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OBJECTIVES: Contrary to advanced cardiac life support guidelines that recommend immediate defibrillation for shockable in-hospital cardiac arrest (IHCA), epinephrine administration before first defibrillation is common and associated with lower survival at a "patient-level." Whether this practice varies across hospitals and its association with "hospital-level" IHCA survival remains unknown. The purpose of this study was to determine hospital variation in rates of epinephrine administration before defibrillation for shockable IHCA and its association with IHCA survival. DESIGN: Observational cohort study. SETTING: Five hundred thirteen hospitals participating in the Get With The Guidelines Resuscitation Registry. PATIENTS: A total of 37,668 adult patients with IHCA due to an initial shockable rhythm from 2000 to 2019. INTERVENTIONS: Epinephrine before first defibrillation. MEASUREMENTS AND MAIN RESULTS: Using multivariable hierarchical regression, we examined hospital variation in epinephrine administration before first defibrillation and its association with hospital-level rates of risk-adjusted survival. The median hospital rate of epinephrine administration before defibrillation was 18.8%, with large variation across sites (range, 0-68.8%; median odds ratio: 1.54; 95% CI, 1.47-1.61). Major teaching status and annual IHCA volume were associated with hospital rate of epinephrine administration before defibrillation. Compared with hospitals with the lowest rate of epinephrine administration before defibrillation (Q1), there was a stepwise decline in risk-adjusted survival at hospitals with higher rates of epinephrine administration before defibrillation (Q1: 44.3%, Q2: 43.4%; Q3: 41.9%; Q4: 40.3%; p for trend < 0.001). CONCLUSIONS: Administration of epinephrine before defibrillation in shockable IHCA is common and varies markedly across U.S. hospitals. Hospital rates of epinephrine administration before defibrillation were associated with a significant stepwise decrease in hospital rates of risk-adjusted survival. Efforts to prioritize immediate defibrillation for patients with shockable IHCA and avoid early epinephrine administration are urgently needed. [ABSTRACT FROM AUTHOR]

Background: For out-of-hospital cardiac arrest (OHCA), assignment of race/ethnicity data can be challenging. Validation of race/ethnicity in registry data with patients' self-reported race/ethnicity would provide insights regarding misclassification.Methods: Using recently linked 2013-2019 Cardiac Arrest Registry to Enhance Survival (CARES) data with Medicare files, we examined the concordance of race/ethnicity in CARES with self-reported race/ethnicity in Medicare. Among patients with unknown race/ethnicity in CARES, race/ethnicity data from Medicare files were reported.Results: Of 26,875 patients in the linked data, 5757 (21.4%) had unknown race/ethnicity in CARES. Of the remaining 21,118 patients, 14,284 (67.6%) were identified in CARES as non-Hispanic White, 4771 (22.6%) as non-Hispanic Black, 1213 (5.7%) as Hispanic, 760 (3.6%) as Asian or Pacific Islander, and 90 (0.4%) as American Indian or Alaskan Native. The concordance rate for race/ethnicity between CARES and Medicare was 93.4% for patients reported as non-Hispanic White in CARES, 89.1% for non-Hispanic Blacks, 74.6% for Hispanics, 69.6% for Asians and Pacific Islanders, and 37.8% for American Indian or Alaskan Natives. For the 5757 patients with unknown race/ethnicity in CARES, 3973 (69.0%) self-reported in Medicare as non-Hispanic White, 617 (10.7%) as non-Hispanic Black, 425 (7.4%) as Hispanic, 491 (8.5%) as Asian or Pacific Islander, and 52 (0.9%) as American Indian or Alaskan Native. Race/ethnicity remained unknown in 199 (3.5%) of patients.Conclusion: Race/ethnicity in CARES was highly concordant with self-reported race/ethnicity in Medicare, especially for non-Hispanic White and Black individuals. For patients with unknown race/ethnicity data in CARES, the vast majority were of White race. [ABSTRACT FROM AUTHOR]

What We Already Know About This Topic: Rapid response to witnessed, pulseless cardiac arrest is associated with increased survival.What This Article Tells Us That Is New: Assessment of witnessed, pulseless cardiac arrests occurring at 538 hospitals during a 9-yr period indicates that CPR did not occur immediately at 0 min in 5.7% of patients despite guidelines for instantaneous initiation. Delay in initiation of CPR was associated with significantly decreased survival.Time to initiation of CPR and subsequent time to initiation of administration of defibrillation shock (for shockable arrhythmias) and epinephrine were both associated with reduced patient survival.Background: Because the extent to which delays in initiating cardiopulmonary resuscitation (CPR) versus the time from CPR to defibrillation or epinephrine treatment affects survival remains unknown, it was hypothesized that all three independently decrease survival in in-hospital cardiac arrest.Methods: Witnessed, index cases of cardiac arrest from the Get With The Guidelines-Resuscitation Database occurring between 2000 and 2008 in 538 hospitals were included in this analysis. Multivariable risk-adjusted logistic regression examined the association of time to initiation of CPR and time from CPR to either epinephrine treatment or defibrillation with survival to discharge.Results: In the overall cohort of 57,312 patients, there were 9,802 survivors (17.1%). Times to initiation of CPR greater than 2 min were associated with a survival of 14.7% (91 of 618) as compared with 17.1% (9,711 of 56,694) if CPR was begun in 2 min or less (adjusted odds ratio [95% CI], 0.68 [0.54 to 0.87]; P < 0.002). Times from CPR to either defibrillation or epinephrine treatment of 2 min or less were associated with a survival of 18.0% (7,654 of 42,475), as compared with 15.0% (1,680 of 11,227) for 3 to 5 min (reference, 0 to 2 min; adjusted odds ratios [95% CI], 0.83 [0.78 to 0.88]; P < 0.001), 12.8% (382 of 2,983) for 6 to 8 min (0.67 [0.60 to 0.76], P < 0.001), and 13.7% (86 of 627) for 9 to 11 min (0.54 [0.42 to 0.69], P < 0.001).Conclusions: Delays in the initiation of CPR and from CPR to defibrillation or epinephrine treatment were each associated with lower survival. [ABSTRACT FROM AUTHOR]

