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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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Background Respective proportions of final etiologies are disparate in cohorts of cardiac arrest patients, depending on examined population and diagnostic algorithms. In particular, prevalence and characteristics of sudden unexplained death syndrome (SUDS) are debated. We aimed at describing etiologies in a large cohort of aborted out-of-hospital cardiac arrest (OHCA) patients, in order to assess prevalence and outcome of SUDS. Patients and methods We analyzed data from our prospective registry of successfully resuscitated OHCA patients admitted to a cardiac arrest centre between January 2002 and December 2014. The in-ICU diagnostic strategy included early coronary angiogram, brain and chest CT scan. This was completed by an extensive diagnostic strategy, encompassing biological and toxicological tests, repeated electrocardiograms and echocardiography, MRI and pharmacologic tests. Two independent investigators reviewed each final diagnosis. Baseline characteristics were compared between subgroups of patients. Three-month mortality was compared between subgroups using univariate Kaplan-Meier curves. Results Over the study period, 1657 patients were admitted to our unit after an aborted OHCA. The event was attributed to a non-cardiac and a cardiac cause in 478 (32.0%) and 978 (65.5%) patients, respectively. The main cause of cardiac related OHCA was ischemic heart disease (76.7%) while primary electrical diseases accounted for only 2.5%. Sudden unexplained deaths (SUDS) were observed in 37 (2.5%) patients. Conclusion We observed that ischemic heart disease was by far the most common cause of cardiac arrest, while primary electrical diseases were much less frequent. SUDS accounted for a very small proportion of patients who suffered an aborted OHCA.

The impact of time of occurrence has been extensively evaluated for in-hospital cardiac arrests but less for Out-of-Hospital Cardiac Arrests (OHCA). We assessed the impact of the time of occurrence on the characteristics and prognosis of OHCA.Using data from the Paris Sudden Cardiac Death Expertise Center prospective study that includes all OHCA in the Paris Area, we compared characteristics and outcomes of off-hours OHCA (nights and days off) to regular-hours OHCA between 2011 and 2014.Among a total of 9834 OHCA (70.0±17years old, 62.1% males), off-hours OHCA accounted for 63.4%. Although bystanders were more often present (74.4 vs. 72.1%, P=0.01), rates of bystander CPR (46.7 vs. 50.6%, P=0.001) and AED use (1.0 vs. 1.9%, P=0.01) were lower during off-hours. While EMS arrival delays were similar, patients were less often in shockable rhythm (16.3 vs. 19.1%, P0.0001), and return of spontaneous circulation was less frequent (27.5 vs. 31.1%, P0.0001). There was no difference in rates of targeted temperature control (54.8 vs. 54.7%, P=0.75), coronary angiography (57.3 vs. 58.2%, P=0.68) and angioplasty use (32.2 vs. 35.6%, P=0.22). Survival at hospital discharge was lower (4.7 vs. 6.5%, P0.0001) during off-hours. After adjusting for potential confounders, time of occurrence was not associated with worse outcome (OR 0.85, 95% CI 0.69-1.06, P=0.15), and bystander-initiated CPR, shockable initial rhythm and AED use were the main survival predictors (P0.0001).Off-hours OHCA have a 30% lower survival rate, mainly due to differences in initial management (bystander CPR and AED use), illustrating the need to improve bystanders' responsiveness in all circumstances.

Background Even if a large majority of out-of-hospital cardiac arrest (OHCA) survivors appear to have a good neurological recovery with no important sequellae, whether health-related quality of life (HRQOL) is altered is less explored. Patients and methods HRQOL was evaluated by telephone interview using SF-36 questionnaire. Each OHCA case was age and gender-matched with 4 controls from the French general population. Association between current condition of the survivors with the 8 dimensions of the SF-36 questionnaire was investigated using MANCOVA. Cluster analysis was performed to identify patterns of HRQOL among CPC1 survivors. Results 255 patients discharged alive from our referral centre between 2000 and 2013 (median age of 55y [45,64], 73.7% males) were interviewed. Global physical and mental components did not differ between CPC 1 survivors and controls (47.0 vs. 47.1, p=0.88 and 46.4 vs. 46.9, p=0.45) but substantially differed between CPC2, CPC3 and the corresponding controls. Younger age, male gender, good neurological recovery and daily-life autonomy at telephone interview were significantly associated with better scores in each SF-36 dimensions. Cluster analysis individualized 4 distinct subgroups of CPC1 patients characterised by progressively increased score of SF-36. Return to work and daily-life autonomy were differently distributed across these 4 groups while pre-hospital Utstein variables were not. Conclusion HRQOL of CPC1 OHCA survivors appeared similar to that of the general population, but patients with CPC2 or 3 had altered HRQOL. Younger age, male gender, good neurological recovery and daily-life autonomy were independently associated with a better HRQOL.

