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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2010.08.003 Byline: Paul Chase, Ross Arena, Marco Guazzi, Jonathan Myers, Mary Ann Peberdy, Daniel Bensimhon Abstract: Peak oxygen consumption derived from cardiopulmonary exercise (CPX) testing provides important prognostic information in patients with heart failure (HF). The oxygen consumption at the ventilatory threshold (VT) has also been shown to be prognostic. However, the VT cannot always be detected in patients with HF. Other variables such as the difference between peak oxygen consumption and oxygen consumption at the VT (termed the functional aerobic reserve [FAR]) may also provide prognostic information. The purpose of this study was to determine the prognostic value of an undetectable VT and FAR. Article History: Received 19 March 2010; Accepted 7 August 2010

Background: Time to initial treatment is important in any response to out-of-hospital cardiac arrest (OHCA). The purpose of this paper was to quantify the time delay for providing initial EMS treatments supplemented by comparison with those of other EMS systems conducting clinical trials.Methods: Data were collected between 1/1/16-2/15/19. Dispatched, EMS-worked, adult OHCA cases occurring before EMS arrival were included and compared with published treatment time data. Response time and time-to-treatment intervals were profiled in both groups. Time intervals were calculated by subtracting the following timepoints from 9-1-1 call receipt: ambulance in route; at curb; patient contact; first defibrillation; first epinephrine; and first antiarrhythmic.Results: 342 subjects met study inclusion/exclusion. Mean time intervals (min [95%CI]) from 9-1-1 call receipt to the following EMS endpoints were: dispatch 0.1 [0.05-0.2]; at curb 5.0 [4.5, 5.5]; at patient 6.7 [6.1, 7.2];, first defibrillation initially shockable 11.7 [10.1, 13.3]; first epinephrine (initially shockable 15.0 [12.8, 17.2], initially non-shockable 14.8 [13.5, 15.9]), first antiarrhythmic 25.1 [22.0, 28.2]. These findings were similar to data in 5 published clinical trials involving 12,954 subjects.Conclusions: Delay to EMS treatments are common and may affect clinical outcomes. Neither Utstein out-of-hospital guidelines [1] nor U.S. Cardiac Arrest Registry to Enhance Survival (CARES) databases require capture of these elements. EMS is often not providing treatments quickly enough to optimize clinical outcomes. Further regulatory change/research are needed to determine whether OHCA outcome can be improved by novel changes such as enhancing bystander effectiveness through drone-delivered drugs/devices & real-time dispatcher direction on their use. [ABSTRACT FROM AUTHOR]

Background: Currently, ≤5% of bystanders witnessing an opioid overdose (OD) in the US administer antidote to the victim. A possible model to mitigate this crisis would be a system that enables 9-1-1 dispatchers to both rapidly deliver naloxone by drone to bystanders at a suspected opioid OD and direct them to administer it while awaiting EMS arrival.Methods: A simulated 9-1-1 dispatcher directed thirty subjects via 2-way radio to retrieve naloxone nasal spray from atop a drone located outside the simulation building and then administer it using scripted instructions. The primary outcome measure was time from first contact with the dispatcher to administration of the medication.Results: All subjects administered the medication successfully. The mean time interval from 9 -1-1 contact until antidote administration was 122 [95%CI 109-134] sec. There was a significant reduction in time interval if subjects had prior medical training (p = 0.045) or had prior experience with use of a nasal spray device (p = 0.030). Five subjects had difficulty using the nasal spray and four subjects had minor physical impairments, but these barriers did not result in a significant difference in time to administration (p = 0.467, p = 0.30). A significant number of subjects (29/30 [97%], p = 0.044) indicated that they felt confident they could administer intranasal naloxone to an opioid OD victim after participating in the simulation.Conclusions: Our results suggest that bystanders can carry out 9-1-1 dispatcher instructions to fetch drone-delivered naloxone and potentially decrease the time interval to intranasal administration which supports further development and testing of a such a system. [ABSTRACT FROM AUTHOR]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2005.09.012 Byline: Ross Arena (a), Marco Guazzi (b), Jonathan Myers (c), Mary Ann Peberdy (d) Abstract: The rate in which heart rate recovers from exercise has recently been shown to be a strong predictor of mortality in patients suspected of having coronary disease, but its prognostic value in patients with heart failure (HF) has not been explored. We sought to assess the prognostic utility of heart rate recovery (HRR) in patients with HF. Author Affiliation: (a) Department of Physical Therapy, Virginia Commonwealth University, Health Sciences Campus, Richmond, VA (b) Cardiopulmonary Laboratory, Cardiology Division, University of Milano, San Paolo Hospital, Milano, Italy (c) Cardiology Division, VA Palo Alto Health Care System, Stanford University, Palo Alto, CA (d) Department of Internal Medicine, Virginia Commonwealth University, Health Sciences Campus, Richmond, VA Article History: Received 29 April 2005; Accepted 14 September 2005

Abstract: Both commercial aviation and resuscitation are complex activities in which team members must respond to unexpected emergencies in a consistent, high quality manner. Lives are at stake in both activities and the two disciplines have similar leadership structures, standard setting processes, training methods, and operational tools. Commercial aviation crews operate with remarkable consistency and safety, while resuscitation team performance and outcomes are highly variable. This commentary provides the perspective of two physician–pilots showing how commercial aviation training, operations, and safety principles can be adapted to resuscitation team training and performance. [Copyright &y& Elsevier]

