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Prognostic Performance and Management of Post-Cardiac Arrest Care Patients

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Emergency Medicine".

Deadline for manuscript submissions: closed (31 January 2021) | Viewed by 25442

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Prof. Dr. Won Young Kim

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Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
Interests: cardiac arrest; post-cardiac arrest care; sepsis; septic shock
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Dear Colleagues,

Significant improvements have been achieved in both resuscitation for cardiac arrest and post-cardiac arrest care, but mortality remains high. One of the most pressing issues for relatives and healthcare workers is to quickly obtain reliable information on the probability of obtaining a satisfactory neurological outcome. Neurological prognostication is based on clinical examinations and additional tools to assess the structural (neuroimaging), functional (neurophysiology), and quantitative (biochemical markers) aspects of brain injury. In the absence of perfect predictors of prognosis, current guidelines recommend the timely application of multimodal approaches for these patients. Although assessing the likelihood of poor neurological outcome and minimizing false-positive rates seems reasonable, tools to predict early a good neurological outcome would be very helpful to tailor medical therapies to the appropriate patients. Given a broader knowledge of the outcomes, physicians could introduce more or less aggressive treatment and address specific treatment.

This Special Issue, “Prognostic Performance and Management of Post-Cardiac Arrest Care Patients”, welcomes clinical manuscripts on studies about a multimodal approach, stepwise approach, patient-centric outcomes (quality-of-life, cognitive, or psychosocial), and tools for predicting good neurologic outcome. We also welcome all research which aims to extend our knowledge of the management of post-cardiac arrest care.

Prof. Won Young Kim
Guest Editor

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Keywords

post-cardiac arrest care
prognosis
biomarker
scoring system
out-of-hospital cardiac arrest
in-hospital cardiac arrest

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Research

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11 pages, 1465 KiB

Open AccessArticle

Cardiac Magnetic Resonance Imaging for Nonischemic Cardiac Disease in Out-of-Hospital Cardiac Arrest Survivors Treated with Targeted Temperature Management: A Multicenter Retrospective Analysis

by Sang-Min Kim, Chun-Song Youn, Gun-Tak Lee, Tae-Gun Shin, June-Sung Kim, Youn-Jung Kim and Won-Young Kim

J. Clin. Med. 2021, 10(4), 794; https://doi.org/10.3390/jcm10040794 - 16 Feb 2021

Cited by 2 | Viewed by 2026

Abstract

(1) Background: Cardiac magnetic resonance (CMR) imaging is an emerging tool for investigating nonischemic cardiomyopathies and cardiac systemic disease. However, data on the cardiac arrest population are limited. This study aimed to evaluate the usefulness of CMR imaging in out-of-hospital cardiac arrest (OHCA) survivors treated with targeted temperature management (TTM). (2) Methods: We conducted the retrospective observational study using a multicenter registry of adult non-traumatic comatose OHCA survivors who underwent TTM between January 2010 and December 2019. Of the 949 patients, 389 with OHCA of non-cardiac cause, 145 with significant lesions in the coronary artery, 151 who died during TTM, 81 without further evaluation due to anticipated poor neurological outcome, and 51 whose etiology is underlying disease were excluded. In 36 of the 132 remaining patients, the etiologies included variant angina, long QT syndrome, and complete atrioventricular block in ancillary studies. Fifty-six patients were diagnosed idiopathic ventricular fibrillation without CMR. (3) Results: CMR imaging was performed in the remaining 40 patients with cardiac arrest of unknown cause. The median time from cardiac arrest to CMR imaging was 10.1 days. The CMR finding was normal in 23 patients, non-diagnostic in 12, and abnormal in 5, which suggested non-ischemic cardiomyopathy but did not support the final diagnosis. (4) Conclusions: CMR imaging may not be useful for identifying unknown causes of cardiac arrest in OHCA survivors treated with targeted temperature management without definitive diagnosis even after coronary angiography, echocardiography, and electrophysiology studies. However, further large-scale studies will be needed to confirm these findings. Full article

(This article belongs to the Special Issue Prognostic Performance and Management of Post-Cardiac Arrest Care Patients)

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10 pages, 1063 KiB

Open AccessArticle

Predictive Value of Estimated Lean Body Mass for Neurological Outcomes after Out-of-Hospital Cardiac Arrest

by Sung Eun Lee, Hyuk Hoon Kim, Minjung Kathy Chae, Eun Jung Park and Sangchun Choi