Background Obesity prevalence has dramatically increased over recent years and is associated with cardiovascular diseases, but data are lacking on its prognostic impact in out-of-hospital cardiac arrest (OHCA) patients. Methods Data of all consecutive OHCA patients admitted in two cardiac arrest centers from Paris and suburbs between 2005 and 2012 were prospectively collected. Patients treated by therapeutic hypothermia (TH) were included in the analysis. Logistic and Cox regression analyses were used to quantify the association between body mass index (BMI) at hospital admission and day-30 and 1-year mortality respectively. Results 818 patients were included in the study (median age 60.9 [50.8–72.7] year, 70.2% male). Obese patients (BMI>30kgm −2 ) were older, more frequently male and evidenced more frequently cardiovascular risk factors than normally (18.5 −2 ) or overweight patients (25 −2 ). Post-resuscitation shock and therapeutic hypothermia failure were more frequent in obese patients. Overall mortality at day-30 and one-year was 63.8 and 67.2%, respectively. After multivariate adjustment, BMI>30kgm −2 was independently associated with day-30 mortality (Odds ratio [OR] in comparison with normally weight patients 2.45; 95% confidence interval [95%CI: 1.32–4.56; p Conclusion In the present study, obesity was independently associated with day-30 mortality in successfully resuscitated ICU TH OHCA patients. Further studies are needed to understand the mechanisms that underpin this finding.

Despite the cardiovascular benefits of regular sports, sudden cardiac arrest (SCA) risk is increased during or shortly after exercise. Association with coronary artery disease (CAD) has been described in small studies, mainly autopsic with potential bias given the high sports-related SCA survival, and focusing on young competitive athletes, whereas sports-related SCA occurs mostly in recreational athletes. 1-5 Through the Paris Sudden Death Expertise Center prospective registry that includes all SCAs in Paris and suburbs since May 2011, we performed the first broad comprehensive CAD description in sports-related SCAs, with a comparison with matched non-sports-related SCAs.

Objective After out-of-hospital cardiac arrest (OHCA) associated with obstructive coronary artery disease (CAD), the risk of recurrence during the early period is unclear and the indication for anti-arrhythmic treatment is debated. We assessed the incidence and predisposing factors for severe cardiac arrhythmias in this population. Design Retrospective study in a cardiac arrest center. Settings The primary endpoint was the occurrence of major cardiac arrhythmias from hospital admission to intensive care unit (ICU) discharge in patients admitted after an OHCA associated with obstructive CAD. A major arrhythmia was defined as any arrhythmic event (auricular or ventricular) associated with cardiac arrest recurrence and/or severe arterial hypotension. Secondary outcomes were time from ICU admission to arrhythmia occurrence and all-cause in-ICU mortality. Risk factors for recurrence of a major arrhythmia were assessed using multivariate analysis. Patients We included all consecutive OHCA patients resuscitated from ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) as initial rhythm associated with obstructive CAD, and who had a successful primary percutaneous coronary intervention. Intervention None. Measurements and main results Among 256 patients, a major arrhythmia occurred in 29 (11.3%), within the first 24 h in 79.3% of cases and were mostly VF (44.8%). Mortality rate was significantly increased in patients with major arrhythmia recurrence (69% vs 41%; p = 0.006). Factor significantly associated with recurrence of severe arrhythmia was male gender (OR 0.32 [0.12–0.92]; p = 0.034). Treatment with prophylactic anti-arrhythmic in the ICU was not associated with a change in the risk of recurrence (OR 0.85 [0.21–3.65], p = 0.82). Conclusion An early recurrence of major arrhythmia was observed in more than 10% of post-cardiac arrest patients. These events happened mostly within the first 24 h. The interest of prophylactic anti-arrhythmic treatment remains to be evaluated in this population.