Abstract: Background: An estimated 350,000–750,000 adult, in-hospital cardiac arrest (IHCA) events occur annually in the United States. The impact of resuscitation system errors on survival during IHCA resuscitation has not been evaluated. The purpose of this paper was to evaluate the impact of resuscitation system errors on survival to hospital discharge after IHCA. Methods and results: We evaluated subjective and objective errors in 118,387 consecutive, adult, index IHCA cases entered into the Get with the Guidelines National Registry of Cardiopulmonary Resuscitation database from January 1, 2000 through August 26, 2008. Cox regression analysis was used to determine the relationship between reported resuscitation system errors and other important clinical variables and the hazard ratio for death prior to hospital discharge. Of the 108,636 patients whose initial IHCA rhythm was recorded, resuscitation system errors were committed in 9,894/24,467 (40.4%) of those with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) and in 22,599/84,169 (26.8%) of those with non-VF/pVT. The most frequent system errors related to delay in medication administration (>5min time from event recognition to first dose of a vasoconstrictor), defibrillation, airway management, and chest compression performance errors. The presence of documented resuscitation system errors on an IHCA event was associated with decreased rates of return of spontaneous circulation, survival to 24h, and survival to hospital discharge. The relative risk of death prior to hospital discharge based on hazard ratio analysis was 9.9% (95% CI 7.8, 12.0) more likely for patients whose initial documented rhythm was non-VF/pVT when resuscitation system errors were reported compared to when no errors were reported. It was 34.2% (95% CI 29.5, 39.1) more likely for those with VF/pVT. Conclusions: The presence of resuscitation system errors that are evident from review of the resuscitation record is associated with decreased survival from IHCA in adults. Hospitals should target the training of first responders and code team personnel to emphasize the importance of early defibrillation, early use of vasoconstrictor medication, and compliance with ACLS protocols. [Copyright &y& Elsevier]

Cardiopulmonary exercise testing (CPX) might aid in the diagnosis of coronary artery disease. However, a heterogeneous clinical population without previous workup bias has not been studied nor has a more extensive list of CPX variables. A total of 303 subjects (age 49.9 ± 11.6 years, 157 men) with symptoms suggestive of coronary artery disease underwent CPX and a single photon emission computed tomographic myocardial perfusion study (MPS). Ventilatory efficiency was calculated using the oxygen uptake efficiency slope (OUES). The change in the OUES was calculated by subtracting the OUES response during the first 50% of CPX from the OUES obtained during the last 25% of CPX. A negative change in the OUES (<0) from the first 50% to the last 25% of CPX was predictive of positive MPS findings only in the male subjects. The diagnostic significance of the change in OUES in men was found for any level (including equivocal studies) of positive MPS findings (area under the curve 0.67, 95% confidence interval 0.59 to 0.76, p <0.0001) and was even stronger in those with a more definitive (excluding equivocal studies) perfusion defect (area under the curve 0.76, 95% confidence interval 0.67 to 0.85; relative risk 5.4, 95% confidence interval 2.1 to 13.8, p <0.0001). In conclusion, this is the first time that a change in ventilatory efficiency, assessed using the OUES, has been shown to be predictive of positive MPS findings However, the OUES change only provided diagnostic information for men, a finding that warrants additional analysis. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine If the attainment of at least 85% of age-predicted maximal heart rate (APMHR), using the equation 220-age, and/or at least 25,000 as the product of maximal heart rate and systolic blood pressure (rate pressure product, RPP) is an accurate indicator of exertion level during exercise stress testing. PATIENTS AND METHODS: From May 1, 2009, to February 15, 2010,238 patients (mean ± SD age, 49.3±11.9 years; 50% male) with symptoms suggestive of myocardial ischemia underwent an exercise stress test with the addition of ventilatory expired gas analysis and a myocardial perfusion study. Ventilatory expired gas analysis determined the peak respiratory exchange ratio (RER), which is considered a valid and reliable variable for quantifying a patient's exertion during exercise. RESULTS: Of the patients, 207 (87%) attained a peak RER of 1.00 or more, and 123 (52%) attained a peak RER of 1.10 or more. An APMHR of 85% or more and peak RPP of 25,000 or more were both ineffective in identifying patients who put forth a maximal exercise effort (ie, peak RER, ≥1.10). Perceived exertion was a significant indicator (P=.04) of patient exertion, with a threshold of 15 (6-20 scale) being an optimal cut point. The percentage of equivocal myocardial perfusion study results was significantly higher in patients who demonstrated a submaximal exercise effort by peak RER (P≤.007). CONCLUSION: Aerobic exercise testing is an integral component in the assessment of patients with suspected myocardial ischemia. Our findings indicate that the currently used percentage of APMHR and peak RPP thresholds are ineffective in quantifying a patient's level of exertion during exercise stress testing. [ABSTRACT FROM AUTHOR]

Abstract: Background: Cardiopulmonary exercise testing (CPET) provides powerful information on risk of death in heart failure (HF). We sought to define the relative and additive contribution of the 3 landmark (CPET) prognostic markers—peak oxygen consumption (VO2), minute ventilation/carbon dioxide production (VE/VCO2) slope, and exercise periodic breathing (EPB)—to the overall risk of cardiac death and to develop a prognostic score for optimizing risk stratification in HF patients. Methods and Results: A total of 695 stable HF patients (average LVEF: 25 ± 8%) underwent a symptom-limited CPET maximum test after familiarization and were prospectively tracked for cardiac mortality. At multivariable Cox analysis EPB emerged as the strongest prognosticator. Using a statistical bootstrap technique (5000 data resamplings), point estimates, and 95% confidence intervals were obtained. Thirty-two configurations were adopted to classify patients into a given cell, according to EPB presence or absence and values of the 2 other covariates. Configurations without EPB and with VE/VCO2 slope ≤30 were not significantly different from 0 (reference value). Statistical power of configurations increased with higher VE/VCO2 slope and lower peak VO2. This prompted us to formulate a score including EPB as a discriminating variable, the (P)e(R)i(O)dic (B)reathing during (E)xercise (PROBE), which ranges between -1 and 1, with zero as reference configuration, that would help to optimize the prognostic accuracy of CPET-derived variables. The greatest PROBE score impact was provided by EPB, followed by VE/VCO2 slope, whereas peak VO2 added minimal prognostic power. Conclusions: EPB with an elevated VE/VCO2 slope leads to the highest and most precise PROBE score, whereas no additional risk information emerges when EPB is present with a peak VO2 ≤10 mL O2·kg−1·min−1. PROBE score appears to provide a step forward for optimizing CPET use in HF prognostic definition. [Copyright &y& Elsevier]

