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IMPORTANCE: There is wide variability among emergency medical systems (EMS) with respect to transport to hospital during out-of-hospital cardiac arrest (OHCA) resuscitative efforts. The benefit of intra-arrest transport during resuscitation compared with continued on-scene resuscitation is unclear. OBJECTIVE: To determine whether intra-arrest transport compared with continued on-scene resuscitation is associated with survival to hospital discharge among patients experiencing OHCA. DESIGN, SETTING, AND PARTICIPANTS: Cohort study of prospectively collected consecutive nontraumatic adult EMS-treated OHCA data from the Resuscitation Outcomes Consortium (ROC) Cardiac Epidemiologic Registry (enrollment, April 2011-June 2015 from 10 North American sites; follow-up until the date of hospital discharge or death [regardless of when either event occurred]). Patients treated with intra-arrest transport (exposed) were matched with patients in refractory arrest (at risk of intra-arrest transport) at that same time (unexposed), using a time-dependent propensity score. Subgroups categorized by initial cardiac rhythm and EMS-witnessed cardiac arrests were analyzed. EXPOSURES: Intra-arrest transport (transport initiated prior to return of spontaneous circulation), compared with continued on-scene resuscitation. MAIN OUTCOMES AND MEASURES: The primary outcome was survival to hospital discharge, and the secondary outcome was survival with favorable neurological outcome (modified Rankin scale

Importance Emergency medical services (EMS) deliver essential initial care for patients with out-of-hospital cardiac arrest (OHCA), but the extent to which patient outcomes vary between different EMS agencies is not fully understood. Objective To quantify variation in patient outcomes after OHCA across EMS agencies. Design, Setting, and Participants This observational cohort study was conducted in the Resuscitation Outcomes Consortium (ROC) Epistry, a prospective multicenter OHCA registry at 10 sites in North America. Any adult with OHCA treated by an EMS from April 2011 through June 2015 was included. Data analysis occurred from May 2017 to March 2018. Exposure Treating EMS agency. Main Outcomes and Measures The primary outcome was survival to hospital discharge. Secondary outcomes were return of spontaneous circulation at emergency department arrival and favorable functional outcome at hospital discharge (defined as a modified Rankin scale score ≤3). Multivariable hierarchical logistic regression models were used to adjust confounders and clustering of patients within EMS agencies, and calculated median odds ratios (MORs) were used to quantify the extent of residual variation in outcomes between EMS agencies. Results We identified 43 656 patients with OHCA treated by 112 EMS agencies. At EMS agency level, we observed large variations in survival to hospital discharge (range, 0%-28.9%; unadjusted MOR, 1.43 [95% CI, 1.34-1.54]), return of spontaneous circulation on emergency department arrival (range, 9.0%-57.1%; unadjusted MOR, 1.53 [95% CI, 1.43-1.65]), and favorable functional outcome (range, 0%-20.4%; unadjusted MOR, 1.54 [95% CI, 1.40-1.73]). This variation persisted despite adjustment for patient-level and EMS agency–level factors known to be associated with outcomes (adjusted MOR for survival 1.56 [95% CI 1.44-1.73]; adjusted MOR for return of spontaneous circulation at emergency department arrival, 1.50 [95% CI, 1.41-1.62]; adjusted MOR for functionally favorable survival, 1.53 [95% CI, 1.37-1.78]). After restricting analysis to those who survived more than 60 minutes after hospital arrival and including hospital treatment characteristics, the variation persisted (adjusted MOR for survival, 1.49 [95% CI, 1.36-1.69]; adjusted MOR for functionally favorable survival, 1.34 [95% CI, 1.20-1.59]). Conclusions and Relevance We found substantial variations in patient outcomes after OHCA between a large group of EMS agencies in North America that were not explained by documented patient-level and EMS agency–level variables.

