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Patients with out-of-hospital cardiac arrest (OHCA) due to acute coronary syndromes (ACS) who undergo percutaneous coronary intervention (PCI) are at high risk of bleeding and thrombosis. While predictive bleeding and stent thrombosis risk scores have been established, their performance in patients with OHCA has not been evaluated.All consecutive patients admitted for OHCA due to ACS who underwent PCI between January 2007 and December 2019 were included. The ACTION and CRUSADE bleeding risk scores and the Dangas score for early stent thrombosis risk were calculated for each patient. A C-statistic analysis was performed to assess the performance of these scores.Among 386 included patients, 82 patients (21.2%) experienced severe bleeding and 30 patients (7.8%) experienced stent thrombosis. The predictive performance of the ACTION and CRUSADE bleeding risk scores for major bleeding was poor, with areas under the curve (AUCs) of 0.596 and 0.548, respectively. Likewise, the predictive performance of the Dangas stent thrombosis risk score was poor (AUC 0.513). Using multivariable analysis, prolonged low-flow (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00-1.05; P=0.025), reduced haematocrit or fibrinogen at admission (OR 0.93, 95% CI 0.88-0.98; P=0.010 and OR 0.61; 95% CI 0.41-0.89; P=0.012, respectively) and the use of glycoprotein IIb/IIIa inhibitors (OR 2.10, 95% CI 1.18-3.73; P=0.011) were independent risk factors for major bleeding.The classic bleeding and stent thrombosis risk scores have poor performance in a population of patients with ACS complicated by OHCA. Other predictive factors might be more pertinent to determine major bleeding and stent thrombosis risks in this specific population.

Aims Guidelines recommend that in the absence of reversible cause for sudden cardiac arrest (SCA), implantable cardioverter defibrillator (ICD) should be performed to prevent further fatal event. We sought to describe the frequency and characteristics of patients discharged from the hospital without ICD after the SCA in the daily practice. Methods and results From 2011 to 2018, all SCAs related to a cardiac cause admitted alive across the 48 hospitals of Great Paris Area were prospectively enrolled. Two investigators thoroughly reviewed each medical report to ensure accuracy of the assigned diagnosis towards identifying the cause of SCA and ICD implantation. Out of the 4314 SCA admitted alive at hospital admission, 1064 cardiac-related SCA survivors were discharged alive from hospital, including 356 patients (33.5%) with an ICD and 708 (66.5%) without. The principal underlying cause of SCA among those discharged without an ICD was acute coronary syndrome (ACS; 602, 85%), chronic coronary artery disease (41, 5.8%), structural non-ischaemic heart disease (48, 6.8%), and non-structural heart disease (17, 2.4%). Among ACS-related SCA, 93.8% (602/642) discharged without an ICD. The unique factor associated with non-ICD implantation in the setting of ACS was immediate coronary angioplasty (odds ratio 4.22, 95% confidence interval 1.86–9.30, P Conclusion Two-thirds of SCA survivors were discharged without an ICD, mainly in the setting of ACS. The unique factor associated with non-ICD implantation among ACS was immediate coronary angioplasty emphasizing the fact that ACS definition must be precise since associated with ICD implantation or not.

L’arrêt cardiaque intra hospitalier (ACIH) est un évènement rare (1 cas pour 1000 admissions hospitalières approximativement) mais associé à une mortalité et une morbidité importante. Beaucoup d’éléments de la prise en charge sont calqués sur l’arrêt cardiaque extrahospitalier (ACEH) et/ou la disponibilité immédiate d’un plateau technique hospitalier complet. La prévention incluant l’amélioration de la détection des ACIH, mais aussi la prédiction de leur survenue nécessite la mise en place de registre exhaustif tels qu’ils existent déjà dans des pays notamment scandinaves mais font défaut en 2021 en France. Les causes de l’ACIH sont équilibrées entre causes cardiaques similaires aux ACEH et causes extracardiaques avec en premier lieu l’asphyxie. Cette épidémiologie conduit à une prise en charge spécifique de manière plus fréquente que dans le cadre de l’ACEH. La prise en charge non spécialisée repose sur les compressions thoraciques, l’oxygénation avec ou sans intubation trachéale et l’administration d’Adrénaline. La prise en charge après récupération d’une activité cardiaque spontanée est guidée par l’étiologie et les mesures neuroprotectrices pouvant être proposées. L’évaluation du pronostic étant cruciale comme dans le cadre de l’ACEH avec néanmoins une place particulière pour les comorbidités, la fragilité et la pathologie responsable du séjour hospitalier.

Individualize treatment after cardiac arrest could potentiate future clinical trials selecting patients most likely to benefit from interventions. We assessed the Cardiac Arrest Hospital Prognosis (CAHP) score for predicting reason for death to improve patient selection. Consecutive patients in two cardiac arrest databases were studied between 2007 and 2017. Reasons for death were categorised as refractory post-resuscitation shock (RPRS), hypoxic-ischaemic brain injury (HIBI) and other. We computed the CAHP score, which relies on age, location at OHCA, initial cardiac rhythm, no-flow and low-flow times, arterial pH, and epinephrine dose. We performed survival analyses using the Kaplan–Meier failure function and competing-risks regression. Of 1543 included patients, 987 (64%) died in the ICU, 447 (45%) from HIBI, 291 (30%) from RPRS, and 247 (25%) from other reasons. The proportion of deaths from RPRS increased with CAHP score deciles; the sub-hazard ratio for the tenth decile was 30.8 (9.8–96.5; p

Major efforts have been made to reduce the burden of sports-related sudden cardiac arrest (SrSCA). The extent to which the incidence, management, and outcomes changed over time has not been investigated.The purpose of this study was to assess temporal trends in SrSCA incidence, management, and survival.Using data from the French National Institute of Health and Medical Research, we evaluated the evolution of incidence, prehospital management, and survival at hospital discharge of SrSCA among subjects aged 18 to 75 years, over 6 successive 2-year periods between 2005 and 2018.Among the 377 SrSCA, 20 occurred in young competitive athletes (5.3%), whereas 94.7% occurred in middle-aged recreational sports participants. Comparing the last 2-year to the first 2-year period, SrSCA incidence remained stable (6.24 vs 7.00 per million inhabitants/y; P = 0.51), with no significant differences in patients' mean age (46.6 ± 13.8 years vs 51.0 ± 16.4 years; P = 0.42), sex (men 94.7% vs 95.2%; P = 0.99), and history of heart disease (12.5% vs 15.9%; P = 0.85). However, frequency of bystander cardiopulmonary resuscitation and public automated external defibrillator use increased significantly (34.9% vs 94.7%; P 0.001 and 1.6% vs 28.8%; P = 0.006, respectively). Survival to hospital discharge improved steadily, reaching 66.7% in the last study period compared with 23.8% in the first (P 0.001).Incidence of SrSCA remained relatively stable over time, suggesting a need for improvement in screening strategies. However, major improvements in on-field resuscitation led to a 3-fold increase in survival, underlining the value of public education in basic life support that should serve as an example for SCA in general.

Summary Balance between thrombosis and bleeding is now well recognized in patients treated for acute coronary syndrome, with impact on short- and long-term prognosis, including survival. Recent data suggest that patients who are resuscitated after out-of-hospital cardiac arrest related to myocardial infarction are at an even higher risk of bleeding and thrombosis than those with uncomplicated acute coronary syndrome. Delayed enteral absorption of medication due to induced hypothermia and systemic inflammation increases thrombosis risk, whereas transfemoral access site, cardiopulmonary resuscitation manoeuvres and mechanical circulatory support devices increase bleeding risk. In addition, post-resuscitation syndrome and renal or hepatic impairment are potential risk factors for both bleeding and thrombotic complications. There are currently no randomized controlled trials comparing various P2Y12 inhibitor and/or anticoagulation strategies in the setting of out-of-hospital cardiac arrest, and current practice is largely derived from management of patients with uncomplicated acute coronary syndrome. The aim of this review is therefore to describe the bleeding and thrombosis risk factors in this specific population, and to review recent data on antithrombotic drugs in this patient subset.