Abstract: Context: Hypothermia improves neurological outcome for comatose survivors of out-of-hospital cardiac arrest. Use of computer controlled high surface area devices for cooling may lead to faster cooling rates and potentially improve patient outcome. Objective: To compare the effectiveness of surface cooling with the standard blankets and ice packs to the Arctic Sun, a mechanical device used for temperature management. Design, setting, and patients: Multi-center randomized trial of hemodynamically stable comatose survivors of out-of-hospital cardiac arrest. Intervention: Standard post-resuscitative care inducing hypothermia using cooling blankets and ice (n =30) or the Arctic Sun (n =34). Main outcome measures: The primary end point was the proportion of subjects who reached a target temperature within 4h of beginning cooling. The secondary end points were time interval to achieve target temperature (34°C) and survival to 3 months. Results: The proportion of subjects cooled below the 34°C target at 4h was 71% for the Arctic Sun group and 50% for the standard cooling group (p =0.12). The median time to target was 54min faster for cooled patients in the Arctic Sun group than the standard cooling group (p <0.01). Survival rates with good neurological outcome were similar; 46% of Arctic Sun patients and 38% of standard patients had a cerebral performance category of 1 or 2 at 30 days (p =0.6). Conclusions: While the proportion of subjects reaching target temperature within 4h was not significantly different, the Arctic Sun cooled patients to a temperature of 34°C more rapidly than standard cooling blankets. Trial registration: ClinicalTrials.gov NCT00282373, registered January 24, 2006. [Copyright &y& Elsevier]

Abstract: Aim of the review: To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome. Methods: Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment. Results: The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology. Conclusions: A growing body of knowledge suggests that the individual components of the postcardiac arrest syndrome are potentially treatable. [Copyright &y& Elsevier]

Abstract: Background: Patients with heart failure (HF) have abnormal cellular anatomy and myocardial mechanics that may impact the initial rhythm and subsequent outcomes in cardiac arrest (CA). Hypothesis: Patients with pre-existing HF are less likely to have ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) as the first documented rhythm in CA and have poorer survival than patients without pre-existing HF. Purpose: Identify the first documented cardiac arrest rhythm (FDR) in hospitalized patients with and without a pre-existing history of HF. Methods: We evaluated 60,389 consecutive, adult, index, pulseless CA events with documented initial rhythm in the National Registry of Cardiopulmonary Resuscitation. The primary endpoint was the FDR in patients with and without a history of pre-existing HF. Secondary endpoints were return of spontaneous circulation (ROSC), survival to discharge, and neurological outcome. Results: Thirty three percent of patients had a pre-existing diagnosis of HF. HF patients were more likely to have VF/pVT (25.9 vs. 23.2%) and less likely to have asystole (34.4 vs. 35.3%, p =<.0001) than non-HF. There was no difference in survival to discharge (18.3 vs. 18.2%, p =.66), or good neurological outcomes (82.2 vs. 83.2%, p =.23) between the groups. Women were less likely to have VF/pVT as the first documented rhythm in both HF and non-HF groups. Conclusions: Hospitalized patients with HF are more likely than those without HF to have VF/pVT as the FDR in CA, however the clinical magnitude of this difference is small. Overall survival and neurological outcomes are no different than hospitalized arrest patients without HF. [Copyright &y& Elsevier]

Abstract: Background: The lowest minute ventilation (VE) and carbon dioxide production (VCO2) ratio during exercise has been suggested to be the most stable and reproducible marker of ventilatory efficiency in patients with heart failure (HF). However, the prognostic power of this index is unknown. Methods and Results: A total of 847 HF patients underwent cardiopulmonary exercise testing (CPX) and were followed for 3 years. The associations between the lowest VE/VCO2 ratio, maximal oxygen uptake (peak VO2), the VE/VCO2 slope, and major events (death or transplantation) were evaluated using proportional hazards analysis; adequacy of the predictive models was assessed using Akaike information criterion (AIC) weights. There were 147 major adverse events. In multivariate analysis, the lowest VE/VCO2 ratio (higher ratio associated with greater risk) was similar to the VE/VCO2 slope in predicting risk (hazard ratios [HR] per unit increment 2.0, 95% CI 1.1–3.4, and 2.2, 95% CI 1.3–3.7, respectively; P < .01), followed by peak VO2 (HR 1.6, 95% CI 1.1–2.4, P =.01). Patients exhibiting abnormalities for all 3 responses had an 11.6-fold higher risk. The AIC weight for the 3 variables combined (0.94) was higher than any single response or any combination of 2. The model including all 3 responses remained the most powerful after adjustment for β-blocker use, type of HF, and after applying different cut points for high risk. Conclusions: The lowest VE/VCO2 ratio adds to the prognostic power of conventional CPX responses in HF. [Copyright &y& Elsevier]

