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Incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrest with cardiac etiology in Osaka, Japan: a population-based study according to the Utstein style
Resuscitation 59 (2003) 329 /335 www.elsevier.com/locate/resuscitation
Incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrest with cardiac etiology in Osaka, Japan: a population-based study according to the Utstein style Tatsuya Nishiuchi a,*, Atsushi Hiraide b, Yasuyuki Hayashi c, Toshifumi Uejima d, Hiroshi Morita e, Hidekazu Yukioka f, Tatsuhiro Shigemoto g, Hisashi Ikeuchi h, Masanori Matsusaka i, Taku Iwami j, Hiroshi Shinya k, Junichiro Yokota a a
Osaka Prefectural Senshu Critical Care Medical Center, 2-24 Rinku-Orai Kita, Izumisano city, Osaka 598-0048, Japan b Department of General Medicine, Osaka University Medical School, Osaka, Japan c Osaka Prefectural Senri Critical Care Medical Center, Osaka, Japan d Department of Emergency and Critical Care Medicine, Kinki University School of Medicine, Kinki, Japan e Osaka Mishima Critical Care Medical Center, Osaka, Japan f Department Of Emergency and Critical Care Medicine, Osaka City University Medical School, Osaka, Japan g Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan h Department Of Emergency Medicine, Osaka Prefectural General Hospital, Osaka, Japan i Osaka Prefectural Nakakawachi Medical Center Of Acute Medicine, Osaka, Japan j Department of General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan k Department of Emergency and Critical Care Medicine, Kansai Medical University, Kansai, Japan Received 22 July 2002; received in revised form 4 June 2003; accepted 4 June 2003
Abstract Purpose: To clarify the incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrests (OHCA) with cardiac etiology in Osaka Prefecture, Japan, with a population of nearly 9 million according to the Utstein style. Subjects and Methods: 5047 consecutive OHCA cases were treated by ambulance personnel during the 12-month period starting since 1 May 1998. 974 cases were considered to be bystander-witnessed OHCA with cardiac etiology and analyzed using the Utstein style. Results: Of the 974 cases (100%), 50 cases (5.1%) survived after 1 month and 28 (2.9%) of them after 1 year. The Ventricular fibrillation (VF)/ventricular tachycardia (VT) group comprised 164 (16.8%) cases and there were statistically differences between the two groups as below (the VF/VT group vs. the non-VF/VT group): gender (male: 76.8 vs. 60.7%), age (61.79/14.7 vs. 68.79/17.1), history of ischemic heart disease (IHD) (30.5 vs. 15.3%), performance rate of bystander cardiopulmonary resuscitation (CPR) (34.1 vs. 21.4%) and time interval between receipt of an emergency call and arrival at the scene (5.59/2.9 vs. 6.09/2.9 min). Conclusion: The incidence of bystander-witnessed (OHCA) with cardiac etiology and VF or VT were remarkably low compared with those reported by other studies conducted in some areas of Europe or the USA. # 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Witnessed cardiac arrest; Utstein template; Ischemia; Heart disease; Ventricular fibrillation; Outcome
Resumo Objectivo: Clarificar a incideˆncia e taxa de sobrevida das paragens cardı´acas presenciadas, fora do Hospital (OHAC) de etiologia cardı´aca, na comarca de Osaka, Japa˜o com uma populac¸a˜o de 9 milho˜es, de acordo com o modelo de Utstein. Material e me´todos: o pessoal das ambulaˆncias tratou 5047 OHCA num perı´odo de 12 meses com inı´cio a 1 de Maio de 1998. Desses 974 foram considerados OHCA presenciados e com etiologia cardı´aca e analisados com o modelo de Utstein. Resultados: dos 974 casos (100%), sobreviveram um meˆs 50 (5.1%) e ao fim de um ano estavam vivos 28 (2.9%). O grupo da fibrilhac¸a˜o ventricular (VF) e da
* Corresponding author. Tel.: /81-724-64-9911; fax: /81-724-64-9932. E-mail address: [email protected] (T. Nishiuchi). 0300-9572/03/$ - see front matter # 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0300-9572(03)00241-7
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taquicardia ventricular (VT) incluiu 164 casos (16.8%) e havia diferenc¸as significativas entre os dois grupos (grupo VF/VT e grupo na˜o VF/VT), no que se refere ao: sexo (masculino 76.8% vs. 60.7%), idade (61.79/14.7 vs. 68.79/17.1), histo´ria de doenc¸a isque´mica corona´ria (HID) (30.5 vs. 15.3%), desempenho das testemunhas (CPR) (34.1 vs. 21.4%) e tempo decorrido da recepc¸a˜o da chamada de ajuda a` chegada ao local (5.59/2.9 vs. 6.09/2.9 min.). Concluso˜es: a incideˆncia de paragens cardı´acas de etiologia cardı´aca presenciadas, fora do Hospital, e a de VF e VT eram notavelmente baixas quando comparadas com as relatadas noutros estudos em algumas das a´reas da Europa e dos EUA. # 2003 Elsevier Ireland Ltd. All rights reserved. Palavras chave: Paragem cardı´aca testemunhada; Modelo de Utstein; Isquemia; Doenc¸a cardı´aca; Fibrilhac¸a˜o ventricular; Resultados
