Aims
The purpose of this study was to develop a practical risk score to predict poor neurological outcome after out-of-hospital cardiac arrest (OOHCA) for use on arrival to a Heart Attack Centre.
Methods and results
From May 2012 to December 2017, 1055 patients had OOHCA in our region, of whom 373 patients were included in the King’s Out of Hospital Cardiac Arrest Registry (KOCAR). We performed prediction modelling with multivariable logistic regression to identify predictors of the primary outcome to derive a risk score. This was externally validated in two independent cohorts comprising 473 patients. The primary endpoint was poor neurological outcome at 6-month follow-up (Cerebral Performance Category 3–5). Seven independent predictors of outcome were identified: missed (unwitnessed) arrest, initial non-shockable rhythm, non-reactivity of pupils, age (60–80 years—1 point; >80 years—3 points), changing intra-arrest rhythms, low pH <7.20, and epinephrine administration (2 points). The MIRACLE2 score had an area under the curve (AUC) of 0.90 in the development and 0.84/0.91 in the validation cohorts. Three risk groups were defined—low risk (MIRACLE2 ≤2—5.6% risk of poor outcome); intermediate risk (MIRACLE2 of 3–4—55.4% of poor outcome); and high risk (MIRACLE2 ≥5—92.3% risk of poor outcome). The MIRACLE2 score had superior discrimination than the OHCA [median AUC 0.83 (0.818–0.840); P < 0.001] and Cardiac Arrest Hospital Prognosis models [median AUC 0.87 (0.860–0.870; P = 0.001] and equivalent performance with the Target Temperature Management score [median AUC 0.88 (0.876–0.887); P = 0.092].
Conclusions
The MIRACLE2 is a practical risk score for early accurate prediction of poor neurological outcome after OOHCA, which has been developed for simplicity of use on admission.
Sudden cardiac arrest is the most common single cause of death in the contemporary world, but the proportion of survivors is increasing thanks to modern intensive methods of hospital treatment. However, data show that survivors experience high rates of neurological and cognitive deficits and poorer emotional well-being, which is a major challenge in treating these individuals and encouraging their integration in everyday life. These issues range from a number of emotional problems, such as anxiety and depression, to lower levels of participation in social life and a low rate of return to their workplace. The need for security and support increases because of the feelings of insecurity, vulnerability and fear of the recurrence of symptoms. Relatives/caregivers who report emotional problems and a higher level of post-traumatic stress are physically and mentally burdened, too. Hence, sudden cardiac arrest is a life-threatening event which is traumatic for survivors and their close relatives. It triggers strong emotional responses that are characteristic of all types of trauma (reliving the trauma, avoidance, negative thoughts and mood, increased agitation). People who have survived trauma thus suffer long-term effects, which are reflected in various dysfunctional behaviours and activities due to inadequate regulation of affective states. Because of these issues, there is a need for effective interventions that can psychologically help patients and relatives after surviving sudden cardiac arrest. In this paper, we will present the model of Relational Family Therapy, which can enable survivors and their relatives to appropriately emotionally-affectively process this experience and thus more appropriately integrate into a new way of life. With the qualitative research method of task analysis, we will show the process of change, which is based on the establishment of a new regulation of affect and allows in-depth processing of difficult emotional states after this event.
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