Introduction Overall survival of patients with out-of-hospital cardiac arrest (OHCA) remains low, even in those with return of spontaneous circulation (ROSC). In addition to usual prognostic characteristics, patients’ medical history may also influence their outcome. This study aimed to investigate the role of pre-arrest comorbidities on hospital survival, neurological outcome and mode of death in OHCA patients with successful ROSC. Methods From Jan 2012 to Sep 2017, all consecutive non-traumatic OHCA adults, admitted with a stable ROSC were included. Utstein characteristics, circumstances of arrest and interventions were prospectively recorded. Prior comorbidities were measured using the Charlson Comorbidity Index (CCI), and the population was divided into 3 groups (CCI 0, CCI 1–3 and CCI ≥ 4). The association of CCI with early and long-term mortality was assessed using logistic regression and association with withdrawal-of-life sustaining treatments (WLST) or another cause of death using multinomial regression. Results During the study period, 777 patients were analyzed and 483 (62%) died before hospital discharge, with death rate of 49%, 60% and 70% in CCI 0, CCI 1–3 and CCI ≥ 4 respectively. After adjustment, an increase CCI was significantly associated with in-hospital mortality (OR = 2.47 [1.35–4.52], p = 0.001 for CCI 1–3; OR = 2.82 [1.49–5.33], p = 0.003 for CCI ≥ 4; ref = CCI 0). Other independent predictors were non-shockable rhythm (OR = 3.23 [2.08–5]), lack of bystander CPR (OR = 1.96 [1.22–3.13]), epinephrine dose ≥ 2 mg (OR = 5.56 [3.70–8.33]), CA to CPR ≥ 5 min (OR = 1.96 [1.28–3.03]) and CPR to ROSC ≥ 20 min (OR = 2.13 [1.39–3.23]). Using multinomial regression, an increase in CCI was associated with all modes of in-hospital death, particularly with WLST-related death (RRadj = 2.48 [1.26–4.90], p = 0.01 for CCI = 1–3 and 3.75 [1.85−8.7.58], p Conclusion Alteration of chronic health status, as assessed by an elevated CCI, was associated with a higher mortality and a worse neurological outcome in OHCA patients. Presence and burden of comorbidities should be considered in the evaluation of the prognosis in patients admitted in hospital after cardiac arrest.

Hypothesis Aqueous Two-Phase Systems (ATPS) are aqueous droplets dispersed in an aqueous phase. This specific behavior arises from interactions between at least two water-soluble entities, such as thermodynamically incompatible polymers. A simple, fast, and “green” process to produce ATPS with an aqueous core would be of high interest to the pharmaceutical field for drug delivery. However, to date, rapid destabilization of ATPS represents the main hurdle for their use. Herein we present a novel process to achieve a stabilized microparticle-ATPS, without the use of organic solvents. Experiments ATPS composed of dextran and polyethylene oxide were prepared. A Pickering-like emulsion technique was used to stabilize the ATPS by adsorbing semi-solid particles (chitosan-grafted lipid nanocapsules) at the interface between the two aqueous phases. Finally, microparticles were formed by a polyelectrolyte complexation and gelation. The structure and stability of ATPS were characterized using microscopy and Turbiscan analysis. Findings Adding chitosan-grafted lipid nanocapsules induced ATPS stabilization. Adding a polyelectrolyte such as sodium alginate allowed the formation of microparticles with a gelled shell that strengthened the formulation against shear stress and improved long-term stability, thus demonstrating that is possible to use ATPS to form delivery systems to encapsulate hydrophilic molecules.

Summary Background Survivors of out-of-hospital cardiac arrest undergoing percutaneous coronary intervention are at high thrombotic and bleeding risk. The type of antiplatelet that should be used in these patients remains controversial. Aim To compare the impact of the use of more potent P2Y12 receptor inhibitors on thrombotic and bleeding events with that of clopidogrel in survivors of out-of-hospital cardiac arrest undergoing percutaneous coronary intervention. Methods This was an observational study including consecutive patients treated for out-of-hospital cardiac arrest associated with acute coronary syndrome by percutaneous coronary intervention with stent implantation and dual antiplatelet therapy between January 2007 and December 2017. Baseline characteristics, mortality and in-hospital haemorrhagic and thrombotic events were compared between patients who received clopidogrel and those who received more potent P2Y12 receptor inhibitors. Results Among the 359 included patients, 197 received clopidogrel and 162 received ticagrelor or prasugrel. The primary composite endpoint of death, definite stent thrombosis or major bleeding was similar in the two groups (57.4% in the clopidogrel group vs. 53.7% in the new P2Y12 receptor inhibitors group; P = 0.49). Fewer haemorrhagic events occurred in the clopidogrel group (21.8% vs. 31.5%; P = 0.04), whereas similar rates of definite stent thrombosis were observed (5.1% vs. 6.2%; P = 0.65). The use of more potent P2Y12 receptor inhibitors was an independent predictor of major bleeding (odds ratio 2.69, 95% confidence interval 1.37–5.25; P = 0.004). Conclusions In this specific population, the use of more potent P2Y12 receptor inhibitors was not associated with a reduced thrombosis rate compared with clopidogrel, but with a higher haemorrhagic risk. Prospective studies should be performed on the optimal antithrombotic therapy in this subset of patients.

Background Among patients successfully resuscitated after an out-of-hospital cardiac arrest (OHCA), 10% to 15% evolve toward brain death (BD), thus becoming potential organ donors. Research Question Is it possible to establish a score for early estimation of BD risk after OHCA? Study Design and Methods The BD after cardiac arrest (BDCA) score was developed from data available within 24 hours after OHCA from two OHCA trials: Cyclosporine in Cardiac Arrest Resuscitation and Erythropoietin After OHCA. The BDCA score was then validated in another large prospective multicenter data set. The main outcome was the occurrence of BD. Independent prognostic covariates for BD were identified using a binomial two-stage adaptive least absolute shrinkage and selection operator procedure. Results The development cohort included 569 patients alive 24 hours after OHCA, among whom 84 (14.8%) experienced BD. Independent predictors of BD used to build the BDCA score were being female (4 points), nonshockable rhythm (24 points), cardiac cause of OHCA (−6 points), neurological cause of OHCA (45 points), natremia at 24 hours (natremia in millimoles per liter minus 140 points), and vasoactive drug at admission (4 points) and at 24 hours (6 points). The area under the curve (AUC) of the BDCA score was 0.82 (95% CI, 0.77-0.86), and the discrimination value in the validation cohort (n = 487) was consistent (AUC, 0.81; 95% CI, 0.76-0.86). In the validation cohort, BD occurred in 4.0%, 20.4%, and 67.7% of patients with scores of 50, respectively. Interpretation The BDCA score allows early detection of patients with a high probability of experiencing BD, which may help increase organ donation after OHCA. Clinical Trial Registration ClinicalTrials.gov; No.: NCT01595958, and ClinicalTrials.gov ; No.: NCT00999583; URL: www.clinicaltrials.gov