Resumen Propo´sito : Aclarar, de acuerdo al estilo Utstein, la incidencia y tasa de sobrevida de paro cardı´aco extrahospitalario(OHCA)de etiologı´a cardı´aca, presenciado por testigos en la Prefectura de Osaka, Japo´n, que tiene una poblacio´n de casi 9 millones. Sujetos y me´todo : Un total de 5047 casos consecutivos de OHCA fueron tratados por el personal de ambulancias durante un perı´odo de 12 meses iniciado el 1 de Mayo de 1998. 974 casos fueron considerados como OHCA de etiologı´a cardı´aca presenciados por transeu´ntes y fueron analizados usando el estilo Utstein. Resultados : de los 974 casos (100%), 50 casos (5.1%) sobrevivieron despue´s de un mes y 28 de ellos (2.9%) despue´s de un an˜o. El grupo de fibrilacio´n ventricular(VF)/taquicardia ventricular comprendı´a 164 (16.8%) casos y hubo diferencias estadı´sticas entre los dos grupos sen˜alados mas abajo (el grupo VF/VT vs. grupo noVF/VT): sexo (masculino 76.8 vs. 60.7%), edad (61.79/14.7 vs. 68.79/17.1), historia de enfermedad cardı´aca isque´mica (IHD) (30.5 vs. 15.3%), tasa de desempen˜o de reanimacio´n cardiopulmonar (CPR)por testigos reanimadores (34.1 vs. 21.4%) y tiempo de intervalo entre la recepcio´n de la llamada de emergencia y la llegada a la escena (5.59/2.9 vs. 6.09/2.9 min). Conclusio´n : La incidencia de OHCA de etiologı´a cardı´aca presenciado por testigos y FV o TV fue marcadamente baja comparada con aquellas reportadas en estudios conducidos en Europa o en los Estados Unidos. # 2003 Elsevier Ireland Ltd. All rights reserved. Palabras clave: Paro cardı´aco presenciado; Templado de Utstein; Isquemia; Enfermedad cardı´aca; Fibrilacio´n ventricular; Resultado
1. Introduction
2. Materials and methods
It is in the interest of any community to provide effective treatment for out-of-hospital cardiac arrest (OHCA). Cardiac arrest with cardiac etiology are thought to result in a better outcome than those with non-cardiac etiology [1]. Ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) as the initial rhythm has been found to be particularly relevant for survival of OHCA in many communities [2 /10]. At present, the most successful treatment of OHCA is early defibrillation combined with the ‘‘chain of survival’’ [11] for the patients identified with VF or VT [12 /14]. Emergency medical service (EMS) systems are, therefore, usually compared by the outcome of bystander-witnessed OHCA with cardiac etiology. We report here the incidence and survival rate of bystander-witnessed OHCA with cardiac etiology in Osaka, Japan, in accordance with the Utstein style [15]. In order to study the background of VF or VT cases, we examined the differences between those with pulseless electrical activity or asystole and established a better understanding of the distinguishing features of VF or VT cases in OHCA. We also showed the marked difference in VF or VT incidence related to OHCA between Osaka and other communities in the USA or European countries.
2.1. Patients Data for all the patients who were considered for cardiopulmonary resuscitation (CPR) by the EMS of Osaka Prefecture, Japan, were recorded prospectively using the Utstein style from 1 May 1998. Data for bystander-witnessed OHCA cases with cardiac etiology treated during the 12-month period between 1 May 1998 and 30 April 1999 were analyzed in this study. 2.2. Target area The target area for this study was Osaka Prefecture, one of 47 administrative districts in Japan. Osaka Prefecture has an area of 1892 km2 and a residential population of 8 832 606 inhabitants. Its area and population account for 0.5 and 6.9%, respectively, of the national totals. Males make up 49% of the population and 13.6% are more than 65 years old. The total number of deaths from all causes in Osaka Prefecture in 1998 was 59 647, an incidence of 675 per 100 000 people. 2.3. EMS organization and equipment The 119 emergency telephone number is accessible anywhere in Japan including the Osaka Prefecture. On
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receipt of a 119 call, an emergency dispatch center sends the nearest available ambulance to the site. These dispatch centers are operated by municipal fire stations managed by the municipal government and 36 such fire stations, and emergency dispatch centers are located in Osaka Prefecture. The EMS systems consist of a singletiered system with a three-person unit providing life support 24 h a day. Ambulance squads are staffed with EMS personnel, some of whom are called Emergency Life-Saving Technicians. The latter have passed a state examination and are allowed to insert an intravenous line, to use airway adjuncts and to defibrillate using a semi-automated external defibrillator for OHCA patients after receiving on-line medical direction from an emergency physician in a hospital. They are not allowed to perform tracheal intubation and administer resuscitative drugs under the present Japanese law.
2.4. Task organization This study was conducted by the task force committee for this project, consisting of ten staff physicians from the main hospitals providing emergency critical care and six representatives of fire stations in Osaka Prefecture. The Osaka Medical Association and the Emergency Medical Information Center of Osaka Prefecture, which usually provides advice by telephone concerning hospitals available for various emergencies cooperated with the committee.
2.5. Data collection The committee designed the data sheets based on the Utstein style recommendation and collected data prospectively. For each case the EMS personnel completed the data with the cooperation of the physician who treated the patient. The EMS personnel who took care of the patients also followed up their outcome for 1 month. The data sheets were then transferred to the Emergency Medical Information Center of Osaka Prefecture. The collected data were checked by the physicians of the committee and followed up for 1 year with the cooperation of the Osaka Medical Association and all hospitals to which patients had been transferred.
