Long-term survival benefit from treatment at a specialty center after cardiac arrest

Abstract

Introduction The Institute of Medicine and American Heart Association have called for tiered accreditation standards and regionalization of post-cardiac arrest care, but there is little data to support that regionalization has a durable effect on patient outcomes. We tested the effect of treatment at a high-volume center on long-term outcome after sudden cardiac arrest (SCA). Methods We included patients hospitalized at one of 7 medical centers in Southwestern Pennsylvania after SCA from 2005 to 2013. Centers were one regional referral center with an organized systems for post-SCA care, two moderate volume tertiary care centers and 4 low-volume centers. We abstracted clinical characteristics and outcomes at hospital discharge, and for survivors to discharge we queried the National Death Index for long-term survival data. We used Cox regression to determine the unadjusted associations of baseline predictors and survival, and built an adjusted model controlling for baseline predictors. Results Overall, 987 patients survived to discharge. During 2196 person-years of follow-up, median survival was 5.3 years and there were 396 deaths. In unadjusted analysis, treating center, age, arrest location, Charlson Comorbidity Index, initial rhythm, cardiac catheterization, defibrillator placement, discharge disposition, and neurological status at discharge were associated with long-term outcome. In adjusted analysis, treatment at the high-volume cardiac arrest center was associated with improved survival compared to treatment at other centers (hazards ratio 1.49, 95% confidence interval 1.19 – 1.86). Conclusion Treatment at a high-volume cardiac arrest center with organized systems for post-arrest care is associated with a substantial long-term survival benefit after hospital discharge.

Decision tree model for predicting in‐hospital cardiac arrest among patients admitted with acute coronary syndrome

“…( P > .05), however, age, diabetes, CCI and culprit artery were significantly different in the two groups ( P < .05). According to previous reports, age, diabetes, and CCIwere risk factors in predicting CA, so these may also be candidate predictors in our further analysis. The culprit artery of ACS cannot be clearly defined until an angiocardiography is done, which takes time and is unsuitable for early prediction, and so was not included in our analysis.…”

Long-Term Outcomes of Out-of-Hospital Cardiac Arrest Care at Regionalized Centers

“…The NDI is a comprehensive database of vital statistics obtained from state death records that has been used extensively to determine vital status. 13, 20–23 We linked NDI results to patient records using probabilistic linkage (Supplemental Appendix), 13 then de-identified and aggregated each sites’ data for analysis.…”

“…24–26 Briefly, we believed that during days 0 to 1 and 1 to 3 patients would be at high risk for rearrest or early withdrawal of life sustaining treatment for perceived poor neurological prognosis; 24, 25 day 3 to 7 to be the period during which delayed neurological prognostication is recommended by consensus guidelines; 26, 27 and, beyond day 7 to be the post-acute period during which a majority of subjects would have revealed their neurological trajectory but still be at risk for medical sequelae of OHCA, critical illness and pre-existing comorbidities. 13, 24, 25 …”

“…6, 7 Although hospital-level characteristics such as case volume or advanced procedural capabilities are inconsistently associated with in-hospital mortality, 4, 8–12 small studies suggest long-term benefit from care at specialty centers that provide a comprehensive bundle of SCA care. 13, 14 Similarly, allowing emergency medical services (EMS) to bypass nearby hospitals in favor of transport directly to specialized centers has been associated improved outcomes in several regions. 15, 16 …”

Association of antiplatelet therapy with patient outcomes after out-of-hospital cardiac arrest

“…We identified subjects from our prospective registry, and excluded those who were under 18 years of age as well as those who arrested secondary to trauma or a primary neurological catastrophe. At our hospital, an established Post-Cardiac Arrest Service (PCAS) coordinates these patients' care, as we have previously described in detail [18, 19]. Briefly, our role includes partnering with emergency and critical care providers to ensure a consistent package of initial resuscitation and diagnostic workup, intensive care, multimodal neurological prognostication, secondary prevention and post-acute rehabilitation.…”