cohorts. 3 risk groups of the MIRA2CLE2 were defined − Low risk (≤2−5.6% risk of poor outcome; Intermediate risk (3−4−55.4% of poor outcome) and high risk (≥5−92.3% risk of poor outcome). The risk-score performance was equivalent in a sub-group of patients referred for early angiography and revascularisation where appropriate.ConclusionsThe MIRA2CLE2 score is a practical risk score for early accurate prediction of poor neurological outcome after OOHCA, which has been developed for simplicity of use on admission to a Heart Attack Centre.

Download Full-text

Abstract 01: The Importance of Time to Cooling in Out-Of-Hospital Cardiac Arrest Patients to Influence Neurologically Intact Survival: A Sub-Analysis of the Princess Trial

Circulation ◽

10.1161/circ.140.suppl_2.01 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Akil Awad ◽

Fabio Silvio Taccone ◽

Martin Jonsson ◽

Sune Forsberg ◽

Jacob Hollenberg ◽

...

Keyword(s):

Cardiac Arrest ◽

Propensity Score ◽

Life Support ◽

Cerebral Performance Category ◽

Neurologic Outcome ◽

Secondary Outcome ◽

Control Group ◽

Shockable Rhythm ◽

Good Neurologic Outcome ◽

Hospital Cardiac Arrest

Background: Early initiation of hypothermia has shown to be important to reduce brain injuries in experimental cardiac arrest models. The aim of this study was to investigate the association between time to initiate cooling and neurological intact survival in patients with out-of-hospital cardiac arrest (OHCA). Methods: A secondary analysis of prospectively collected data from the PRINCESS trial (NCT01400373) including 677 OHCA patients randomized to transnasal evaporative intra-arrest cooling or standard advanced life support and cooling started subsequent to hospital arrival. Time to randomization was used a proxy measurement for time to initiate cooling. An early treatment group was defined as patients randomized by the EMS <20 minutes from the time of the cardiac arrest. Propensity scores were used to find matching patients in the control group. Patients with initial shockable rhythms were analyzed as a predefined subgroup. The primary outcome was good neurologic outcome, Cerebral Performance Category (CPC) 1-2 at 90 days. Secondary outcome was complete recovery (CPC 1). Results: In total 406 patients were randomized <20 minutes from the cardiac arrest and were propensity score matched (1:1). In the propensity score matched analysis the proportion of patients with CPC 1-2 was 21.7% in the intervention and 17.2% in the control group, odds ratio (OR) 1.33, 95% confidence interval (CI) 0.80-2.21, p=0.273. In patients with initial shockable rhythm (79 intervention, 79 control) the difference in CPC 1-2 was 48.1% versus 32.0%, OR 2.05, 95%CI 1.00-4.21, p=0.0498. The proportion of patients with complete neurologic recovery, CPC 1, was 19.7% in the intervention and 13.3% in the control group, OR 1.60, 95% CI 0.92-2.79, p=0.097. In patients with initial shockable rhythm the proportion with CPC 1 was 45.6% versus 24.6%, OR 2.81, 95% CI 1.23-6.42, p=0.014. Conclusions: In this ancillary study of OHCA patients receiving intra-arrest cooling, there were differences in survival with good neurologic outcome and in complete neurological recovery in favor of early intra-arrest cooling patient group compared to standard care. These differences were statistically significant in the subgroup of patients with initial shockable rhythms.