2.6. Data analysis The statistical differences were analyzed by means of unpaired Student’s t-test or a chi-squared (x2) test. A P value of less than 0.05 was regarded as significant for all tests and data are shown as mean9/standard deviation (S.D.).
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3. Results Fig. 1 shows the results of this study using the Utstein style. During the 12-months study period, 5047 OHCA cases were dealt with by EMS in Osaka Prefecture. EMS personnel attempted CPR in 4871 of these cases, and in 3047 cases the cause of cardiac arrest was presumed to be a cardiac etiology. Bystander-witnessed OHCA with cardiac etiology accounted for 974 cases. Besides these 974 cases, there were eight cases who had resuscitation attempted by lay rescuers but were observed by EMS personnel to have a pulse on arrival. Attempt at bystander defibrillation was not reported in these eight cases. We also had another 175 cases who were witnessed by EMS personnel. The analysis of EMS witnessed cases was reported by Uejima [16]. In this study we focused on the 974 bystander-witnessed and EMS-confirmed OHCA. Of the 974 bystander-witnessed OHCA with cardiac etiology VF or VT accounted for 164 cases. Since there was only one case of VT, it was combined with VF into one group (the VF/VT group). As a result, the annual incidence rates of OHCA, bystander-witnessed OHCA with cardiac etiology and with VF or VT in the target area were 55.1, 11.0 and 1.8 per 100 000 population, respectively. The mean age of the bystander-witnessed cardiac arrest cases with cardiac etiology was 67.5 years and males accounted for 63.4% (Table 1). Of these 974 patients (100%), 334 patients (34.3%) achieved return of spontaneous circulation (ROSC), 236 (24.2%) were admitted to hospital, 50 (5.1%) remained alive after 1 month and 28 (2.9%) after 1 year. A comparison of the characteristics of the VF/VT group with those of other cases (the non-VF/VT group) is shown in Table 1. The ratio of males was higher (76.8 vs. 60.7%) and the patients were younger (61.79/14.7 vs. 68.79/17.1) in the VF/VT group. It should be emphasized that the VF/VT group was more likely to have a past history of cardiac disease (60.4 vs. 42.3%), especially IHD (30.5 vs. 15.3%). There were no statistical differences between the two groups in terms of arrhythmia, hypertension or other cardiac diseases. The rates of patients who attained ROSC and survived after 1 month and 1 year were more favorable for the VF/VT group than the non-VF/VT group. It was also found that the percentage of bystander CPR for the VF/VT group was significantly higher than the non-VF/VT group (34.1 vs. 21.4%). Although the difference was not significant, the interval from receipt of the emergency call to arrival at the scene was shorter for the VF/VT group (5.59/2.9 vs. 6.09/2.9 min). We also compared the annual incidences of (1) OHCA, (2) witnessed OHCA with cardiac etiology and (3) VF or VT of witnessed OHCA with cardiac etiology between Osaka Prefecture and other areas where data had been previously reported using the
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Fig. 1. The Utstein template for bystander-witnessed cardiac arrests with cardiac etiology. CPR, cardiopulmonary resuscitation; EMS, emergency medical service; VF, ventricular fibrillation; VT, ventricular tachycardia; PEA, pulseless electrical activity; ROSC, return of spontaneous circulation.
Utstein style [2 /4,6,17] (Fig. 2). Osaka Prefecture showed that the lowest incidences of witnessed OHCA with cardiac etiology and VF or VT in witnessed OHCA with cardiac etiology. Survival difference between the VF/VT group and the non-VF/VT group could be evaluated in four reports including this study. In the reports of Kuisma et al. from Finland [2], Fischer et al. from Germany [6], Giraud et al. from France [3], and the present study from Japan, the survival rates of the VF/VT group in the bystanderwitnessed cardiac etiology were 42/127 (33.1%), 28/119 (23.5%), 2/31 (6.5%), 12/164 (7.3%), respectively. The survival rate of the non-VF/VT group were 2/67 (3.0%), 6/95 (6.3%), 0/46 (0%), 16/810 (2.0%), respectively.
4. Discussion VF or VT cases are thought to achieve a much better rate of ROSC as a result of early defibrillation than other cases whose initial cardiac rhythms are asystole or pulseless electrical activity [12 /14]. Therefore, comparison of the background features of the VF/VT group and the non-VF/VT group is of great value in order to explain the difference of the incidence of VF or VT. As is shown in Fig. 2, the incidence of OHCA in Osaka Prefecture is low. In addition, the most striking result of our study is that the incidences of cardiac arrests with cardiac etiology and VF or VT are lowest among other regions [2 /4,6,17].
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Table 1 Comparison between VF/VT and non-VF/VT group Total
VF/VT group
Non-VF/VT group
P value
Cases (%) Male/female (male %) Age (year; mean9/S.D.)
974 618/356 (63.4) 67.59/16.9
164 (16.8) 126/38 (76.8) 61.79/14.7
810 (83.2) 492/318 (60.7) 68.79/17.1
B/0.001 B/0.001
Past history of cardiac arrest (%) AMI and/or angina pectoris Arrhythmia Hypertension Others
442 (45.5%) 174 (17.9) 41 (4.2) 160 (16.4) 128 (13.1)
99 (60.4) 50 (30.5) 9 (5.5) 22 (13.4) 26 (15.9)
343 (42.3) 124 (15.3) 32 (4.0) 138 (17.0) 102 (12.6)
B/0.001 B/0.001 N.S. N.S. N.S.