Recent guidelines have emphasized actively avoiding fever to improve outcomes in patients who are comatose following resuscitation from cardiac arrest (ie, out-of-hospital cardiac arrest). However, whether targeted temperature management between 32°C and 36°C (TTM32-36) can improve neurologic outcome in some patients remains debated.Is there an association between the use of TTM32-36 and outcome according to severity assessed at ICU admission using a previously derived risk score?Data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (France) between May 2011 and December 2017 and in the Resuscitation Outcomes Consortium Continuous Chest Compressions (ROC-CCC) trial (United States and Canada) between June 2011 and May 2015 were used for this study. Severity at ICU admission was assessed through a modified version of the Cardiac Arrest Hospital Prognosis (mCAHP) score, divided into tertiles of severity. The study explored associations between TTM32-36 and favorable neurologic status at hospital discharge by using multiple logistic regression as well as in tertiles of severity for each data set.A total of 2,723 patients were analyzed in the SDEC data set and 4,202 patients in the ROC-CCC data set. A favorable neurologic status at hospital discharge occurred in 728 (27%) patients in the French data set and in 1,239 (29%) patients in the North American data set. Among the French data set, TTM32-36 was independently associated with better neurologic outcome in the tertile of patients with low (adjusted OR, 1.63; 95% CI, 1.15-2.30; P = .006) and high (adjusted OR, 1.94; 95% CI, 1.06-3.54; P = .030) severity according to mCAHP at ICU admission. Similar results were observed in the North American data set (adjusted ORs of 1.36 [95% CI, 1.05-1.75; P = .020] and 2.42 [95% CI, 1.38-4.24; P = .002], respectively). No association was observed between TTM32-36 and outcome in the moderate groups of the two data sets.TTM32-36 was significantly associated with a better outcome in patients with low and high severity at ICU admission assessed according to the mCAHP score. Further studies are needed to evaluate individualized temperature control following out-of-hospital cardiac arrest.

Post-cardiac arrest myoclonus (PCAM) is a frequent finding in resuscitated patients after cardiac arrest (CA), with rather poor prognostic significance. In this study, we evaluated the association of PCAM within intensive care unit (ICU) mortality from a university hospital CA patients’ registry. Clinical data of consecutive CA survivors admitted in the intensive care unit (ICU) between January and December 2016 at the Paris Cochin University Hospital were assessed from the Parisian registry of cardiac arrest (PROCAT) and analyzed. Neurologic outcome was assessed using the Cerebral Performance Categories (CPC) scale at ICU discharge. Prevalence of PCAM and their association with mortality at ICU discharge were computed. One hundred thirty-two (132) patients were included (73.5% males), median age of 66 years. Among them, 37 (28%) developed PCAM during their ICU stay. Only two patients with PCAM survived (5.4%). PCAM was strongly associated with mortality at ICU discharge (odds ratio 17.5 [4.2–123.2]). Sensitivity, specificity, PPV, and NPV of PCAM for prediction of death were 41%, 96%, 95%, and 46%, respectively. PCAM was observed in nearly one-third of CA patients admitted in ICU. Patients with PCAM had a significantly higher likelihood of ICU mortality and a low likelihood of a good outcome. The prognostic value of PCAM seems rather bleak but remains nuanced and merits study in larger-scale prospective studies taking into account confounding factors.

International audience; Purpose: Mesenteric ischaemia after successfully resuscitated cardiac arrest (CA) has been insufficiently studied. We aimed to assess the frequency, risk factors, and outcomes of non-occlusive mesenteric ischaemia (NOMI) after CA. Methods: We retrospectively included patients admitted to a CA centre with sustained return of spontaneous circulation between 2007 and 2017. NOMI was suspected based on clinical symptoms and classified as possible if no tests were feasible or the only test was a negative abdominal computed tomography (CT) scan and as confirmed if diagnosed by endoscopy, CT, or surgery. Results: Of 1343 patients, 82 (6%) had suspected NOMI, including 33 (2.5%) with confirmed NOMI. Investigations for suspected NOMI were done in 47/82 (57%) patients (CT, n = 30; lower digestive endoscopy, n = 14; and upper digestive endoscopy, n = 12); 11 patients underwent surgery. By multivariate analysis, factors associated with suspected NOMI were female sex (OR, 1.8; 95%CI, 1.1–2.9, p = 0.02), cardiovascular comorbidities (OR, 1.6; 95%CI, 1.0–2.7; p = 0.047), admission lactate >5 mmol/L (OR, 2.0; 95%CI, 1.2–3.4; p = 0.01), low flow >17 min (OR, 2.2; 95%CI, 1.3–3.8; p = 0.003), and inotropic score >7 μg/kg/min (OR, 1.8; 95%CI, 1.1–3.2; p = 0.03). ICU mortality was 96% (79/82), with 61% of patients dying from multi-organ failure (MOF) and 35% from post-anoxic brain injury. Of the eight patients who regained consciousness, 5 finally died from MOF, leaving 3 patients discharged alive from the ICU with a good neurologic outcome. Conclusions: NOMI may affect 2.5–6% of patients after CA. Mortality was extremely high in patients, and very few survived with a good neurological outcome.

AimsData on sports-related sudden cardiac arrest (SrSCA) among young adults in the general population are scarce. We aimed to determine the overall SrSCA incidence, characteristics, and outcomes in young adults.Methods and resultsProspective cohort study of all cases of SrSCA between 2012 and 2019 in Germany and Paris area, France, involving subjects aged 18–35 years. Detection of SrSCA was achieved via multiple sources, including emergency medical services (EMS) reporting and web-based screening of media releases. Cases and aetiologies were centrally adjudicated. Overall, a total of 147 SrSCA (mean age 28.1 ± 4.8 years, 95.2% males) occurred, with an overall burden of 4.77 [95% confidence interval (CI) 2.85–6.68] cases per million-year, including 12 (8.2%) cases in young competitive athletes. While bystander cardiopulmonary resuscitation (CPR) was initiated in 114 (82.6%), automated external defibrillator (AED) use by bystanders occurred only in a minority (7.5%). Public AED use prior to EMS arrival (odds ratio 6.25, 95% CI 1.48–43.20, P = 0.02) was the strongest independent predictor of survival at hospital discharge (38.1%). Among cases that benefited from both immediate bystander CPR and AED use, survival rate was 90.9%. Coronary artery disease was the most frequent aetiology (25.8%), mainly through acute coronary syndrome (86.9%).ConclusionSports-related sudden cardiac arrest in the young occurs mainly in recreational male sports participants. Public AED use remains disappointingly low, although survival may reach 90% among those who benefit from both bystander CPR and early defibrillation. Coronary artery disease is the most prevalent cause of SrSCA in young adults.

Aims Age and sex disparities in out-of-hospital cardiac arrest (OHCA) have been described. Reproductive age may have a protected effect on females vs. males, although results are conflicting. We aimed to clarify this using the Paris Sudden Death Expertise Centre (SDEC) registry. Methods and results The Paris SDEC registry collects OHCAs occurring in the Greater Paris Area. We included all OHCAs of presumed cardiac causes occurring between 2013 and 2018. Patients were divided into age groups: 1–13, 13–50, 50–75, and >75 years. Sex and age disparities in OHCA incidence and outcomes were analysed using multivariable negative binomial and logistic regression models. There were 19 782 OHCAs meeting inclusion criteria: 0.37% aged 1–13 years, 12.4% aged 13–50 years, 40.4% aged 50–75 years, and 46.9% aged >75 years. Adjusted incidence rate ratios (IRRs) in females vs. males were for the youngest to the older age groups: 1.29 [95% confidence interval (CI) 0.78–2.13], 0.54 [0.49–0.59], 0.60 [0.56–0.64], and 0.75 [0.67–0.84]. At reproductive age, females were more likely than males to have a return of spontaneous circulation [adjusted odds ratio (OR) 1.60 (1.27–2.02)], to be alive at hospital admission [OR: 1.49 (1.18–1.89)]. In both sexes, patients aged 13–50 years were more likely to survive at hospital discharge than those aged 50–75 years [males: OR 1.81 (1.49–2.20), females: 2.24 (1.54–3.25)]. However, at reproductive age, no sex disparity was observed in survival at hospital discharge [OR: 1.16 (0.75–1.80)]. Conclusion Incidence rate ratios were similar between pre- and post-menopausal aged patients. At reproductive age, no sex disparity in survival at hospital discharge was observed, suggesting that menopausal status may not influence OHCA occurrence and prognosis.