Abstract: Background: Quality of chest compressions (CC) is an important determinant of resuscitation outcome for cardiac arrest patients. Purpose: To characterize the quality of CC performed by hospital personnel, evaluate for predictors of CC performance, and determine the effects of audiovisual feedback on CC performance. Methods: Seven hundred and fifty four individuals participated in a CPR quality improvement challenge at 30 US hospitals. Participants performed 2min of CC on a manikin with an accelerometer-based system for measuring both rate (CC/min) and depth (in.) of CC (AED Plus:ZOLL Medical). Real-time audiovisual feedback was disabled. A subset of participants performed a second trial of CC with the audiovisual feedback prompts activated. Results: Mean depth of CC was below AHA minimum guidelines (<1.5in.) for 34% (1.30±0.14in.) and above maximum guidelines (>2.0in.) for 12% of participants (2.20±0.22in.). Depth of CC was greater for male vs. female (p <0.001) and younger vs. older (p =0.009) but did not differ between ACLS, BCLS, and non-certified participants (p =0.6). Predictors of CC depth included CC rate (r part =−0.34, p <0.0001), gender (r part =0.13, p =0.001), and age (r part =−0.09, p =0.02). Mean depth of CC increased, mean rate decreased, and variance in CC depth and rate declined when feedback was used (p ≤0.0001 vs. without feedback). The percentage of CC performed within AHA guidelines (1.5–2in.) improved from 15 to 78% with feedback. Conclusions: The quality of CC performed by personnel at US hospitals as judged by their performance on a manikin is often suboptimal. Quality of CC can be improved with use of CPR feedback technologies. [Copyright &y& Elsevier]

Abstract: Aim of the review: To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome. Methods: Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment. Results: The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology. Conclusions: A growing body of knowledge suggests that the individual components of the postcardiac arrest syndrome are potentially treatable. [Copyright &y& Elsevier]

Abstract: A prospective, multicenter trial was conducted in patients with nontraumatic chest pain in 4 hospitals to determine whether an 80-lead body surface map electrocardiogram system (80-lead BSM ECG) improves detection of ST-segment elevation in acute myocardial infarction (STEMI) compared with a standard 12-lead electrocardiogram (ECG) in an emergency department (ED) setting. A trained ED or cardiology staff member (technician or nurse) recorded a 12-lead ECG and 80-lead BSM ECG from each subject at initial presentation. Serial biomarkers (total creatine kinase [CK], CK-MB, and/or troponin) were obtained according to individual hospital practice. Of the 647 patients evaluated, 589 had available biomarkers results. Eighty-lead BSM ECG improved detection of biomarker-confirmed STEMI compared with the 12-lead ECG for CK-MB–defined STEMI (100% vs 72.7%, P = .031; n = 364) or troponin-defined STEMI (92.9% vs 60.7%, P = .022; n = 225). Specificity for STEMI was high (range, 94.9%-97.1%) with no significant difference between 80-lead BSM ECG and 12-lead ECG. Right ventricular involvement complicating inferior STEMI was detected by 80-lead BSM ECG in 2 (22%) of 9 patients with CK-MB–defined MI and in 2 (22%) of 9 patients with troponin-defined MI. The infarct location missed most commonly on 12-lead ECG but detected by 80-lead BSM ECG was inferoposterior MI. We conclude that BSM using 80-lead BSM ECG is more sensitive for detection of STEMI than 12-lead ECG, while retaining similar specificity. [Copyright &y& Elsevier]

Objective: The aim of this study is to evaluate the predictive accuracy of a cardiopulmonary exercise test (CPX) score. Background: Cardiopulmonary exercise test responses, including peak VO2, markers of ventilatory inefficiency (eg, the VE/VCO2 slope and oxygen uptake efficiency slope [OUES]), and hemodynamic responses, such as heart rate recovery (HRR) and chronotropic incompetence (CRI) are strong predictors of outcomes in patients with heart failure (HF). However, there is a need for simplified approaches that integrate the additive prognostic information from CPX. Methods: At 4 institutions, 710 patients with HF (568 male/142 female, mean age 56 ± 13 years, resting left ventricular ejection fraction 33 ± 14%) underwent CPX and were followed for cardiac-related mortality and separately for major cardiac events (death, hospitalization for HF, transplantation, left ventricular assist device implantation) for a mean of 29 ± 25 months. The age-adjusted prognostic power of peak VO2, VE/VCO2 slope, OUES (VO2 = a log10VE + b), resting end-tidal carbon dioxide pressure (PetCO2), HRR, and CRI were determined using Cox proportional hazards analysis, optimal cutpoints were determined, the variables were weighted, and a multivariate score was derived. Results: There were 175 composite outcomes. The VE/VCO2 slope (≥34) was the strongest predictor of risk and was attributed a relative weight of 7, with weighted scores for abnormal HRR (≤6 beats at 1 minute), OUES (>1.4), PetCO2 (<33 mm Hg), and peak VO2 (≤14 mL kg−1 min−1) having scores of 5, 3, 3, and 2, respectively. Chronotropic incompetence was not a significant predictor and was excluded from the score. A summed score >15 was associated with an annual mortality rate of 27% and a relative risk of 7.6, whereas a score <5 was associated with a mortality rate of 0.4%. The composite score was the most accurate predictor of cardiovascular events among all CPX responses considered (concordance indexes 0.77 for mortality and 0.75 for composite outcome composed of mortality, transplantation, left ventricular assist device implantation, and HF-related hospitalization). The summed score remained significantly associated with increased risk after adjusting for age, gender, body mass index, ejection fraction, and cardiomyopathy type. Conclusion: A multivariable score based on readily available CPX responses provides a simple and integrated method that powerfully predicts outcomes in patients with HF. [Copyright &y& Elsevier]

