Results of cardiopulmonary resuscitation in a cardiology hospital

Resuscitation, Elsevier

18 (1989) 75-84

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Publishers

75 Ireland Ltd.

RESULTS OF CARDIOPULMONARY CARDIOLOGY HOSPITAL

AR1 TIMERMAN*,

LEOPOLD0

SOARES

RESUSCITATION

PIEGAS

and J. EDUARDO

IN A

M.R. SOUSA

Emergency and Intensive Care Department, Dante Pazzanese Institute Dante Pazzanese, 50@Ibirapuera, 04012, Sao Pa&o, SP lBrexiU

of Cardiology,

Av. Dr.

(Received August 13th, 1988) (Revision received January 17th, 1989) (Accepted January 20th, 1989)

SUMMARY

The authors analysed a series of 557 consecutive patients who suffered cardiorespiratory arrest at the Dante Pazzanese Institute of Cardiology (DPIC) during a period of 5 years in order to examine factors predicting successful resuscitation and long-term survival. Cardiopulmonary resuscitation KPR) maneuvers were tried in 536 patients, with the following results: 284 patients (53%~)died immediately, another 102 (19O/6)died within the first 24 h after the cardiac arrest and 150 patients (28%) survived more than 24 h. Among these, 65 (12.1%1)died in the first month after cardiac arrest and other 29 (5.4%) died after that period. There were 43 late survivors (8%). Thirteen patients (2.4%) were lost to follow-up. After 9 years, the accumulative life expectancy was 8.7%. Coronary heart disease, cardiomyopathy and valvular heart disease were the most frequent underlying diseases. None of the 49 patients with cyanotic congenital heart disease survived. The heart arrest was mostly caused by heart failure (55.8%) and primary arrhythmia (17.2%) in the whole group, whereas the survivor group showed primary arrhythmia in 81.7% and heart failure in 7.3%. In those patients where the initial mechanism of cardiac arrest was ventricular fibrillation, 33.20/bsurvived more than 1 month, while among those on ventricular asystole, only 3.4% survived more than 1 month. Key words: Survival after cardiopulmonary resuscitation hospital

Cardiology

INTRODUCTION

The technique of CPR by external cardiac massage, introduced in 1960 by *To whom reprint requests

should be sent.

0 1989 Elsevier 0300-9572/89/$03.50 Printed and Published in Ireland

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Ireland Ltd.

76

Kouwenhoven [l] represented a great advance in intensive medicine and allowed many patients to be saved. Several studies on CPR in a hospitalized population have shown the effectiveness of the resuscitation maneuvers with a significant number of patients being discharged from General Hospital or from University Hospital, where the studies were carried out. We intend to report here short and long-term results of our experience with 536 patients who suffered a cardiorespiratory arrest in a Heart Medical Center, during a fiveyear period and who were followed up to 9 years. The study was conducted to address questions related to the demographic and clinical characteristics of patients suffering cardiopulmonary arrest, and also to the predictors of outcome and of long-term survival, in an attempt to provide some useful perspectives to physicians involved in CPR. PATIENTS

AND METHODS

From February 1978 to February 1983 we evaluated prospectively all patients who suffered cardiac arrest at any of the DPIC wards and departments, excluding the operating room. This Institute is specifically dedicated to cardiology and it has out-patients areas, diagnostic areas and a 78bed Hospital, which has all its wards in one floor, permitting therefore rapid arrival of physicians, nurses, defibrillator and drugs to the site of arrest. The Institute has a staff which includes 120 physicians working in its departments and 60 medical residents. Because of the reduced size of the Institute, a specific cardiac arrest team is not available, and therefore, cardiac arrests are attended by the professional house staff, each one having passed an effective training in CPR technique according to the standards of the American Heart Association [2-41. The CPR training program with the use of mannequins is regularly given, every year, by the doctors responsible for the Emergency Unit to other physicians, nurses and health professionals working at the Institute, and to any other person who wants to participate in the Course as well. Monthly, the CPR training program is given to medical residents rotating at the Emergency Unit. The cardiorespiratory arrest, defined as the sudden cessation of circulation or respiration resulting in documented loss of conciousness and requiring initiation of CPR, is initially attended by the closest physician or nurse while other cardiologists, residents and nurses from the Emergency Unit proceed to the site of arrest. In this study, only the first arrest on each admission was counted; second or subsequent arrests, if unsuccessfully treated, were recorded as later death, and have been ignored if the patient survived. Resuscitation was deemed successful if a stable circulation was established and the resuscitators disbanded. The patients who survived the cardiorespiratory arrest were followed-up through review of their clinical file, personal interviews, contact by letter, phone contacts, or by communications of their personal physician. When necessary, the patient’s family was contacted in order to assess the long-term outcome. Underlying diseases as well as determinant causes of cardiorespiratory arrest were

