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Long-term survival after acute myocardial infarction with or without out-of-hospital cardiac arrest
Resuscitation 106S (2016) e23–e95
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Resuscitation 2016, ERC Symposium on Guidelines: Abstract Presentations
Poster Presentations AP001 Prehospital acute coronary syndrome: How often do emergency physicians get it right? Alexander Harald Niederhauser ∗ , Claus-Martin Muth, Alexander Dinse-Lambracht University Hospital Ulm, Ulm, Germany Purpose: Acute coronary syndrome (ACS) is one of the main reasons for hospitalisation and death in Europe. Further, this diagnosis is often made on suspicion in a preclinical setting. The aim of the study is to analyse the positive predictive value of the ACS diagnosis made by emergency physicians in the area of Ulm, Germany. Materials and methods: In this retrospective study, we used all emergency logs from 2013 (NADOKlive® protocols). Emergency physicians wrote one emergency protocol each on an obligatory basis. Inclusion criteria were: Diagnosis of ACS and/or signs of infarction in electrocardiogram. Exclusion criteria were: Emergencies within hospitals, cases with previous troponin test at the general practitioner’s, missing documentation and/or death of patient on site. The next step was to compare those diagnoses with the definite diagnoses written in the medical reports of hospitals using their clinical information systems. Results: See Fig. 1. Out of 5169 protocols, we selected 679 using the criteria above. Most of the patients (93.1%; 632/679) were treated by the emergency physician. Out of those, only 49.1% (310/632) actually had an ACS; 6.9% (47/679) of the patients were
Fig. 1. 0300-9572/
not treated actively in the ambulance; 55.3% (26/47) of those untreated patients, that is, 3.8% (26/679) of all patients, effectively had an ACS. Conclusion: Our results showed that the positive predictive value of the analysed diagnosis is not high. Regarding the fact that it is often only a suspected diagnosis, early treatment is not overtreatment but is time saving and heart saving. Additionally, it is notable that the prehospital care missed the treatment in 3.8% of cases. http://dx.doi.org/10.1016/j.resuscitation.2016.07.049 AP002 Long-term survival after acute myocardial infarction with or without out-of-hospital cardiac arrest Simone Savastano 1,∗ , Gianmarco Iannopollo 1 , Marco Ferlini 1 , Gabriele Crimi 1 , Alessandra Repetto 1 , Barbara Marinoni 1 , Maurizio Ferrario 1 , Enrico Baldi 3 , Chiara Mosca 3 , Maurizio Raimondi 2 , Fabrizio Canevari 2 , Gaetano Maria De Ferrari 3 , Stefano De Servi 3 , Luigi Oltrona Visconti 1 1 Fondazione IRCCS Policlinico San Matteo, Pavia, Italy 2 AAT 118 AREU Lombardia, Pavia, Italy 3 Universisty of Pavia, Pavia, Italy
Purpose: Out-of-hospital cardiac arrest (OHCA) is a fairly common presentation of ST-elevation myocardial infarction (STEMI). Comparative data describing the real weight of OHCA on the survival rate of STEMI patients are limited to a short- or a mid-term follow-up. The primary outcome of our study was the long-term survival of STEMI patients who underwent a percutaneous coronary intervention (PCI) with or without OHCA. Materials and methods: We retrospectively enrolled 742 STEMI patients treated with emergency PCI from 2011 to 2014 of whom 50 experienced an OHCA (first rhythm 95.7% FV, 4.3% asystole/PEA). Clinical and prehospital data were computed; in-hospital and 4year mortality were calculated. Results: OHCA patients had a worse clinical presentation (cardiogenic shock 24% vs. 8%, p < 0.001). PCI was successfully performed (TIMI flow 2–3) in 88% of the OHCA patients and 93%
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Abstracts / Resuscitation 106S (2016) e23–e95