J. Clin. Med. 2021, 10(1), 71; https://doi.org/10.3390/jcm10010071 - 28 Dec 2020

Cited by 2 | Viewed by 1824

Abstract

Background: Postcardiac arrest patients with a return of spontaneous circulation (ROSC) are critically ill, and high body mass index (BMI) is ascertained to be associated with good prognosis in patients with a critically ill condition. However, the exact mechanism has been unknown. To assess the effectiveness of skeletal muscles in reducing neuronal injury after the initial damage owing to cardiac arrest, we investigated the relationship between estimated lean body mass (LBM) and the prognosis of postcardiac arrest patients. Methods: This retrospective cohort study included adult patients with ROSC after out-of-hospital cardiac arrest from January 2015 to March 2020. The enrolled patients were allocated into good- and poor-outcome groups (cerebral performance category (CPC) scores 1–2 and 3–5, respectively). Estimated LBM was categorized into quartiles. Multivariate regression models were used to evaluate the association between LBM and a good CPC score. The area under the receiver operating characteristic curve (AUROC) was assessed. Results: In total, 155 patients were analyzed (CPC score 1–2 vs. 3–5, n = 70 vs. n = 85). Patients’ age, first monitored rhythm, no-flow time, presumed cause of arrest, BMI, and LBM were different (p < 0.05). Fourth-quartile LBM (≥48.98 kg) was associated with good neurological outcome of postcardiac arrest patients (odds ratio = 4.81, 95% confidence interval (CI), 1.10–25.55, p = 0.04). Initial high LBM was also a predictor of good neurological outcomes (AUROC of multivariate regression model including LBM: 0.918). Conclusions: Initial LBM above 48.98kg is a feasible prognostic factor for good neurological outcomes in postcardiac arrest patients. Full article

(This article belongs to the Special Issue Prognostic Performance and Management of Post-Cardiac Arrest Care Patients)

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11 pages, 1400 KiB

Open AccessArticle

The Usefulness of Quantitative Analysis of Blood-Brain Barrier Disruption Measured Using Contrast-Enhanced Magnetic Resonance Imaging to Predict Neurological Prognosis in Out-of-Hospital Cardiac Arrest Survivors: A Preliminary Study

by Ho Il Kim, In Ho Lee, Jung Soo Park, Da Mi Kim, Yeonho You, Jin Hong Min, Yong Chul Cho, Won Joon Jeong, Hong Joon Ahn, Changshin Kang and Byung Kook Lee

J. Clin. Med. 2020, 9(9), 3013; https://doi.org/10.3390/jcm9093013 - 18 Sep 2020

Cited by 5 | Viewed by 2617

Abstract

We aimed to evaluate neurological outcomes associated with blood-brain barrier (BBB) disruption using contrast-enhanced magnetic resonance imaging (CE-MRI) in out-of-hospital cardiac arrest (OHCA) survivors. This retrospective observational study involved OHCA survivors who had undergone CE-MRI for prognostication. Qualitative and quantitative analyses were performed using the presence of BBB disruption (pBD) and the BBB disruption score (sBD) in CE-MRI scans, respectively. For the sBD, 1 point was assigned for each area of BBB disruption, and 6 points were assigned when an absence of intracranial blood flow due to severe brain oedema was confirmed. The primary outcome was poor neurological outcome at 3 months (defined as cerebral performance categories 3–5). We analysed 46 CE-MRI brain scans (27 patients). Of these, 15 (55.6%) patients had poor neurological outcomes. Poor neurological outcome group patients showed a significantly higher proportion of pBD than those in the good neurological outcome group (22 (88%) vs. 6 (28.6%) patients, respectively, p < 0.001) and a higher sBD (5.0 (4.0–5.0) vs. 0.0 (0.0–1.0) patients, p < 0.001). Poor neurological outcome predictions showed that the sBD had a significantly better prognostic performance (area under the curve (AUC) 0.95, 95% confidence interval (CI) 0.84–0.99) than the pBD (AUC 0.80, 95% CI 0.65–0.90). The sBD cut-off value was >1 point (sensitivity, 96.0%; specificity, 81.0%). The sBD is a highly predictive and sensitive marker of 3-month poor neurological outcome in OHCA survivors. Multicentre prospective studies are required to determine the generalisability of these results. Full article

(This article belongs to the Special Issue Prognostic Performance and Management of Post-Cardiac Arrest Care Patients)