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analysed on basis of clinical, laboratorial and surgical findings. Postmortem examinations were performed on 97 patients. Particular attention was given in comparing the characteristics of those patients who survived more than one month after the cardiac arrest, to those of the whole group. Life-table analysis was done by the method of Cutler and Ederer [5] and statistical analysis by x2 tests. RESULTS

From February 1st. 1978 to February 28th, 1983 there were 339 008 outpatients visits and 7694 hospital admissions, at the DPIC. During this 5-year period, 557 patients suffered cardiac arrest (excluded those which occurred inside the operating room); in 21 terminally ill patients, CPR maneuvers were not initiated. CPR maneuvers were tried in 536 patients; 56 (10.40/b)were at the out-patient department and 480 (89.6Orbl in hospitalized patients (Table Il. There were 331 men (61.80/b)and 205 women (38.2%11,ranging from 9 days to 86 years of age with a mean age of 46.4 years. Table II shows the age distribution related to the outcome of resuscitation. Table III summarizes the underlying diseases of the patients undergoing resuscitation. The most common underlying disease was coronary heart disease occurring in 168 patients (31.3%) with 96 patients (17.9O/blin the course of acute myocardial infarction (AMI), followed by cardiomyopathy in 142 patients (26.5Ohl and valvular heart disease in 114 patients (21.3O/bl.Among the cardiorespiratory arrest determinant causes (Table IV), heart failure predominated, occurring in 299 patients (55.80~1, followed by primary arrhythmia in 92 patients (17.2°~l and respiratory failure in 34 patients (6.3%). Arrhythmia occurring in consequence of a significantly depressed myocardial TABLE I LOCATION OF THE CARDIORESPIRATORY ARREST General group

Survived + 1 month

Lost before 1 month of follow-up

2 54

-

-

5(9.3%)

-

General ward Postoperative care unit Coronary care unit Intensive care unit Cardiac cath. lab. Hemodialysis room Others

61 66 71 225 35 6 16

11(18.0%) 9 (13.6%) 13 (18.3%) 18 (8.0%) 24 (68.6%) 2 (12.5%)

1 1 1 -

Total

536

82

3

Out-patients department

General Emergency

78 TABLE II AGE OF PATIENTS WHO SUFFERED CARDIORESPIRATORY ARREST Age (years)

General group

Survived + 1 month

Lost before 1 month of follow-up

o-1 l-10 10-15 15-20 20-30 30-40 40-56 50-60 60-70 >70

24 22 18 21 40 47 85 114 105 60

3 (16.7%) 3 (14.3%) 8 (20.0%) 9 (19.1%) 16 &?&‘,+I) 19 (16.7%) 20 (19.0%) 4 (6.7%)

1 0 0 0 0 0 1 1 0 0

Total

536

82

3

0

0

contractility was not defined as primary arrhythmia. It was possible to determine the initial mechanism of cardiorespiratory arrest in 498 patients. Ventricular asystole occurred in 264 patients (49.3%1, ventricular fibrillation in 205 patients (38.2%1, respiratory arrest in 19 patients (3.5%) and electromechanical dissociation in 10 patients (1.9%). Analysis of the results of CPR maneuvers revealed that 284 patients (530~1, died immediately: another 102 (19%) died within the first 24 h after the cardiac arrest (after an initial recov-

TABLE III UNDERLYING DISEASES No. patients Coronary heart disease Cardiomyopathy Valvular heart disease Congenital heart disease: Cyanotic Acyanotic Chronic renal failure Chronic “Cor pulmonale” Systemic arterial hypertension Dissecting aneurysm of the aorta Primary pulmonary hypertension Carcinoma Miscellaneous

168 (31.3%) 142 (26.5%) 114 (21.3%)