Bystander CPR (%) Call receipt to arrival at scene (mean9/S.D.) ROSC (%) Survived to admission
229 (23.5) 5.99/2.9 334 (34.3) 236 (24.2)
56 (34.1) 5.59/2.9 70 (42.7) 49 (29.9)
173 (21.4) 6.09/2.9 264 (32.6) 187 (23.1)
B/0.001 B/0.05 B/0.01 N.S.
Outcome (%) Alive after 1 month Alive after 1 year
50 (5.1) 28 (2.9)
18 (11.0) 12 (7.3)
32 (4.0) 16 (2.0)
B/0.001 B/0.001
VF, Ventricular fibrillation; VT, ventricular tachycardia; AMI, acute myocardial infarction; CPR, cardiopulmonary resuscitation; ROSC, return of spontaneous circulation; S.D., standard deviation.
There seem to be several factors that affect the initial rhythm of OHCA victims. For example, male predominance is of obvious interest. This is consistent with results reported concerning with the influence of gender on the feature of cardiac arrests [18]. However, this cannot explain the specific difference between the Osaka region and others because gender distribution cannot be markedly different among communities with a certain minimum population. Although time factors and the presence or absence of bystander CPR may explain the diversity in VF or VT incidence [4,6,10,19], the response time was approximately 6 min, which was rather short compared with other areas (5.5 /11 min) [2 /4,6]. Bystander CPR can prolong VF [20] and consequently increases the chance of defibrillation by first responders. The fact that the
VF/VT group received more bystander CPR than the non-VF/VT group implies that bystander CPR would have contributed to the difference in VF or VT incidence. Overall, however, only 23.5% of the subjects received bystander CPR, which was rather unsatisfactory compared with previously reported rates that range from 18 to 57% [4,9,14,20 /23]. We hypothesized that existing heart disease, especially IHD, might contribute to the difference in initial rhythm because mortality as a result of IHD (ICD-9, 410 /414) in Osaka Prefecture was low since it was responsible for 5088 deaths, or only 57.6 per 100 000 individuals per year. As shown in Table 1, IHD had occurred twice as often in the VF/VT group than in the non-VF/VT group, whereas differences in arrhythmia, hypertension and other cardiac diseases were not statistically signifi-
Fig. 2. Annual incidence of out-of-hospital cardiac arrests, witnessed cardiac arrests with cardiac etiology and VF or VT in witnessed cardiac arrest with cardiac etiology in Osaka, Saint-Etienne, New York City, Bonn, South Glamorgan and Helsinki (cases per 100 000 populations in a year). j, out-of-hospital cardiac arrest; I, bystander-witnessed cardiac arrest with cardiac etiology; , VF or VT in witnessed cardiac arrest with cardiac etiology
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Fig. 3. Mortality of IHD (ICD-9, 410-414) in Japan, France, United States of America (USA), Germany, United Kingdom (UK) and Finland and incidence of VF or VT in witnessed cardiac arrest with cardiac etiology in Osaka, Saint-Etienne, New York City, Bonn, South Glamorgan and Helsinki (cases per 100 000 populations in a year). I, VF or VT in witnessed cardiac arrest with cardiac etiology; j, IHD.
cant. Fig. 3 showed the mortality of IHD in the six countries included in Fig. 2 [24], and indicated that the incidence of VF or VT in OHCA increased in proportion to the mortality of IHD. The ischemic-reperfusion mechanism of VF in IHD provides a rational support for our results and suggests a correlation between incidence of VF or VT and mortality of IHD. This would provide an explanation for the marked difference in VF or VT incidence between Osaka Prefecture and other areas. Survival difference between the VF/VT group and the non-VF/VT group was reported from Finland [2], Germany [6] and France [3]. These reports were population-based study for OHCA demonstrated by the Utstein recommendation. While survival rates of the non-VF/VT group in these areas were low (0 /6.3%), 33.1% of the VF/VT group in Finland and 23.5% of those in Germany discharged alive. The survival rate of our VF/VT group was 11.0% after 1 month and 7.3% after 1 year, respectively. We have no definite reason that explains what makes such difference of survival rate between our area and Finland or Germany. Time interval from collapse to initiation of defibrillation would be one reason for such difference. In our study period, Emergency Life-Saving Technicians must receive on-line medical direction for defibrillation from an emergency physician. This necessitated delays in defibrillating for VF or VT patients. The system has been reviewed and defibrillation by EMS without on-line medical direction will be permitted in Japan. Kuisma et al. published an interesting report on a significant decrease in the incidence of VF or VT in Helsinki [25], supporting the views that the incidence of VF or VT cases cannot be the result of a single factor.
However, IHD appears to be a promising factor to account for changes in the VF or VT incidence. We conducted a population-based study in Osaka Prefecture, Japan to determine the incidence and survival rates of bystander-witnessed OHCA with cardiac etiology, which were 11.0 per 100 000 populations, 5.2% for 1 month and 2.9% for 1 year survival. In Japan, where IHD is not so common as in North America or Europe, VF was less likely to occur among OHCA victims, so that the survival rates tended to be lower. Less prevalence of IHD and a lower incidence of OHCA with VF or VT appear to be consistent features of OHCA in Japan.
Acknowledgements This study was funded by a Grant-in-Aid for Scientific Research (B) 14370770, Japan Society for the Promotion of Science. We greatly appreciate the task of Mrs Yoshio Yamashiro, Yasuo Yoshida, Masato Iimori, Yasushi Nakanishi, Keiju Yoshii, and Yasuhiro Hashimoto, all members of the committee for this project.