Download Full-text

Clinical and Electroencephalographic Correlates in Pediatric Cardiac Arrest: Experience at a Tertiary Care Center

Neuropediatrics ◽

10.1055/s-0038-1657757 ◽

2018 ◽

Vol 49 (05) ◽

pp. 324-329 ◽

Cited By ~ 8

Author(s):

Jun Park ◽

Garrett Brooks

Keyword(s):

Cardiac Arrest ◽

Clinical Laboratory ◽

Cardiopulmonary Arrest ◽

Pediatric Population ◽

Care Center ◽

Tertiary Care ◽

Cerebral Performance Category ◽

Neurologic Outcome ◽

Background Suppression ◽

Poor Outcome

AbstractPediatric cardiac arrest is a significant cause of death and neurologic disability; however, there is a paucity of literature specifically evaluating the utility of prognostic factors in the pediatric population. This retrospective chart review examines clinical, laboratory, and electroencephalographic (EEG) data in children following cardiopulmonary arrest to better characterize findings that may inform prognosis. Pre-arrest clinical characteristics, resuscitation details, and post-arrest hospital course variables were analyzed and neurologic outcome was determined using the Pediatric Cerebral Performance Category scale. Forty-one patients were identified who had cardiac arrest from March, 2011 to January, 2015. Duration of cardiopulmonary resuscitation (p = 0.013), out-of-hospital arrest (p = 0.005), arterial pH (0.014), arterial lactate (0.004), lack of pupil reactivity to light (p < 0.001), absent motor response to noxious stimuli (p < 0.001), and absent brainstem reflexes (p < 0.001) were all predictors of poor neurologic outcome. EEG background suppression (p = 0.005) was associated with poor outcome. Nine patients had electrographically recorded seizures, which began up to 1 week following cardiac arrest. Two patients (4.9%) experienced post-anoxic myoclonic status epilepticus and both had a poor outcome.

Download Full-text

How many prehospital defibrillation attempts should be performed in out-of-hospital cardiac arrest patients with shockable rhythm?

10.21203/rs.3.rs-106512/v1 ◽

2020 ◽

Author(s):

Byuk Sung Ko ◽

Youn-Jung Kim ◽

Kap Su Han ◽

You Hwan Jo ◽

Jonghwan Shin ◽

...

Keyword(s):

Cardiac Arrest ◽

Odds Ratio ◽

Cerebral Performance Category ◽

Spontaneous Circulation ◽

Neurologic Outcome ◽

Secondary Outcome ◽

Extracorporeal Cardiopulmonary Resuscitation ◽

Shockable Rhythm ◽

Good Neurologic Outcome ◽

Hospital Cardiac Arrest

Abstract Background: Early defibrillation is vital to improve outcomes after out-of-hospital cardiac arrest (OHCA) with shockable rhythm. Currently, there is no agreed consensus on the number of defibrillation attempts before transfer to a hospital. This study aimed to evaluate the correlation between the number of defibrillations on the prehospital return of spontaneous circulation (ROSC).Methods: A multicenter, prospective, observational registry-based study was conducted for OHCA in patients with presumed cardiac etiology that underwent prehospital defibrillation between October 2015 and June 2017. The primary outcome was prehospital ROSC, and the secondary outcome was a good neurologic outcome at hospital discharge, defined as Cerebral Performance Category score 1 or 2. Results: Among 2,155 OHCA patients’ data, 178 patients with missing data were excluded, a total of 1,983 OHCA patients who received prehospital defibrillation were included. The median age was 61 years and prehospital ROSC was observed in 738 patients (37.2%). The median time from arrest to first defibrillation was 10 (interquartile range: 7-15) minutes. The cumulative ROSC rates and good neurologic outcome from the initial defibrillation to the sixth defibrillation were 43%, 68%, 81%, 90%, 95%, 98% and 42%, 66%, 81%, 90%, 95%, 98%, respectively. After clinical characteristics adjustment and time to defibrillation, the number of defibrillations were independently associated with ROSC (odds ratio 0.81 95% CI 0.76-0.86) and good neurologic outcome (odds ratio 0.86 95% CI 0.80-0.91). Moreover, subgroup analysis results with patients that underwent the initial defibrillation within 10 minutes from arrest were consistent (95% up to five times).Conclusion: More than 95% of prehospital ROSC was achieved within five times of defibrillation in OHCA patients. This result provides a basis for the ideal number of defibrillation attempts before transfer to hospital with the possibility of extracorporeal cardiopulmonary resuscitation in these refractory ventricular fibrillation patients.