Background Although rates of survival to hospital discharge after in-hospital cardiac arrest (IHCA) have improved over the last decade, it is unknown if these survival gains are sustained after hospital discharge. Objective To examine 1-year survival trends overall and by rhythm after IHCA. Methods Using Medicare beneficiaries (age ≥ 65 years) with IHCA occurring between 2000 and 2011 at Get With The Guidelines®-Resuscitation Registry participating hospitals we used multivariable regression, to examine temporal trends in risk-adjusted rates of 1-year survival. Results Among 45,567 patients with IHCA, the unadjusted 1-year survival was 9.4%. Unadjusted 1-year survival was 21.8% among the 9,223 (20.2%) of patients with Ventricular Fibrillation or Pulseless Ventricular Tachycardia (VF/VT) and 6.2% among the 36,344 (79.8%) of patients with Pulseless Electrical Activity or asystole (PEA/asystole). After adjustment for patient and arrest characteristics, 1-year survival increased over time for all IHCA from 8.9% in 2000–2001 to 15.2% in 2011 (adjusted rate ratio [RR] per year, 1.05; 95% CI, 1.03–1.06; P < 0.001 for trend). Improvements in 1-year risk adjusted survival were also observed for VF/VT (19.4% in 2000–2001 to 25.6% in 2011 [RR per year, 1.02; 95% CI, 1.01–1.04; P 0.004 for trend]) and PEA/asystole arrests (4.7% in 2000–2001 to 10.2% in 2011 [RR per year, 1.07; 95% CI, 1.05–1.08; P < 0.001 for trend]). Conclusion Among Medicare beneficiaries in the GWTG-Resuscitation registry, 1-year survival after IHCA has increased for over the past decade. Temporal improvements in survival were noted for both shockable and non-shockable presenting arrest rhythms. [ABSTRACT FROM AUTHOR]

Risk-standardized survival rates (RSSR) for in-hospital cardiac arrest (IHCA) have been widely used for hospital benchmarking and research. The novel coronavirus 2019 (COVID-19) pandemic has led to a substantial decline in IHCA survival as COVID-19 infection is associated with markedly lower survival. Therefore, there is a need to update the model for computing RSSRs for IHCA given the COVID-19 pandemic. Within Get With The Guidelines ® -Resuscitation, we identified 53,922 adult patients with IHCA from March, 2020 to December, 2021 (the COVID-19 era). Using hierarchical logistic regression, we derived and validated an updated model for survival to hospital discharge and compared the performance of this updated RSSR model with the previous model. The survival rate was 21.0% and 20.8% for the derivation and validation cohorts, respectively. The model had good discrimination (C-statistic 0.72) and excellent calibration. The updated parsimonious model comprised 13 variables—all 9 predictors in the original model as well as 4 additional predictors, including COVID-19 infection status. When applied to data from the pre-pandemic period of 2018–2019, there was a strong correlation (r = 0.993) between RSSRs obtained from the updated and the previous models. We have derived and validated an updated model to risk-standardize hospital rates of survival for IHCA. The updated model yielded RSSRs that were similar to the initial model for IHCAs in the pre-pandemic period and can be used for supporting ongoing efforts to benchmark hospitals and facilitate research that uses data from either before or after the emergence of COVID-19. [ABSTRACT FROM AUTHOR]

Objective: For comatose survivors of out-of-hospital cardiac arrest (OHCA), current guidelines recommend targeted temperature management (TTM) with a goal temperature of 32°C - 36°C for at least 24 hours. We examined adherence to temperature targets, quantified as time-in-therapeutic range (TTR), and association of TTR with survival and neurologic outcomes.Methods: We conducted a retrospective cohort study of the Resuscitation Outcomes Consortium-Continuous Chest Compressions trial, including adults with OHCA who underwent TTM for >12 hours. We imputed continuous temperatures between consecutive temperature measurements using the linear interpolation method and calculated TTR for multiple target temperatures. The association of TTR with survival to hospital discharge and favorable neurological outcome was evaluated using hierarchical regression models.Main Results: Among 2,637 patients (mean age 62.3 years, 29.9% female), the median duration of TTR for TTM between 32°C - 36°C was 23 (IQR: 21-24) hours with a median time outside therapeutic range of 0.9 (IQR: 0.0 - 4.2) hours. In risk-adjusted analyses, there was no association of TTR of 32°C - 36°C with overall survival (OR 1.00 [95% CI, 0.90 - 1.10]) or favorable neurologic outcome (1.02 [95% CI, 0.90 - 1.14]). However, in assessments of TTR 33°C - 36°C, there was a significant association with favorable neurologic survival (OR 1.12 [1.01 - 1.25]) but not overall survival (OR 1.04 [0.94 - 1.15]).Conclusions: Among patients with OHCA who underwent TTM, we found variability in adherence to guideline-recommended treatment targets. Higher TTR was not associated with overall survival, but for certain temperature thresholds, TTR was associated with favorable neurologic outcome. [ABSTRACT FROM AUTHOR]

Background: For patients with in-hospital cardiac arrests attributable to nonshockable rhythms, delays in epinephrine administration beyond 5 minutes is associated with worse survival. However, the extent of hospital variation in delayed epinephrine administration and its effect on hospital-level outcomes is unknown.Methods: Within Get With The Guidelines-Resuscitation, we identified 103 932 adult patients (≥18 years) at 548 hospitals with an in-hospital cardiac arrest attributable to a nonshockable rhythm who received at least 1 dose of epinephrine between 2000 and 2014. We constructed 2-level hierarchical regression models to quantify hospital variation in rates of delayed epinephrine administration (>5 minutes) and its association with hospital rates of survival to discharge and survival with functional recovery.Results: Overall, 13 213 (12.7%) patients had delays to epinephrine, and this rate varied markedly across hospitals (range, 0%-53.8%). The odds of delay in epinephrine administration were 58% higher at 1 randomly selected hospital in comparison with a similar patient at another randomly selected hospital (median odds ratio, 1.58; 95% confidence interval, 1.51-1.64). The median risk-standardized survival rate was 12.0% (range, 5.4%-31.9%), and the risk-standardized survival with functional recovery was 7.4% (range, 0.9%-30.8%). There was an inverse correlation between a hospital's rate of delayed epinephrine administration and its risk-standardized rate of survival to discharge (ρ=-0.22, P<0.0001) and survival with functional recovery (ρ=-0.14, P=0.001). In comparison with a median survival rate of 12.9% (interquartile range, 11.1%-15.4%) at hospitals in the lowest quartile of epinephrine delay, risk-standardized survival was 16% lower at hospitals in the quartile with the highest rate of epinephrine delays (10.8%; interquartile range, 9.7%-12.7%).Conclusions: Delays in epinephrine administration following in-hospital cardiac arrest are common and variy across hospitals. Hospitals with high rates of delayed epinephrine administration had lower rates of overall survival for in-hospital cardiac arrest attributable to nonshockable rhythm. Further studies are needed to determine whether improving hospital performance on time to epinephrine administration, especially at hospitals with poor performance on this metric, will lead to improved outcomes. [ABSTRACT FROM AUTHOR]