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Incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrest with cardiac etiology in Osaka, Japan: a population-based study according to the Utstein style Tatsuya Nishiuchi a,*, Atsushi Hiraide b, Yasuyuki Hayashi c, Toshifumi Uejima d, Hiroshi Morita e, Hidekazu Yukioka f, Tatsuhiro Shigemoto g, Hisashi Ikeuchi h, Masanori Matsusaka i, Taku Iwami j, Hiroshi Shinya k, Junichiro Yokota a a
Osaka Prefectural Senshu Critical Care Medical Center, 2-24 Rinku-Orai Kita, Izumisano city, Osaka 598-0048, Japan b Department of General Medicine, Osaka University Medical School, Osaka, Japan c Osaka Prefectural Senri Critical Care Medical Center, Osaka, Japan d Department of Emergency and Critical Care Medicine, Kinki University School of Medicine, Kinki, Japan e Osaka Mishima Critical Care Medical Center, Osaka, Japan f Department Of Emergency and Critical Care Medicine, Osaka City University Medical School, Osaka, Japan g Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan h Department Of Emergency Medicine, Osaka Prefectural General Hospital, Osaka, Japan i Osaka Prefectural Nakakawachi Medical Center Of Acute Medicine, Osaka, Japan j Department of General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan k Department of Emergency and Critical Care Medicine, Kansai Medical University, Kansai, Japan Received 22 July 2002; received in revised form 4 June 2003; accepted 4 June 2003
Abstract Purpose: To clarify the incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrests (OHCA) with cardiac etiology in Osaka Prefecture, Japan, with a population of nearly 9 million according to the Utstein style. Subjects and Methods: 5047 consecutive OHCA cases were treated by ambulance personnel during the 12-month period starting since 1 May 1998. 974 cases were considered to be bystander-witnessed OHCA with cardiac etiology and analyzed using the Utstein style. Results: Of the 974 cases (100%), 50 cases (5.1%) survived after 1 month and 28 (2.9%) of them after 1 year. The Ventricular fibrillation (VF)/ventricular tachycardia (VT) group comprised 164 (16.8%) cases and there were statistically differences between the two groups as below (the VF/VT group vs. the non-VF/VT group): gender (male: 76.8 vs. 60.7%), age (61.79/14.7 vs. 68.79/17.1), history of ischemic heart disease (IHD) (30.5 vs. 15.3%), performance rate of bystander cardiopulmonary resuscitation (CPR) (34.1 vs. 21.4%) and time interval between receipt of an emergency call and arrival at the scene (5.59/2.9 vs. 6.09/2.9 min). Conclusion: The incidence of bystander-witnessed (OHCA) with cardiac etiology and VF or VT were remarkably low compared with those reported by other studies conducted in some areas of Europe or the USA. # 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Witnessed cardiac arrest; Utstein template; Ischemia; Heart disease; Ventricular fibrillation; Outcome
Resumo Objectivo: Clarificar a incideˆncia e taxa de sobrevida das paragens cardı´acas presenciadas, fora do Hospital (OHAC) de etiologia cardı´aca, na comarca de Osaka, Japa˜o com uma populac¸a˜o de 9 milho˜es, de acordo com o modelo de Utstein. Material e me´todos: o pessoal das ambulaˆncias tratou 5047 OHCA num perı´odo de 12 meses com inı´cio a 1 de Maio de 1998. Desses 974 foram considerados OHCA presenciados e com etiologia cardı´aca e analisados com o modelo de Utstein. Resultados: dos 974 casos (100%), sobreviveram um meˆs 50 (5.1%) e ao fim de um ano estavam vivos 28 (2.9%). O grupo da fibrilhac¸a˜o ventricular (VF) e da
* Corresponding author. Tel.: /81-724-64-9911; fax: /81-724-64-9932. E-mail address: [email protected] (T. Nishiuchi). 0300-9572/03/$ - see front matter # 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0300-9572(03)00241-7
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taquicardia ventricular (VT) incluiu 164 casos (16.8%) e havia diferenc¸as significativas entre os dois grupos (grupo VF/VT e grupo na˜o VF/VT), no que se refere ao: sexo (masculino 76.8% vs. 60.7%), idade (61.79/14.7 vs. 68.79/17.1), histo´ria de doenc¸a isque´mica corona´ria (HID) (30.5 vs. 15.3%), desempenho das testemunhas (CPR) (34.1 vs. 21.4%) e tempo decorrido da recepc¸a˜o da chamada de ajuda a` chegada ao local (5.59/2.9 vs. 6.09/2.9 min.). Concluso˜es: a incideˆncia de paragens cardı´acas de etiologia cardı´aca presenciadas, fora do Hospital, e a de VF e VT eram notavelmente baixas quando comparadas com as relatadas noutros estudos em algumas das a´reas da Europa e dos EUA. # 2003 Elsevier Ireland Ltd. All rights reserved. Palavras chave: Paragem cardı´aca testemunhada; Modelo de Utstein; Isquemia; Doenc¸a cardı´aca; Fibrilhac¸a˜o ventricular; Resultados
