Blood Pressure and Oxygenation Targets in Post Resuscitation Care - BOX

Mar 10, 2023
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Author/Summarized by Author:
Anthony A. Bavry, MD,MPH,FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, FACC, MBA
Trial Sponsor:
Novo Nordisk Foundation
Date Presented:
11/06/2022
Date Published:
03/09/2023
Date Updated:
03/10/2023
Original Posted Date:
11/06/2022
References

Contribution To Literature:

The BOX trial failed to show that a longer period of targeted temperature management after out-of-hospital cardiac arrest improved outcomes.

Description:

The goal of the trial was to evaluate targeted temperature management for 12 hours after the initial 24-hour targeted temperature period compared with 48 hours among patients who remained comatose after out-of-hospital cardiac arrest.

Study Design

  • Randomized
  • Parallel

Patients who remained comatose after out-of-hospital cardiac arrest and received targeted temperature control of 36 degrees Celsius for 24 hours were randomized to a target of 37 degrees Celsius for 12 hours (n = 393) vs. target of 37 degrees Celsius for 48 hours (n = 396).

  • Total number of enrollees: 789
  • Duration of follow-up: 90 days
  • Mean patient age: 62 years
  • Percentage female: 19%
  • Percentage with diabetes: 12%

Inclusion criteria:

  • Comatose after out-of-hospital cardiac arrest
  • Return of spontaneous circulation

Exclusion criteria:

  • Unwitnessed asystole
  • Suspected acute intracranial bleeding
  • Stroke

Principal Findings:

The primary outcome, all-cause mortality or hospital discharge with a Cerebral Performance Category of 3 or 4 (range 1-5, with higher scores indicating more severe disability), occurred in 32.3% of the 12-hour group vs. 33.6% of the 48-hour group (p = 0.70).

Secondary outcomes:

  • All-cause mortality at 90 days: 29.5% of the 12-hour group vs. 30.3% of the 48-hour group

Interpretation:

Among patients who remained comatose after out-of-hospital cardiac arrest and treated with initial 24 hours of targeted temperature management, 48 hours of additional targeted temperature management to 37 degrees Celsius did not improve outcomes compared with 12 hours of additional targeted temperature management to 37 degrees Celsius.

References:

Highlighted text has been updated as of March 10, 2023.

Hassager C, Schmidt H, Møller JE, et al. Duration of Device-Based Fever Prevention After Cardiac Arrest. N Engl J Med 2023;888-97.

Editorial: Bernard S, Bray J. Temperature Management After Cardiac Arrest — All In or Fold? N Engl J Med 2023;388:941-2.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Acute Coronary Syndrome, AHA Annual Scientific Sessions, AHA22, Arrhythmias, Cardiac, Coma, Heart Arrest, Hypothermia, Induced, Out-of-Hospital Cardiac Arrest, Patient Discharge, Return of Spontaneous Circulation, Secondary Prevention, Temperature


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