Importance: Therapeutic hypothermia is used for patients following both out-of-hospital and in-hospital cardiac arrest. However, randomized trials on its efficacy for the in-hospital setting do not exist, and comparative effectiveness data are limited.Objective: To evaluate the association between therapeutic hypothermia and survival after in-hospital cardiac arrest.Design, Setting, and Patients: In this cohort study, within the national Get With the Guidelines-Resuscitation registry, 26 183 patients successfully resuscitated from an in-hospital cardiac arrest between March 1, 2002, and December 31, 2014, and either treated or not treated with hypothermia at 355 US hospitals were identified. Follow-up ended February 4, 2015.Exposure: Induction of therapeutic hypothermia.Main Outcomes and Measures: The primary outcome was survival to hospital discharge. The secondary outcome was favorable neurological survival, defined as a Cerebral Performance Category score of 1 or 2 (ie, without severe neurological disability). Comparisons were performed using a matched propensity score analysis and examined for all cardiac arrests and separately for nonshockable (asystole and pulseless electrical activity) and shockable (ventricular fibrillation and pulseless ventricular tachycardia) cardiac arrests.Results: Overall, 1568 of 26 183 patients with in-hospital cardiac arrest (6.0%) were treated with therapeutic hypothermia; 1524 of these patients (mean [SD] age, 61.6 [16.2] years; 58.5% male) were matched by propensity score to 3714 non-hypothermia-treated patients (mean [SD] age, 62.2 [17.5] years; 57.1% male). After adjustment, therapeutic hypothermia was associated with lower in-hospital survival (27.4% vs 29.2%; relative risk [RR], 0.88 [95% CI, 0.80 to 0.97]; risk difference, -3.6% [95% CI, -6.3% to -0.9%]; P = .01), and this association was similar (interaction P = .74) for nonshockable cardiac arrest rhythms (22.2% vs 24.5%; RR, 0.87 [95% CI, 0.76 to 0.99]; risk difference, -3.2% [95% CI, -6.2% to -0.3%]) and shockable cardiac arrest rhythms (41.3% vs 44.1%; RR, 0.90 [95% CI, 0.77 to 1.05]; risk difference, -4.6% [95% CI, -10.9% to 1.7%]). Therapeutic hypothermia was also associated with lower rates of favorable neurological survival for the overall cohort (hypothermia-treated group, 17.0% [246 of 1443 patients]; non-hypothermia-treated group, 20.5% [725 of 3529 patients]; RR, 0.79 [95% CI, 0.69 to 0.90]; risk difference, -4.4% [95% CI, -6.8% to -2.0%]; P < .001) and for both rhythm types (interaction P = .88).Conclusions and Relevance: Among patients with in-hospital cardiac arrest, use of therapeutic hypothermia compared with usual care was associated with a lower likelihood of survival to hospital discharge and a lower likelihood of favorable neurological survival. These observational findings warrant a randomized clinical trial to assess efficacy of therapeutic hypothermia for in-hospital cardiac arrest. [ABSTRACT FROM AUTHOR]

An editorial is presented that discusses the role of low-hanging fruit for prevention of Cardiometabolic Disease Policy. Topics discussed improving risk factor and pharmacological and technological advances in the management of coronary heart disease and stroke; increasing sugar intake in obesity and type 2 diabetes mellitus prevalence; and mentions the Nutrition Labeling and Education Act on packaged foods.

Cardiac arrest is a leading cause of death in developed countries. Although a majority of cardiac arrest patients die during the acute event, a substantial proportion of cardiac arrest deaths occur in patients following successful resuscitation and can be attributed to the development of post-cardiac arrest syndrome. There is growing recognition that integrated post-resuscitation care, which encompasses targeted temperature management (TTM), early coronary angiography and comprehensive critical care, can improve patient outcomes. TTM has been shown to improve survival and neurological outcome in patients who remain comatose especially following out-of-hospital cardiac arrest due to ventricular arrhythmias. Early coronary angiography and revascularisation if needed may also be beneficial during the post-resuscitation phase, based on data from observational studies. In addition, resuscitated patients usually require intensive care, which includes mechanical ventilator, haemodynamic support and close monitoring of blood gases, glucose, electrolytes, seizures and other disease-specific intervention. Efforts should be taken to avoid premature withdrawal of life-supporting treatment, especially in patients treated with TTM. Given that resources and personnel needed to provide high-quality post-resuscitation care may not exist at all hospitals, professional societies have recommended regionalisation of post-resuscitation care in specialised 'cardiac arrest centres' as a strategy to improve cardiac arrest outcomes. Finally, evidence for post-resuscitation care following in-hospital cardiac arrest is largely extrapolated from studies in patients with out-of-hospital cardiac arrest. Future studies need to examine the effectiveness of different post-resuscitation strategies, such as TTM, in patients with in-hospital cardiac arrest. [ABSTRACT FROM AUTHOR]

Establishing the validity of appropriate use criteria (AUC) for percutaneous coronary intervention (PCI) in the setting of stable ischemic heart disease can support their adoption for quality improvement. We conducted a post hoc analysis of 2,287 Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial patients with stable ischemic heart disease randomized to PCI with optimal medical therapy (OMT) or OMT alone. Within appropriateness categories, we compared rates of death, myocardial infarction, revascularization subsequent to initial therapy, and angina-specific health status as determined by the Seattle Angina Questionnaire in patients randomized to PCI + OMT to those randomized to OMT alone. A total of 1,987 patients (87.9%) were mapped to the 2012 publication of the AUC, with 1,334 (67.1%) classified as appropriate, 551 (27.7%) uncertain, and 102 (5.1%) as inappropriate. There were no significant differences between PCI and OMT alone in the rate of mortality and myocardial infarction by appropriateness classification. Rates of revascularization were significantly lower in patients initially receiving PCI + OMT who were classified as appropriate (hazard ratio 0.65; 95% confidence interval 0.53 to 0.80; p <0.001) or uncertain (hazard ratio 0.49; 95% confidence interval 0.32 to 0.76; p = 0.001). Furthermore, among patients classified as appropriate by the AUC, Seattle Angina Questionnaire scores at 1 month were better in the PCI-treated group compared with the medical therapy group (80 ± 23 vs 75 ± 24 for angina frequency, 73 ± 24 vs 68 ± 24 for physical limitations, and 68 ± 23 vs 60 ± 24 for quality of life; all p <0.01), with differences generally persisting through 12 months. In contrast, health status scores were similar throughout the first year of follow-up in PCI + OMT patients compared with OMT alone in patients classified as uncertain or inappropriate. In conclusion, these findings support the validity of the AUC in efforts to improve health care quality through optimal use of PCI. [ABSTRACT FROM AUTHOR]