International audience; Background: Data is scarce on hemorrhagic and thrombotic complications in patients with ST-elevation myocardial infarction (STEMI) associated with out-of-hospital cardiac arrest (OHCA).Methods: This is a monocentric, retrospective study conducted from January 2012 to December 2017 in a tertiary university hospital, which serves as a cardiac arrest center for a large urban area. Over the study period, all consecutive patients who were treated with stent implantation for STEMI with or without OHCA were included. Baseline characteristics, treatments, hemorrhagic and thrombotic events were compared between STEMI patients with and without OHCA. Univariate and multivariate analysis were performed in order to identify predictors of 30-day mortality, occurrence of major bleeding (MB), and early stent thrombosis (ST).Results: A total of 549 patients treated for STEMI without OHCA and 146 patients for STEMI with OHCA were included. The incidence of definite ST and MB after coronary angioplasty was significantly higher in patients with OHCA (2.6% vs. 7.5%, p = 0.004 and 3.3% vs. 19.2%, p < 0.001, respectively). Independent predictors of MB in OHCA patients were anticoagulation therapy (HR = 3.11, 95%CI [1.22-7.98], p = 0.02) and the use of glycoprotein IIb/IIIa inhibitors (HR = 4.16, 95%CI [1.61-10.79], p = 0.003). Independent predictors of mortality in OHCA patients were age (HR = 1.05, 95%CI [1.02-1.09], p = 0.004) and ST (HR = 5.62, 95%CI [1.61-19.65], p = 0.007, with a protective effect of new anti-P2Y12 treatments (HR = 0.20, 95%CI [0.08-0.46], p < 0.001).Conclusion: Patients treated for STEMI associated with OHCA are at higher-risk of ST and MB than those who did not experience cardiac arrest. In this subset of patients, prospective studies are needed to better evaluate the balance of thrombosis and hemorrhage.

Research has suggested mixed results regarding the relations between dimensions of ethnic-racial identity (ERI) and academic outcomes. Furthermore, little scholarship has explored the mechanisms that underlie these relations. In the current study, we investigated the longitudinal relations of 2 dimensions of ERI (embedded achievement, and ethnic affirmation and belonging) with achievement approach goal orientations, and we tested whether these relations were mediated by valuing of school among North African French middle school students (N = 336). Adolescents completed surveys annually during the last 3 years of French middle school (Grades 7, 8, and 9). Results of path analyses indicated positive direct effects of Grade 7 embedded achievement on Grade 9 performance-approach goals. Grade 7 ethnic affirmation/belonging negatively predicted Grade 9 performance approach goals. The anticipated indirect effects of Grade 7 embedded achievement and affirmation/belonging on performance and mastery-approach goals via students’ Grade 8 reports of valuing of school were nonsignificant. These results clarify ways in which aspects of ERI might have different relations with achievement striving among ethnic/racial minority youth, thereby enriching theorizing vis-a-vis ERI and academic motivation in an understudied population in psychological and educational science. (PsycINFO Database Record (c) 2019 APA, all rights reserved)

International audience

Backgound: Whether epinephrine or norepinephrine is preferable as the continuous intravenous vasopressor used to treat postresuscitation shock is unclear. Objectives: To compare outcomes of patients with postresuscitation shock after out-of-hospital cardiac arrest according to whether the continuous intravenous vasopressor used was epinephrine or norepinephrine. Methods: We conducted an observational multicenter study of consecutive patients managed in 2011-2018 for postresuscitation shock. The primary outcome was all-cause hospital mortality, and secondary outcomes were cardiovascular hospital mortality and unfavorable neurological outcome (Cerebral Performance Category 3 to 5). A multivariate regression analysis and a propensity score analysis were performed, as well as several sensitivity analyses. Results: Of the 766 patients included in five hospitals, 285 (37%) received epinephrine and 481 (63%) norepinephrine. All-cause hospital mortality was significantly higher in the epinephrine group (OR 2.6; 95%CI, 1.4-4.7; P =0.002). Cardiovascular hospital mortality was also higher with epinephrine (aOR 5.5; 95%CI 3.0-10.3; P P =0.02). Conclusions: Among patients with postresuscitation shock after out-of-hospital cardiac arrest, use of epinephrine was associated with higher all-cause and cardiovascular-specific mortality, compared with norepinephrine infusion. A randomized controlled trial comparing the two vasopressors in this population is warranted.

Whether epinephrine or norepinephrine is preferable as the continuous intravenous vasopressor used to treat post-resuscitation shock is unclear. We assessed outcomes of patients with post-resuscitation shock after out-of-hospital cardiac arrest according to whether the continuous intravenous vasopressor used was epinephrine or norepinephrine.We conducted an observational multicenter study of consecutive patients managed in 2011-2018 for post-resuscitation shock. The primary outcome was all-cause hospital mortality, and secondary outcomes were cardiovascular hospital mortality and unfavorable neurological outcome (Cerebral Performance Category 3-5). A multivariate regression analysis and a propensity score analysis were performed, as well as several sensitivity analyses.Of the 766 patients included in five hospitals, 285 (37%) received epinephrine and 481 (63%) norepinephrine. All-cause hospital mortality was significantly higher in the epinephrine group (OR 2.6; 95%CI 1.4-4.7; P = 0.002). Cardiovascular hospital mortality was also higher with epinephrine (aOR 5.5; 95%CI 3.0-10.3; P 0.001), as was the proportion of patients with CPC of 3-5 at hospital discharge. Sensitivity analyses produced consistent results. The analysis involving adjustment on a propensity score to control for confounders showed similar findings (aOR 2.1; 95%CI 1.1-4.0; P = 0.02).Among patients with post-resuscitation shock after out-of-hospital cardiac arrest, use of epinephrine was associated with higher all-cause and cardiovascular-specific mortality, compared with norepinephrine infusion. Until additional data become available, intensivists may want to choose norepinephrine rather than epinephrine for the treatment of post-resuscitation shock after OHCA.

Aims Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes. Methods and results We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002). Conclusions In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

A higher survival rate was observed in Sudden Cardiac Arrest (SCA) occurring during sports activities, although the underlying mechanisms remain unclear. We tested the hypothesis that better initial management, rather than sports per se, may account for the observed better outcomes during sports activities.Data was taken between May 2011 and March 2016 from a prospective ongoing registry that includes all SCA in Paris and suburbs (6.7 million inhabitants). Sports-related SCA (i.e. SCA occurring during sport activities or within one hour of cessation of the activity) were identified.Over the study period, 13,400 SCA occurred, of which 154 were sports-related (median age: 51.2 years, 96.1% males). At discharge, sports activity was associated with an 8-times higher survival rate (39.7% vs. 5.1%, P 0.001). Logistic regression showed that after considering potential confounders, including age, gender, SCA location, witness presence, time to response, and initial shockable rhythm, occurrence of SCA during sports was associated with a higher survival rate (OR 1.77, 95% CI 1.14-2.74, P = 0.01). However, after further adjustment for initial basic life support, i.e. bystander CPR and AED use, there was no association between sports setting and survival at hospital discharge (OR 1.43, 95% CI 0.91-2.23, P = 0.12).Sports-related SCA is a rare event, with an 8-times higher survival rate compared to non-sports-related SCA. Better initial management, including bystander CPR and AED use, rather than sports per se, mainly accounts this difference. This highlights the major importance of population education to basic life support in improving SCA outcome.