Summary Background Post cardiac arrest shock (PCAS) occurring after resuscitated cardiac arrest (CA) is a main cause of early death. Extracorporeal life support (ECLS) could be useful pending recovery from myocardial failure. Aim To describe our PCAS population, and the factors associated with initiation of ECLS. Methods This analysis included 921 patients admitted to two intensive care units between 2005 and 2014 for CA and PCAS; 43 of these patients had ECLS initiated. Neurological and ECLS-related outcomes were gathered retrospectively. Results The 43 patients treated with ECLS were predominantly (70%) young males with evidence of myocardial infarction on coronary angiography. ECLS was initiated in patients with severe cardiovascular dysfunction (median left ventricular ejection fraction 15% [interquartile range 10–25%]), a median of 9 hours [interquartile range 6–16 hours] after the CA. At 1 year, eight patients (19%) had survived without neurological disability. Blood lactate and coronary aetiology were associated with neurological outcomes. Logistic regression conducted using 878 controls with PCAS identified age > 62 years, location of CA, use of a high dose of adrenaline (> 3 mg) and blood lactate and serum creatinine concentrations (> 5 mmol/L and > 109 μmol/L, respectively) as risk factors for initiation of ECLS. Conclusions ECLS, as a salvage therapy for PCAS, could be an acceptable alternative for highly-selected patients.

Introduction Quantitative waveform measures are a surrogate of the acute physiological status of the myocardium and predict survival following ventricular fibrillation out-of-hospital cardiac arrest (OHCA). We investigated whether the amplitude spectrum area (AMSA) waveform measure mediates the adverse relationship between increasing burden of chronic health conditions and lower likelihood of survival. Methods We performed a cohort investigation of persons > = 18 years who suffered ventricular fibrillation OHCA between 2008–2015 in a metropolitan emergency medical service (EMS) system. The count of chronic health conditions was determined using the Charlson Comorbidity Index (CCI). AMSA was calculated just prior to the initial shock. We used multivariable logistic regression to assess the relationship between CCI and survival-to-discharge in models first without and then with AMSA to determine the extent to which AMSA attenuated the CCI-survival association. Results Of the 716 eligible patients, 422/716 (59%) had at least one chronic health condition; 21.8% with one, 19.6% with two, 10.3% with 3, and 7.3% with ≥4. Survival-to-discharge was 45% (324/716). In the multivariable model adjusted for traditional Utstein characteristics, increasing CCI was associated with lower odds of survival (Odds ratio (OR) (95% confidence interval] = 0.82 [0.72, 0.93] for each additional chronic health condition). The addition of AMSA to the model only modestly attenuated the CCI-survival association (OR = 0.85 [0.74,0.98]). Conclusion The waveform measure AMSA – a surrogate for the physiological status of the myocardium – mediated only a modest portion of the association between increasing burden of chronic health conditions and lower likelihood of survival following ventricular fibrillation OHCA.

International audience; Purpose: To evaluate the predictive value of EEG reactivity assessment and confounders for neurological outcome after cardiac arrest.Methods: All consecutive patients admitted in a tertiary cardiac arrest center between 2007 and 2016 still alive 48 h after admission with at least one EEG recorded during coma. EEG reactivity was defined as a reproducible waveform change in amplitude or frequency following standardized stimulation. Each EEG was classified based on American Clinical Neurophysiology Society nomenclatures and classified in highly malignant (including status epilepticus), malignant, or benign EEG. We assessed the predictive values of EEG reactivity and sedation effect for neurologic outcome at ICU discharge using the Cerebral Performance Category scale (with CPC 1-2 assumed as favorable outcome and CPC 3-4-5 considered as poor outcome).Results: Among 428 patients, a poor outcome was observed in 80% patients. The median time to EEG recording was 3 (1-4) days and 51% patients had a non-reactive EEG. The positive predictive value (PPV) of a non-reactive EEG to predict an unfavorable outcome was 97.1% (IC95% 93.6-98.9), increasing to 98.3% (IC95 94.1-99.8) when the EEG had been performed without sedation. In multivariate analysis, a non-reactive EEG was associated with poor outcome (OR 12.6 IC95% 4.7-33.6; p < 0.001). In multivariate analysis, concomitant sedation was not statistically associated with EEG non-reactivity. The PPV of a benign EEG to predict favorable outcome was 49.7% (IC95% 41.5-57.9), increasing to 66.2% (IC95% 54.3-76.8) when EEG was recorded earlier, with ongoing sedation.Conclusions: After cardiac arrest, absence of EEG reactivity was predictive of unfavorable outcome. By contrast, a benign EEG was slightly predictive of a favorable outcome. Reactivity assessment may have important implications in the neuroprognostication process after cardiac arrest and could be influenced by sedation.