Total

536 (100%)

49 (9.1%)

19 (3.6%) 15 (2.8%) 9 (1.7%) 6 (1.1%) 4 (0.7%) 4 (0.7%) 2 (0.4%) 4 (0.7%)

79 TABLE IV CARDIAC

ARREST

DETERMINANT

CAUSES No. patients

Heart failure Primary arrhythmia Respiratory failure Stroke Anoxic spell Uremia Infectious diseases Hypovolemic shock Cardiac tamponade Hyperkalemia Hypokalemia Mesenteric thrombosis Miscellaneous

299 (55.8%) 92 (17.2%) 34 (6.3%) 29 (5.4%) 2lf3.90~) 17 (3.2%) 16 (3.0%) 13 (2.4%) 3 (0.50~) 2 (0.40/b) 2 (0.4%) 2 (0.4%) 6 (1.1%)

Total

536 (100%)

TABLE V WORLD ARREST

EXPERIENCE

OF

SURVIVAL

FROM

IN-HOSPITAL

Ref.

Year

No. patients

Immediate survival (0~)

Stemmler [20]

1965

103

G&ton [12] Johnson et al. [18] Hollingsworth [15] Jeresaty et al. [13] Camarata et al. [21] Castagna et al. [16] Peatfield et al. [19] Bedell et al. [ll]

1965 1967 1969 1969 1971 1974 1977 1983

37 552 368 237 132 137 1063 294

Pechtel et al. [17] Horimoto et al. [22] Ballin [23] Kyff et al. [24] Goldberg et al. [25] Rozembaum et al. [26]

1984 1985 1986 1987 1987 1988

207 43 200 272 667 71

+ 1 h (35) + 24 h (12.6) (55) + 24 h (31.7) + 24 h (24.7) (41) 38 35 32.5 + 1 h (44) + 24 h (33) 40.5 30 18 37.5 41

CARDIORESPIRATORY

Discharged from hospital alive (%)

Late survival

4.8

-

35 14.9 8.2

-

22 5 10

9-42 -

8.7 14

10 years 3.7% 6 months 11.2%

14 21

6 months 10.3% -

months 18.1%

7 11

-

22 18

9 years 13.6% -

80

eryl. Among the 150 patients (28O/blwho survived more than 24 h, 65 (12.1°/01 died in the first month after cardiac arrest and other 29 (5.40~1,died after that period. Data of the current status of 13 patients (2.4O/olwere not available; three of these were lost before 1 month of follow-up. There were 43 late survivors (8%) up to December, 1986. Data pertaining to site and outcome of arrest is presented in Table I. The best results of CPR were obtained at the cardiac catheterization laboratories (68.6’S survived more than 1 month); the worst results occurred at the hemodialysis room, where there were no survivors beyond 1 month. In the group of 82 patients who survived more than 1 month after recovery of cardiorespiratory arrest, the age ranged from 11 years to 84 years, with a mean age of 48.9 years (Table II). As to sex, there were 48 men (58.5%) and 34 women. In this group, the most common underlying disease was coronary heart disease, occurring in 38 patients (46.3%). with 21 patients (25.6%) in the course of AMI. Cardiomyopathy was present in 21 patients (25.60/o),valvular heart disease in 18 patients (220/b),acyanotic congenital heart disease in three patients (3.70/b) and systemic arterial hypertension in two patients (2.4%).

Fig. 1. Actuarial survival curve of 636 patients who suffered cardiorespiratory follow-up. H, hour (O- 48); D, day (7 and 30); M, months (6); Y, years (l-9).

arrest

-

9 years of

81

As to cardiorespiratory arrest determinant causes, primary arrhythmia predominated, occurring in 67 patients 031.70/b),followed by heart failure in six patients (7.30/b), respiratory failure in three patients (3.7%), drug adverse effects in three patients (3.7(%1,hypovolemic shock in two patients (2.4%) and uremia in one patient (1.2Oh). Ventricular fibrillation was the most common cardiorespiratory arrest initial mechanism, occurring in 68 patients (82.90~1,followed by ventricular asystole occurring in 9 patients (11%) and respiratory arrest in four patients (4.9%). Those patients discharged alive from hospital were followed up and those who remained alive in December, 1986 had a follow-up period ranging from 3 years 10 months to 8 years 10 months. An actuarial survival curve was constructed (Fig. 11,and the accumulative life expectancy in 6 months, 1, 2.3, 4, 5 and 6 years was, 14.6%, 14.4%, 12.9O/6, 11.7%, 10.80/b,10.2%, and 9.80/b,respectively and in 7,8 and 9 years, was 8.7O,6. DISCUSSION

