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Targeted Temperature Management for Cardiac Arrest
Study Questions:
What is the effectiveness of moderate therapeutic hypothermia in patients with nonshockable rhythms (asystole or pulseless electrical activity)?
Methods:
The CRICS-TRIGGERSEP trial investigators performed an open-label, randomized, controlled trial comparing moderate therapeutic hypothermia (33°C during the first 24 hours) with targeted normothermia (37°C) in patients with a coma who had been admitted to the intensive care unit (ICU) after resuscitation from cardiac arrest with nonshockable rhythm. The primary outcome was survival with a favorable neurologic outcome, assessed on day 90 after randomization with the use of the Cerebral Performance Category (CPC) scale (which ranges from 1 to 5, with higher scores indicating greater disability). The authors defined a favorable neurologic outcome as a CPC score of 1 or 2. Outcome assessment was blinded. Mortality and safety were also assessed. To estimate the treatment effect on the primary outcome, the authors estimated the between-group difference and its 95% confidence interval (CI) using a linear model with an identity link function.
Results:
From January 2014 through January 2018, a total of 584 patients from 25 ICUs underwent randomization, and 581 were included in the analysis (three patients withdrew consent). On day 90, a total of 29 of 284 patients (10.2%) in the hypothermia group were alive with a CPC score of 1 or 2, as compared with 17 of 297 (5.7%) in the normothermia group (difference, 4.5 percentage points; 95% CI, 0.1-8.9; p = 0.04). Mortality at 90 days did not differ significantly between the hypothermia group and the normothermia group (81.3% and 83.2%, respectively; difference, −1.9 percentage points; 95% CI, −8.0 to 4.3). The incidence of prespecified adverse events did not differ significantly between groups.
Conclusions:
The authors concluded that among patients with coma who had been resuscitated from cardiac arrest with nonshockable rhythm, moderate therapeutic hypothermia at 33°C for 24 hours led to a higher percentage of patients who survived with a favorable neurologic outcome at day 90 than with normothermia.
Perspective:
This open-label, multicenter, randomized, controlled trial reports that the targeting of a temperature of 33°C in patients who had cardiac arrest with nonshockable rhythm significantly improved survival with a favorable day-90 neurologic outcome as compared with targeted normothermia. However, overall mortality at 90 days did not differ significantly between the two groups. Furthermore, there were no significant harmful effects of hypothermia at 33°C as compared with targeted normothermia. Based on these data, targeting a temperature of 33°C in patients who had cardiac arrest with nonshockable rhythm seems like a reasonable strategy to improve neurologic outcomes.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiovascular Care Team, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Acute Coronary Syndrome, Arrhythmias, Cardiac, Coma, Heart Arrest, Hypothermia, Hypothermia, Induced, Intensive Care Units, Neurologic Manifestations, Primary Prevention, Resuscitation, Temperature
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