Background: The resting partial pressure of end-tidal carbon dioxide (Petco 2) has been shown to reflect cardiac performance in acute care settings in patients with heart failure (HF). The purpose of the present study was to compare the prognostic ability of the partial pressure of Petco 2 at rest to other commonly collected resting variables in patients with systolic HF. Methods: A total of 353 patients (mean age 58.6 ± 13.7, 72% male) with systolic HF were included in this study. All patients underwent cardiopulmonary exercise testing where New York Heart Association (NYHA) class, resting Petco 2, peak oxygen consumption, and the minute ventilation/carbon dioxide production slope were determined. Subjects were then followed for major cardiac events (mortality, left ventricular assist device implantation implantation, urgent heart transplantation). Results: There were 104 major cardiac events during the 23.6 ± 17.0-month tracking period. Multivariate Cox regression analysis revealed NYHA class (χ2 28.7, P < .001), left ventricular ejection fraction (residual χ2 21.7, P < .001), and resting Petco 2 (residual χ2 14.1, P < .001) were all prognostically significant and retained in the regression. In a separate Cox regression analysis, left ventricular ejection fraction (residual χ2 8.8, P = .003), NYHA class (residual χ2 7.7, P = .005), and resting Petco 2 (residual χ2 5.7, P = .02) added prognostic value to the minute ventilation/carbon dioxide production slope (χ2 26.0, P < .001). Conclusion: Resting Petco 2 can be noninvasively collected from subjects in a short period, at a low cost, and with no risk or discomfort to the patient. Given the prognostic value demonstrated in the present study, the clinical assessment of resting Petco 2 in the HF population may be warranted. [Copyright &y& Elsevier]

Abstract: Background: Ventilatory efficiency, commonly assessed by the minute ventilation (VE)-carbon dioxide production (VCO2) slope, has proven to be a strong prognostic marker in the heart failure (HF) population. Recently, the oxygen uptake efficiency slope (OUES) has demonstrated prognostic value, but additional comparisons to established cardiopulmonary exercise test (CPET) variables are required. Methods and Results: A total of 341 subjects were diagnosed with HF participated in this analysis. The VE/VCO2 slope and the OUES were calculated using 50% (VE/VCO2 slope50 or OUES50) and 100% (VE/VCO2 slope100 or OUES100) of the exercise data. Peak oxygen consumption (VO2) was also determined. There were 47 major cardiac-related events during the 3-year tracking period. Receiver operating characteristic (ROC) curve analysis demonstrated the classification schemes for both VE/VCO2 slope and OUES calculations as well as peak VO2 were statistically significant (all areas under the ROC curve: ?0.74, P < .001). Area under the ROC curve for the VE/VCO2 slope100 was, however, significantly greater than OUES50, OUES100, and peak VO2 (P < .05). Conclusions: Although the OUES was a significant predictor of mortality, the VE/VCO2 slope maintained optimal prognostic value. An elevated VE/VCO2 slope may be the single best indicator of increased risk for adverse events. [Copyright &y& Elsevier]

Summary: The adverse event (AE) profile of lay volunteer CPR and public access defibrillation (PAD) programs is unknown. We undertook to investigate the frequency, severity, and type of AE''s occurring in widespread PAD implementation. Design: A randomized-controlled clinical trial. Setting: One thousand two hundred and sixty public and residential facilities in the US and Canada. Participants: On-site, volunteer, lay personnel trained in CPR only compared to CPR plus automated external defibrillators (AEDs). Intervention: Persons experiencing possible cardiac arrest receiving lay volunteer first response with CPR+AED compared with CPR alone. Main outcome measure: An AE is defined as an event of significance that caused, or had the potential to cause, harm to a patient or volunteer, or a criminal act. AE data were collected prospectively. Results: Twenty thousand three hundred and ninety six lay volunteers were trained in either CPR or CPR+AED. One thousand seven hundred and sixteen AEDs were placed in units randomized to the AED arm. There were 26,389 exposure months. Only 36 AE''s were reported. There were two patient-related AEs: both patients experienced rib fractures. There were seven volunteer-related AE''s: one had a muscle pull, four experienced significant emotional distress and two reported pressure by their employee to participate. There were 27 AED-related AEs: 17 episodes of theft involving 20 devices, three involved AEDs that were placed in locations inaccessible to the volunteer, four AEDs had mechanical problems not affecting patient safety, and three devices were improperly maintained by the facility. There were no inappropriate shocks and no failures to shock when indicated (95% upper bound for probability of inappropriate shock or failure to shock=0.0012). Conclusions: AED use following widespread training of lay-persons in CPR and AED is generally safe for the volunteer and the patient. Lay volunteers may report significant, usually transient, emotional stress following response to a potential cardiac arrest. Within the context of this prospective, randomized multi-center study, AEDs have an exceptionally high safety profile when used by trained lay responders. [Copyright &y& Elsevier]

Abstract: Background: Cardiopulmonary exercise testing (CPET) variables provide valuable prognostic information in the heart failure (HF) population. The purpose of the present study is to assess the ability of resting end-tidal carbon dioxide partial pressure (PETCO2) to predict cardiac-related events in patients with HF. Methods: 121 subjects diagnosed with compensated HF underwent CPET on an outpatient basis. Mean age and ejection fraction were 49.3 years (±14.7) and 28.4% (±13.4), respectively. Resting PETCO2 was determined immediately prior to the exercise test in the seated position. Peak oxygen consumption (VO2) and the minute ventilation-carbon dioxide production (VE/VCO2) slope were also acquired during CPET. Results: There were 41 cardiac-related hospitalizations and 9 cardiac-related deaths in the year following CPET. Mean resting PETCO2, peak VO2 and VE/VCO2 slope were 34.1 mmHg (±4.6), 14.5 ml•kg−1•min−1 (±5.1) and 35.9 (±8.7) respectively. Univariate Cox regression analysis revealed that resting PETCO2 (Chi-square=28.4, p <0.001), peak VO2 (Chi-square=21.6, p <0.001) and VE/VCO2 slope (Chi-square=54.9, p <0.001) were all significant predictors of cardiac related events. Multivariate Cox regression analysis revealed resting PETCO2 added to the prognostic value of VE/VCO2 slope in predicting cardiac related events (residual Chi-square=4.4, p =0.04). Peak VO2 did not add additional value and was removed (residual Chi-square=3.2, p =0.08). Conclusions: These results indicate a resting ventilatory expired gas variable possesses prognostic value independently and in combination with an established prognostic marker from the CPET. Resting PETCO2 may therefore be a valuable objective measure to obtain during both non-exercise and exercise evaluations in patients with HF. [Copyright &y& Elsevier]