Background--Despite intensive efforts over many years, the United States has made limited progress in improving rates of survival from out-of-hospital cardiac arrest. Recently, national organizations, such as the American Heart Association, have focused on promoting bystander cardiopulmonary resuscitation, use of automated external defibrillators, and other performance improvement efforts. Methods and Results--Using the Cardiac Arrest Registry to Enhance Survival (CARES), a prospective clinical registry, we identified 70 027 U.S. patients who experienced an out-of-hospital cardiac arrest between October 2005 and December 2012. Using multilevel Poisson regression, we examined temporal trends in risk-adjusted survival. After adjusting for patient and cardiac arrest characteristics, risk-adjusted rates of out-of-hospital cardiac arrest survival increased from 5.7% in the reference period of 2005 to 2006 to 7.2% in 2008 (adjusted risk ratio, 1.27; 95% confidence interval, 1.12--1.43; P<0.001). Survival improved more modestly to 8.3% in 2012 (adjusted risk ratio, 1.47; 95% confidence interval, 1.26--1.70; P<0.001). This improvement in survival occurred in both shockable and nonshockable arrest rhythms (P for interaction=0.22) and was also accompanied by better neurological outcomes among survivors (P for trend=0.01). Improved survival was attributable to both higher rates of prehospital survival, where risk-adjusted rates increased from 14.3% in 2005 to 2006 to 20.8% in 2012 (P for trend<0.001), and in-hospital survival (P for trend=0.015). Rates of bystander cardiopulmonary resuscitation and automated external defibrillator use modestly increased during the study period and partly accounted for prehospital survival trends. Conclusions--Data drawn from a large subset of U.S communities suggest that rates of survival from out-of-hospital cardiac arrest have improved among sites participating in a performance improvement registry. [ABSTRACT FROM AUTHOR]

Objectives: This study assessed practice variations in secondary prevention medication prescriptions among coronary artery disease (CAD) patients treated in outpatient practices participating in the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) registry. Background: Among patients with CAD, secondary prevention with a combination of beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins reduces cardiac mortality and myocardial infarction (MI). Accordingly, every CAD patient should receive the combination of these medications for which they are eligible. However, little is known about current prescription patterns of these medications and the variation in use among outpatient cardiology clinics. Methods: Using data from NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed medication prescription patterns among eligible CAD patients, between July 2008 and December 2010. Overall rates of prescription and variation by practice were calculated, adjusting for patient characteristics. Results: Among 156,145 CAD patients in 58 practices, 103,830 (66.5%) patients were prescribed the optimal combination of medications for which they were eligible. The median rate of optimal combined prescription by practice was 73.5% and varied from 28.8% to 100%. After adjustment for patient factors, the practice median rate ratio for prescription was 1.25 (95% confidence interval: 1.20 to 1.32), indicating a 25% likelihood that 2 random practices would differ in treating identical CAD patients. Conclusions: Among a national registry of CAD patients treated in outpatient cardiology practices, over one-third of patients failed to receive their optimal combination of secondary prevention medications. Significant variation was observed across practices, even after adjusting for patient characteristics, suggesting that quality improvement efforts may be needed to support more uniform practice. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to examine whether rates of inappropriate percutaneous coronary intervention (PCI) differ by demographic characteristics and insurance status. Background: Prior studies have found that blacks, women, and those who have public or no health insurance are less likely to undergo PCI. Whether this reflects potential overuse in whites, men, and privately insured patients, in addition to underuse in disadvantaged populations, is unknown. Methods: Within the National Cardiovascular Data Registry CathPCI Registry, we identified 221,254 nonacute PCIs performed between July 2009 and March 2011. The appropriateness of PCI was determined using the Appropriate Use Criteria for coronary revascularization. Multivariable hierarchical regression was used to evaluate the association between patient demographics and insurance status and inappropriate PCI, as defined by the Appropriate Use Criteria. Results: Of 211,254 nonacute PCIs, 25,749 (12.2%) were classified as inappropriate. After multivariable adjustment, men (adjusted odd ratio [OR]: 1.08 [95% CI: 1.05 to 1.11]; p < 0.001) and whites (adjusted OR: 1.09 [95% CI: 1.05 to 1.14]; p < 0.001) were more likely to undergo an inappropriate PCI in comparison with women and nonwhites. Compared with privately insured patients, those who had Medicare (adjusted OR: 0.85 [95% CI: 0.83 to 0.88]), other public insurance (adjusted OR: 0.78 [95% CI: 0.73 to 0.83]), and no insurance (adjusted OR: 0.56 [95% CI: 0.50 to 0.61]) were less likely to undergo an inappropriate PCI (p < 0.001). In addition, compared with urban hospitals, those admitted at rural hospitals were less likely to undergo inappropriate PCI, whereas those at suburban hospitals were more likely. Conclusions: For nonacute indications, PCIs categorized as inappropriate were more commonly performed in men, whites, and those who had private insurance. Higher rates of PCI in these patient populations may, in part, be due to procedural overuse. [Copyright &y& Elsevier]

Objectives: The purpose of this study is to develop a method for risk-standardizing hospital survival after cardiac arrest. Background: A foundation with which hospitals can improve quality is to be able to benchmark their risk-adjusted performance against other hospitals, something that cannot currently be done for survival after in-hospital cardiac arrest. Methods: Within the Get With The Guidelines (GWTG)-Resuscitation registry, we identified 48,841 patients admitted between 2007 and 2010 with an in-hospital cardiac arrest. Using hierarchical logistic regression, we derived and validated a model for survival to hospital discharge and calculated risk-standardized survival rates (RSSRs) for 272 hospitals with at least 10 cardiac arrest cases. Results: The survival rate was 21.0% and 21.2% for the derivation and validation cohorts, respectively. The model had good discrimination (C-statistic 0.74) and excellent calibration. Eighteen variables were associated with survival to discharge, and a parsimonious model contained 9 variables with minimal change in model discrimination. Before risk adjustment, the median hospital survival rate was 20% (interquartile range: 14% to 26%), with a wide range (0% to 85%). After adjustment, the distribution of RSSRs was substantially narrower: median of 21% (interquartile range: 19% to 23%; range 11% to 35%). More than half (143 [52.6%]) of hospitals had at least a 10% positive or negative absolute change in percentile rank after risk standardization, and 50 (23.2%) had a ≥20% absolute change in percentile rank. Conclusions: We have derived and validated a model to risk-standardize hospital rates of survival for in-hospital cardiac arrest. Use of this model can support efforts to compare hospitals in resuscitation outcomes as a foundation for quality assessment and improvement. [ABSTRACT FROM AUTHOR]

The article presents the results of a research that linked data from a large, national registry of in-hospital cardiac arrests with Medicare claims files. Findings reveal that survival and readmission rates varied according to the demographic characteristics of the patients and neurologic status at discharge. It is cited that 60% of elderly survivors were alive at 1 year, and the rate of 3-year survival was the same to those with heart failure.

