Outcomes of Therapeutic Hypothermia in Cardiac Arrest. Saad Mohammed Shariff, MBBS Aravind Herle, MD, FACC
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1 Outcomes of Therapeutic Hypothermia in Cardiac Arrest Saad Mohammed Shariff, MBBS Aravind Herle, MD, FACC
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9 Benjamin M. Scirica Circulation. 2013;127:
10 Objectives To evaluate if Therapeutic Hypothermia(TH) had improved survival and neurological outcomes in patients 1. Out of hospital cardiac arrest (OHCA) with Asystole / Pulseless Electrical Activity. 2. Out of Hospital Cardiac arrest with Ventricular Tachycardia/ Ventricular Fibrillation. 3. In hospital cardiac arrest (IHCA). 4. Overall survival of cardiac arrest patients.
11 Methods Retrospective chart review and data analysis of all patients with Cardiac arrest and Return of spontaneous circulation (ROSC) Data collected from Soarian database Study group will be all patients who received MTH protocol treatment with routine post resuscitation care Control group received routine post resuscitation care with ROSC after cardiac arrest Study done in Mercy Hospital of Buffalo
12 Inclusion Criteria Cardiac arrest was witnessed. Return of spontaneous circulation within 60min of initiation of basic and advanced cardiac life support. Both in hospital and out of hospital cardiac arrest. Comatose on arrival to hospital or at time of evaluation for MTH for in hospital cardiac arrest (GCS <8). Initial rhythm known at time of arrival of ACLS.
13 Exclusion Criteria If patient is DNR/DNI on arrival to hospital Hemorrhagic stroke Cardiac arrest due to trauma Glasgow coma scale score > 8 at time of evaluation for MTH Pre existing hypothermia (<34 degree Celsius). Pregnancy Prolonged cardiac arrest > 60 minutes. Refractory hypotension despite fluid and vasopressor support. Thrombocytopenia (Platelet count < 50,000) or baseline coagulopathy Terminal condition or poor baseline status (unable to carry out simple activities of daily living)
14 Primary End Point Survival to discharge from hospital to rehab/home. Secondary end point Neurological outcome of survivors in each group.
15 Results
16 Baseline Characteristics All Patients No Hypothermia (n=44) Hypothermia (n=42) p Value Mean Age (SD) Gender, Male 22 (50%) 31 (74%) Race, Caucasian 42 (96%) 35 (83%) Smoking, History 17 (39%) 21 (50%) Alcohol use, History 3 (7%) 7 (17%) Procedure History Coronary stents 10 (23%) 3 ( 7%) Pacemaker 3 ( 7%) 1 (2 %) CABG 8 (19%) 6 ( 14%) 0.591
17 Baseline Characteristics All Patients No Hypotherma (n=44) Hypothermia (n=42) Significance, p Co morbidities Hypertension 34 ( 77%) 26 (62%) Coronary artery Disease 18 ( 41%) 14 ( 34%) 0.52 Diabetes Mellitus 22 (50%) 12 ( 29%) Congestive Heart Failure 16( 36%) 10 (24%) CVA 5 ( 11%) 3 (7%) Dyslipidemia 23(52%) 22(52%) Renal Failure 11(25%) 7(16%) Dialysis Dependant 1(2.2%) 4(9.5%) Thyroid disease 11(25%) 7(16%) Atrial Fibrillation 8.1(18%) 10(23%) COPD 13(29%) 10(23%) Pneumonia 1(2.2%) 3(7.1%) GI Bleed 0() 1(2.3%) Pulmonary embolism 0 2(4.7%) Asthma 2(4.5%) 1(2.3%) 0.587
18 Other Diagnosis on admission Other Diagnosis on Admission No Hypothermia Hypothermia Significance, p Acute Coronary Syndrome 21/44 (45%) 25/42 (56%) 0.08 Sepsis 7(15%) 9(21%) Respiratory Insufficiency 31(70%) 34(80%) 0.26 Metabolic or Electrolyte abnormality 13(29%) 17(40%) Hypotension 19(43%) 19(45%) Seizure 3(6.8%) 4(9.5%) 0.652
19 Causes of Cardiac Arrest Causes of Cardiac Arrest No Hypothermia Hypothermia p Value ACUTE CORONARY SYNDROME 13(29%) 17(40%) ACUTE RESPIRATORY INSUFFICIENCY 17(38%) 11(26%) ARRHYTHMIA 12(27%) 9(21%) SEPSIS 8(18%) 9(21%) ACUTE PNEUMOTHORAX 1(2%) 1(2%) ACUTE STROKE 0 1(2%) ACUTE PULMONARY EDEMA 2(4.5%) 2(4.7%) CONSIOUS/PROCEDURAL SEDATION 0 2(4%) HYPOTENSION 4(9%) 2(4%) DRUG OVERDOSE/ADVERSE EFFECT 5(11%) 4(9%) 0.78 ACUTE PULMONARY EMBOLISM 1(2%) ACUTE ABDOMINAL EVENT 2(4%) 1(2%) 0.587
20 Location of Cardiac Arrest Location of Cardiac Arrest No Hypothermia Hypothermia p Value OUT OF HOSPITAL 30 ( 68%) 30 ( 71%) IN HOSPITAL 14 ( 32 %) 12 (29%) 0.743
21 Survival data No Hypothermia Hypothermia pvalue Survivors 10 (22.7%) 19 (45.2%) Home 4 (8.7%) 12 ( 29%) 0.02 Nursing Home 0 (0%) 1 (2.2%) Rehab facility 6 ( 14%) 6 (14%) 0.81