Purpose of review There is a need for an early assessment of outcome in patients with return of spontaneous circulation after cardiac arrest. During the last decade, several models were developed in order to identify predictive factors that may facilitate prognostication and stratification of outcome. Recent findings In addition to prognostication tools that are used in intensive care, at least five scores were recently developed using large datasets, based on simple and immediately available parameters, such as circumstances of arrest and early in-hospital indicators. Regarding neurological outcome, predictive performance of these models is good and even excellent for some of them. These scores perform very well for identifying patients at high-risk of unfavorable outcome. The most important limitation of these scores remains the lack of replication in different communities. In addition, these scores were not developed for individual decision- making, but they could instead be useful for the description and comparison of different cohorts, and also to design trials targeting specific categories of patients regarding outcome. Finally, the recent development of big data allows extension of research in epidemiology of cardiac arrest, including the identification of new prognostic factors and the improvement of prediction according to the profile of populations. Summary In addition to the development of artificial intelligence, the prediction approach based on adequate scores will further increase the knowledge in prognostication after cardiac arrest. This strategy may help to develop treatment strategies according to the predicted severity of the outcome.

Background: In out-of-hospital cardiac arrest (OHCA), geographic disparities in outcomes may reflect baseline variations in patients’ characteristics but may also result from differences in the number of ambulances providing basic life support (BLS) and advanced life support (ALS). We aimed at assessing the association between allocated ambulance resources and outcomes in OHCA patients in a large urban community. Methods: From May 2011 to January 2016, we analyzed a prospectively collected Utstein database for all OHCA adults. Cases were geocoded according to 19 neighborhoods and the number of BLS (firefighters performing cardiopulmonary resuscitation and applying automated external defibrillator) and ALS ambulances (medicalized team providing advanced care such as drugs and endotracheal intubation) was collected. We assessed the respective associations of Utstein parameters, socioeconomic characteristics, and ambulance resources of these neighborhoods using a mixed-effect model with successful return of spontaneous circulation as the primary end point and survival at hospital discharge as a secondary end point. Results: During the study period, 8754 nontraumatic OHCA occurred in the Greater Paris area. Overall return of spontaneous circulation rate was 3675 of 8754 (41.9%) and survival rate at hospital discharge was 788 of 8754 (9%), ranging from 33% to 51.1% and from 4.4% to 14.5% respectively, according to neighborhoods ( P P for trend P 1.5 per neighborhood and aOR, 1.21 [1.04–1.41]; P =0.01 for BLS ambulances >4 per neighborhood). Regarding survival at discharge, only the number of ALS ambulances >1.5 per neighborhood was significant (aOR, 1.30 [1.06–1.59] P =0.01). Conclusions: In this large urban population-based study of out-of-hospital cardiac arrests patients, we observed that allocated resources of emergency medical service are associated with outcome, suggesting that improving healthcare organization may attenuate disparities in prognosis.

Introduction Lumbar puncture is among the investigations used to identify various neurological conditions, including some that can cause cardiac arrest (CA). However, CA per se may alter cerebrospinal fluid (CSF) characteristics. Few studies have investigated CSF findings after CA. In this descriptive work, we assessed the frequency and risk factors of abnormal CSF findings after CA and the contribution of CSF analysis to the etiological diagnosis. Materials and methods We retrospectively studied data from prospectively established databases of consecutive patients who were admitted to two French ICUs in 2007–2016 with sustained return of spontaneous circulation (ROSC) after CA and who underwent lumbar puncture as an etiological investigation. Results Of 1984 patients with sustained ROSC, 55 (2.7%) underwent lumbar puncture and were included. Lumbar puncture identified a neurological cause of CA in 2/55 (3.6%) patients. Nonspecific CSF abnormalities were noted in 37/53 (69.8%) patients. By multivariate analysis, postresuscitation shock was positively associated with CSF abnormalities (OR, 6.92; 95% confidence interval [95%CI], 1.62–37.26; P = 0.013). A no-flow time above 6 minutes (OR, 0.19; 95%CI, 0.03–1.11; P = 0.076) and a respiratory cause of CA (OR, 2.91; 95%CI, 0.53–23.15; P = 0.24) were not statistically associated with CSF abnormalities. Nonspecific CSF abnormalities were not significantly associated with poor outcomes (Cerebral Performance Category ≥3; P = 0.06). Conclusions Lumbar puncture, although infrequently performed, may contribute to the etiological diagnosis of CA, albeit rarely. Nonspecific CSF abnormalities seem common after CA, notably with postresuscitation shock, and may be related to blood-brain barrier disruption. These findings may help to interpret CSF findings after CA. Further studies are warranted to assess our results.

Purpose To explore diagnostic pitfalls and treatment issues in out-of-hospital cardiac arrest of neurological cause (OHCA-NC). Methods Retrospective analysis of all consecutive patients from the Paris Sudden Death Expertise Centre (France) registry from May 2011 to September 2015 presenting with a sustained return of spontaneous circulation (ROSC) at hospital admission and a final diagnosis of OHCA-NC. Description of the early diagnostic check-up performed to identify the cause of cardiac arrest. Logistic multivariate regression to identify factors associated with immediate coronary angiography (iCAG) in OHCA-NC patients. Results Among 3542 patients with ROSC, a final diagnosis of OHCA-NC was established in 247 (7%). The early diagnostic check-up consisted in a total of 207 (84%) immediate cranial CT-scan, 66 (27%) iCAG and 25 (10%) chest CT-scan. The brain CT-scan allowed identifying a neurovascular cause in 116 (47%) patients. An iCAG was performed as the first line exam in 57 (23%) patients, in whom a final diagnosis of neurovascular cause for OHCA-NC was later identified in 41 patients. By multivariate analysis, decision for iCAG was independently associated with ST-segment elevation on post-ROSC electrocardiogram (OR, 5.94; 95%CI, 2.14–18.28; P = 0.0009), whereas an obvious cause of cardiac arrest on scene was negatively associated with iCAG (OR, 0.14; 95%CI, 0.02–0.51; P = 0.01). Conclusions OHCA-NC is a rare event that is mainly related to neurovascular causes. The initial ECG pattern may be a confounder regarding triage for early diagnostic check-up. Further studies are required to explore the potential harmfulness associated with decision to perform an iCAG in this population.

Purpose of review Early coronary angiogram (CAG) remains a cornerstone in postcardiac arrest management as coronary disease (CAD)-related cardiac arrest is the leading cause of sudden death in adults. The opportunity to treat the cause early on with immediate CAG may improve outcome in cardiac arrest patients with AMI. Identifying the patients who will benefit from such an early invasive strategy is an unanswered question. Recent and ongoing trials may improve the level of evidence on this problematic, especially for some subgroup; however, current guidelines remain founded upon a very heterogeneous level of evidence. Recent findings The key variable to argue for immediate CAD remains the pattern of the ECG monitored after return of spontaneous of circulation (ROSC). ST-segment elevation (STE) on postresuscitation ECG is the strongest argument to rule for an early CAG strategy. In other situations, identifying the best candidates for early CAG is very challenging. Different approaches including elements, such as circumstances of cardiac arrest and expected outcomes. may also drive the strategy. Summary This review aims to provide an overview of these different discussion points. The indication for early CAG should rely on multiple factors and an individual approach.