The National Registry of Cardiopulmonary Resuscitation (NRCPR) is an American Heart Association (AHA)-sponsored, prospective, multisite, observational study of in-hospital resuscitation. The NRCPR is currently the largest registry of its kind. The purpose of this article is to describe the NRCPR and to provide the first comprehensive, Utstein-based, standardized characterization of in-hospital resuscitation in the United States. All adult (≥18 years of age) and pediatric (<18 years of age) patients, visitors, employees, and staff within a facility (including ambulatory care areas) who experience a resuscitation event are eligible for inclusion in the NRCPR database. Between January 1, 2000, and June 30, 2002, 14 720 cardiac arrests that met inclusion criteria occurred in adults at the 207 participating hospitals. An organized emergency team is available 24 h a day, 7 days a week in 86% of participating institutions. The three most common reasons for cardiac arrest in adults were (1) cardiac arrhythmia, (2) acute respiratory insufficiency, and (3) hypotension. Overall, 44% of adult in-hospital cardiac arrest victims had a return of spontaneous circulation (ROSC); 17% survived to hospital discharge. Despite the fact that a primary arrhythmia was one of the precipitating events in nearly one half of adult cardiac arrests, ventricular fibrillation (VF) was the initial pulseless rhythm in only 16% of in-hospital cardiac arrest victims. ROSC occurred in 58% of VF cases, yielding a survival-to-hospital discharge rate of 34% in this subset of patients. An automated external defibrillator was used to provide initial defibrillation in only 1.4% of patients whose initial cardiac arrest rhythm was VF. Neurological outcome in discharged survivors was generally good. Eighty-six percent of patients with Cerebral Performance Category-1 (CPC-1) at the time of hospital admission had a postarrest CPC-1 at the time of hospital discharge. [Copyright &y& Elsevier]

Abstract: Background: The development of advanced life support (ALS) termination of resuscitation (TOR) guidelines for out-of-hospital cardiac arrest (OHCA) seeks to improve the efficiency of scarce pre-hospital resources. However, as pre-hospital treatment for OHCA evolves and survival improves, these TOR guidelines must be reevaluated in the contemporary context of emergency medical services (EMS) providing access to advanced resuscitation care. Methods: Retrospective review of all adult (>18 years old), non-traumatic, OHCA patients (defined as patients with absence of pulse who received either CPR and/or defibrillation) treated by EMS in Richmond, VA, from January 1, 2009 to December 31, 2010. In addition to standard ALS, intra-arrest cold saline, mechanical CPR, and transportation to a comprehensive post-resuscitation center (CPRC) was provided. Patient treatment and outcomes were recorded via prehospital patient care reports and data were evaluated against previously established criteria for termination of resuscitation in an ALS EMS system. According to the aforementioned previously described criteria for TOR, patients meeting a single criterion for transport are recommended to be transported emergently to a comprehensive post-resuscitation care facility. Conversely, patients failing to meet any of the TOR criteria can be presumed to be expired without exception. Survival at 180 days was presumed when death could not be verified from publically reportable sources. Results: Of the 322 OHCA patients enrolled, the majority were male (59%), unwitnessed (52%), received no bystander CPR (67%), and presented in a non-shockable initial rhythm (79%), with an average age of 62.5 years. Overall survival was 17%, 14%, 12%, and 11% at 7, 14, 30, and 180 days, respectively. Of the 75 patients for which TOR guidelines recommended termination, none survived yielding both 100% specificity (95% CI 100–92.8%) and positive predictive value (95% CI 100–94.1%). However, TOR guidelines recommended transport of 208 of the 283 patients who died within 30 days, resulting in a sensitivity of 26.5% (95% CI 34.5–23.4%). Conclusion: The TOR guidelines continue to have a reliable positive predictive value for death even in the setting of advanced EMS resuscitation methods and access to a CPRC. However, as the potential for survival from OHCA improves, the efficiency gained from their use is impacted greatly. [Copyright &y& Elsevier]

Abstract: Objectives: Identify the occurrence rate of post-arrest psychological distress; evaluate methodological approaches; suggest future research priorities; address clinical implications. Methods: The electronic databases PubMed/MEDLINE and PsychInfo/APA PsycNET were utilized to search for terms including ‘Cardiac Arrest’, ‘Therapeutic Hypothermia’ and ‘Depression’, ‘Anxiety’, ‘Quality of Life’, ‘Posttraumatic Stress Disorder (PTSD)’, ‘Psychological Outcomes’, ‘Hospital Anxiety and Depression Scale (HADS)’, and ‘Beck Depression Inventory (BDI)’. Results: High rates of psychological distress have been reported after OHCA. Specifically, incidence rates of depression have ranged from 14% to 45%; anxiety rates have ranged from 13% to 61%; PTSD rates reportedly range from 19% to 27%. Variability between studies is likely attributable to methodological variations relating to measures used, time since arrest, and research setting. Discussion: Given the occurrence rate of psychological distress after OHCA, psychological screening and early intervention seems indicated in the cardiac arrest population. Further studies are needed to better establish occurrence rates in both inpatient and outpatient settings, determine appropriate measures and normative cut off scores, and decide on the most appropriate method of intervention. [Copyright &y& Elsevier]

