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Risk Stratification of Cardiac Arrest Survivors
Quick Takes
- Patients successfully resuscitated from cardiac arrest with ≥6 unfavorable features have a poor long-term prognosis.
- Age >85 years, >30 minutes to ROSC, and nonshockable rhythm appear to be associated with ≤10% survivability.
Study Questions:
How many unfavorable features are required before prognosis is significantly worsened, and which features are most impactful in predicting prognosis among survivors of cardiac arrest?
Methods:
Using the INTCAR (International Cardiac Arrest Registry), the impact of each proposed “unfavorable feature” on survival to hospital discharge was individually analyzed. Logistic regression was performed to assess the association of such unfavorable features with poor outcomes.
Results:
Seven unfavorable features (of 10 total) were captured in 2,508 patients successfully resuscitated after cardiac arrest (ongoing cardiopulmonary resuscitation and noncardiac etiology were exclusion criteria in the registry). Chronic kidney disease was used in lieu of end-stage renal disease. In total, 39% survived to hospital discharge. The odds ratio (OR) of survival to hospital discharge for each unfavorable feature was as follows: age >85 years (OR, 0.30; 95% confidence interval [CI], 0.15-0.61), time-to-return of spontaneous circulation (ROSC) >30 minutes (OR, 0.30; 95% CI, 0.23-0.39), nonshockable rhythm (OR, 0.39; 95% CI, 0.29-0.54), no bystander cardiopulmonary resuscitation (OR, 0.49; 95% CI, 0.38-0.64), lactate >7 mmol/L (OR, 0.50; 95% CI, 0.40-0.63), unwitnessed arrest (OR, 0.58; 95% CI, 0.44-0.78), pH <7.2 (OR, 0.78; 95% CI, 0.63-0.98), and chronic kidney disease (OR, 0.96; 95% CI, 0.70-1.33). The presence of any three more unfavorable features predicted <40% survival. Presence of the three strongest risk factors (age >85 years, time-to-ROSC >30 minutes, and non–ventricular tachycardia/ventricular fibrillation) together or ≥6 unfavorable features predicted a ≤10% chance of survival to discharge.
Conclusions:
Patients successfully resuscitated from cardiac arrest with ≥6 unfavorable features have a poor long-term prognosis. Delaying or even forgoing invasive procedures in such patients is reasonable.
Perspective:
The authors attempt to identify patients who are more likely to survive cardiac arrest to hospital discharge based on 10 clinical characteristics. They used a large international patient registry of cardiac arrest (INTCAR) to assess clinical factors and their predictive power to identify patients most likely to survive to discharge and those who would not benefit from escalation of care. Age >85 years, >30 minutes to ROSC, and nonshockable rhythm appear to be associated with ≤10% survivability. Although a simplified algorithmic approach may not be easily applied to these complex patients, it may help lead discussion regarding their management.
Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Arrhythmias, Cardiac, Cardiopulmonary Resuscitation, Coronary Angiography, Geriatrics, Heart Arrest, Kidney Failure, Chronic, Patient Discharge, Renal Insufficiency, Chronic, Risk Assessment, Secondary Prevention, Survivors, Tachycardia, Ventricular, Ventricular Fibrillation
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