Aim Out-of-hospital Cardiac Arrest (OHCA) carries a poor prognostic with high mortality rates and multiple scoring systems have been developed to assess its prognostic. This study sought to evaluate the performance of three prognostic scores to predict survival in OHCA patients due to acute coronary syndrome (ACS). Methods and results This is an observational, monocentric study including 386 consecutive patients treated for OHCA due to ACS, treated by percutaneous coronary intervention, between 2007 and 2019. The OHCA, NULL-PLEASE and CAHP scores were calculated respectively for 370 patients (95.9%), 371 patients (96.1%) and 350 patients (90.7%). A C-statistic analysis was performed to determine score performance. The areas under the curve for the OHCA, NULL-PLEASE and CAHP scores were 0.861 (95% CI, 0.823–0.898), 0.789 (95% CI, 0.744–0.834) and 0.830 (95% CI, 0.788–0.872) respectively demonstrating good performance. The OHCA score performed better than the NULL-PLEASE score (p = 0.001), and there was no difference between the CAHP and the NULL-PLEASE score (p = 0.062) nor between the OHCA and the CAHP score (p = 0.105). Conclusion The OHCA score, the NULL-PLEASE score and the CAHP score performed well in predicting in-hospital death in patients presenting OHCA secondary to ACS. The NULL-PLEASE score is the easiest to use but performed less accurately than the OHCA score.

Background: Significant improvements in survival from out-of-hospital cardiac arrest (OHCA) have been reported; however, these are based only on data from OHCA in whom resuscitation is initiated by emergency medical services (EMS). We aimed to assess the characteristics and temporal trends of OHCA without resuscitation attempt by EMS. Methods: Prospective population-based study between 2011 and 2016 in the Greater Paris area (6.7 million inhabitants). All cases of OHCA were included in collaboration with EMS units, 48 different hospitals, and forensic units. Results: Among 15 207 OHCA (mean age 70.7±16.9 years, 61.6% male), 5486 (36.1%) had no resuscitation attempt by EMS. Factors that were independently associated with increase in likelihood of no resuscitation attempt included: age of patients (odds ratio, 1.06 per year [95% CI, 1.05–1.06], P P =0.002), OHCA at home location (odds ratio, 3.38 [95%CI, 2.86–4.01], P P P =0.028). This increase was related to an increase of the annual number of OHCA without resuscitation attempt by EMS by 26.3% (from 993 to 1253, P =0.012), while the annual number of OHCA with resuscitation attempt by EMS did not significantly change (from 1930 to 1936, P =0.416). Considering only cases with resuscitation attempt, survival rate at hospital discharge increased (from 7.3% to 9.5%, P =0.02). However, when considering all OHCA, survival improvement did not reach statistical significance (from 4.8% to 5.7%, P =0.17). Conclusions: We demonstrated an increase of the total number of OHCA related to an increase of the number of OHCA without resuscitation attempt by EMS. This increasing proportion of OHCA without resuscitation attempt attenuates improvement in survival rates achieved in EMS-treated patients.

International audience; Background: Out of hospital cardiac arrest (OHCA) patients requiring percutaneous coronary intervention (PCI) are at higher risk of both stent thrombosis and bleeding. The use of aggressive antiplatelet therapy could lead to a higher risk of bleeding in these patients. Indeed, data on glycoprotein IIb/IIIa inhibitor (GPi) use in this specific indication is scarce.Aim: We sought to evaluate the benefit and safety of GPi use in OHCA patients requiring PCI.Methods and results: Between January 2007 and December 2017, we retrospectively included all consecutive patients treated with PCI for an OHCA from cardiac cause. Clinical, procedural data and in-hospital outcomes were collected. Three hundred and eighty-five patients were included. GPi were administrated in 41.3% of cases (159 patients). Patients who received GPi were younger, had less prior PCI, more often a TIMI 0 or 1 flow before PCI and thromboaspiration use. There were no differences regarding in-hospital definite stent thrombosis among the two groups (11.9% in the GPi group vs 7.1% in the non-GPi group, p = 0.10) or in-hospital mortality (48.6% vs 49.3%, p = 0.68). The incidence of any bleeding (33.3% vs. 19.6%; p = 0.002), and major bleeding (BARC 3-5) (21.9% vs. 16.8%; p = 0.007) was significantly higher in patients receiving GPi. Indeed, using multivariate analysis, GPi use was predictor of major bleeding (OR: 1.81; 95% CI: 1.06-3.08; p = 0.03).Conclusions: In patients treated with PCI for OHCA from cardiac cause, GPi use was associated with an increased risk of major bleeding events, without difference on in-hospital stent thrombosis or death.

Background: Conflicting data exist regarding the benefit of urgent coronary angiogram and percutaneous coronary intervention (PCI) after sudden cardiac arrest, particularly in the absence of ST-segment elevation. We hypothesized that the type of lesions treated (stable versus unstable) influences the benefit derived from PCI. Methods: Data were taken between May 2011 and 2014 from a prospective registry enrolling all sudden cardiac arrest in Paris and suburbs (6.7 million inhabitants). Patients undergoing emergent coronary angiogram were included. Decision to perform PCI was left to the discretion of local teams. We assessed the impact of emergent PCI on survival at discharge according to whether the treated lesion was angiographically unstable or stable, and we investigated the predictive factors for unstable coronary lesions. Results: Among 9265 sudden cardiac arrests occurring during the study period, 1078 underwent emergent coronary angiogram (median age: 59.6 years, 78.3% males): 463 (42.9%) had an unstable lesion, 253 (23.5%) only stable lesions, and 362 (33.6%) no significant lesions. Emergent PCI was performed in 478 patients (91.4% of unstable and 21.7% of stable lesions). At discharge, PCI of unstable lesions was associated with twice-higher survival rate compared with untreated unstable lesions (47.9% versus 25.6%, P =0.013), while stable lesions PCI did not improve survival (25.5% versus 26.3%, P =1.00). After adjustment, PCI of unstable coronary lesions was independently associated with improved survival (odds ratio, 2.09 [95% CI, 1.42–3.09], P P =0.824). Angina, initial shockable rhythm, ST-segment elevation, and absence of known coronary artery disease were independent predictors of unstable lesions. Conclusions: Emergent PCI of unstable lesions is associated with improved survival after sudden cardiac arrest, contrary to PCI of stable lesions. Accordingly, early PCI should only be performed in patients with unstable lesions. Four factors (chest pain, ST-elevation, absence of coronary artery disease history, and shockable initial rhythm) could help identify patients with unstable lesions who would, therefore, benefit from emergent coronary angiogram.

Background: Lumbar puncture is among the investigations used to determine the aetiology and prognosis of cardiac arrest, despite a dearth of data on its performance. We aimed to assess the diagnostic and prognostic performance of lumbar puncture after cardiac arrest. Methods: We retrospectively studied data from prospectively established databases of consecutive patients who were admitted to two French ICUs in 2007-2016 with sustained return of spontaneous circulation (ROSC) after cardiac arrest and who underwent lumbar puncture as an aetiological investigation. Results: Of 1984 patients with sustained ROSC, 65 (3.3%) underwent lumbar puncture and were included. Lumbar puncture identified a neurological cause of cardiac arrest in 6/65 (9%) patients, including 5 with neurologic prodromal symptoms before cardiac arrest and 4 with the lumbar puncture done post-mortem. Lumbar puncture performed before death showed nonspecific cerebrospinal fluid abnormalities in 37/53 (69.8%) patients. By univariate analysis, factors significantly associated with cerebrospinal fluid abnormalities were shorter no-flow time (0 min [0-3] versus 4 min [2-10], p=0.004) and post-resuscitation shock (26 [70%] versus 5 [31%], pp=0.06). Conclusions: Lumbar puncture, although rarely performed, can contribute to the aetiological diagnosis of cardiac arrest. As a second-line investigation, it identified the cause in 9% of our patients. Nonspecific cerebrospinal fluid abnormalities are common after cardiac arrest, perhaps due to blood-brain barrier disruption, and may carry prognostic significance.