Abstract: Objectives: To determine the rate of appropriate documentation of endotracheal tube (ET) position confirmation in the American Heart Association''s Get With the Guidelines-Resuscitation (GWTG-R) and to determine whether outcomes of patients who experience in-hospital cardiac arrest differ in relation to documentation rate. Design: Analysis of data from the GWTG-R, a prospective observational registry of in-hospital cardiac arrest and resuscitation. Setting: Database containing clinical information from the 507 hospitals participating in the GWTG-R. Patients: Adults resuscitated after in-hospital cardiac arrest. Measurements: The rate of appropriate documentation of ET position confirmation, defined as the use of capnography or an esophageal detector device (EDD); relationship between appropriate documentation of ET position confirmation and return of spontaneous circulation (ROSC) or survival to hospital discharge. Proportions with 95% CI are reported for prevalence data. Binary logistic regression was used to determine the relationship between appropriate documentation of ET position confirmation and outcome (ROSC, survival to hospital discharge). Adjusted and unadjusted odds ratios are reported. Main results: Of the 176,054 patients entered into the GWTG-R database, 75,777 had an ET placed. For 13,263 (17.5%) of these patients, ET position confirmation was not documented in the chart. Auscultation alone was documented in 19,480 (25.7%) cases. Confirmation of ET position by capnography or EDD was documented in 43,034 (56.8%) cases. ROSC occurred in 39,063 (51.6%), and 13,474 (17.8%) survived to discharge. Patients whose ET position was confirmed by capnography or EDD were more likely to have ROSC (adjusted OR 1.229 [1.179, 1.282]) and to survive to hospital discharge (adjusted OR 1.093 [1.033, 1.157]). Conclusion: Documentation of ET position confirmation in patients who experience cardiac arrest is suboptimal. Appropriate documentation of ET position confirmation in the GWTG-R is associated with greater likelihood of ROSC and survival to hospital discharge. [Copyright &y& Elsevier]

Abstract: Background: Previous investigations have established the prognostic value of variables obtained from both echocardiography with tissue Doppler Imaging (TDI) and cardiopulmonary exercise testing (CPX) in patients with heart failure (HF). Past prognostic comparisons of variables obtained from these evaluation techniques have been limited to the comparison of left ventricular ejection fraction (LVEF) vs. peak oxygen consumption (VO2). The present investigation undertakes a more thorough correlative and prognostic assessment. Methods: Two hundred and forty-three patients with HF (190 male/53 female, age: 62.2±9.7) underwent echocardiography with TDI and CPX to determine the following variables: 1) the ratio between mitral early (E) to mitral annular (E´) velocity, 2) LVEF, 3) LV mass, 4) LV end systolic volume (LVESV), 5) Peak VO2, 6) The minute ventilation/carbon dioxide production (VE/VCO2) slope, and 7) Exercise oscillatory ventilation (EOV). Results: There were 43 cardiac-related deaths during the four-year tracking period. In the multivariate analysis, E/E′ was the strongest prognostic variable (Chi-square: 46.1, p < 0.001). LV mass (Residual chi-square: 16.8, p < 0.001), LVESV (Residual chi-square: 8.0, p =0.005) and the VE/VCO2 slope (Residual chi-square: 4.6, p = 0.03) all added significant predictive value and were retained in the regression. Conclusions: The results of the present study indicate several variables obtained from echocardiography with TDI are prognostically important in HF. The VE/VCO2 slope, which is one of the strongest prognostic markers obtained from CPX, adds prognostic value to these variables. A combined analysis of both noninvasive techniques may improve the prognostic characterization of patients with HF. [Copyright &y& Elsevier]

Summary: Background: Little is known about cardiac arrests (CA) in the Emergency Department (ED). The objective of this study was to determine the characteristics of ED CAs. Methods: 60,852 adult, in-patient CA events in the National Registry of Cardiopulmonary Resuscitation were included. Multiple regression analysis compared ED CA with those occurring in the ICU, telemetry, or general floors. Subgroup analysis examined traumatic vs. non-traumatic ED CA and ED CA occurring after a successful pre-hospital resuscitation (recurrent) vs. primary ED event. Results: In multivariate analysis, ED location predicted improved survival to discharge (OR 0.74, 95%CI [0.67–0.82]). ED CAs had higher survival to discharge rates (ED 22.2, ICU 15.5, Tele 19.8, Floor 10.8, p <0.0001), better cerebral performance category scores (ED 1.59, ICU 1.73, Tele 1.96, Floor 1.69, p <0.0001), and shorter post-event length of stays (ED 8.6, ICU 17.5, Tele 16.5, Floor 14.2 days, p <0.0001) than other locations. Recurrent ED CAs were less likely to survive to discharge (10.1% vs. 24.6%, p <0.0001) than primary events. Trauma-related ED CAs had a lower survival to discharge rate (7.5% vs. 23.8%, p <0.0001), were less likely to be caused by an arrhythmia (23.6% vs. 32.5%, p <0.0008), and more likely to be preceded by hypotension or shock (41.6% vs. 29.0%, p <0.0001) than non-trauma ED events. Conclusions: ED CAs have unique characteristics, and better survival and neurologic outcomes compared to other hospital locations. Primary ED CAs have a better chance of survival to discharge than recurrent events. Traumatic ED CAs have worse outcomes than non-traumatic CA. [Copyright &y& Elsevier]