We examined whether resuscitation care and outcomes vary by the racial composition of the neighborhood where out-of-hospital cardiac arrests (OHCAs) occur.To evaluate the association between bystander treatments (cardiopulmonary resuscitation and automatic external defibrillation) and timing of emergency medical services personnel on OHCA outcomes according to the racial composition of the neighborhood where the OHCA event occurred.This retrospective observational cohort study examined patients with OHCA from January 1, 2008, to December 31, 2011, using data from the Resuscitation Outcomes Consortium. Neighborhoods where OHCA occurred were classified by census tract, based on percentage of black residents: less than 25%, 25% to 50%, 51% to 75%, or more than 75%. Multilevel mixed-effects logistic regression modeling examined the association between racial composition of neighborhoods and OHCA survival, adjusting for patient, neighborhood, and treatment characteristics.Survival to discharge, return of spontaneous circulation on emergency department arrival, and favorable neurologic status at discharge.We examined 22 816 adult patients with nontraumatic OHCA at Resuscitation Outcomes Consortium sites in the United States. The median age of patients with OHCA was 64 years (interquartile range [IQR], 51-78). Compared with patients who experienced OHCA in neighborhoods with a lower proportion of black residents, those in neighborhoods with more than 75% black residents were slightly younger, were more frequently women, had lower rates of initial shockable rhythm, and less frequently experienced OHCA in a public location. The percentage of patients with OHCA receiving bystander cardiopulmonary resuscitation or a lay automatic external defibrillation was inversely associated with the percentage of black residents in neighborhoods. Compared with OHCA in predominantly white neighborhoods (25% black), those with OHCA in mixed to majority black neighborhoods had lower adjusted survival rates to hospital discharge (25%-50% black: odds ratio, 0.76; 95% CI, 0.61-0.93; 51%-75% black: odds ratio, 0.67; 95% CI, 0.49-0.90;75% black: odds ratio, 0.63; 95% CI, 0.50-0.79; P .001). There was similar mortality risk for black and white patients with OHCA in each neighborhood racial quantile. When the primary model included geographic site, there was an attenuated nonsignificant association between racial composition in a neighborhood and survival.Those with OHCA in predominantly black neighborhoods had the lowest rates of bystander cardiopulmonary resuscitation and automatic external defibrillation use and significantly lower likelihood for survival compared with predominantly white neighborhoods. Improving bystander treatments in these neighborhoods may improve cardiac arrest survival.

Background: During the last 5 years, many studies have produced conflicting results concerning the survival of women hospitalized with acute myocardial infarction (AMI). Objective: To determine if gender is associated with hospital mortality and long-term survival in individuals with AMI. Methods: This prospective study included 4255 consecutive women (34%) and 8076 (66%) men who developed AMI in 19 Seattle, Wash, area hospitals between January 1988 and June 1994. Key information was abstracted from hospital records and entered in the Myocardial Infarction Triage and Intervention registry database. In addition, data concerning survival and rehospitalization were obtained from the state of Washington and linked to the Myocardial Infarction Triage and Intervention registry. Results: In comparison with men, women were 8 years older, more often had history of congestive heart failure, hypertension, or diabetes mellitus, and less often had history of myocardial infarction or coronary surgery. During hospitalization, women were less likely to undergo coronary angiography, thrombolytic therapy, coronary angioplasty, or bypass surgery. After adjustment for covariates, women were 20% more likely to die in the hospital (odds ratio, 1.22; 95% confidence interval, 1.06-1.39), yet long-term survival was similar in the 2 groups (hazard ratio, 0.97; 95% confidence interval, 0.90-1.05). The use of thrombolytic therapy or revascularization during the index hospitalization did not change the association between gender and survival. Conclusions: All things being equal, women with AMI were more likely to die in the hospital, yet survival after hospital discharge did not differ according to gender. Appropriate treatment to reduce hospital mortality in women is needed. Arch Intern Med. 1997;157:1379-1384

Objective. —To determine the effect of prehospital-initiated vs hospital-initiated treatment of myocardial infarction on clinical outcome. Design. —Randomized, controlled clinical trial. Setting. —Multicenter study involving 19 hospitals and all paramedic systems in the Seattle, Wash, metropolitan area. Patients. —A total of 360 patients with symptoms for 6 hours or less, no risk factors for serious bleeding, and ST-segment elevation were selected by paramedics and a remote physician for inclusion into the trial. They represented 4% of patients with chest pain who were screened and 21% of those with acute infarction. Interventions. —Patients were allocated to have aspirin and alteplase treatment initiated before or after hospital arrival. Intravenous sodium heparin was administered to both groups in the hospital. Main Outcome Measure. —The primary endpoint was a ranked composite score (combining death, stroke, serious bleeding, and infarct size). The relation between time to treatment and outcome (composite score, infarct size, ejection fraction, and mortality) was also assessed. Results. — Initiating treatment before hospital arrival decreased the interval from symptom onset to treatment from 110 to 77 minutes (P Conclusion. —There was no improvement in outcome associated with initiating treatment before hospital arrival; however, treatment within 70 minutes of symptom onset—whether in the hospital or in the field—minimized the infarct process and its complications. (JAMA. 1993;270:1211-1216)

Manual of Cardiac Arrhythmias is one of a series of clinically oriented manuals on cardiovascular disease, electrocardiography, and arrhythmias authored by E. K. Chung. The text, like its predecessors, is understandably written for and primarily directed to the primary care physician. It is not intended to be, nor should it be regarded as, an exhaustive treatise of arrhythmias. "The contents," according to the author, "are intended to be clinical, concise, and practical, so that this manual will provide all readers with up-to-date materials that will assist them directly in the daily care of patients with common cardiac arrhythmias." Dr Chung neatly organizes a concise discussion of a broad variety of cardiac arrhythmias, ranging from typical supraventricular and ventricular arrhythmias to more unusual rhythm disturbances such as aberrant atrial conduction, atrial dissociation, and rhythms observed following cardiac transplantation. Rhythms are individually defined, well exemplified by a variety of figures and illustrations