The article offers information regarding duration of resuscitation attempts. It presents a case study for analyzing survival after in-hospital cardiac arrest of patients and variation in duration of resuscitation attempts. It discusses the methodology for the study conducted which used median duration of resuscitation, multilevel regression models, and risk-adjusted survival. INSET: Panel: Research in context.

The article discusses a study that developed a simple, bedside prediction tool that provides accurate estimation of favorable neurological survival after in-hospital cardiac arrest. Findings show that the rates of favorable neurological survival were similar in the derivation cohort and validation cohort patients. Evidence suggests that the tool provides accurate prognostication after cardiac arrest for physicians, patients and families.

Warfarin is a complex but highly effective treatment for decreasing thromboembolic risk in atrial fibrillation (AF). We examined contemporary warfarin treatment rates in AF before the expected introduction of newer anticoagulants and extent of practice-level variation in warfarin use. Within the National Cardiovascular Data Registry Practice Innovation and Clinical Excellence program from July 2008 through December 2009, we identified 9,113 outpatients with AF from 20 sites who were at moderate to high risk for stroke (congestive heart failure, hypertension, age, diabetes, stroke score >1) and would be optimally treated with warfarin. Using hierarchical models, the extent of site-level variation was quantified with the median rate ratio, which can be interpreted as the likelihood that 2 random practices would differ in treating “identical” patients with warfarin. Overall rate of warfarin treatment was only 55.1% (5,018 of 9,913). Untreated patients and treated patients had mean congestive heart failure, hypertension, age, diabetes, stroke scores of 2.5 (p = 0.38) and similar rates of heart failure, hypertension, diabetes mellitus, and previous stroke, suggesting an almost “random” pattern of treatment. At the practice level, however, there was substantial variation in treatment ranging from 25% to 80% (interquartile range for practices 50 to 65), with a median rate ratio of 1.31 (1.22 to 1.55, p <0.001). In conclusion, within the Practice Innovation and Clinical Excellence registry, we found that warfarin treatment in AF was suboptimal, with large variations in treatment observed across practices. Our findings suggest important opportunities for practice-level improvement in stroke prevention for outpatients with AF and define a benchmark treatment rate before the introduction of newer anticoagulant agents. [ABSTRACT FROM AUTHOR]

The article discusses the relevance of percutaneous coronary intervention (PCI), which is performed in about 600,000 cases in the U.S. per year and costs a total of 12 billion U.S. dollars. In a study conducted by the authors to understand the need for the procedure, they use data from the National Cardiovascular Data Registry between July 1, 2009 and September 30, 2010 with an aim of finding the proportion of appropriate, uncertain or inappropriate PCI. They conclude that most PCIs done in the U.S. were appropriate with only 12% being tagged as inappropriate.

Although fast food is affordable and convenient, it is also high in calories, saturated fat, and sodium. The frequency of fast food intake at the time of and after acute myocardial infarction (AMI) is modifiable. However, patterns of fast food intake and characteristics associated with its consumption in patients with AMI are unknown. The aim of this study was to study fast food consumption at the time of AMI and 6 months later in 2,481 patients from the prospective, 24-center Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients'' Health Status (TRIUMPH) study of patients with AMI. Fast food intake was categorized as frequent (weekly or more often) or infrequent (less than weekly). Multivariate log-binomial regression was used to identify patient characteristics associated with frequent fast food intake 6 months after AMI. At baseline, 884 patients (36%) reported frequent fast food intake, which decreased to 503 (20%) 6 months after discharge (p <0.001). Male gender, white race, lack of college education, current employment, and dyslipidemia were independently associated with frequent fast food intake 6 months after AMI. In contrast, older patients and those who underwent coronary bypass surgery were less likely to eat fast food frequently. Documentation of discharge dietary counseling was not associated with 6-month fast food intake. In conclusion, fast food consumption by patients with AMI decreased 6 months after the index hospitalization, but certain populations, including younger patients, men, those currently working, and less educated patients were more likely to consume fast food, at least weekly, during follow-up. Novel interventions that go beyond traditional dietary counseling may be needed to address continued fast food consumption after AMI in these patients. [Copyright &y& Elsevier]

Objectives: The objective of this study was to compare the consistency in appropriate use criteria (AUC) ratings among a broad range of practicing cardiologists and the AUC Technical Panel. Background: AUC for coronary revascularization have been developed by selected experts. Methods: Before AUC publication, 85 cardiologists from 10 U.S. institutions assessed the appropriateness of coronary revascularization for 68 indications that had been evaluated by the AUC Technical Panel. Each indication was classified as appropriate, uncertain, or inappropriate, based on the physician group''s median rating. Rates of concordance between the physician group and the AUC Technical Panel (i.e., same appropriateness category assignment) and rates of nonagreement within the physician group (≥25% of panelists'' ratings outside the group''s appropriateness category assessment) were determined. Results: Overall concordance between the 2 groups was 84%. Among indications classified as appropriate by the AUC Technical Panel, concordance between the 2 groups was excellent (94% [34 of 36]); however, nonagreement within the physician group was 44% (16 of 36). Among indications classified as uncertain, there was 73% (16 of 22) concordance between the 2 groups. Among inappropriate indications, concordance was moderate (70% [7 of 10]), but nonagreement occurred frequently (70% [7 of 10]). Moreover, there was substantial variation in appropriateness ratings between individual physicians and the AUC Technical Panel (weighted kappa range: 0.05 to 0.76). Conclusions: Although there was good concordance in assessments of appropriateness for coronary revascularization between physicians and the AUC Technical Panel, nonagreement within the physician group was common and there was marked variation in ratings between individual physicians and the AUC Technical Panel. [Copyright &y& Elsevier]

The article discusses a meta-analysis study which investigated the effect of the coverage of tele-medicine intensive care unit (ICU) on the length of stay (LOS) and mortality of patients. It also determines several key hospital, ICU, and patient factors that mitigate of improve the effectiveness of the coverage of tele-medicine systems ICU. The findings of the meta-analysis revealed the association of tele-ICU coverage with lower ICU LOS and mortality but not with lower mortality of LOS of in-house patients.