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14 pages, 729 KiB

Open AccessArticle

Early Post-Rewarming Fever Is Associated with Favorable 6-Month Neurologic Outcomes in Patients with Out-Of-Hospital Cardiac Arrest: A Multicenter Registry Study

by Hyoung Youn Lee, Dong Hun Lee, Byung Kook Lee, Kyung Woon Jeung, Yong Hun Jung, Seung Phil Choi, Jung Soo Park, Jae Hoon Lee, Kap Su Han and Yong Il Min

J. Clin. Med. 2020, 9(9), 2927; https://doi.org/10.3390/jcm9092927 - 10 Sep 2020

Cited by 2 | Viewed by 3444

Abstract

We investigated the association between post-rewarming fever (PRF) and 6-month neurologic outcomes in cardiac arrest survivors. This was a multicenter study based on a registry of comatose adult (≥18 years) out-of-hospital cardiac arrest (OHCA) survivors who underwent targeted temperature management between October 2015 to December 2018. PRF was defined as peak temperature ≥ 38.0 °C within 72 h after completion of rewarming, and PRF timing was categorized as within 24, 24–48, and 48–72 h epochs. The primary outcome was neurologic outcomes at six months after cardiac arrest. Unfavorable neurologic outcome was defined as cerebral performance categories three to five. A total of 1031 patients were included, and 642 (62.3%) had unfavorable neurologic outcomes. PRF developed in 389 (37.7%) patients in 72 h after rewarming: within 24 h in 150 (38.6%), in 24–48 h in 155 (39.8%), and in 48–72 h in 84 (21.6%). PRF was associated with improved neurologic outcomes (odds ratio (OR), 0.633; 95% confidence interval (CI), 0.416–0.963). PRF within 24 h (OR, 0.355; 95% CI, 0.191–0.659), but not in 24–48 h or 48–72 h, was associated with unfavorable neurologic outcomes. Early PRF within 24 h after rewarming was associated with favorable neurologic outcomes. Full article

(This article belongs to the Special Issue Prognostic Performance and Management of Post-Cardiac Arrest Care Patients)

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14 pages, 2112 KiB

Open AccessArticle

Risks According to the Timing and Frequency of Hypotension Episodes in Postanoxic Comatose Patients

by Yong Hwan Kim, Jae Hoon Lee, Jung In Seo, Dong Hoon Lee, Won Young Kim and Byung Kook Lee

J. Clin. Med. 2020, 9(9), 2750; https://doi.org/10.3390/jcm9092750 - 25 Aug 2020

Viewed by 2607

Abstract

The aim of this study was to assess the risk of unfavorable outcomes according to the timing of hypotension episodes in cardiac arrest patients. This prospectively conducted multicenter observational study included 1373 out-of-hospital cardiac arrest patients treated with 33 °C targeted temperature management (TTM). Unfavorable neurological outcome and the incidence of complications were analyzed according to the timing of hypotension. Compared with hypotension before TTM initiation (adjusted hazard ratio (aHR) 1.51), hypotension within 6 h after TTM initiation was associated with an increased risk of unfavorable neurologic outcome (aHR 1.693), and after 24 h of TTM, was connected with decreased risk (aHR 1.277). The risk of unfavorable neurological outcome was gradually reduced over time after TTM initiation. Hypotension, persisting both before and during TTM, demonstrated a greater risk (aHR 2) than transient hypotension (aHR 1.265). Hypotension was correlated with various complications. Differences in lactate levels were persistent, regardless of the initial fluid therapy (p < 0.001). Hypotension showed a strong correlation with unfavorable neurological outcome, especially in the early phase after TTM initiation, and complications. It is essential to manage hypotension that occurs at the beginning of TTM initiation to recover cerebral function in cardiac arrest patients. Full article

(This article belongs to the Special Issue Prognostic Performance and Management of Post-Cardiac Arrest Care Patients)

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9 pages, 873 KiB

Open AccessArticle

Prolonged Length of Stay in the Emergency Department and Increased Risk of In-Hospital Cardiac Arrest: A nationwide Population-Based Study in South Korea, 2016–2017

by June-sung Kim, Dong Woo Seo, Youn-Jung Kim, Jinwoo Jeong, Hyunggoo Kang, Kap Su Han, Su Jin Kim, Sung Woo Lee, Shin Ahn and Won Young Kim

