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Therapeutic hypothermia: is it effective for non-VF/VT cardiac arrest?

Sandroni C, Cavallaro F, Antonelli M - Crit Care (2013)

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In adults, the prevalence of out-of-hospital cardiac arrest (OHCA) attended by the emergency medical services (EMS) ranges from 52 to 112 per 100,000 person-years in developed countries, whereas the prevalence of adult in-hospital cardiac arrest (IHCA) ranges from 1 to 5 per 1,000 patient admissions... Mortality from cardiac arrest exceeds 90% in OHCA and 70% in most studies on IHCA... However, only 25-30% of OHCA patients have VF/VT as the initial recorded cardiac rhythm, and this percentage has decreased in recent years, partly because of the advent of implantable cardioverter-defibrillators for the prevention and treatment of patients at risk of lethal arrhythmias... The prevalence of VF/VT rhythms in IHCA does not exceed 25-30% either... The rate of the combined endpoint of death (CPC = 5) and poor neurological outcome (CPC 3-4) was also lower - although not significantly - in the mild therapeutic hypothermia group (89/124 [71%] vs. 59/73 [81%] p = 0.21)... In this study, only univariate analysis was performed, so no correction was made for pre- and intra-arrest potential confounders... The study included a total of 491 patients with OHCA with all rhythms, of whom 313 (74%) had non-VF/VT cardiac arrest... The quality of evidence was assessed using the GRADE methodology... The results showed that the quality of evidence in all studies was very low... Meta-analysis of the 12 observational studies showed a significant reduction in hospital mortality (RR 0.84 [0.78-0.92]) and a non-significant trend towards better neurological out come (RR for poor neurological outcome 0.95 [0.90-1.01]) after mild therapeutic hypothermia... The authors concluded that mild therapeutic hypothermia was associated with reduced in-hospital mortality for adult patients resuscitated from non-shockable cardiac arrest, but also suggested caution in interpreting the results, given a substantial risks of bias and the low quality of the evidence... A first study by Dumas et al. reported data from a prospective French database including 1,145 OHCA patients, 437 of whom were non-VF/VT patients... In contrast with the previous two studies, the rates of good neurological outcome (15/52 [29%] vs. 6/48 [13%]; p = 0.021) and survival to discharge (20/52 [38%] vs. 9/48 [19%]; p = 0.03) were significantly higher in patients treated with mild therapeutic hypothermia... These results were confirmed after controlling for confounders using binomial logistic regression (OR 4.35 [1.10-17.24], p = 0.04 and OR 5.65 [1.66-19.23], p = 0.006, respectively)... For example, some studies included only OHCA patients, whereas others included both IHCA and OHCA (see Table 1).

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Forest plot of risk ratio for mortality (a) and poor neurological outcome (b) in observational studies of patients resuscitated from non-VF/VT cardiac arrest. Data were partially reproduced from [31] with Author's permission.
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Figure 1: Forest plot of risk ratio for mortality (a) and poor neurological outcome (b) in observational studies of patients resuscitated from non-VF/VT cardiac arrest. Data were partially reproduced from [31] with Author's permission.

Mentions: The Forest plots in Figure 1a, b summarize the results of 12 observational studies reporting survival to discharge (1,581 patients, Figure 1a) and of 13 observational studies reporting neurological outcome (1,998 patients, Figure 1b). Data pooled according to a fixed effect model show a significant reduction in the RR for hospital mortality (0.88 [0.82-0.95]) and a smaller but significant reduction in RR for poor neurological outcome (0.95 [0.90-0.99]) in patients treated using mild therapeutic hypothermia. However, in spite of pooled results favoring treatment, the effect is not consistent, with large studies showing increased RR for poor neurological outcome associated with use of mild therapeutic hypothermia [33] (Figure 1b).


Therapeutic hypothermia: is it effective for non-VF/VT cardiac arrest?

Sandroni C, Cavallaro F, Antonelli M - Crit Care (2013)

Forest plot of risk ratio for mortality (a) and poor neurological outcome (b) in observational studies of patients resuscitated from non-VF/VT cardiac arrest. Data were partially reproduced from [31] with Author's permission.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3672513&req=5

Figure 1: Forest plot of risk ratio for mortality (a) and poor neurological outcome (b) in observational studies of patients resuscitated from non-VF/VT cardiac arrest. Data were partially reproduced from [31] with Author's permission.
Mentions: The Forest plots in Figure 1a, b summarize the results of 12 observational studies reporting survival to discharge (1,581 patients, Figure 1a) and of 13 observational studies reporting neurological outcome (1,998 patients, Figure 1b). Data pooled according to a fixed effect model show a significant reduction in the RR for hospital mortality (0.88 [0.82-0.95]) and a smaller but significant reduction in RR for poor neurological outcome (0.95 [0.90-0.99]) in patients treated using mild therapeutic hypothermia. However, in spite of pooled results favoring treatment, the effect is not consistent, with large studies showing increased RR for poor neurological outcome associated with use of mild therapeutic hypothermia [33] (Figure 1b).

View Article: PubMed Central - HTML - PubMed

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

In adults, the prevalence of out-of-hospital cardiac arrest (OHCA) attended by the emergency medical services (EMS) ranges from 52 to 112 per 100,000 person-years in developed countries, whereas the prevalence of adult in-hospital cardiac arrest (IHCA) ranges from 1 to 5 per 1,000 patient admissions... Mortality from cardiac arrest exceeds 90% in OHCA and 70% in most studies on IHCA... However, only 25-30% of OHCA patients have VF/VT as the initial recorded cardiac rhythm, and this percentage has decreased in recent years, partly because of the advent of implantable cardioverter-defibrillators for the prevention and treatment of patients at risk of lethal arrhythmias... The prevalence of VF/VT rhythms in IHCA does not exceed 25-30% either... The rate of the combined endpoint of death (CPC = 5) and poor neurological outcome (CPC 3-4) was also lower - although not significantly - in the mild therapeutic hypothermia group (89/124 [71%] vs. 59/73 [81%] p = 0.21)... In this study, only univariate analysis was performed, so no correction was made for pre- and intra-arrest potential confounders... The study included a total of 491 patients with OHCA with all rhythms, of whom 313 (74%) had non-VF/VT cardiac arrest... The quality of evidence was assessed using the GRADE methodology... The results showed that the quality of evidence in all studies was very low... Meta-analysis of the 12 observational studies showed a significant reduction in hospital mortality (RR 0.84 [0.78-0.92]) and a non-significant trend towards better neurological out come (RR for poor neurological outcome 0.95 [0.90-1.01]) after mild therapeutic hypothermia... The authors concluded that mild therapeutic hypothermia was associated with reduced in-hospital mortality for adult patients resuscitated from non-shockable cardiac arrest, but also suggested caution in interpreting the results, given a substantial risks of bias and the low quality of the evidence... A first study by Dumas et al. reported data from a prospective French database including 1,145 OHCA patients, 437 of whom were non-VF/VT patients... In contrast with the previous two studies, the rates of good neurological outcome (15/52 [29%] vs. 6/48 [13%]; p = 0.021) and survival to discharge (20/52 [38%] vs. 9/48 [19%]; p = 0.03) were significantly higher in patients treated with mild therapeutic hypothermia... These results were confirmed after controlling for confounders using binomial logistic regression (OR 4.35 [1.10-17.24], p = 0.04 and OR 5.65 [1.66-19.23], p = 0.006, respectively)... For example, some studies included only OHCA patients, whereas others included both IHCA and OHCA (see Table 1).

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Related in: MedlinePlus