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Expedited Transfer to a Cardiac Arrest Center for Non-ST-Elevation Out-of-Hospital Cardiac Arrest - ARREST
Contribution To Literature:
The ARREST trial showed that in patients without STEMI, expedited transfer to a cardiac arrest center after resuscitated OHCA was not associated with decreased 30-day mortality compared with standard of care.
Description:
The goal of the trial was to determine whether immediate transfer to a cardiac arrest center was associated with decreased mortality compared with standard of care among field-resuscitated out-of-hospital cardiac arrest (OHCA) patients who did not have evidence of ST-segment elevation myocardial infarction (STEMI) on post-resuscitation electrocardiography (ECG).
Study Design
- Randomized
- Multicenter
- Open-label
Patients with return of spontaneous circulation (ROSC) in the field after OHCA without STEMI identified on post-ROSC ECG were randomized to immediate transfer to a cardiac arrest center (n = 431) or standard of care (i.e., transfer to the nearest emergency department; n = 431). The participating centers comprised all 35 hospitals capable of receiving acute patients in London, United Kingdom, including 7 cardiac arrest centers with 24-hour availability of intensive care and cardiac catheterization services.
- Total number of enrollees: 862
- Duration of follow-up: 3 months
- Mean patient age: 63 years
- Percentage female: 32%
Inclusion criteria:
- Age ≥18 years
- ROSC achieved in field after OHCA
Exclusion criteria:
- STEMI on post-arrest ECG
- Do not attempt resuscitation order
- Presumed noncardiac cause of arrest (e.g., trauma)
- Suspected pregnancy
- Post-arrest withdrawal of consent by patient or representative
Other salient features/characteristics:
- Initial bystander resuscitation: 73%
- Shockable initial rhythm: 55%
- Median time to first defibrillation (if applicable): 10-11 minutes
- Median time to ROSC: 24-25 minutes
- Median time to hospital arrival, cardiac arrest center vs. standard of care: 84 vs. 77 minutes
- Cardiac etiology of arrest (e.g., acute coronary syndrome, primary arrhythmia, primary cardiomyopathy): 61%
Post-arrest interventions, cardiac arrest center vs. standard of care:
- Coronary angiography: 56% vs. 37%
- Intensive care admission: 80% vs. 69%
- Hemodynamic support: 72% vs. 62%
- Invasive mechanical ventilation: 86% vs. 76%
- Renal replacement therapy: 11% vs. 8%
Principal Findings:
The primary outcome, all-cause mortality at 30 days for cardiac arrest center vs. standard of care, was: 63% vs. 63% (p = 0.96).
Subgroup analysis of primary outcome by age (p for interaction = 0.0029):
- <57 years: relative risk (RR) 0.76 (0.90-0.97) favoring cardiac arrest center
- 57-71 years: RR 1.28 (1.05-1.56) favoring standard of care
- ≥72 years: RR 0.94 (0.82-1.07)
Secondary outcomes for cardiac arrest center vs. standard of care:
- All-cause mortality at 3 months: 65% vs. 64%
- Modified Rankin scale (mRS) score ≤3 (favorable neurologic status) at discharge: 32% vs. 32%
- mRS score ≤3 at 3 months: 30% vs. 31%
Interpretation:
The ARREST study is the first randomized trial of immediate transfer to a cardiac center following resuscitated OHCA. Contrary to prior observational data, no difference was observed in short- and longer-term mortality compared to standard of care, which is transfer to the geographically closest emergency department. This may reflect the selection bias inherent to observational studies, where patients with fewer comorbidities or greater perceived chance of survival may be preferentially transported to a cardiac arrest center.
Despite randomization and comparable baseline and OHCA characteristics, patients at cardiac arrest centers were more likely to undergo coronary angiography and other invasive support. This may reflect the heterogeneity in treatment approaches across providers and centers, particularly considering the comparable outcomes. The interaction of age with the primary outcome remains exploratory but may pose an avenue of further research into a population that may benefit from direct transfer to a cardiac arrest center.
Given the single-city nature of this study, these findings are not readily generalizable to more rural areas, which must face the competing risks of increased travel time to a cardiac arrest center as well as the potentially greater disparities in locally available health care resources. These data therefore provide an important first step in understanding the potential role of cardiac arrest centers in resuscitated OHCA. Finally, although not directly tested here, these results are in line with trials such as COACT and TOMAHAWK, which did not find a survival benefit with immediate angiography vs. delayed or selective angiography (which is likely logistically easier to pursue at dedicated cardiac arrest centers).
References:
Patterson T, Perkins GD, Perkins A, et al., on behalf of the ARREST Trial Collaborators. Expedited transfer to a cardiac arrest center for non-ST-elevation out-of-hospital cardiac arrest (ARREST): a UK prospective, multicenter, parallel, randomized clinical trial. Lancet 2023;Aug 27:[Epub ahead of print].
Editorial Comment: Hansen CM, Granger CB. Back to basics for out-of-hospital cardiac arrest. Lancet 2023;Aug 27:[Epub ahead of print].
Presented by Dr. Tiffany Patterson at the European Society of Cardiology Congress, Amsterdam, Netherlands, August 27, 2023.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure
Keywords: Acute Coronary Syndrome, Arrhythmias, Cardiac, Emergency Service, Hospital, ESC Congress, ESC23, Heart Arrest, Heart Failure, Ischemia, Out-of-Hospital Cardiac Arrest, Patient Care Team
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