The article discusses a research study on the acceptance by intensive care unit (ICU) staff of tele-ICU coverage. The procedure included studying several articles focusing on critical care telemedicine systems published between January 1950 and March 2010. The results were grouped into several categories of staff evaluation including organizational impact, impact on staff and impact on patient care.

The article focuses on a study which evaluated the association between automated external defibrillators (AEDs) use and survival for in-hospital cardiac arrest. The researchers examined 11,695 hospitalized patients who experienced cardiac arrests between January 1, 2000 to August 26, 2008 at U.S. hospitals following the introduction of AEDs on general and hospital wards. Study results indicated that hospitalized patients with cardiac arrest and use of AED were not associated with improved survival.

Beta-Blockers and Microvolt T-Wave Alternans. Introduction: Results of microvolt T-wave alternans (MTWA) studies vary and may be influenced by whether beta-blocker therapy was withheld prior to MTWA assessment. We conducted a meta-analysis of the predictive value of MTWA screening for ventricular arrhythmic events in primary prevention patients with left ventricular dysfunction and examined whether results differed depending upon whether beta-blocker use was withheld prior to MTWA testing. Methods and Results: Prospective studies that evaluated whether MTWA predicted ventricular arrhythmic events published between January 1980 and September 2008 were identified. Summary estimates for the predictive value of MTWA were derived with random-effects models. Nine studies involving 3,939 patients were identified. Overall, an abnormal MTWA (positive and indeterminate) test was associated with an almost 2-fold increased risk for arrhythmic events (pooled RR = 1.95, 95% CI: 1.29–2.96; P = 0.002). However, significant heterogeneity across studies was observed (P = 0.024). In the 4 studies in which beta-blocker therapy was not withheld prior to MTWA assessment, an abnormal MTWA test was associated with a 5-fold increased risk for arrhythmic events (pooled RR = 5.39, 95% CI: 2.68–10.84; P < 0.001) and was robust to sensitivity analyses. In contrast, the association was much weaker in those studies where the use of beta-blocker therapy was withheld prior to MTWA testing (pooled RR = 1.40, 95% CI: 1.06–1.84; P = 0.02). Conclusions: In primary prevention patients with left ventricular dysfunction, the predictive power of MTWA varied widely, based on whether beta-blocker therapy was withheld prior to its assessment. This observation may explain the inconsistent results of MTWA studies in this population. (J Cardiovasc Electrophysiol, Vol. 21, pp. 1009-1014, September 2010) [ABSTRACT FROM AUTHOR]

Objectives: We examined compliance with performance measures for 14,464 patients enrolled from July 2008 through June 2009 into the American College of Cardiology''s PINNACLE (Practice Innovation And Clinical Excellence) program to provide initial insights into the quality of outpatient cardiac care. Background: Little is known about the quality of care of outpatients with coronary artery disease (CAD), heart failure, and atrial fibrillation, and whether sex and racial disparities exist in the treatment of outpatients. Methods: The PINNACLE program is the first, national, prospective office-based quality improvement program of cardiac patients designed, in part, to capture, report, and improve outpatient performance measure compliance. We examined the proportion of patients whose care was compliant with established American College of Cardiology, American Heart Association, and American Medical Association-Physician Consortium for Performance Improvement (ACC/AHA/PCPI) performance measures for CAD, heart failure, and atrial fibrillation. Results: There were 14,464 unique patients enrolled from 27 U.S. practices, accounting for 18,021 clinical visits. Of these, 8,132 (56.4%) had CAD, 5,012 (34.7%) had heart failure, and 2,786 (19.3%) had nonvalvular atrial fibrillation. Data from the PINNACLE program were feasibly collected for 24 of 25 ACC/AHA/PCPI performance measures. Compliance with performance measures ranged from being very low (e.g., 13.3% of CAD patients screened for diabetes mellitus) to very high (e.g., 96.7% of heart failure patients with blood pressure assessments), with moderate (70% to 90%) compliance observed for most performance measures. For 3 performance measures, there were small differences in compliance rates by race or sex. Conclusions: For more than 14,000 patients enrolled from 27 practices in the outpatient PINNACLE program, we found that compliance with performance measures was variable, even after accounting for exclusion criteria, suggesting an important opportunity to improve the quality of outpatient care. [Copyright &y& Elsevier]

The article presents a study that evaluates the efficiency of rapid response teams (RRTs) in the reduction of mortality rates and cardiopulmonary arrest in hospitals. It states that systemic reviews of studies from 1950 to 2008 were conducted. Results show that RRT reduced arrest outside intensive care unit (ICU) by 33.8% in adults and 37.7% in children, but was not associated with mortality. It concludes that though RRT has a broad appeal, it still lacks the evidence to support its efficiency.

The article focuses on a study which estimated the racial differences in survival for patients with in-hospital cardiac arrests. The study also examined the link between sociodemographic and clinical factors, and admitting hospital. It included 10,011 patients diagnosed with cardiac arrests due to ventricular fibrillation or pulseless ventricular tachycardia. Such patients were from 274 hospitals within the National Registry of Cardiopulmonary Resuscitation. Study authors found that rates of survival to discharge are lower in black patients compared to white patients. They concluded that the racial difference in survival rates was associated with hospital center.

The article focuses on a study which focuses on the understanding of the hospital-level variation in rates of delayed defibrillation at acute-care hospitals in the U.S. It reveals that the adjusted rate of delayed defibrillation ranges from 2.4%-50.9% among hospitals. However, rates of delayed defibrillation through traditional hospital factors are largely unexplained. The result of the study reveals that the rates of delayed defibrillation varies among hospitals differently.

A letter to the editor is presented in response to the article "Rosuvastatin to Prevent Vascular Events in Men and Women With Elevated C-Reactive Protein" by P. M. Ridker, E. Danielson and F. A. H. Fonseca in the November 20, 2008 issue.

The article presents a prospective cohort study which determined the rates of mortality and hospital codes before and after the introduction of long-term rapid response teams in hospitals. The authors explain that rapid response teams have been shown to decrease cardiopulmonary arrest code rates. Adult inpatients admitted between January 1, 2004 and August 31, 2007 were used for the study. 24,193 patient admissions were evaluated prior to the implementation of a rapid response team. 24,978 were evaluated after the intervention. Researchers found that implementation of the rapid response team was not associated with reductions in mortality or hospital-wide code rates.