of the non-OHCA one (p = ns). Patients with OHCA had a higher overall mortality (log rank p < 0.0001) and in-hospital mortality (35% vs. 3.2% p < 0.001, log rank p < 0.0001), compared to STEMI patients. However, when considering patients who survived to hospital discharge, long-term survival was similar for both groups (log rank p = 0.57). In the overall population, OHCA, need for both an intra-aortic balloon pump (IABP) and an extra-corporeal membrane oxygenation (ECMO) were independent predictors of long-term mortality at multivariable Cox analysis [HR 2.6 (95% CI 1.3–5.2) p = 0.006; HR 4.8 (95% CI 2.6–9) p < 0.001 and HR 26 (95% CI 8.2–82.3) p < 0.001 respectively]. In OHCA patients, the need of ECMO and number of DC shocks to achieve ROSC were independent predictors of in-hospital mortality [HR 7.2 (95% CI 1.7–31) p < 0.01 and HR 1.1 (95% CI 1–1.2) p = 0.04 respectively]. Conclusions: STEMI patients resuscitated from an OHCA have a worse clinical presentation and worse short-term outcome compared to those without OHCA. Notably, patients surviving the acute phase have the same long-term outcome compared to those without OHCA. It is important to provide better pre-hospital and in-hospital care to give a good chance of long-term survival. http://dx.doi.org/10.1016/j.resuscitation.2016.07.050
AP004 Survival out-of hospital cardiac arrest in patients with acute myocardial infarction Victoria Barreiro Diaz ∗ , Luisa Chayan Zas, Antonio Iglesias Vazquez, Maria Pedreira Pernas, Jose Manuel Aguilera Luque, Luis Sanchez Santos FPUSG-061, Galicia, Spain Objective: To analyze CPR-related complications experienced by patients with acute myocardial infarction transported in ambulances for PTCA. Method: Registration of all acute myocardial infarctions transported by ambulances medicalized from April 2005 to December 2014. The analyzed events were ventricular fibrillation and cardiac arrest necessitating resuscitation. Results: During the study period, 6651 patients were transferred with acute myocardial infarction. The incidence of VF during transport was 4.25% (283 patients); 393 (5.95%) patients required CPR. Mortality during transport was 0.7% (43 exitus). The survival of patients who had VF as the initial rhythm in witnessed CPR was 96%.
AP003 http://dx.doi.org/10.1016/j.resuscitation.2016.07.052 Acute coronary syndrome without ST elevation in diabetics: Prognostic value of ultrasensitive troponin Zied ∗ ,
Guermazi Nouira Nourelhouda, Ammar Rief, Lahmer Sana, Ouaz Ines, Boussen Monia, Ben Cheikh Maamoun CHU Mongi Slim, La Marsa, Tunisia Introduction: The most common form of acute coronary syndrome is without ST segment elevation (NSTEMI) and approximately 31% are diabetics with high ischemic risk; in this group, global mortality remains high despite the progress achieved regarding evaluation of death risk and complications based on risk factors and measurable parameters such as troponin. Aim: To study specificity of clinical approach, treatment and mortality in diabetic patients admitted to the emergency department with NSTEMI and to determine prognostic value of the ultra-sensitive troponin at 1 and 6 months. Methods: Prospective study including 81 diabetic patients admitted for NSTEMI to the emergency department. Results: Average age was 65 ± 10 years with a sex ratio at 1.38. In 82% of the cases, patients consulted the emergency department directly. The median consultation period was 12 h. Associated risk factors where: HTA (70%), dyslipidemia (48%) and tobacco (38%). In 21% of cases, the symptomatology was atypical. In terms of electrocardiographic stratification: 42% of patients showed a T negative wave and 37% a sub-ST segment. In patients consulting in the first 4 h of onset of chest pain, the initial rate of troponin I by a sensitivity test was positive in 56% of cases. The initial rate of troponin and its peak were correlated with a greater risk of death at 6 months (p < 0.05). The median TIMI risk score was 4 and the median Grace score was 111, with a risk of short-term mortality of 1–3% and medium-term mortality of 3–8%. The average length of stay in the emergency department was 50–37 h. In our study, the mortality rate at 1 and 6 months were 3.7% and 12.3%, respectively. Conclusions: In the presence of ultra-sensitive tests of troponin I, ischemic risk stratification and management of NSTEMI in diabetics could be initiated earlier and more effectively with the collaboration of the emergency physician and cardiologist. http://dx.doi.org/10.1016/j.resuscitation.2016.07.051