Resumen Propo´sito : Aclarar, de acuerdo al estilo Utstein, la incidencia y tasa de sobrevida de paro cardı´aco extrahospitalario(OHCA)de etiologı´a cardı´aca, presenciado por testigos en la Prefectura de Osaka, Japo´n, que tiene una poblacio´n de casi 9 millones. Sujetos y me´todo : Un total de 5047 casos consecutivos de OHCA fueron tratados por el personal de ambulancias durante un perı´odo de 12 meses iniciado el 1 de Mayo de 1998. 974 casos fueron considerados como OHCA de etiologı´a cardı´aca presenciados por transeu´ntes y fueron analizados usando el estilo Utstein. Resultados : de los 974 casos (100%), 50 casos (5.1%) sobrevivieron despue´s de un mes y 28 de ellos (2.9%) despue´s de un an˜o. El grupo de fibrilacio´n ventricular(VF)/taquicardia ventricular comprendı´a 164 (16.8%) casos y hubo diferencias estadı´sticas entre los dos grupos sen˜alados mas abajo (el grupo VF/VT vs. grupo noVF/VT): sexo (masculino 76.8 vs. 60.7%), edad (61.79/14.7 vs. 68.79/17.1), historia de enfermedad cardı´aca isque´mica (IHD) (30.5 vs. 15.3%), tasa de desempen˜o de reanimacio´n cardiopulmonar (CPR)por testigos reanimadores (34.1 vs. 21.4%) y tiempo de intervalo entre la recepcio´n de la llamada de emergencia y la llegada a la escena (5.59/2.9 vs. 6.09/2.9 min). Conclusio´n : La incidencia de OHCA de etiologı´a cardı´aca presenciado por testigos y FV o TV fue marcadamente baja comparada con aquellas reportadas en estudios conducidos en Europa o en los Estados Unidos. # 2003 Elsevier Ireland Ltd. All rights reserved. Palabras clave: Paro cardı´aco presenciado; Templado de Utstein; Isquemia; Enfermedad cardı´aca; Fibrilacio´n ventricular; Resultado
1. Introduction
2. Materials and methods
It is in the interest of any community to provide effective treatment for out-of-hospital cardiac arrest (OHCA). Cardiac arrest with cardiac etiology are thought to result in a better outcome than those with non-cardiac etiology [1]. Ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) as the initial rhythm has been found to be particularly relevant for survival of OHCA in many communities [2 /10]. At present, the most successful treatment of OHCA is early defibrillation combined with the ‘‘chain of survival’’ [11] for the patients identified with VF or VT [12 /14]. Emergency medical service (EMS) systems are, therefore, usually compared by the outcome of bystander-witnessed OHCA with cardiac etiology. We report here the incidence and survival rate of bystander-witnessed OHCA with cardiac etiology in Osaka, Japan, in accordance with the Utstein style [15]. In order to study the background of VF or VT cases, we examined the differences between those with pulseless electrical activity or asystole and established a better understanding of the distinguishing features of VF or VT cases in OHCA. We also showed the marked difference in VF or VT incidence related to OHCA between Osaka and other communities in the USA or European countries.
2.1. Patients Data for all the patients who were considered for cardiopulmonary resuscitation (CPR) by the EMS of Osaka Prefecture, Japan, were recorded prospectively using the Utstein style from 1 May 1998. Data for bystander-witnessed OHCA cases with cardiac etiology treated during the 12-month period between 1 May 1998 and 30 April 1999 were analyzed in this study. 2.2. Target area The target area for this study was Osaka Prefecture, one of 47 administrative districts in Japan. Osaka Prefecture has an area of 1892 km2 and a residential population of 8 832 606 inhabitants. Its area and population account for 0.5 and 6.9%, respectively, of the national totals. Males make up 49% of the population and 13.6% are more than 65 years old. The total number of deaths from all causes in Osaka Prefecture in 1998 was 59 647, an incidence of 675 per 100 000 people. 2.3. EMS organization and equipment The 119 emergency telephone number is accessible anywhere in Japan including the Osaka Prefecture. On
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receipt of a 119 call, an emergency dispatch center sends the nearest available ambulance to the site. These dispatch centers are operated by municipal fire stations managed by the municipal government and 36 such fire stations, and emergency dispatch centers are located in Osaka Prefecture. The EMS systems consist of a singletiered system with a three-person unit providing life support 24 h a day. Ambulance squads are staffed with EMS personnel, some of whom are called Emergency Life-Saving Technicians. The latter have passed a state examination and are allowed to insert an intravenous line, to use airway adjuncts and to defibrillate using a semi-automated external defibrillator for OHCA patients after receiving on-line medical direction from an emergency physician in a hospital. They are not allowed to perform tracheal intubation and administer resuscitative drugs under the present Japanese law.
2.4. Task organization This study was conducted by the task force committee for this project, consisting of ten staff physicians from the main hospitals providing emergency critical care and six representatives of fire stations in Osaka Prefecture. The Osaka Medical Association and the Emergency Medical Information Center of Osaka Prefecture, which usually provides advice by telephone concerning hospitals available for various emergencies cooperated with the committee.
2.5. Data collection The committee designed the data sheets based on the Utstein style recommendation and collected data prospectively. For each case the EMS personnel completed the data with the cooperation of the physician who treated the patient. The EMS personnel who took care of the patients also followed up their outcome for 1 month. The data sheets were then transferred to the Emergency Medical Information Center of Osaka Prefecture. The collected data were checked by the physicians of the committee and followed up for 1 year with the cooperation of the Osaka Medical Association and all hospitals to which patients had been transferred.
2.6. Data analysis The statistical differences were analyzed by means of unpaired Student’s t-test or a chi-squared (x2) test. A P value of less than 0.05 was regarded as significant for all tests and data are shown as mean9/standard deviation (S.D.).