Previous studies have demonstrated that microvolt T-wave alternans (MTWA) screening effectively risk-stratifies patients with ischemic cardiomyopathy. Whether the prognostic utility of MTWA diminishes over 3 years of follow-up remains unknown. In this study, a prospective cohort of 768 patients with ischemic cardiomyopathy (left ventricular ejection fraction <35%) and no previous sustained ventricular arrhythmia was developed, of whom 514 (67%) screened MTWA nonnegative (positive and indeterminate). The mean follow-up period was 18 ± 11 months. The primary end point was all-cause mortality and appropriate implantable cardioverter-defibrillator shocks. Stratified Cox regression analyses (by implantable cardioverter-defibrillator status) estimated the predictive power of MTWA within each year of follow-up and determined whether this diminished over time. There were 99 deaths (MTWA negative: 21 [8.3%]; MTWA nonnegative: 78 [15.2%]) and 33 appropriate implantable cardioverter-defibrillator shocks (MTWA negative: 3 [4.0%]; MTWA nonnegative: 30 [9.5%]). After multivariate adjustment, a nonnegative MTWA test result was associated with a greater than twofold increased risk for events in each of the 3 years of follow-up (year 1: stratified hazard ratio 2.19, 95% confidence interval 1.10 to 4.34, p = 0.03; year 2: stratified hazard ratio 3.36, 95% confidence interval 1.28 to 8.83, p = 0.01; year 3: stratified hazard ratio 2.06, 95% confidence interval 0.81 to 5.22, p = 0.13). There were no significant interactions between the time periods (year 1 vs year 2: p = 0.47; year 1 vs year 3: p = 0.92). In conclusion, MTWA reliably and consistently predicts mortality and arrhythmic risk throughout the first 2 to 3 years of follow-up. Although these findings need further validation, they suggest that rescreening with MTWA may not need to be performed more frequently than once every 2 years. [Copyright &y& Elsevier]

Paul S. Chan, Graham Nichol and Brahmajee K. Nallamothu respond to a letter to the editor about their article "Time to Defibrillation After In-Hospital Cardiac Arrest" in the January 3, 2008 issue.

Background: Expert guidelines advocate defibrillation within 2 minutes after an in-hospital cardiac arrest caused by ventricular arrhythmia. However, empirical data on the prevalence of delayed defibrillation in the United States and its effect on survival are limited. Methods: We identified 6789 patients who had cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia at 369 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. Using multivariable logistic regression, we identified characteristics associated with delayed defibrillation. We then examined the association between delayed defibrillation (more than 2 minutes) and survival to discharge after adjusting for differences in patient and hospital characteristics. Results: The overall median time to defibrillation was 1 minute (interquartile range, <1 to 3 minutes); delayed defibrillation occurred in 2045 patients (30.1%). Characteristics associated with delayed defibrillation included black race, noncardiac admitting diagnosis, and occurrence of cardiac arrest at a hospital with fewer than 250 beds, in an unmonitored hospital unit, and during after-hours periods (5 p.m. to 8 a.m. or weekends). Delayed defibrillation was associated with a significantly lower probability of surviving to hospital discharge (22.2%, vs. 39.3% when defibrillation was not delayed; adjusted odds ratio, 0.48; 95% confidence interval, 0.42 to 0.54; P<0.001). In addition, a graded association was seen between increasing time to defibrillation and lower rates of survival to hospital discharge for each minute of delay (P for trend <0.001). Conclusions: Delayed defibrillation is common and is associated with lower rates of survival after in-hospital cardiac arrest. N Engl J Med 2008;358:9-17. [ABSTRACT FROM AUTHOR]

The article discusses the results of a study about the effectiveness of implantable cardioverter-defibrillators (ICD) to reduce mortality in patients with ischemic heart disease and left ventricular dysfunction. A 47% reduction in all-cause mortality was observed in patients with ICD. A lower arrhythmia-related mortality was seen in patients with ICD. The study's limitations are enumerated.

Objectives: This study was designed to compare the cost-effectiveness of implantable cardioverter-defibrillator (ICD) placement with and without risk stratification with microvolt T-wave alternans (MTWA) testing in the MADIT-II (Second Multicenter Automatic Defibrillator Implantation Trial) eligible population. Background: Implantable cardioverter-defibrillators have been shown to prevent mortality in the MADIT-II population. Microvolt T-wave alternans testing has been shown to be effective in risk stratifying MADIT-II–eligible patients. Methods: On the basis of published data, cost-effectiveness of three therapeutic strategies in MADIT-II–eligible patients was assessed using a Markov model: 1) ICD placement in all; 2) ICD placement in patients testing MTWA non-negative;, and 3) medical management. Outcomes of expected cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness were determined for patient lifetime. Results: Under base-case assumptions, providing ICDs only to those who test MTWA non-negative produced a gain of 1.14 QALYs at an incremental cost of $55,700 when compared to medical therapy, resulting in an incremental cost-effectiveness ratio (ICER) of $48,700/QALY. When compared with a MTWA risk-stratification strategy, placing ICDs in all patients resulted in an ICER of $88,700/QALY. Most (83%) of the potential benefit was achieved by implanting ICDs in the 67% of patients who tested MTWA non-negative. Results were most sensitive to the effectiveness of MTWA as a risk-stratification tool, MTWA negative screen rate, cost and efficacy of ICD therapy, and patient risk for arrhythmic death. Conclusions: Risk stratification with MTWA testing in MADIT-II–eligible patients improves the cost-effectiveness of ICDs. Implanting defibrillators in all MADIT-II–eligible patients, however, is not cost-effective, with one-third of patients deriving little additional benefit at great expense. [Copyright &y& Elsevier]

Objectives: We sought to compare the cost-effectiveness of left atrial catheter ablation (LACA), amiodarone, and rate control therapy in the management of atrial fibrillation (AF). Background: Left atrial catheter ablation has been performed to eliminate AF, but its cost-effectiveness is unknown. Methods: We developed a decision-analytic model to evaluate the cost-effectiveness of LACA in 55- and 65-year-old cohorts with AF at moderate and low stroke risk. Costs, health utilities, and transition probabilities were derived from published literature and Medicare data. We performed primary threshold analyses to determine the minimum level of LACA efficacy and stroke risk reduction needed to make LACA cost-effective at $50,000 and $100,000 per quality-adjusted life-year (QALY) thresholds. Results: In 65-year-old subjects with AF at moderate stroke risk, relative reduction in stroke risk with an 80% LACA efficacy rate for sinus rhythm restoration would need to be ≥42% and ≥11% to yield incremental cost-effectiveness ratios (ICERs) <$50,000 and $100,000 per QALY, respectively. Higher and lower LACA efficacy rates would require correspondingly lower and higher stroke risk reduction for equivalent ICER thresholds. In the 55-year-old moderate stroke risk cohort, lower LACA efficacy rates or stroke risk reduction would be needed for the same ICER thresholds. In patients at low stroke risk, LACA was unlikely to be cost-effective. Conclusions: The use of LACA may be cost-effective in patients with AF at moderate risk for stroke, but it is not cost-effective in low-risk patients. Our threshold analyses may provide a framework for the design of future clinical trials by providing effect size estimates for LACA efficacy needed. [Copyright &y& Elsevier]

