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BACKGROUND Out-of-hospital cardiac arrest (OHCA) is associated with poor in-hospital outcomes. However, the impact of pre- and in-hospital factors on long-term survival, healthcare utilization and functional outcomes is ill-defined, mainly related to challenges combining disparate data sources. METHODS AND RESULTS Adult non-traumatic OHCAs from the British Columbia Cardiac Arrest Registry (Jan 2009 to Dec 2016) were linked to provincial datasets comprising co-morbidities, medications, cardiac procedures, mortality, and hospital admission and discharge. Among hospital-discharge survivors, the 3-year endpoint of mortality or mortality and all-cause readmission was examined using the Kaplan-Meier (KM) method and multivariable Cox model for predictors. Functional status, defined as the use of publicly funded home care and community services (HCCS) within 1-year post-discharge, was evaluated by logistic regression. Of 10,876 linked, emergency medical services (EMS)-treated OHCAs, 3230 were admitted to hospital. Compared to hospital non-survivors (n=1905), hospital survivors (n=1325) had fewer co-morbidities and were more likely to have favorable resuscitation characteristics (shockable rhythm, witnessed arrest, bystander CPR). Among hospital survivors, 78.6% were treated with mechanical ventilation, 69.1% received coronary angiography, 37.5% and 10.3% were revascularized via PCI or CABG, respectively, and 24.8% received an intracardiac defibrillator (ICD) prior to discharge. At 3 years post-discharge, the estimated Kaplan-Meier (KM) survival rate was 84.1% [95% CI: 81.7%, 86.1%] and freedom from death and all-cause readmission was 31.8% (CI: 29.0%, 34.7%) (Figure). Predictors of post-discharge 3-year mortality included: older age, history of heart failure (HF), history of chronic kidney disease (CKD), non-public cardiac arrest location, initial non-shockable rhythm, and concomitant HF on admission; predictors of a lower risk of death included EMS witnessed arrest (HR 0.61, 95% CI: 0.40, 0.93), revascularization (HR 0.42, 95% CI: 0.28, 0.63), or ICD implant (HR 0.44, 95% CI: 0.27, 0.71). After excluding patients receiving HCCS prior to OHCA, 23.7% (n=289/1218) had poor functional outcome. Predictors of poor functional outcome included age > 75, female sex, history of CKD, non-public cardiac arrest location, initial non-shockable rhythm, and mechanical ventilation; ICD implantation was associated with a lower risk of poor functional status (OR 0.55, 95% CI: 0.38, 0.81). CONCLUSION While the long-term death or readmission risk persists even among OHCA hospital survivors, only 1 in 4 survivors accessed HCCS 1-year post-discharge, indicating overall good functional outcome. These results show that post-discharge outcomes are strongly influenced by both pre- and in-hospital factors, and supports efforts to improve care processes to increase survival to hospital discharge.

Out-of-hospital cardiac arrest (OHCA) affects 134 per 100,000 citizens annually. Extracorporeal cardiopulmonary resuscitation (ECPR), providing mechanical circulatory support, may improve the likelihood of survival among those with refractory OHCA. Compared with in-hospital ECPR candidates, those in the out-of-hospital setting tend to be sudden unexpected arrests in younger and healthier patients. The aims of this review were to summarize, and identify the limitations of, the evidence evaluating ECPR for OHCA, and to provide an approach for ECPR program application. Although there are many descriptions of ECPR-treated cohorts, we identified a paucity of robust data showing ECPR effectiveness compared with conventional resuscitation. However, it is highly likely that ECPR, provided after a prolonged attempt with conventional resuscitation, does benefit select patient populations compared with conventional resuscitation alone. Although reliable data showing the optimal patient selection criteria for ECPR are lacking, most implementations sought young previously healthy patients with rapid high-quality cardiopulmonary resuscitation. Carefully planned development of ECPR programs, in high-performing emergency medical systems at experienced extracorporeal membrane oxygenation centres, may be reasonable as part of systematic efforts to determine ECPR effectiveness and globally improve care. Protocol evaluation requires regional-level assessment, examining the incremental benefit of survival compared with standard care, while accounting for resource utilization.

Recent research and contemporary ST elevation myocardial infarction guidelines emphasize the importance of prompt reperfusion and have redefined the traditional time to treatment metric to include prehospital paramedical staff as the point of first medical contact. However, an important knowledge gap exists relating to data systematically addressing the impact of arrival at the hospital by ambulance and the delays inherent in transfer from a community hospital to tertiary centres for percutaneous coronary intervention (PCI).The Which Early ST Elevation Myocardial Infarction Therapy (WEST) study initiated treatment at the point of first medical contact, including prehospital contact. Patients were randomly assigned to receive fibrinolysis with usual care or coupled with mechanical cointervention, or primary PCI. To assess the impact of this strategy on time to treatment, the following randomly assigned patient groups were compared: prehospital versus in-hospital; those arriving at the hospital by ambulance versus ambulatory self transport; and those whose initial hospital care was a community versus PCI centre.Of the 328 patients enrolled in the study, 221 received fibrinolysis and 107 received primary PCI. Compared with the in-hospital group, patients who underwent prehospital random assignment (44%, n=145) experienced a 48 min reduction in median (interquartile range) time from symptom onset to first study medication (87 min [65 min to 147 min] versus 135 min [95 min to 186 min]; P0.001) and a 56 min reduction in time to first balloon inflation (148 min [117 min to 214 min] versus 204 min [166 min to 290 min]; P0.001). Arrival by ambulance without prehospital random assignment (n=90) incurred a substantial delay from first medical contact to reperfusion (fibrinolysis 76 min [63 min to 105 min] and PCI 160 min [141 min to 212 min]) compared with prehospital random assignment (n=145; fibrinolysis 43 min [33 min to 54 min] and PCI 105 min [90 min to 127 min]) or ambulatory patients (n=93; fibrinolysis 47 min [32 min to 68 min] and PCI 108 min [85 min to 150 min]). Community (n=165) versus PCI hospital (n=163) random assignment was associated with a longer delay from first medical contact to reperfusion: fibrinolysis, 56 min versus 47 min (P=0.008) and primary PCI, 139 min versus 105 min (P=0.001).Prehospital diagnosis, random assignment and treatment substantially reduced treatment delay with both pharmacological and mechanical reperfusion. Those activating the prehospital medical response system without receiving prehospital random assignment experienced the longest delay from first medical contact to reperfusion, indicating a lost opportunity to enhance ST elevation myocardial infarction patient outcomes.