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3. Results Fig. 1 shows the results of this study using the Utstein style. During the 12-months study period, 5047 OHCA cases were dealt with by EMS in Osaka Prefecture. EMS personnel attempted CPR in 4871 of these cases, and in 3047 cases the cause of cardiac arrest was presumed to be a cardiac etiology. Bystander-witnessed OHCA with cardiac etiology accounted for 974 cases. Besides these 974 cases, there were eight cases who had resuscitation attempted by lay rescuers but were observed by EMS personnel to have a pulse on arrival. Attempt at bystander defibrillation was not reported in these eight cases. We also had another 175 cases who were witnessed by EMS personnel. The analysis of EMS witnessed cases was reported by Uejima [16]. In this study we focused on the 974 bystander-witnessed and EMS-confirmed OHCA. Of the 974 bystander-witnessed OHCA with cardiac etiology VF or VT accounted for 164 cases. Since there was only one case of VT, it was combined with VF into one group (the VF/VT group). As a result, the annual incidence rates of OHCA, bystander-witnessed OHCA with cardiac etiology and with VF or VT in the target area were 55.1, 11.0 and 1.8 per 100 000 population, respectively. The mean age of the bystander-witnessed cardiac arrest cases with cardiac etiology was 67.5 years and males accounted for 63.4% (Table 1). Of these 974 patients (100%), 334 patients (34.3%) achieved return of spontaneous circulation (ROSC), 236 (24.2%) were admitted to hospital, 50 (5.1%) remained alive after 1 month and 28 (2.9%) after 1 year. A comparison of the characteristics of the VF/VT group with those of other cases (the non-VF/VT group) is shown in Table 1. The ratio of males was higher (76.8 vs. 60.7%) and the patients were younger (61.79/14.7 vs. 68.79/17.1) in the VF/VT group. It should be emphasized that the VF/VT group was more likely to have a past history of cardiac disease (60.4 vs. 42.3%), especially IHD (30.5 vs. 15.3%). There were no statistical differences between the two groups in terms of arrhythmia, hypertension or other cardiac diseases. The rates of patients who attained ROSC and survived after 1 month and 1 year were more favorable for the VF/VT group than the non-VF/VT group. It was also found that the percentage of bystander CPR for the VF/VT group was significantly higher than the non-VF/VT group (34.1 vs. 21.4%). Although the difference was not significant, the interval from receipt of the emergency call to arrival at the scene was shorter for the VF/VT group (5.59/2.9 vs. 6.09/2.9 min). We also compared the annual incidences of (1) OHCA, (2) witnessed OHCA with cardiac etiology and (3) VF or VT of witnessed OHCA with cardiac etiology between Osaka Prefecture and other areas where data had been previously reported using the
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Fig. 1. The Utstein template for bystander-witnessed cardiac arrests with cardiac etiology. CPR, cardiopulmonary resuscitation; EMS, emergency medical service; VF, ventricular fibrillation; VT, ventricular tachycardia; PEA, pulseless electrical activity; ROSC, return of spontaneous circulation.
Utstein style [2 /4,6,17] (Fig. 2). Osaka Prefecture showed that the lowest incidences of witnessed OHCA with cardiac etiology and VF or VT in witnessed OHCA with cardiac etiology. Survival difference between the VF/VT group and the non-VF/VT group could be evaluated in four reports including this study. In the reports of Kuisma et al. from Finland [2], Fischer et al. from Germany [6], Giraud et al. from France [3], and the present study from Japan, the survival rates of the VF/VT group in the bystanderwitnessed cardiac etiology were 42/127 (33.1%), 28/119 (23.5%), 2/31 (6.5%), 12/164 (7.3%), respectively. The survival rate of the non-VF/VT group were 2/67 (3.0%), 6/95 (6.3%), 0/46 (0%), 16/810 (2.0%), respectively.
4. Discussion VF or VT cases are thought to achieve a much better rate of ROSC as a result of early defibrillation than other cases whose initial cardiac rhythms are asystole or pulseless electrical activity [12 /14]. Therefore, comparison of the background features of the VF/VT group and the non-VF/VT group is of great value in order to explain the difference of the incidence of VF or VT. As is shown in Fig. 2, the incidence of OHCA in Osaka Prefecture is low. In addition, the most striking result of our study is that the incidences of cardiac arrests with cardiac etiology and VF or VT are lowest among other regions [2 /4,6,17].
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Table 1 Comparison between VF/VT and non-VF/VT group Total
VF/VT group
Non-VF/VT group
P value
Cases (%) Male/female (male %) Age (year; mean9/S.D.)
974 618/356 (63.4) 67.59/16.9
164 (16.8) 126/38 (76.8) 61.79/14.7
810 (83.2) 492/318 (60.7) 68.79/17.1
B/0.001 B/0.001
Past history of cardiac arrest (%) AMI and/or angina pectoris Arrhythmia Hypertension Others
442 (45.5%) 174 (17.9) 41 (4.2) 160 (16.4) 128 (13.1)
99 (60.4) 50 (30.5) 9 (5.5) 22 (13.4) 26 (15.9)
343 (42.3) 124 (15.3) 32 (4.0) 138 (17.0) 102 (12.6)
B/0.001 B/0.001 N.S. N.S. N.S.
