Time to Centralize Care for Out-of-Hospital Cardiac Arrest?

With better outcomes seen at invasive heart centers, despite travel delays, some say it’s time for guidelines to change.

Time to Centralize Care for Out-of-Hospital Cardiac Arrest?

Patients who experience out-of-hospital cardiac arrest fare better when taken directly to a medical center capable of invasive cardiovascular care, even if a less capable hospital is closer, according to more than a decade’s worth of nationwide data from Denmark. The findings echo those of several other studies, and experts believe the time has come to develop a centralized system of care for out-of-hospital cardiac arrest in the United States.

Tinne Tranberg, MD (Aarhus University Hospital, Aarhus, Denmark), and colleagues published the results of their large, historical follow-up study early online in the European Heart Journal.

As Christian Spaulding, MD, PhD (European Hospital Georges Pompidou, Paris, France), explained to TCTMD by email, prehospital response teams typically bring out-of-hospital cardiac arrest survivors to the closest hospital but approximately 30% die during transportation. Most hospitals, however, are not specialized in the treatment of survivors of out-of-hospital cardiac arrest and lack 24-hour coronary angiography and intensive care units, he said.

Spaulding, who has also conducted research in this field and wrote an editorial accompanying Tranberg et al’s study, says Danish registries offer unique opportunities to answer “real life” questions as to the benefits of preferentially transporting patients with out-of-hospital cardiac arrest to an invasive heart center.

Tranberg and colleagues used the Danish Cardiac Arrest Registry to identify 41,186 unselected patients who experienced an out-of-hospital cardiac arrest and in whom resuscitation was attempted between 2001 and 2013. The likelihood that patients would receive CPR from a bystander, experience return to spontaneous circulation, be admitted directly to an invasive heart center, and survive 30 days all increased between 2001 and 2013, the researchers observed.

Changes in Outcomes Over Time

 

2001

2013

P Value

Bystander CPR

18%

60%

< 0.001

Return to Spontaneous Circulation

10%

29%

< 0.001

Admitted Directly to Invasive Center

26%

45%

< 0.001

30-Day Survival

5%

12%

< 0.001


Among the patients who achieved return to spontaneous circulation, a larger population underwent CABG or PCI in 2013 as compared with 2001 (27% vs 5%, P < 0.001). Variables independently associated with lower mortality were direct admission to an invasive heart center, high CABG/PCI index (calculated based on the proportion of patients who undergo these procedures in a particular region), high population density, CPR delivered by a bystander, and the presence of a witness to the out-of-hospital cardiac arrest.

Independent Predictors of Lower Mortality in Patients Who Achieved Return to Spontaneous Circulation

 

Hazard Ratio

95% CI

Admitted Directly to Invasive Center

0.91

0.89-0.93

CABG/PCI Index

0.33

0.25-0.45

Population Density > 2,000/km2

0.94

0.89-0.98

Bystander CPR

0.97

0.95-0.99

Witness Cardiac Arrest

0.87

0.85-0.89


Notably, the distance to the nearest invasive center was not associated with survival.

“These results support a centralized strategy for immediate post-resuscitation care in [out-of-hospital cardiac arrest] patients,” Tranberg and colleagues conclude.

Feasibility Worldwide

Another “true believer” in a centralized system of care is Joseph P. Ornato, MD (Virginia Commonwealth University Medical Center, Richmond, VA), who commented on the study for TCTMD. Ornato works at a tertiary care medical center that functions as a regional post-cardiac arrest center.

“It is very clear to me and some of my colleagues who work in similar centers that the care and the outcomes that the center can provide very commonly can well exceed the care that single, small-to-medium-sized hospitals can provide, in part because of repetitiveness and the frequency with which these kinds of patients are cared for and the expertise that the physicians and nurses gain over time.” In addition, he continued, “there is an economy of scale in terms of the investment the institution can make in both technology and elements of care going beyond the obvious initial elements such as temperature control management, a trip to cath lab, and a PCI if indicated.” These include not only expertise among the medical staff in the ICU but also the ability to provide rigorous neurocognitive testing by a trained neuropsychologist, both upon discharge and at follow-up.

But would these Danish insights also apply to a larger country? Both Spaulding and Ornato believe they do.

“Decisions are simpler in countries in Europe like Denmark, Sweden, or France where the health system is managed by the government and decisions are centralized, with registries to assess the results,” Spaulding observed. “In the US, the system is more complex, does not favor centralized decisions, and makes networks more difficult to organize. However, some areas such as Seattle, Minnesota, and Arizona have published encouraging results.”

Ornato echoed this sentiment, adding that Virginia Commonwealth University, the University of Pittsburgh, and the University of California, Davis School of Medicine have also published findings demonstrating the feasibility of centralized systems.

Spaulding noted that additional data are still needed, particularly with regard to ideal timing of angiograms for patients with non-STEMI out-of-hospital cardiac arrest. His team is currently working on a randomized trial that compares immediate angiography with one that is deferred for 48 to 96 hours.

Ornato says an important next step is to update American Heart Association and American College of Cardiology guidelines. The last update, from 2015, stopped short of insisting upon regionalization of care, he said, because some of the most recent data were not yet available.

“Given that such guidelines are reasonably respected in the community in North America, this paper and others are adding to the body of evidence that a center of care with high volumes, aggressive early care, and good neurocognitive and rehabilitative care do appear to be offering better opportunities for outcome,” he said.

Sources
  • Tranberg T, Lippert FK, Christensen EF, et al. Distance to invasive heart centre, performance of acute coronary angiography, and angioplasty and associated outcome in out-of-hospital cardiac arrest: a nationwide study. Eur Heart J. 2017;Epub ahead of print.

Disclosures
  • Tranberg and Ornato report no relevant conflicts of interest.
  • Spaulding reports receiving research grants from the French Ministry of Health on out-of-hospital cardiac arrest; consulting fees from Abiomed, Zoll, Medtronic, and Medpass; and speaker fees from Astra-Zeneca, Cordis, Servier, Lead-Up, Bayer, the Medicines Company, Eli Lilly, and WebMD.

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