AP005 Improving patient selection for refractory out-of-hospital cardiac arrest treated with extracorporeal life support: Preliminary assessment of the OSCAR-ECLS procedure Tahar Chouihed 1 , Adrien Lauvray 1 , Antoine Kimmoun 1 , Deborah Jaeger 1,∗ , Franc¸ois-Xavier Laithier 1 , Simon Lemoine 1 , Juan Pablo Maureira 1 , Lionel Nace 1 , Kevin Duarte 1 , Stephane Albizzati 2 , Nicolas Girerd 1 , Bruno Levy 1 1 2
CHRU, Nancy, France CH Saint-Charles, Saint-Dié-des-Vosges, France
Introduction: Despite recent management improvements including extra-corporeal life support (ECLS), in refractory out-ofhospital cardiac arrest (ROHCA), survival with good neurological outcome remains low. In a French referral centre for cardiac assistance, we designed and evaluated an innovative strategy (OSCAR-ECLS) to optimise access to ECLS of ROHCA patients and, thus, reduce the delay from recognition to ECLS implantation. Methods: This single-centre observational study was conducted in a tertiary teaching hospital in France. The study compared two periods in ROHCA management (10 patients in 12 months during the “Before OSCAR-ECLS” period and 17 patients in 18 months during the “OSCAR-ECLS” period). This second period targeted: • the use of a new paradigm of ROHCA (two defibrillation failures and 10 min of advanced CPR with no return of spontaneous circulation (ROSC)) • the optimization of patient selection for ECLS and reduction in time to ECLS initiation (i.e., estimated time between collapse and arrival in the catheterization laboratory) to less than 45 min. Results: Time to ECLS initiation (i.e., no flow + low flow) was 77.5 (67.0–83.0) min before OSCAR-ECLS versus 50.0 (42.0–60.0) during the OSCAR-ECLS period (p < 0.0001), mostly due to a reduction in the time spent on site by the mobile intensive care team: 46.0 (40.0–52.0) min versus 24.0 (16.0–27.0), p = 0.001). Survival at hospital discharge was 10% (1/10) before OSCAR-ECLS and 35.5%
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Resuscitation 2016, ERC Symposium on Guidelines: Abstract Presentations
Poster Presentations AP001 Prehospital acute coronary syndrome: How often do emergency physicians get it right? Alexander Harald Niederhauser ∗ , Claus-Martin Muth, Alexander Dinse-Lambracht University Hospital Ulm, Ulm, Germany Purpose: Acute coronary syndrome (ACS) is one of the main reasons for hospitalisation and death in Europe. Further, this diagnosis is often made on suspicion in a preclinical setting. The aim of the study is to analyse the positive predictive value of the ACS diagnosis made by emergency physicians in the area of Ulm, Germany. Materials and methods: In this retrospective study, we used all emergency logs from 2013 (NADOKlive® protocols). Emergency physicians wrote one emergency protocol each on an obligatory basis. Inclusion criteria were: Diagnosis of ACS and/or signs of infarction in electrocardiogram. Exclusion criteria were: Emergencies within hospitals, cases with previous troponin test at the general practitioner’s, missing documentation and/or death of patient on site. The next step was to compare those diagnoses with the definite diagnoses written in the medical reports of hospitals using their clinical information systems. Results: See Fig. 1. Out of 5169 protocols, we selected 679 using the criteria above. Most of the patients (93.1%; 632/679) were treated by the emergency physician. Out of those, only 49.1% (310/632) actually had an ACS; 6.9% (47/679) of the patients were
Fig. 1. 0300-9572/