Bystander CPR (%) Call receipt to arrival at scene (mean9/S.D.) ROSC (%) Survived to admission
229 (23.5) 5.99/2.9 334 (34.3) 236 (24.2)
56 (34.1) 5.59/2.9 70 (42.7) 49 (29.9)
173 (21.4) 6.09/2.9 264 (32.6) 187 (23.1)
B/0.001 B/0.05 B/0.01 N.S.
Outcome (%) Alive after 1 month Alive after 1 year
50 (5.1) 28 (2.9)
18 (11.0) 12 (7.3)
32 (4.0) 16 (2.0)
B/0.001 B/0.001
VF, Ventricular fibrillation; VT, ventricular tachycardia; AMI, acute myocardial infarction; CPR, cardiopulmonary resuscitation; ROSC, return of spontaneous circulation; S.D., standard deviation.
There seem to be several factors that affect the initial rhythm of OHCA victims. For example, male predominance is of obvious interest. This is consistent with results reported concerning with the influence of gender on the feature of cardiac arrests [18]. However, this cannot explain the specific difference between the Osaka region and others because gender distribution cannot be markedly different among communities with a certain minimum population. Although time factors and the presence or absence of bystander CPR may explain the diversity in VF or VT incidence [4,6,10,19], the response time was approximately 6 min, which was rather short compared with other areas (5.5 /11 min) [2 /4,6]. Bystander CPR can prolong VF [20] and consequently increases the chance of defibrillation by first responders. The fact that the
VF/VT group received more bystander CPR than the non-VF/VT group implies that bystander CPR would have contributed to the difference in VF or VT incidence. Overall, however, only 23.5% of the subjects received bystander CPR, which was rather unsatisfactory compared with previously reported rates that range from 18 to 57% [4,9,14,20 /23]. We hypothesized that existing heart disease, especially IHD, might contribute to the difference in initial rhythm because mortality as a result of IHD (ICD-9, 410 /414) in Osaka Prefecture was low since it was responsible for 5088 deaths, or only 57.6 per 100 000 individuals per year. As shown in Table 1, IHD had occurred twice as often in the VF/VT group than in the non-VF/VT group, whereas differences in arrhythmia, hypertension and other cardiac diseases were not statistically signifi-
Fig. 2. Annual incidence of out-of-hospital cardiac arrests, witnessed cardiac arrests with cardiac etiology and VF or VT in witnessed cardiac arrest with cardiac etiology in Osaka, Saint-Etienne, New York City, Bonn, South Glamorgan and Helsinki (cases per 100 000 populations in a year). j, out-of-hospital cardiac arrest; I, bystander-witnessed cardiac arrest with cardiac etiology; , VF or VT in witnessed cardiac arrest with cardiac etiology
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Fig. 3. Mortality of IHD (ICD-9, 410-414) in Japan, France, United States of America (USA), Germany, United Kingdom (UK) and Finland and incidence of VF or VT in witnessed cardiac arrest with cardiac etiology in Osaka, Saint-Etienne, New York City, Bonn, South Glamorgan and Helsinki (cases per 100 000 populations in a year). I, VF or VT in witnessed cardiac arrest with cardiac etiology; j, IHD.
cant. Fig. 3 showed the mortality of IHD in the six countries included in Fig. 2 [24], and indicated that the incidence of VF or VT in OHCA increased in proportion to the mortality of IHD. The ischemic-reperfusion mechanism of VF in IHD provides a rational support for our results and suggests a correlation between incidence of VF or VT and mortality of IHD. This would provide an explanation for the marked difference in VF or VT incidence between Osaka Prefecture and other areas. Survival difference between the VF/VT group and the non-VF/VT group was reported from Finland [2], Germany [6] and France [3]. These reports were population-based study for OHCA demonstrated by the Utstein recommendation. While survival rates of the non-VF/VT group in these areas were low (0 /6.3%), 33.1% of the VF/VT group in Finland and 23.5% of those in Germany discharged alive. The survival rate of our VF/VT group was 11.0% after 1 month and 7.3% after 1 year, respectively. We have no definite reason that explains what makes such difference of survival rate between our area and Finland or Germany. Time interval from collapse to initiation of defibrillation would be one reason for such difference. In our study period, Emergency Life-Saving Technicians must receive on-line medical direction for defibrillation from an emergency physician. This necessitated delays in defibrillating for VF or VT patients. The system has been reviewed and defibrillation by EMS without on-line medical direction will be permitted in Japan. Kuisma et al. published an interesting report on a significant decrease in the incidence of VF or VT in Helsinki [25], supporting the views that the incidence of VF or VT cases cannot be the result of a single factor.
However, IHD appears to be a promising factor to account for changes in the VF or VT incidence. We conducted a population-based study in Osaka Prefecture, Japan to determine the incidence and survival rates of bystander-witnessed OHCA with cardiac etiology, which were 11.0 per 100 000 populations, 5.2% for 1 month and 2.9% for 1 year survival. In Japan, where IHD is not so common as in North America or Europe, VF was less likely to occur among OHCA victims, so that the survival rates tended to be lower. Less prevalence of IHD and a lower incidence of OHCA with VF or VT appear to be consistent features of OHCA in Japan.
Acknowledgements This study was funded by a Grant-in-Aid for Scientific Research (B) 14370770, Japan Society for the Promotion of Science. We greatly appreciate the task of Mrs Yoshio Yamashiro, Yasuo Yoshida, Masato Iimori, Yasushi Nakanishi, Keiju Yoshii, and Yasuhiro Hashimoto, all members of the committee for this project.
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