J. Clin. Med. 2020, 9(7), 2284; https://doi.org/10.3390/jcm9072284 - 18 Jul 2020

Cited by 14 | Viewed by 2505

Abstract

This study was to determine whether prolonged emergency department (ED) length of stay (LOS) is associated with increased risk of in-hospital cardiac arrest (IHCA). A retrospective cohort with a nationwide database of all adult patients who visited the EDs in South Korea between January 2016 and December 2017 was performed. A total of 18,217,034 patients visited an ED during the study period. The median ED LOS was 2.5 h. IHCA occurred in 9,180 patients (0.2%). IHCA was associated with longer ED LOS (4.2 vs. 2.5 h), and higher rates of intensive care unit (ICU) admission (58.6% vs. 4.7%) and in-hospital mortality (35.7% vs. 1.5%). The ED LOS correlated positively with the development of IHCA (Spearman ρ = 0.91; p < 0.01) and was an independent risk factor for IHCA (odds ratio (OR) 1.10; 95% confidence interval (CI), 1.10–1.10). The development of IHCA increased in a stepwise fashion across increasing quartiles of ED LOS, with ORs for the second, third, and fourth relative to the first being 3.35 (95% CI, 3.26–3.44), 3.974 (95% CI, 3.89–4.06), and 4.97 (95% CI, 4.89–5.05), respectively. ED LOS should be reduced to prevent adverse events in patients visiting the ED. Full article

(This article belongs to the Special Issue Prognostic Performance and Management of Post-Cardiac Arrest Care Patients)

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11 pages, 1134 KiB

Open AccessArticle

Inter-Hospital Transfer after Return of Spontaneous Circulation Shows no Correlation with Neurological Outcomes in Cardiac Arrest Patients Undergoing Targeted Temperature Management in Cardiac Arrest Centers

by Yoon Hee Choi, Dong Hoon Lee, Je Hyeok Oh, Jin Hong Min, Tae Chang Jang, Won Young Kim, Won Jung Jeong and Je Sung You

J. Clin. Med. 2020, 9(6), 1979; https://doi.org/10.3390/jcm9061979 - 24 Jun 2020

Cited by 2 | Viewed by 2577

Abstract

This study evaluated whether inter-hospital transfer (IHT) after the return of spontaneous circulation (ROSC) was associated with poor neurological outcomes after 6 months in post-cardiac-arrest patients treated with targeted temperature management (TTM). We used data from the Korean Hypothermia Network prospective registry from November 2015 to December 2018. These out-of-hospital cardiac arrest (OHCA) patients had either received post-cardiac arrest syndrome (PCAS) care at the same hospital or had been transferred from another hospital after ROSC. The primary endpoint was the neurological outcome 6 months after cardiac arrest. Subgroup analyses were performed to determine differences in the time from ROSC to TTM induction according to the electrocardiography results after ROSC. We enrolled 1326 patients. There were no significant differences in neurological outcomes between the direct visit and IHT groups. In patients without ST elevation, the mean time to TTM was significantly shorter in the direct visit group than in the IHT group. IHT after achieving ROSC was not associated with neurologic outcomes after 6 months in post-OHCA patients treated with TTM, even though TTM induction was delayed in transferred patients. Full article

(This article belongs to the Special Issue Prognostic Performance and Management of Post-Cardiac Arrest Care Patients)

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11 pages, 4806 KiB

Open AccessArticle

Prognostic Value of Early Intermittent Electroencephalography in Patients after Extracorporeal Cardiopulmonary Resuscitation

by Yong Oh Kim, Ryoung-Eun Ko, Chi Ryang Chung, Jeong Hoon Yang, Taek Kyu Park, Yang Hyun Cho, Kiick Sung, Gee Young Suh and Jeong-Am Ryu

J. Clin. Med. 2020, 9(6), 1745; https://doi.org/10.3390/jcm9061745 - 4 Jun 2020

Cited by 7 | Viewed by 2334

Abstract

The aim of this study was to investigate whether early intermittent electroencephalography (EEG) could be used to predict neurological prognosis of patients who underwent extracorporeal cardiopulmonary resuscitation (ECPR). This was a retrospective and observational study of adult patients who were evaluated by EEG scan within 96 h after ECPR. The primary endpoint was neurological status upon discharge from the hospital assessed with a Cerebral Performance Categories (CPC) scale. Among 69 adult cardiac arrest patients who underwent ECPR, 17 (24.6%) patients had favorable neurological outcomes (CPC score of 1 or 2). Malignant EEG patterns were more common in patients with poor neurological outcomes (CPC score of 3, 4 or 5) than in patients with favorable neurological outcomes (73.1% vs. 5.9%, p < 0.001). All patients with highly malignant EEG patterns (43.5%) had poor neurological outcomes. In multivariable analysis, malignant EEG patterns and duration of cardiopulmonary resuscitation were significantly associated with poor neurological outcomes. In this study, malignant EEG patterns within 96 h after cardiac arrest were significantly associated with poor neurological outcomes. Therefore, an early intermittent EEG scan could be helpful for predicting neurological prognosis of post-cardiac arrest patients after ECPR. Full article