not treated actively in the ambulance; 55.3% (26/47) of those untreated patients, that is, 3.8% (26/679) of all patients, effectively had an ACS. Conclusion: Our results showed that the positive predictive value of the analysed diagnosis is not high. Regarding the fact that it is often only a suspected diagnosis, early treatment is not overtreatment but is time saving and heart saving. Additionally, it is notable that the prehospital care missed the treatment in 3.8% of cases. http://dx.doi.org/10.1016/j.resuscitation.2016.07.049 AP002 Long-term survival after acute myocardial infarction with or without out-of-hospital cardiac arrest Simone Savastano 1,∗ , Gianmarco Iannopollo 1 , Marco Ferlini 1 , Gabriele Crimi 1 , Alessandra Repetto 1 , Barbara Marinoni 1 , Maurizio Ferrario 1 , Enrico Baldi 3 , Chiara Mosca 3 , Maurizio Raimondi 2 , Fabrizio Canevari 2 , Gaetano Maria De Ferrari 3 , Stefano De Servi 3 , Luigi Oltrona Visconti 1 1 Fondazione IRCCS Policlinico San Matteo, Pavia, Italy 2 AAT 118 AREU Lombardia, Pavia, Italy 3 Universisty of Pavia, Pavia, Italy
Purpose: Out-of-hospital cardiac arrest (OHCA) is a fairly common presentation of ST-elevation myocardial infarction (STEMI). Comparative data describing the real weight of OHCA on the survival rate of STEMI patients are limited to a short- or a mid-term follow-up. The primary outcome of our study was the long-term survival of STEMI patients who underwent a percutaneous coronary intervention (PCI) with or without OHCA. Materials and methods: We retrospectively enrolled 742 STEMI patients treated with emergency PCI from 2011 to 2014 of whom 50 experienced an OHCA (first rhythm 95.7% FV, 4.3% asystole/PEA). Clinical and prehospital data were computed; in-hospital and 4year mortality were calculated. Results: OHCA patients had a worse clinical presentation (cardiogenic shock 24% vs. 8%, p < 0.001). PCI was successfully performed (TIMI flow 2–3) in 88% of the OHCA patients and 93%
e24
Abstracts / Resuscitation 106S (2016) e23–e95
of the non-OHCA one (p = ns). Patients with OHCA had a higher overall mortality (log rank p < 0.0001) and in-hospital mortality (35% vs. 3.2% p < 0.001, log rank p < 0.0001), compared to STEMI patients. However, when considering patients who survived to hospital discharge, long-term survival was similar for both groups (log rank p = 0.57). In the overall population, OHCA, need for both an intra-aortic balloon pump (IABP) and an extra-corporeal membrane oxygenation (ECMO) were independent predictors of long-term mortality at multivariable Cox analysis [HR 2.6 (95% CI 1.3–5.2) p = 0.006; HR 4.8 (95% CI 2.6–9) p < 0.001 and HR 26 (95% CI 8.2–82.3) p < 0.001 respectively]. In OHCA patients, the need of ECMO and number of DC shocks to achieve ROSC were independent predictors of in-hospital mortality [HR 7.2 (95% CI 1.7–31) p < 0.01 and HR 1.1 (95% CI 1–1.2) p = 0.04 respectively]. Conclusions: STEMI patients resuscitated from an OHCA have a worse clinical presentation and worse short-term outcome compared to those without OHCA. Notably, patients surviving the acute phase have the same long-term outcome compared to those without OHCA. It is important to provide better pre-hospital and in-hospital care to give a good chance of long-term survival. http://dx.doi.org/10.1016/j.resuscitation.2016.07.050
AP004 Survival out-of hospital cardiac arrest in patients with acute myocardial infarction Victoria Barreiro Diaz ∗ , Luisa Chayan Zas, Antonio Iglesias Vazquez, Maria Pedreira Pernas, Jose Manuel Aguilera Luque, Luis Sanchez Santos FPUSG-061, Galicia, Spain Objective: To analyze CPR-related complications experienced by patients with acute myocardial infarction transported in ambulances for PTCA. Method: Registration of all acute myocardial infarctions transported by ambulances medicalized from April 2005 to December 2014. The analyzed events were ventricular fibrillation and cardiac arrest necessitating resuscitation. Results: During the study period, 6651 patients were transferred with acute myocardial infarction. The incidence of VF during transport was 4.25% (283 patients); 393 (5.95%) patients required CPR. Mortality during transport was 0.7% (43 exitus). The survival of patients who had VF as the initial rhythm in witnessed CPR was 96%.