Emergency management of deliberate self-poisoning (DSP) by drug overdose is common in emergency medicine. There is a paucity of data about the prehospital care of these patients. The principal aim was to describe the intensity of care received by patients with DSP who were managed by prehospital emergency medical service (EMS) physicians. A 48-h cross-sectional study was conducted in 319 EMS and emergency units in France. Patient and poisoning characteristics and treatments administered were recorded. Complications of poisoning, hospitalization, intensive care unit admission and death were recorded until day 30. The primary endpoint was the probability of receiving prehospital intensive care, including fluid resuscitation, vasopressor therapy, invasive ventilation, or antidotal treatments, depending whether prehospital treatment was carried out by an EMS physician or not. Data from 703 patients (median age was 43 [30-52] years, 288 (40%) men) were analyzed. One hundred and fifteen (16%) patients were attended by an EMS physician. Patients attended by EMS physicians were more likely to receive intensive treatment in the prehospital setting [odds ratio (OR) 7.4, 95% confidence interval 4.3-12.9]. These patients had more severe poisoning as suggested mainly by a lower Glasgow Coma Score (13 [8-15] vs. 15 [15-15]; p 0.001) and a higher rate of admission to an intensive care unit [29 (25%) vs. 15 (2%), p 0.001]. Patients with DSP attended by prehospital EMS physicians frequently received intensive care. The level of care seemed appropriate for the severity of the poisoning.

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.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.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 ( P0.001). Patient and socio-demographic characteristics significantly differed between neighborhoods ( P for trend0.001). After adjustment, a higher density of ambulances was associated with successful return of spontaneous circulation (respectively adjusted odds-ratio [aOR], 1.31 [1.14-1.51]; P0.001 for ALS ambulances1.5 per neighborhood and aOR, 1.21 [1.04-1.41]; P=0.01 for BLS ambulances4 per neighborhood). Regarding survival at discharge, only the number of ALS ambulances1.5 per neighborhood was significant (aOR, 1.30 [1.06-1.59] P=0.01).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.

Evaluate long-term neurologic outcome for paediatric survivors of OHCA.Subjects19 years who experienced OHCA from 1976-2007 and survived to hospital discharge were included. Demographics, neurologic outcomes and years of survival were determined using the King County Emergency Medical Service cardiac arrest database, Seattle Children's Hospital medical records, Washington State Death Database and National Death Index. A Paediatric Cerebral Performance Category (PCPC) score (1-6) was determined for the index hospitalization discharge and all subsequent visits.From 1976-2007, 1683 cases of OHCA resulted in 91 survivors to hospital discharge. 18/91 survivors identified had pre-morbid conditions. 72/91 survivors had follow-up PCPC scores. Patients were: ≤5 years (53%) and 54% female. 33/35 patients with initial favorable neurologic outcomes (PCPC 1-2) maintained favorable neurologic status in long-term follow-up. 14/37 patients with initial unfavorable neurologic outcomes (PCPC 3-5) remained unfavorable over long-term follow-up. Six unfavorable patients showed some improvement, three of whom achieved favorable PCPC scores at last evaluation. One unfavorable patient declined from PCPC 4 to PCPC 5. Twenty patients with an initial unfavorable neurologic outcome died in long-term follow-up.In this cohort study of neurologic outcomes for paediatric OHCA survivors, a favorable initial PCPC score was highly associated with stable long-term neurological outcomes. Those with poor neurologic status at initial discharge were unlikely to improve and were at greatest risk to die in follow-up. Future studies should focus on improving neurologic outcomes and prospectively evaluating the long-term neurologic course.