Download Full-text

Cerebral Oximetry as an Early Predictor of Neurologic Outcome after Out-of-hospital Cardiac Arrest

Academic Emergency Medicine ◽

10.1197/j.aem.2007.03.716 ◽

2007 ◽

Vol 14 (5 Supplement 1) ◽

pp. S11-S11

Author(s):

P. Medado ◽

V. Miller ◽

A. Ryder ◽

D. Robinson ◽

R. Jackson ◽

...

Keyword(s):

Cardiac Arrest ◽

Cerebral Oximetry ◽

Neurologic Outcome ◽

Hospital Cardiac Arrest ◽

Early Predictor

Download Full-text

Abstract 310: Validation of the Cardiac Arrest Hospital Prognosis (CAHP) Score in an American Out-of-hospital Cardiac Arrest Cohort: Results From a Large Single Center Cardiac Arrest Registry

Circulation ◽

10.1161/circ.142.suppl_4.310 ◽

2020 ◽

Vol 142 (Suppl_4) ◽

Author(s):

Jason J Grady ◽

Katie A Atwell ◽

Tomo Oshimura ◽

Nima Ghasemzadeh

Keyword(s):

Cardiac Arrest ◽

Medical Center ◽

Cerebral Performance Category ◽

Serum Lactate ◽

Neurologic Outcome ◽

Temperature Management ◽

Single Center ◽

Neurologic Outcomes ◽

Increased Risk ◽

Hospital Cardiac Arrest

Background: The cardiac arrest hospital prognosis (CAHP) score has been shown in French studies to predict neurologic outcomes in patients who suffer an out-of-hospital cardiac arrest (OHCA), but this score has not been studied in an American cohort. We aimed to validate the CAHP score in an independent, single center, large cardiac arrest registry. Methods: Between January 2015 to June 2020 there were 925 patients who suffered OHCA and were transferred to Northeast Georgia Medical Center out of whom 450 patients survived to hospital admission. Cerebral Performance Category (CPC) score was used for assessment of neurologic outcome at discharge ranging from 1-5. The primary endpoint was poor neurologic outcome defined as CPC 3-5. Logistic regression was performed to identify independent predictors of poor neurologic outcome. Results: Included patients were mostly male 57% (256 of 450) with a mean age of 52±15. STEMI was present on 11% (51 of 450) and a shockable rhythm on 35% (150 of 450) of patients. Targeted temperature management (TTM) and a mechanical compression device (MCD) were used in 72% (327 of 450) and 74% (336 of 450) respectively. 76% (344 of 450) had a CPC of 3-5 at discharge. After adjusting for covariates, including gender, BMI, serum lactate level, witnessed arrest status, STEMI on ECG, and use of MCD and TTM, the only independent predictors of a CPC of 3-5 were CAHP score (p<0.001), witnessed cardiac arrest, (p=0.039, OR: 0.45) and STEMI on admission ECG (P=0.001, OR: 0.22). Compared with CAHP< 150, CAHP 150-200 and CAHP>200 were associated with a 12-fold (p<0.00001) and 79-fold (p<0.00001) increased risk of poor neurologic outcome. Area under ROC curve for CAHP score predicting neurologic outcome was 0.92 (95% CI: 0.89-0.94). Conclusion: Here we show, for the first time, in an independent, large American cardiac arrest registry that CAHP score predicts neurologic outcomes in patients with OHCA. Further research is needed to assess how this prognostication tool would help clinicians decide on early vs. delayed invasive strategy in patients with OHCA admitted to hospitals across the U.S.