Objectives: To investigate the generalizability of the reduction in mortality posed by implantable cardioverter-defibrillators, we examined the effectiveness of defibrillators as applied in routine medical practice. Background: Implantable cardioverter-defibrillators have been shown to be efficacious in the primary and secondary prevention of overall and cardiovascular mortality in clinical trials. Methods: Using the National Veterans Administration database, we identified a cohort of 6,996 patients from 1995 to 1999 with new-onset ventricular arrhythmia and pre-existing ischemic heart disease and congestive heart failure, of which 1,442 received a defibrillator, and followed them for three years to determine rates of mortality. With multivariate logistic regression analyses that adjusted for demographics, illness severity, and comorbidity, we assessed overall, cardiovascular, and noncardiovascular rates of mortality. To further address potential confounding, we also stratified the cohort by quintiles using a multivariable propensity score for each patient and determined mortality rates. Results: For the overall cohort, multivariate regression showed that those who received defibrillators had significantly lower all-cause (odds ratio [OR] 0.52; 95% confidence interval [CI] 0.45 to 0.60) and cardiovascular (OR 0.56; 95% CI 0.49 to 0.65)] rates of mortality at three years. No significant differences were noted between groups in their rates of noncardiovascular mortality (OR 0.92; 95% CI 0.77 to 1.10). Propensity score analysis demonstrated similar mortality reduction benefits at three years: risk ratio (RR) 0.72 (95% CI 0.69 to 0.79) for all-cause; RR 0.70 (95% CI 0.63 to 0.78) for cardiovascular; and RR 0.95 (95% CI 0.83 to 1.08) for noncardiovascular rates of mortality. These results suggest that one death is prevented in this patient population for every four to five patients receiving a defibrillator for three years. Conclusions: Implantable cardioverter-defibrillators in routine medical practice significantly reduce cardiovascular and all-cause rates of mortality at levels similar to secondary prevention trials. [Copyright &y& Elsevier]

The article focuses on questioning the interpretation of the primary results of a restrictive transfusion strategy in acute myocardial infarction patients by Carson et al., emphasizing the potential harms overlooked by null-hypothesis testing. Bayesian analyses, incorporating prior probabilities, indicate a high probability of harm from a restrictive transfusion strategy, ranging from 90.8 percent to 99.8 percent, challenging the notion that the trial's results are negative.

Every 10 years, the American Heart Association (AHA) Emergency Cardiovascular Care Committee establishes goals to improve survival from cardiac arrest. These goals align with broader AHA Impact Goals and support the AHA's advocacy efforts and strategic investments in research, education, clinical care, and quality improvement programs. This scientific statement focuses on 2030 AHA emergency cardiovascular care priorities, with a specific focus on bystander cardiopulmonary resuscitation, early defibrillation, and neurologically intact survival. This scientific statement also includes aspirational goals, such as establishing cardiac arrest as a reportable disease and mandating reporting of standardized outcomes from different sources; advancing recognition of and knowledge about cardiac arrest; improving dispatch system response, availability, and access to resuscitation training in multiple settings and at multiple time points; improving availability, access, and affordability of defibrillators; providing a focus on early defibrillation, in-hospital programs, and establishing champions for debriefing and review of cardiac arrest events; and expanding measures to track outcomes beyond survival. The ability to track and report data from these broader aspirational targets will potentially require expansion of existing data sets, development of new data sets, and enhanced integration of technology to collect process and outcome data, as well as partnerships of the AHA with national, state, and local organizations. The COVID-19 (coronavirus disease 2019) pandemic, disparities in COVID-19 outcomes for historically excluded racial and ethnic groups, and the longstanding disparities in cardiac arrest treatment and outcomes for Black and Hispanic or Latino populations also contributed to an explicit focus and target on equity for the AHA Emergency Cardiovascular Care 2030 Impact Goals. [ABSTRACT FROM AUTHOR]

A response from the authors of the article "Regional Variation in Out-of-Hospital Cardiac Arrest Survival in the United States" which appeared in the previous issue is presented.

Background: Although rates of survival to hospital discharge after in-hospital cardiac arrest (IHCA) have improved over the last decade, it is unknown if these survival gains are sustained after hospital discharge.Objective: To examine 1-year survival trends overall and by rhythm after IHCA.Methods: Using Medicare beneficiaries (age≥65years) with IHCA occurring between 2000 and 2011 at Get With The Guidelines®-Resuscitation Registry participating hospitals we used multivariable regression, to examine temporal trends in risk-adjusted rates of 1-year survival.Results: Among 45,567 patients with IHCA, the unadjusted 1-year survival was 9.4%. Unadjusted 1-year survival was 21.8% among the 9,223 (20.2%) of patients with Ventricular Fibrillation or Pulseless Ventricular Tachycardia (VF/VT) and 6.2% among the 36,344 (79.8%) of patients with Pulseless Electrical Activity or asystole (PEA/asystole). After adjustment for patient and arrest characteristics, 1-year survival increased over time for all IHCA from 8.9% in 2000-2001 to 15.2% in 2011 (adjusted rate ratio [RR] per year, 1.05; 95% CI, 1.03-1.06; P<0.001 for trend). Improvements in 1-year risk adjusted survival were also observed for VF/VT (19.4% in 2000-2001 to 25.6% in 2011 [RR per year, 1.02; 95% CI, 1.01-1.04; P 0.004 for trend]) and PEA/asystole arrests (4.7% in 2000-2001 to 10.2% in 2011 [RR per year, 1.07; 95% CI, 1.05-1.08; P<0.001 for trend]).Conclusion: Among Medicare beneficiaries in the GWTG-Resuscitation registry, 1-year survival after IHCA has increased for over the past decade. Temporal improvements in survival were noted for both shockable and non-shockable presenting arrest rhythms. [ABSTRACT FROM AUTHOR]