Background: Mechanisms leading to heart failure (HF) are numerous. Etiology-based differences are, however, frequently not taken into account when assessing results of an exercise test. The purpose of this investigation is to: (1) compare subject characteristics and ventilatory expired gas measures demonstrating clinical value between subjects with ischemic and non-ischemic HF. (2) Examine the prognostic value of HF etiology. Methods: 71 subjects (44 male/27 female) diagnosed with compensated HF underwent exercise testing with ventilatory expired gas analysis. Mean age and ejection fraction (EF) were 51.3% (±12.8) and 27.0% (±12.5%) for the entire group. HF etiology was ischemic in 30 subjects (16 male/14 female) and non-ischemic in 41 (28 male/13 female). Results: Age (57.5±10.7 vs. 46.7±12.5, p<0.001), minute ventilation–carbon dioxide production (VE/VCO2) slope (39.5±9.1 vs. 32.6±7.7, p=0.001), and duration of phase 1 kinetics in seconds (46.0±23.0 vs. 30.0±15.6, p=0.001) were significantly higher while peak oxygen consumption (VO2) in ml O2 kg-1 min-1 (12.5±4.7 vs. 16.0±5.2, p=0.006) and partial pressure of end-tidal CO2 (PETCO2) in mm Hg at rest (32.1±4.8 vs. 36.1±8.0, p=0.02) and peak exercise (31.7±4.3 vs. 36.2±5.9, p=0.001) were significantly lower in the ischemic group. Difference in EF did not reach statistical significance (28.4% ±12.5%—ischemic vs. 26.1%±12.5%—non-ischemic, p=0.44). Ischemic etiology was additionally a significant predictor of cardiac-related events (p=0.04). Conclusions: These findings demonstrate noninvasive indicators of cardiac function and prognosis is poorer in subjects with ischemic HF etiology. Consideration of HF etiology may therefore be prudent, particularly when considering prognosis. [Copyright &y& Elsevier]

Background: Several prospective studies have demonstrated that the echocardiographic detection of any myocardial activity during PEA is strongly associated with higher rates of return of spontaneous circulation (ROSC). We hypothesized that PEA represents a spectrum of disease in which not only the presence of myocardial activity, but more specifically that the degree of left ventricular (LV) function would be a predictor of outcomes. The purpose of this study was to retrospectively assess the association between LV function and outcomes in patients with OHCA.Materials and Methods: Using prospectively obtained data from an observational cohort of patients receiving focused echocardiography during cardiopulmonary resuscitation (CPR) in the Emergency Department (ED) setting, we analyzed 312 consecutive subjects with available echocardiography images with initial rhythm of PEA. We used left ventricular systolic fractional shortening (LVFS), a unidimensional echocardiographic parameter to perform the quantification of LV function during PEA. Regression analyses were performed independently to evaluate for relationships between LVFS and a primary outcome of ROSC and secondary outcome of survival to hospital admission. We analyzed LVFS both as a continuous variable and as a categorial variable using the quartiles and the median to perform multiple different comparisons and to illustrate the relationship of LVFS and outcomes of interest. We performed survival analysis using Cox proportional hazards model to evaluate the hazard corresponding to length of resuscitation.Results: We found a positive association between LVFS and the primary outcome of ROSC (OR 1.04, 95%CI 1.01-1.08), but not with the secondary outcome of survival to hospital admission (OR 1.02, 95%CI 0.96-1.08). Given that the relationship was not linear and that we observed a threshold effect in the relationship between LVFS and outcomes, we performed an analysis using quartiles of LVFS. The predicted probability of ROSC was 75% for LVFS between 23.4-96% (fourth quartile) compared to 47% for LVFS between 0-4.7% (first quartile). The hazard of not achieving ROSC was significantly greater for subjects with LVFS below the median (13.1%) compared to the subgroup with LVFS greater than 13.1% (p < 0.05), with the separation of the survival curves occurring at approximately 40 min of resuscitation duration.Conclusions: Left ventricular function measured by LVFS is positively correlated with higher probability of ROSC and may be associated with higher chances of survival in patients with PEA arrest. [ABSTRACT FROM AUTHOR]

Abstract: Chronic phosphodiesterase-5 inhibition improves peak oxygen consumption, ventilatory efficiency (VE/VCO2 slope) and pulmonary artery pressure (PAP) in heart failure (HF). In 40 male patients, Sildenafil treatment produced a significant (p <0.001) decrease in dyspnea upon exertion (DOE) at maximal exercise. The correlations between the change in systolic PAP and both the change in the VE/VCO2 slope (r =0.57, p <0.001) and DOE at maximal exercise (r s =0.49, p <0.001) were significant. DOE at maximal exercise is significantly reduced and the degree of improvement in PAP is reflected by the degree of improvement in the VE/VCO2 slope and DOE following Sildenafil therapy. [ABSTRACT FROM AUTHOR]

Abstract: The purpose of this investigation was to examine the ability of heart rate recovery (HRR) to predict mortality secondary to pump failure or sudden cardiac death (SCD) in patients with heart failure (HF). Kaplan–Meier analysis revealed a significant difference in survival for both SCD (100% vs. 73.9%, log-rank: 50.5, p <0.001) and pump failure (96.1% vs. survival=78.4%, log-rank: 24.4, p <0.001) endpoints according to a

Focused transthoracic echocardiography (TTE) during cardiac arrest resuscitation can enable the characterization of myocardial activity, identify potentially treatable pathologies, assist with rhythm interpretation, and provide prognostic information. However, an important limitation of TTE is the difficulty obtaining interpretable images due to external and patient-related limiting factors. Over the last decade, focused transesophageal echocardiography (TEE) has been proposed as a tool that is ideally suited to image patients in extremis-those in cardiac arrest and periarrest states. In addition to the same diagnostic and prognostic role provided by TTE images, TEE provides unique advantages including the potential to optimize the quality of chest compressions, shorten cardiopulmonary resuscitation interruptions, guide resuscitative procedures, and provides a continuous image of myocardial activity. This review discusses the rationale, supporting evidence, opportunities, and challenges, and proposes a research agenda for the use of focused TEE in cardiac arrest with the goal to improve resuscitation outcomes. [ABSTRACT FROM AUTHOR]