Download Full-text

Abstract 29: Comparison of Amiodarone versus Lidocaine for Treatment of In-Hospital Cardiac Arrest

Circulation ◽

10.1161/circ.140.suppl_2.29 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Deborah S Wagner ◽

Humaira Nawer ◽

Steven L Kronick ◽

James A Cranford ◽

Steven M Bradley ◽

...

Keyword(s):

Cardiac Arrest ◽

Hospital Discharge ◽

Randomized Clinical Trials ◽

Life Support ◽

Cerebral Performance Category ◽

Heart Association ◽

The United States ◽

Neurologic Outcome ◽

Multivariable Logistic Regression Analysis ◽

Hospital Cardiac Arrest

Introduction: Over 200,000 patients are treated annually in the United States for in-hospital cardiac arrest (IHCA). Patients with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) have a survival rate of less than 50%. The current American Heart Association (AHA) Advanced Cardiovascular Life Support guidelines suggest amiodarone or lidocaine as first-line agents for shock-refractory VF/pVT based on randomized clinical trials in adults with out-of-hospital cardiac arrest. Based on these results, we hypothesized that amiodarone and lidocaine have equivalent efficacy in treating hospitalized patients with VF/pVT. Methods: This is a retrospective risk-adjusted cohort study using the AHA Get with the Guidelines-Resuscitation® (GWTG-R) registry. The study included adult patients between January 1, 2000 to December 31, 2014 with IHCA due to VF/pVT that received either amiodarone or lidocaine. The primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes were 24-hour survival, survival to hospital discharge, and survival with favorable neurologic outcome based on Cerebral Performance Category (CPC) 1 or 2. Results: A total of 14,630 events were included in the analysis. Among patients who met inclusion criteria, 68.7% (n=10,058) were treated with amiodarone and 31.3% (n=4,572) were treated with lidocaine. Results from multivariable logistic regression analysis showed that, controlling for 19 covariates, ROSC rates were not statistically different with lidocaine treatment vs. amiodarone (AOR = 1.02, 95% CI 0.94, 1.11). However, lidocaine treatment was associated with higher odds of a) 24-hour survival, AOR = 1.14, 95% CI 1.06, 1.23; b) survival to discharge, AOR = 1.15, 95% CI 1.06, 1.24; and c) favorable neurologic outcome at hospital discharge, AOR = 1.21, 95% CI 1.11, 1.31. Conclusion: In adult IHCA patients with VF/pVT, treatment with lidocaine compared to amiodarone was not associated with higher ROSC rates, but was associated with higher rates of survival and favorable neurological outcomes. Additional research is needed to determine the optimal antiarrhythmic therapy for VF/pVT in IHCA.

Download Full-text

A practical risk score for early prediction of neurological outcome after out-of-hospital cardiac arrest: MIRACLE2

European Heart Journal ◽

10.1093/eurheartj/ehaa570 ◽

2020 ◽

Vol 41 (47) ◽

pp. 4508-4517 ◽

Cited By ~ 3

Author(s):

Nilesh Pareek ◽

Peter Kordis ◽

Nicholas Beckley-Hoelscher ◽

Dominic Pimenta ◽

Spela Tadel Kocjancic ◽

...

Keyword(s):