AP003 http://dx.doi.org/10.1016/j.resuscitation.2016.07.052 Acute coronary syndrome without ST elevation in diabetics: Prognostic value of ultrasensitive troponin Zied ∗ ,
Guermazi Nouira Nourelhouda, Ammar Rief, Lahmer Sana, Ouaz Ines, Boussen Monia, Ben Cheikh Maamoun CHU Mongi Slim, La Marsa, Tunisia Introduction: The most common form of acute coronary syndrome is without ST segment elevation (NSTEMI) and approximately 31% are diabetics with high ischemic risk; in this group, global mortality remains high despite the progress achieved regarding evaluation of death risk and complications based on risk factors and measurable parameters such as troponin. Aim: To study specificity of clinical approach, treatment and mortality in diabetic patients admitted to the emergency department with NSTEMI and to determine prognostic value of the ultra-sensitive troponin at 1 and 6 months. Methods: Prospective study including 81 diabetic patients admitted for NSTEMI to the emergency department. Results: Average age was 65 ± 10 years with a sex ratio at 1.38. In 82% of the cases, patients consulted the emergency department directly. The median consultation period was 12 h. Associated risk factors where: HTA (70%), dyslipidemia (48%) and tobacco (38%). In 21% of cases, the symptomatology was atypical. In terms of electrocardiographic stratification: 42% of patients showed a T negative wave and 37% a sub-ST segment. In patients consulting in the first 4 h of onset of chest pain, the initial rate of troponin I by a sensitivity test was positive in 56% of cases. The initial rate of troponin and its peak were correlated with a greater risk of death at 6 months (p < 0.05). The median TIMI risk score was 4 and the median Grace score was 111, with a risk of short-term mortality of 1–3% and medium-term mortality of 3–8%. The average length of stay in the emergency department was 50–37 h. In our study, the mortality rate at 1 and 6 months were 3.7% and 12.3%, respectively. Conclusions: In the presence of ultra-sensitive tests of troponin I, ischemic risk stratification and management of NSTEMI in diabetics could be initiated earlier and more effectively with the collaboration of the emergency physician and cardiologist. http://dx.doi.org/10.1016/j.resuscitation.2016.07.051
AP005 Improving patient selection for refractory out-of-hospital cardiac arrest treated with extracorporeal life support: Preliminary assessment of the OSCAR-ECLS procedure Tahar Chouihed 1 , Adrien Lauvray 1 , Antoine Kimmoun 1 , Deborah Jaeger 1,∗ , Franc¸ois-Xavier Laithier 1 , Simon Lemoine 1 , Juan Pablo Maureira 1 , Lionel Nace 1 , Kevin Duarte 1 , Stephane Albizzati 2 , Nicolas Girerd 1 , Bruno Levy 1 1 2
CHRU, Nancy, France CH Saint-Charles, Saint-Dié-des-Vosges, France
Introduction: Despite recent management improvements including extra-corporeal life support (ECLS), in refractory out-ofhospital cardiac arrest (ROHCA), survival with good neurological outcome remains low. In a French referral centre for cardiac assistance, we designed and evaluated an innovative strategy (OSCAR-ECLS) to optimise access to ECLS of ROHCA patients and, thus, reduce the delay from recognition to ECLS implantation. Methods: This single-centre observational study was conducted in a tertiary teaching hospital in France. The study compared two periods in ROHCA management (10 patients in 12 months during the “Before OSCAR-ECLS” period and 17 patients in 18 months during the “OSCAR-ECLS” period). This second period targeted: • the use of a new paradigm of ROHCA (two defibrillation failures and 10 min of advanced CPR with no return of spontaneous circulation (ROSC)) • the optimization of patient selection for ECLS and reduction in time to ECLS initiation (i.e., estimated time between collapse and arrival in the catheterization laboratory) to less than 45 min. Results: Time to ECLS initiation (i.e., no flow + low flow) was 77.5 (67.0–83.0) min before OSCAR-ECLS versus 50.0 (42.0–60.0) during the OSCAR-ECLS period (p < 0.0001), mostly due to a reduction in the time spent on site by the mobile intensive care team: 46.0 (40.0–52.0) min versus 24.0 (16.0–27.0), p = 0.001). Survival at hospital discharge was 10% (1/10) before OSCAR-ECLS and 35.5%