International audience; Aim: Coronary artery disease (CAD) has recently been emphasized as a major cause of sudden cardiac arrest (SCA) in young adults. We aim to assess the rate of immediate coronary angiography performance in young patients resuscitated from SCA.Methods: From May 2011 to May 2017, all cases of out-of-hospital SCA aged 18-40 years alive at hospital admission were prospectively included in 48 hospitals of the Great Paris area. Cardiovascular causes of SCA were centrally adjudicated, and management including immediate coronary angiography performance was assessed.Results: Out of 3579 SCA admitted alive, 409 (11.4%) patients were under 40 years of age (32.3 ± 6.2 years, 69.7% males), with 244 patients having a definite cause identified. Among those, CAD accounted for 72 (29.5%) cases, of which 64 (88.9%) were acute coronary syndromes. The rate of immediate coronary angiography was only 41.7% compared to 65.1% among those ≥40-years (P < 0.001). During the study period, while the rate of immediate coronary angiography increased from 60.5% to 70.3% (P < 0.001) in patients aged ≥40 years, the rate in patients aged less than 40 years remained stable (43.5% to 45.3%, P = 0.795). Patients younger than 40 years were significantly less likely to undergo immediate coronary angiography (OR = 0.34, 95% CI: 0.25-0.47), although early angiography was associated with survival at hospital discharge (OR = 2.68, 95% CI: 1.21-6.00).Conclusion: CAD is the first cause of SCA in young adults aged less than 40 years. The observed low rates of immediate coronary angiography suggest a missed opportunity for early intervention.

Purpose Recent doubts regarding the efficacy may have resulted in a loss of interest for targeted temperature management (TTM) in comatose cardiac arrest (CA) patients, with uncertain consequences on outcome. We aimed to identify a change in TTM use and to assess the relationship between this change and neurological outcome. Methods We used Utstein data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (capturing CA data from all secondary and tertiary hospitals located in the Great Paris area, France) between May 2011 and December 2017. All cases of non-traumatic OHCA patients with stable return of spontaneous circulation (ROSC) were included. After adjustment for potential confounders, we assessed the relationship between changes over time in the use of TTM and neurological recovery at discharge using the Cerebral Performance Categories (CPC) scale. Results Between May 2011 and December 2017, 3925 patients were retained in the analysis, of whom 1847 (47%) received TTM. The rate of good neurological outcome at discharge (CPC 1 or 2) was higher in TTM patients as compared with no TTM (33% vs 15%, P P P P P = 0.76). After adjustment, year of CA occurrence was not associated with outcome. Conclusions We report a progressive decrease in the use of TTM in post-cardiac arrest patients over the recent years. During this period, neurological outcome remained stable, despite an increase in bystander-initiated resuscitation and a decrease in “no flow” duration.

Background Adrenal gland volume is associated with survival in septic shock. As sepsis and post-cardiac arrest syndrome share many pathophysiological features, we assessed the association between adrenal gland volume measured by computerized tomography (CT)-scan and post-cardiac arrest shock and intensive care unit (ICU) mortality, in a large cohort of out-of-hospital cardiac arrest (OHCA) patients. We also investigated the association between adrenal hormonal function and both adrenal gland volume and outcomes. Patients and Methods Prospective analysis of CT-scan performed at hospital admission in patients admitted after OHCA (2007–2012). A pair of blinded radiologist calculated manually adrenal gland volume. In a subgroup of patients, plasma cortisol was measured at admission and 60 min after a cosyntropin test. Factors associated with post-cardiac arrest shock and ICU mortality were identified using multivariate logistic regression. Results Among 775 patients admitted during this period after OHCA, 138 patients were included: 72 patients (52.2%) developed a post-cardiac arrest shock, and 98 patients (71.1%) died. In univariate analysis, adrenal gland volume was not different between patients with and without post-cardiac arrest shock: 10.6 and 11.3 cm3, respectively (p = 0.9) and between patients discharged alive or dead: 10.2 and 11.8 cm3, respectively (p = 0.4). Multivariate analysis confirmed that total adrenal gland volume was associated neither with post-cardiac arrest shock nor mortality. Neither baseline cortisol level nor delta between baseline and after cosyntropin test cortisol levels were associated with adrenal volume, post-cardiac arrest shock onset or mortality. Conclusion After OHCA, adrenal gland volume is not associated with post-cardiac arrest shock onset or ICU mortality. Adrenal gland volume does not predict adrenal gland hormonal response.

Introduction: Hanging-induced Out-of-Hospital cardiac arrest (OHCA) is poorly studied and a better understanding of these specific OHCA could be helpful to improve patients’ outcome. The main objective of our study was to describe characteristics and outcomes in patients who had OHCA from hanging injuries. Methods: From May 2011 to December 2017 we analyzed a prospectively collected Utstein database for all OHCA adults. All cases due to hanging were included. Utstein style variables were compared for 2 groups of patients: those with a Return of Spontaneous Circulation (ROSC) and those without (non-ROSC). Continuous data are described as means (extremes). Results: Among 25 055 OHCA, 500 patients were included. They were 49 (18-100) years old. Seventy-three (14.6%) hanging were witnessed and 58 (11.6%) benefited from a bystander cardiopulmonary resuscitation before Emergency Medical Service (EMS) arrival. No-flow duration was 29.1 (4-180) minutes. Advance life support was initiated by EMS in 299 (59.8%) cases. Low-flow duration was 23.8 (2-79) minutes. Nine patients (1.8%) had a shockable initial rhythm. We observed 83 (16.6%) ROSC. Four (0.8%) patients were discharged alive from hospital. They were all CPC 1. Table 1 compares characteristics with significant differences between ROSC and non-ROSC groups. Conclusion: As expected, younger age, short no-flow and low-flow durations and shockable rhythm on EMS arrival were significantly associated with ROSC. Overall prognosis is dramatically poor when OHCA is due to hanging (

Little is known about the association between provision of post-resuscitation care and prognosis of out-of-hospital cardiac arrest (OHCA) in elderly patients. Previous studies have suggested futility after 65 years of age.We aimed to evaluate the association of early coronary angiogram (CAG) followed if necessary by percutaneous coronary intervention (PCI), with favorable outcome after OHCA among elderly patients, compared to younger patients.Using a large French registry, we included all OHCA patients with an initial shockable rhythm, transported to hospital from 2011 to 2015. Favorable outcome was defined as hospital discharge with Cerebral Performance Category (CPC) 1 or 2. and were evaluated by multivariate logistic regression. Subgroup analyses were performed according to age groups:65, 65-75 and75 years.Among 1502 included patients, 31% were older than 65 and 12% older than 75 years. An early CAG was performed in 79%, 88% and 76% of patients below 65, between 65 and 75 and above 75, respectively (P = 0.002). The rate of patients discharged with CPC1 or 2 was 42% below 65, 38% between 65 and 75 and 24% above 75 (P 0.001). Among the whole population, early CAG (OR = 6.4, 95% CI = 3.9-10.5, P 0.001) was associated with favorable outcome. In subgroups analysis, CAG was associated with favorable outcome among patients65 and 65-75. In patients75, there was a trend towards a favorable outcome (OR2.9, 95CI = 0.9-9.1).In a large registry of OHCA survivors, the early CAG use was associated with a better prognosis. This benefit was persistent up to 75 years of age, suggesting that age alone should not guide the decision for early invasive strategy.