The success rate of the CPR from out-of-hospital cardiac arrest is significantly associated with short time intervals from collapse to initiation of CPR (within 4 mini and to provision of definitive care, mainly cardiac defibrillation (within 8 mini [6,7] obtaining a mean of 19% of hospital discharge alive from these patients [8 - lo]. When cardiorespiratory arrest occurs inside the hospital, it becomes easier to apply the Basic and the Advanced Cardiac Life Support rapidly. In our study, CPR was initiated within 5 min of the arrest in 97.8% of the cases and all patients who survived for more than 1 month were in this situation. Bedell et al. [ll], suggest that the location of arrest is not an important determinant of survival after cardiorespiratory arrest, when patients receive prompt resuscitation. However, we obtained better results at the cardiac catheterization laboratories, with 68.6%~of the patients surviving over 1 month after the cardiac arrest. Similar results are cited by Gilston and Jeresaty et al. [12,13], probably because the major determinant cause of cardiac arrest in these laboratories is primary arrhythmia. The worst results in our study occurred at the hemodialysis room and at the intensive care unit. This may well be due to the fact that these patients already belonged to a high risk group, with a more severe underlying disease. Coronary heart disease, cardiomyopathy and valvular heart disease were the most frequent underlying diseases, both in the general group and in the group of 82 patients who survived more than 1 month. These three pathologies had a better prognosis when compared to others, regarding survival for more than 1 month (P < 0.01). On the other hand, there were no survivors in the cardiorespiratory arrest in 49 patients with cyanotic congenital heart disease, in 15 patients with chronic renal failure and in 9 patients with chronic ‘car pulmonale’. There was no significant statistical difference regarding sex distribution between the overall group and the group surviving for more than 1 month.

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Our series demonstrated poorer prognosis of patients included in the extreme age groups, confirming the findings of Stephenson [14]. There was no survivor for more than 1 month among the 46 patients between 0 and 10 years (one patient with 26 days was lost before 1 month of follow-up). Among the 60 patients older than 70 years who underwent resuscitation, only four survived for more than 1 month (6.7%). The best results occurred in groups whose age varied from 20 to 30 years (200/b)and from 30 to 40 years (19.1°/61.The mean age of survival group was higher than that of the whole group maybe because of the high mortality rate of the younger group. These data, however, must be analysed with caution. The most part of the younger group (age between 0 and 10 years) was formed by patients with cyanotic congenital heart disease and this fact (and not the age itself) may have determined the poorer outcome in this age group. Regarding the determinant cause of cardiorespiratory arrest in the general group, there is a net predominance of heart failure which was present in 299 patients, among the 536 of the whole group, corresponding to 55.8%, while primary arrhythmia was the determinant cause in 92 patients (17.2%). However, in the group of 82 patients who survived for more than 1 month, there is an inversion on this order, with primary arrhythmia being the determinant cause in 67 patients (81.7%~) and heart failure in 6 patients (7.30/b), which is statistically highly significant (P < 0.00011.Thus, from 299 patients with heart failure, only 6 (2%) survived for more than 1 month; from 92 patients with primary arrhythmia, 67 (72.8%) survived beyond 1 month. Cardiac arrest in ventricular fibrillation had a quite better prognosis than that in ventricular asystole or electromechanical dissociation; our findings are consistent with the observations of other authors [15- 171. From 205 patients with cardiac arrest in ventricular fibrillation, 68 patients (33.2O/blsurvived for more than 1 month, while only nine patients from 264 (3.4O/olwho suffered cardiac arrest in ventricular asystole, survived for more than 1 month. None of the 10 patients with cardiac arrest in electromechanical dissociation survived Cp< 0.00011. Our study revealed an immediate success rate of 47% with the CPR maneuvers; this rate fell down to 28% at the first 24 h. Eighty-two patients (15.3%) survived for more than 1 month. These findings are comparable to previous studies [11,17,18](Table Vl. Regarding the follow-up of survivors, the death-rate decreased after the 3rd year; between the 8th and 9th years no patient died and after 9 years of followup, 43 patients (8%) were alive. Actuarial survival curve is similar to that of Peatfield et al. [19] which, however, showed cessation of death since the 6th year follow-up. In our series, the accumulative life expectancy for the general group after 8 and 9 years was 8.7%. Our findings, therefore, showed a higher resuscitation success and survival rate in those patients included in one of the following categories: age between 11 and 70 years, occurring at cardiac catheterization laboratories, coronary artery disease, cardiomyopathy or valvular heart disease as the underlying disease, primary arrhythmia as the determinant cause and ventricular fibrillation as the initial mechanism.