Cardiac Arrest ◽

Risk Score ◽

Neurological Outcome ◽

Cerebral Performance Category ◽

Temperature Management ◽

Target Temperature Management ◽

Epinephrine Administration ◽

Poor Outcome ◽

Poor Neurological Outcome ◽

Hospital Cardiac Arrest

Abstract Aims The purpose of this study was to develop a practical risk score to predict poor neurological outcome after out-of-hospital cardiac arrest (OOHCA) for use on arrival to a Heart Attack Centre. Methods and results From May 2012 to December 2017, 1055 patients had OOHCA in our region, of whom 373 patients were included in the King’s Out of Hospital Cardiac Arrest Registry (KOCAR). We performed prediction modelling with multivariable logistic regression to identify predictors of the primary outcome to derive a risk score. This was externally validated in two independent cohorts comprising 473 patients. The primary endpoint was poor neurological outcome at 6-month follow-up (Cerebral Performance Category 3–5). Seven independent predictors of outcome were identified: missed (unwitnessed) arrest, initial non-shockable rhythm, non-reactivity of pupils, age (60–80 years—1 point; >80 years—3 points), changing intra-arrest rhythms, low pH <7.20, and epinephrine administration (2 points). The MIRACLE2 score had an area under the curve (AUC) of 0.90 in the development and 0.84/0.91 in the validation cohorts. Three risk groups were defined—low risk (MIRACLE2 ≤2—5.6% risk of poor outcome); intermediate risk (MIRACLE2 of 3–4—55.4% of poor outcome); and high risk (MIRACLE2 ≥5—92.3% risk of poor outcome). The MIRACLE2 score had superior discrimination than the OHCA [median AUC 0.83 (0.818–0.840); P < 0.001] and Cardiac Arrest Hospital Prognosis models [median AUC 0.87 (0.860–0.870; P = 0.001] and equivalent performance with the Target Temperature Management score [median AUC 0.88 (0.876–0.887); P = 0.092]. Conclusions The MIRACLE2 is a practical risk score for early accurate prediction of poor neurological outcome after OOHCA, which has been developed for simplicity of use on admission.

Download Full-text

Abstract 9114: Impact of the Number of Prehospital Defibrillation Attempts on Neurologically Intact Survival in Patients With Out-of-Hospital Cardiac Arrest and Shockable Rhythm

Circulation ◽

10.1161/circ.144.suppl_2.9114 ◽

2021 ◽

Vol 144 (Suppl_2) ◽

Author(s):

Kazuya Tateishi ◽

Yuichi Saito ◽

Hideki Kitahara ◽

Yoshio Tahara ◽

Naohiro Yonemoto ◽

...

Keyword(s):

Cardiac Arrest ◽

Vascular Disease ◽

Cerebral Performance Category ◽

Neurologic Outcome ◽

Cerebral Vascular Disease ◽

Shockable Rhythm ◽

Early Return ◽

Neurologically Intact ◽

Hospital Cardiac Arrest ◽

Cerebral Vascular

Background: Early return of spontaneous circulation (ROSC) leads to survival with a favorable neurologic outcome in patients with out-of-hospital cardiac arrest (OHCA). For the early ROSC, defibrillation plays a crucial role for OHCA with shockable rhythm. However, little is known about the relation between the number of prehospital defibrillation attempts or etiology of OHCA and neurologically intact survival. Methods: Using a nationwide OHCA registry database from 2005 to 2017 in Japan, a cohort of 1,527,447 patients with OHCA were retrospectively analyzed. We included the patients of witnessed OHCAs with initial shockable rhythm. The relation between early ROSC, defined as prehospital ROSC achieved with defibrillation ≤3 times without adrenaline, and a neurologically intact survival rate (cerebral performance category score of 1 or 2 at 1 month) was evaluated. We also analyzed factors related to the successful early ROSC, including etiology of OHCA. Results: A total of 75,342 patients were included. Among patients with OHCA and prehospital ROSC, neurologically intact survival rates were better in patients who achieved early ROSC than their counterpart (62% vs. 36%, p<0.001). Success in early ROSC was an independent predictor of neurologically intact survival after adjustment of multiple cofounders (Table). Multivariate analysis showed cerebral vascular disease as an etiology of OHCA was a predictor of early ROSC (odds ratio 1.15, 95% confidence interval 1.03-1.29, p=0.02), but was significantly associated with a poor neurologic outcome at 1 month (Table). Conclusions: Success in early ROSC was associated with neurologically intact survival in patients with OHCA and initial shockable rhythm. Patients with OHCA due to cerebral vascular disease were likely to be resuscitated from cardiac arrest by defibrillations but had a poor neurologic outcome.

Download Full-text