Introduction Although the survival rate after out-of-hospital cardiac arrest (OHCA) has increased over time, little is known about the return to work of OHCA survivors. We aim to evaluate prevalence and factors associated with return to work (RTW) in OHCA survivors. Patients and methods All consecutive OHCA survivors aged 18–65 years and discharged alive from a Paris tertiary intensive care unit between 2000 and 2013 were included. Pre-hospital care, in-hospital care, and after-hospital discharge data, such as work description (work location, job classification, nature of the job) were compared relative to work status and RTW. Factors associated with RTW were evaluated using multivariable logistic regression. Results 153 OHCA survivors were included in the analysis. Among them, 96 (62.8%) returned to work an average of 714 days after OHCA (SD 1031); mostly to the same job (n = 72, 75%). Six patients changed jobs (4%) and 12 reduced their activity (10.6%). Factors associated with RTW were younger age (adjusted odds ratio (aOR) 3.64 [1.10; 12.02]), being managers and professionals, and service and sales workers (compared to technicians and associate professionals, clerical support workers, respectively aOR 3.43 [1.05; 11.22] and 4.69 [1.14; 19.37]), and workplace occurrence (aOR 11.72 [1.37; 99.93]). Conclusion Two thirds of OHCA survivors, in the present study, returned to work. Patients with a higher-level job, and with the arrest occurring in the workplace, were more likely to return to work. Further research should include more details of job contents, evolution, financial consequences, as well as prevention practices related to work location.

The survival rate of out-of-hospital cardiac arrest (OHCA) remains extremely low, generally under 10%. Post-resuscitation care, and particularly early coronary reperfusion, may improve this outcome. The main objective of the present study was to determine whether patients with immediate coronary angiography at hospital admission (CAA) had a better outcome than patients without immediate CAA.This cohort analysis study was based on data extracted from the French National Cardiac Arrest registry (RéAC). To control for attribution bias, patients were matched using a propensity score, which included age clusters, low flow and no flow delays, initial rhythm and bystander cardiopulmonary resuscitation (CPR). The main endpoint was survival at day 30 (D30). Secondary endpoint was neurological recovery of survivors assessed by the Cerebral Performance Category (CPC) scale, with CPC 1 and 2 at D30 considered as a favorable outcome.From July 1st, 2011 to October 1st, 2016, 63394 OHCA were registered in the database, of which 39444 were of an unknown or suspected cardiac origin. After on-site resuscitation by a mobile medical team, 7584 patients were transported to a hospital facility. Among these patients, 4046 were retained in the analysis after matching for the aforementioned factors and constituted into 2 groups: immediate coronary angiography (iCAA) group (n = 2023) and non-immediate coronary angiography (niCAA) group (n = 2023). The survival rate at D30 after matching was 43.3% in the iCAA group versus 34.5% in the niCAA group (OD = 0.66 [0.58; 0.75], p 0.001). In the iCAA group, (n = 707) 36% of the patients at D30 were CPC 1-2 comparatively to (n = 539) 27.3% in the niCAA group (p 0.01).Both the survival and proportion of patients with favorable neurological recovery were significantly higher in patients who underwent an immediate coronary angiography after a resuscitated OHCA. These observational results warrant further exploration of the benefit of this invasive strategy in randomized studies.

Background Metabolic acidosis is frequently observed as a consequence of global ischemia–reperfusion after out-of-hospital cardiac arrest (OHCA). We aimed to identify risk factors and assess the impact of metabolic acidosis on outcome after OHCA. Methods We included all consecutive OHCA patients admitted between 2007 and 2012. Using admission data, metabolic acidosis was defined by a positive base deficit and was categorized by quartiles. Main outcome was survival at ICU discharge. Factors associated with acidosis severity and with main outcome were evaluated by linear and logistic regressions, respectively. Results A total of 826 patients (68.3% male, median age 61 years) were included in the analysis. Median base deficit was 8.8 [5.3, 13.2] mEq/l. Male gender (p = 0.002), resuscitation duration (p

Objectives This study sought to assess the relationship between an immediate invasive strategy and survival after an out-of-hospital cardiac arrest (OHCA) of presumed cardiac cause, according to prognosis evaluated on hospital arrival. Background An immediate coronary angiogram (CAG) may be associated with better outcome after OHCA in neurologically preserved patients but could be futile in other cases. Methods From May 2011 to May 2015, we collected data for all patients admitted in hospital after OHCA in Paris and its suburbs (France). Risk of in-hospital death was retrospectively calculated using the validated Cardiac Arrest Hospital Prognosis score, which includes age, setting, initial rhythm, durations from collapse to basic life support and from basic life support to return of spontaneous circulation, pH, and epinephrine dose. Independent predictors of survival at discharge (including immediate CAG) were assessed in multivariate logistic regression in each of the 3 pre-defined subgroups of Cardiac Arrest Hospital Prognosis score: low risk ( 200 points) for in-hospital death. Results A total of 1,410 patients were included and overall survival rate at hospital discharge was 32%. Distribution in the low-, medium-, and high-risk Cardiac Arrest Hospital Prognosis subgroups was 667 (47%), 469 (33%), and 274 patients (20%), respectively. The rate of early CAG was 86%, 66%, and 47% in the low-, medium-, and high-risk subgroups, respectively (p Conclusions In cardiac arrest patients, our results suggest that investigations regarding early CAG after OHCA should focus on patients with preserved neurological status.

BackgroundSudden cardiac arrest (SCA) accounts for 10% of adult mortality in Western populations. While several risk factors are observationally associated with SCA, the genetic architecture of SCA in the general population remains unknown. Furthermore, understanding which risk factors are causal may help target prevention strategies.MethodsWe carried out a large genome-wide association study (GWAS) for SCA (n=3,939 cases, 25,989 non-cases) to examine common variation genome-wide and in candidate arrhythmia genes. We also exploited Mendelian randomization methods using cross-trait multi-variant genetic risk score associations (GRSA) to assess causal relationships of 18 risk factors with SCA.ResultsNo variants were associated with SCA at genome-wide significance, nor were common variants in candidate arrhythmia genes associated with SCA at nominal significance. Using cross-trait GRSA, we established genetic correlation between SCA and (1) coronary artery disease (CAD) and traditional CAD risk factors (blood pressure, lipids, and diabetes), (2) height and BMI, and (3) electrical instability traits (QT and atrial fibrillation), suggesting etiologic roles for these traits in SCA risk.ConclusionsOur findings show that a comprehensive approach to the genetic architecture of SCA can shed light on the determinants of a complex life-threatening condition with multiple influencing factors in the general population. The results of this genetic analysis, both positive and negative findings, have implications for evaluating the genetic architecture of patients with a family history of SCA, and for efforts to prevent SCA in highrisk populations and the general community.

Introduction The cumulative burden of chronic health conditions could contribute to out-of-hospital cardiac arrest (OHCA) physiology and response to attempted resuscitation. Yet little is known about how chronic health conditions influence prognosis. We evaluated the relationship between cumulative comorbidity and outcome following ventricular fibrillation OHCA using 3 different scales. Methods We performed a cohort investigation of persons >= 18 years who suffered non-traumatic OHCA and presented with ventricular fibrillation between January 1, 2007 and December 31, 2013 in a metropolitan emergency medical service (EMS) system. Chronic conditions were ascertained from EMS reports. The primary relationship between cumulative comorbidity and outcome (survival to hospital discharge) used the Charlson Index and two other scales. Analyses used logistical regression (LR), multiple imputation and inverse probability weighting. Results During the study period 1166/1488 potential patients were included. The median Charlson Index was 1 (25th-75th%: 0–2). Overall survival was 43.9%. Comorbidity was associated with a dose-dependent decrease in the likelihood of survival. ompared to Charlson Score of 0, the odds ratio of survival was 0.68 (0.48–0.96) for Charslon of 1, 0.49 (0.35–0.69) for Charlson of 2, and 0.43 (0.30–0.61) for Charlson of >= 3 after adjustment for Utstein predictors using multivariable LR. This inverse comorbidity-survival association was similar for the other 2 scales and was observed for different clinical outcomes (admission to hospital, functional survival, 30-day survival, and 1-year survival). Conclusion Based on these results, cumulative comorbidity can help explain survival variability and improve prognostic accuracy. Whether information about cumulative comorbidity or specific health conditions can inform resuscitation care is unknown though the results suggest comorbidity may influence acute pathophysiology and treatment response.