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The worst results occurred in those patients included in one of these categories: age between 0 and 10 years or older than 70, cardiorespiratory arrest in hemodialysis room or in intensive care unit, with underlying disease being cyanotic congenital heart disease, chronic renal failure or chronic ‘car pulmonale’, heart failure, stroke or anoxic spell as the determinant cause and ventricular asystole or electromechanical dissociation being the initial mechanism. The results in our series may serve as a helpful guide to physicians in the hard task of deciding when not to resuscitate or when to stop with resuscitation efforts. The thorough consideration of the history of these patients should dispel anxiety and guilt, at the resuscitation efforts on patients who suffered cardiorespiratory arrest but have little chance of recovery. ACKNOWLEDGEMENTS

This paper is supported in part by grants from the Adib Jatene Foundation and the Dante Pazzanese Institute of Cardiology. The authors thank Mrs. Helga Beyer, Mrs. Vanda L.M. Andrade and Mrs. Zelia M.F.A. Rodrigues for their secretarial assistance, Mr. Takashi Hashitani and Dr. Ricardo Manrique Sipan for assisting with statistical analysis and Dr. Carlos Gun, Dr. Rui F. Ramos and Dr. Sergio Timerman for their assistance in collecting data. We also wish to thank Dr. Renato Mayo1 for his helpful comments and suggestions. REFERENCES 1 W.B. Kouwenhoven, J.R. Jude and G.G. Knickerbocker, Closed chest cardiac massage, J. Am. Med. Assoc., 173 (196011064- 1067. 2 Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECU, J. Am. Med. Assoc., 227 Suppl. (19741833-868. 3 Standards and guidelines for cardiopulmonary resuscitation (CPRl and emergency cardiac care (ECU, J. Am. Med. Assoc., 244 (19801453-509. 4 Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECCl, J. Am. Med. Assoc., 255 (198612905-2989. 5 S.J. Cutler and F. Ederer, Maximum utilization of the life table method in analyzing survival, J. Chronic Dis., 8 (1958) 699-712. 6 M.S. Eisenberg, L. Bergner and A. Hallstrom, Cardiac resuscitation in the community. Importance of rapid provision and implications for program planning, J. Am. Med. Assoc., 241 (197911905- 1907. 7 R.O. Cummins and M.S. Eisenberg, Prehospital cardiopulmonary resuscitation, Is it effective? J. Am. Med. Assoc., 253 (198512408-2412. 8 M.S. Eisenberg, A. Hallstrom and L. Bergner, Long term survival after out-of-hospital cardiac arrest, N. Engl. J. Med., 306 (198211340- 1343. 9 R.J. Myerburg, C.A. Conde, R.J. Sung, A.M. Cortes, S.M. Mallon, D.S. Sheps, R.A. Appel and A. Castellanos, Clinical electrophysiologic and hemodynamic profile of patients resuscitated from prehospital cardiac arrest, Am. J. Med., 68 (19801568- 576. 10 D.D. Tresh, M.H. Keelan Jr., R. Siegel, P.J. Troup, L.I. Bonchek, G.N. Olinger and H.L. Brooks, Long-term survival after prehospital sudden cardiac death, Am. Heart J., 108 (19841l-5. 11 S.E. Bedell, T.L. Delbanco, E.F. Cook and F.H. Epstein, Survival after cardiopulmonary resuscitation in the hospital, N. Engl. J. Med., 309 (19831569- 576. 12 A. Gilston, Clinical and biochemical aspects of cardiac resuscitation, Lancet, 20 (19651 10391043.

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