(This article belongs to the Special Issue Prognostic Performance and Management of Post-Cardiac Arrest Care Patients)

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12 pages, 1845 KiB

Open AccessArticle

Background Frequency Patterns in Standard Electroencephalography as an Early Prognostic Tool in Out-of-Hospital Cardiac Arrest Survivors Treated with Targeted Temperature Management

by Youn-Jung Kim, Min-Jee Kim, Yong Seo Koo and Won Young Kim

J. Clin. Med. 2020, 9(4), 1113; https://doi.org/10.3390/jcm9041113 - 13 Apr 2020

Cited by 10 | Viewed by 2258

Abstract

We investigated the prognostic value of standard electroencephalography, a 30-min recording using 21 electrodes on the scalp, during the early post-cardiac arrest period, and evaluated the performance of electroencephalography findings combined with other clinical features for predicting favourable outcomes in comatose out-of-hospital cardiac arrest (OHCA) survivors treated with targeted temperature management (TTM). This observational registry-based study was conducted at a tertiary care hospital in Korea using the data of all consecutive adult non-traumatic comatose OHCA survivors who underwent standard electroencephalography during TTM between 2010 and 2018. The primary outcome was a 6-month favourable neurological outcome (Cerebral Performance Category score of 1 or 2). Among 170 comatose OHCA survivors with median electroencephalography time of 22 h, a 6-month favourable neurologic outcome was observed in 34.1% (58/170). After adjusting other clinical characteristics, an electroencephalography background with dominant alpha and theta waves had the highest odds ratio of 13.03 (95% confidence interval, 4.69–36.22) in multivariable logistic analysis. A combination of other clinical features (age < 65 years, initial shockable rhythm, resuscitation duration < 20 min) with an electroencephalography background with dominant alpha and theta waves increased predictive performance for favourable neurologic outcomes with a high specificity of up to 100%. A background with dominant alpha and theta waves in standard electroencephalography during TTM could be a simple and early favourable prognostic finding in comatose OHCA survivors. Full article

(This article belongs to the Special Issue Prognostic Performance and Management of Post-Cardiac Arrest Care Patients)

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Review

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12 pages, 2842 KiB

Open AccessReview

Efficacy of Targeted Temperature Management after Pediatric Cardiac Arrest: A Meta-Analysis of 2002 Patients

by Wojciech Wieczorek, Jarosław Meyer-Szary, Milosz J. Jaguszewski, Krzysztof J. Filipiak, Maciej Cyran, Jacek Smereka, Aleksandra Gasecka, Kurt Ruetzler and Lukasz Szarpak

J. Clin. Med. 2021, 10(7), 1389; https://doi.org/10.3390/jcm10071389 - 30 Mar 2021

Cited by 2 | Viewed by 2535

Abstract

Cardiac arrest (CA) is associated with high mortality and poor life quality. Targeted temperature management (TTM) or therapeutic hypothermia is a therapy increasing the survival of adult patients after CA. The study aim was to assess the feasibility of therapeutic hypothermia after pediatric CA. We performed a systematic review and meta-analysis of randomized controlled trials and observational studies evaluating the use of TTM after pediatric CA. The primary outcome was survival to hospital discharge or 30-day survival. Secondary outcomes included a one-year survival rate, survival with a Vineland adaptive behavior scale (VABS-II) score ≥ 70, and occurrence of adverse events. Ten articles (n = 2002 patients) were included, comparing TTM patients (n = 638) with controls (n = 1364). In a fixed-effects meta-analysis, survival to hospital discharge in the TTM group was 49.7%, which was higher than in the non-TTM group (43.5%; odds ratio, OR = 1.22; 95% confidence interval, CI: 1.00, 1.50; p = 0.06). There were no differences in the one-year survival rate or the occurrence of adverse events between the TTM and non-TTM groups. Altogether, the use of TTM was associated with a higher survival to hospital discharge; however, it did not significantly increase the annual survival. Additional high-quality prospective studies are necessary to confer additional TTM benefits. Full article

(This article belongs to the Special Issue Prognostic Performance and Management of Post-Cardiac Arrest Care Patients)

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