Outcomes of Therapeutic Hypothermia in Cardiac Arrest. Saad Mohammed Shariff, MBBS Aravind Herle, MD, FACC

Outcomes of Therapeutic Hypothermia in Cardiac Arrest Saad Mohammed Shariff, MBBS Aravind Herle, MD, FACC

https://my.americanheart.org/idc/groups/ahamah-public/@wcm/@sop/@scon/documents/downloadable/ucm_427331.pdf

Benjamin M. Scirica Circulation. 2013;127:244-250 https://my.americanheart.org/idc/groups/ahamah-public/@wcm/@sop/@scon/documents/downloadable/ucm_427331.pdf

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.

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

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.

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)

Primary End Point Survival to discharge from hospital to rehab/home. Secondary end point Neurological outcome of survivors in each group.

Results

Baseline Characteristics All Patients No Hypothermia (n=44) Hypothermia (n=42) p Value Mean Age (SD) 66 61 0.045 Gender, Male 22 (50%) 31 (74%) 0.023 Race, Caucasian 42 (96%) 35 (83%) 0.066 Smoking, History 17 (39%) 21 (50%) 0.289 Alcohol use, History 3 (7%) 7 (17%) 0.162 Procedure History Coronary stents 10 (23%) 3 ( 7%) 0.039 Pacemaker 3 ( 7%) 1 (2 %) 0.329 CABG 8 (19%) 6 ( 14%) 0.591

Baseline Characteristics All Patients No Hypotherma (n=44) Hypothermia (n=42) Significance, p Co morbidities Hypertension 34 ( 77%) 26 (62%) 0.121 Coronary artery Disease 18 ( 41%) 14 ( 34%) 0.52 Diabetes Mellitus 22 (50%) 12 ( 29%) 0.042 Congestive Heart Failure 16( 36%) 10 (24%) 0.208 CVA 5 ( 11%) 3 (7%) 0.501 Dyslipidemia 23(52%) 22(52%) 0.992 Renal Failure 11(25%) 7(16%) 0.346 Dialysis Dependant 1(2.2%) 4(9.5%) 0.161 Thyroid disease 11(25%) 7(16%) 0.161 Atrial Fibrillation 8.1(18%) 10(23%) 0.562 COPD 13(29%) 10(23%) 0.552 Pneumonia 1(2.2%) 3(7.1%) 0.295 GI Bleed 0() 1(2.3%) 0.323 Pulmonary embolism 0 2(4.7%) 0.159 Asthma 2(4.5%) 1(2.3%) 0.587

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%) 0.517 Respiratory Insufficiency 31(70%) 34(80%) 0.26 Metabolic or Electrolyte abnormality 13(29%) 17(40%) 0.294 Hypotension 19(43%) 19(45%) 0.849 Seizure 3(6.8%) 4(9.5%) 0.652

Causes of Cardiac Arrest Causes of Cardiac Arrest No Hypothermia Hypothermia p Value ACUTE CORONARY SYNDROME 13(29%) 17(40%) 0.294 ACUTE RESPIRATORY INSUFFICIENCY 17(38%) 11(26%) 0.221 ARRHYTHMIA 12(27%) 9(21%) 0.533 SEPSIS 8(18%) 9(21%) 0.709 ACUTE PNEUMOTHORAX 1(2%) 1(2%) 0.973 ACUTE STROKE 0 1(2%) 0.323 ACUTE PULMONARY EDEMA 2(4.5%) 2(4.7%) 0.962 CONSIOUS/PROCEDURAL SEDATION 0 2(4%) 0.159 HYPOTENSION 4(9%) 2(4%) 0.433 DRUG OVERDOSE/ADVERSE EFFECT 5(11%) 4(9%) 0.78 ACUTE PULMONARY EMBOLISM 1(2%) 0 0.322 ACUTE ABDOMINAL EVENT 2(4%) 1(2%) 0.587

Location of Cardiac Arrest Location of Cardiac Arrest No Hypothermia Hypothermia p Value OUT OF HOSPITAL 30 ( 68%) 30 ( 71%) 0.743 IN HOSPITAL 14 ( 32 %) 12 (29%) 0.743

Survival data No Hypothermia Hypothermia pvalue Survivors 10 (22.7%) 19 (45.2%) 0.027 Home 4 (8.7%) 12 ( 29%) 0.02 Nursing Home 0 (0%) 1 (2.2%) 0.303 Rehab facility 6 ( 14%) 6 (14%) 0.81

Primary End Point No Hypothermia n=44 Hypothermia n= 42 pvalue Survivors 10 (22.7%) 19 (45.2%) 0.027 Home 4 (8.7%) 12 ( 29%) 0.02 Nursing Home 0 (0%) 1 (2.2%) 0.303 Rehab facility 6 ( 14%) 6 (14%) 0.81 Deaths 34 (77.3%) 23 ( 54.8%) 0.027 Improved overall survival after Therapeutic Hypothermia

Secondary End point No Hypothermia Hypothermia pvalue Survivors 10 (22.7%) 19 (45.2%) 0.027 Home 4 (8.7%) 12 ( 29%) 0.02 Nursing Home 0 (0%) 1 (2.2%) 0.303 Rehab facility 6 ( 14%) 6 (14%) 0.81 Improved Neurological outcomes after Therapeutic Hypothermia

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%) 0.673 Ventricular tachycardia/ Ventricular fibrillation 4/9 (44.4%) 13/19 (68.4%) 0.225

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%) 0.369 Ventricular tachycardia/ Ventricular fibrillation 2/5 (40%) 1/2 (50%) 0.809 Any Rhythm IHCA 3/14 (21.4%) 4/13 ( 30.7%) 0.302

Limitations Retrospective study Low number of patients for sub analysis of data

Survival data No Hypothermia Hypothermia pvalue Survivors 10 (22.7%) 19 (45.2%) 0.027 Home 4 (8.7%) 12 ( 29%) 0.02 Nursing Home 0 (0%) 1 (2.2%) 0.303 Rehab facility 6 ( 14%) 6 (14%) 0.81 Deaths 34 (77.3%) 23 ( 54.8%) 0.027

Number Needed to Treat = 1 Death Rate in Control Death Rate in Hypothermia = = 1 0.77 0.55 1 0.22 = 4.54

Number Needed to Treat 5 1 life saved for every 5 patients treated with Therapeutic Hypothermia

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. 2001. )

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.

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Acknowledgements Aravind Herle, M.D., FACC Henri Woodman, M.D. Nikhil Satchidanand, PhD, MS IRB committee