22 Primary End Point No Hypothermia n=44 Hypothermia n= 42 pvalue Survivors 10 (22.7%) 19 (45.2%) Home 4 (8.7%) 12 ( 29%) 0.02 Nursing Home 0 (0%) 1 (2.2%) Rehab facility 6 ( 14%) 6 (14%) 0.81 Deaths 34 (77.3%) 23 ( 54.8%) Improved overall survival after Therapeutic Hypothermia
23 Secondary End point No Hypothermia Hypothermia pvalue Survivors 10 (22.7%) 19 (45.2%) Home 4 (8.7%) 12 ( 29%) 0.02 Nursing Home 0 (0%) 1 (2.2%) Rehab facility 6 ( 14%) 6 (14%) 0.81 Improved Neurological outcomes after Therapeutic Hypothermia
24 Sub analysis: Out of Hospital Cardiac Arrest Alive at discharge after Out of hospital Cardiac Arrest No Hypothermia hypothermia p Value Asystole/ PEA 3/21 (14.3%) 1/11 (9.1%) Ventricular tachycardia/ Ventricular fibrillation 4/9 (44.4%) 13/19 (68.4%) 0.225
25 Sub analysis: In Hospital Cardiac Arrest Alive at Discharge after In Hospital Cardiac Arrest No Hypothermia Hypothermia p Value Asystole/PEA 1/9 (11.1%) 3/11 (27.3%) Ventricular tachycardia/ Ventricular fibrillation 2/5 (40%) 1/2 (50%) Any Rhythm IHCA 3/14 (21.4%) 4/13 ( 30.7%) 0.302
26 Limitations Retrospective study Low number of patients for sub analysis of data
27 Survival data No Hypothermia Hypothermia pvalue Survivors 10 (22.7%) 19 (45.2%) Home 4 (8.7%) 12 ( 29%) 0.02 Nursing Home 0 (0%) 1 (2.2%) Rehab facility 6 ( 14%) 6 (14%) 0.81 Deaths 34 (77.3%) 23 ( 54.8%) 0.027
28 Number Needed to Treat = 1 Death Rate in Control Death Rate in Hypothermia = = = 4.54
29 Number Needed to Treat 5 1 life saved for every 5 patients treated with Therapeutic Hypothermia
30 NNT Lung Protective Ventilation for ARDS 1 in 12 survived at discharge (Cochrane Database Syst Rev. 2007) Non Invasive Ventilation for COPD Exacerbation 1 in 8 deaths prevented, 1 in 5 intubations avoided (Cochrane Database Syst Rev. 2004) Early Goal directed therapy for Sepsis 1 in 6 survived (Rivers trial, The New England Journal of Medicine )
31 Conclusion Improved Survival of patients treated with Therapeutic Hypothermia in Cardiac Arrest. Improved Neurological outcome with more discharges home after therapeutic hypothermia. Low number needed to treat for survival and good neurological outcomes. No difference in outcomes on sub group analysis.
32 REFERENCES 1. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out ofhospital cardiac arrest with induced hypothermia. N Engl J Med 2002; 346: Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002; 346: Nolan JP, Morley PT, Vanden Hoek TL, et al., International Liaison Committee on Resuscitation. Therapeutic hypothermia after cardiac arrest: an advisory statement by the advanced life support task force of the International Liaison Committee on Resuscitation. Circulation 2003; 108:
33 4. ECC Committee, Subcommittees and Task Forces of the American Heart Association American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005; 112(suppl 24):IV1 IV Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010; 122(suppl 3):S640 S Mikkelsen ME, Christie JD, Abella BS, et al. American Heart Association s Get With the Guidelines Resuscitation Investigators. Use of therapeutic hypothermia after in hospital cardiac arrest. Crit Care Med Jun;41(6): Merchant RM, Yang L, Becker LB, et al. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011;39: Testori C, Sterz F, Behringer W, et al. Mild therapeutic hypothermia is associated with favourable outcome in patients after cardiac arrest with non shockable rhythms. Resuscitation. 2011;82:
34 9. Lundbye JB, Rai M, Ramu B, et al. Therapeutic hypothermia is associated with improved neurologic outcome and survival in cardiac arrest survivors of nonshockable rhythms. Resuscitation. 2012;83: Mikkelsen M, Christie J, Bellamy S, et al. Use of therapeutic hypothermia after in hospital cardiac arrest. Crit Care Med. 2011;39(12):6 11. Dumas F, Grimaldi D, Zuber B, et al. Is hypothermia after cardiac arrest effective in both shockable and nonshockable patients?: Insights from a large registry. Circulation. 2011;123: Meaney PA, Nadkarni VM, Kern KB, et al. Rhythms and outcomes of adult inhospital cardiac arrest
35 Acknowledgements Aravind Herle, M.D., FACC Henri Woodman, M.D. Nikhil Satchidanand, PhD, MS IRB committee
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