OBJECTIVE To investigate the contribution of endotoxemia to the severity of postcardiac arrest shock. DESIGN A prospective monocentric study. SETTING A tertiary hospital in Paris, France. PATIENTS Patients admitted in our ICU after a successfully resuscitated out-of-hospital cardiac arrest. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Endotoxin measurement was performed in the 12 hours following return of spontaneous circulation using the endotoxin activity assay. Endotoxin level was classified as low (< 0.4 endotoxin activity), intermediate (0.4 to < 0.6 endotoxin activity), or high (≥ 0.6 endotoxin activity) according to manufacture guidelines. Severity of shock was assessed by the vasopressor-free days and by the mean daily dose of vasopressor to insure a mean arterial pressure of 65-75 mm Hg. Among 92 patients included in the study, 60 presented a postcardiac arrest shock. Endotoxemia level was higher in patients with postcardiac arrest shock. Among these patients, by multivariate linear regression, high endotoxin class (adjusted estimate -2.0; 95% CI, -3.90 to -0.11), public place of cardiac arrest (adjusted estimate, 1.47; 95% CI, 0.007 to 2.93), and time to return of spontaneous circulation (adjusted estimate -0.08; 95% CI, -0.13 to -0.03) were independently associated with the number of vasopressor-free days. Furthermore, high endotoxin class (adjusted estimate, 97.95; 95% CI, 20.5 to 175.4) and a nonshockable rhythm (adjusted estimate, 59.9; 95% CI, 6.2 to 113.7) were the sole factors independently associated with the mean daily dose of vasopressors. CONCLUSIONS In patients successfully resuscitated from cardiac arrest with a postcardiac arrest shock, high level of endotoxemia is independently associated with duration of postcardiac arrest shock and the amount of vasopressive drugs. Whether treatment targeting endotoxemia could be beneficial in the management of postcardiac arrest shock needs to be studied in further randomized controlled studies.

International audience; Background In this study, we primarily sought to assess the ability of flow cytometry to predict early clinical deterioration and overall survival in patients with sepsis admitted in the ED and ICU. Methods Patients admitted for community-acquired acute sepsis from 11 hospital centers were eligible. Early (day 7) and late (day 28) deaths were notified. Levels of CD64pos granulocytes, CD16pos monocytes, CD16dim immature granulocytes (IGs), and T and B lymphocytes were assessed by flow cytometry using an identical, cross-validated, robust, and simple consensus standardized protocol in each center. Results Among 1,062 patients screened, 781 patients with confirmed sepsis were studied (age, 67 ± 48 years; Simplified Acute Physiology Score II, 36 ± 17; Sequential Organ Failure Assessment, 5 ± 4). Patients were divided into three groups (sepsis, severe sepsis, and septic shock) on day 0 and on day 2. On day 0, patients with sepsis exhibited increased levels of CD64pos granulocytes, CD16pos monocytes, and IGs with T-cell lymphopenia. Clinical severity was associated with higher percentages of IGs and deeper T-cell lymphopenia. IG percentages tended to be higher in patients whose clinical status worsened on day 2 (35.1 ± 35.6 vs 43.5 ± 35.2, P =.07). Increased IG percentages were also related to occurrence of new organ failures on day 2. Increased IG percentages, especially when associated with T-cell lymphopenia, were independently associated with early (P andlt;.01) and late (P andlt;.01) death. Conclusions Increased circulating IGs at the acute phase of sepsis are linked to clinical worsening, especially when associated with T-cell lymphopenia. Early flow cytometry could help clinicians to target patients at high risk of clinical deterioration. Trial Registry ClinicalTrials.gov; No. NCT01995448; URL www.clinicaltrials.gov © 2018 American College of Chest Physicians

BACKGROUND The quick sequential organ failure assessment (qSOFA) score showed good prognostic performance in patients with suspicion of infection in the emergency department (ED). However, previous studies only assessed the performance of individual values of qSOFA during the ED stay. As this score may vary over short timeframes, the optimal time of measurement, and the prognostic value of its variation are unclear. The objective of the present study was to prospectively assess the prognostic value of the change in qSOFA over the first 3 h (ΔqSOFA = qSOFA at 3 h-qSOFA at inclusion). PATIENTS AND METHODS This is an international prospective cohort study conducted in 17 EDs in France, Belgium, and Spain. From November 2016 to March 2017, patients with a suspected infection and a qSOFA score of 2 or higher were included and followed up until death or hospital discharge. qSOFA was measured at inclusion, 1 h and 3 h. Primary end point was in-hospital mortality, truncated at 28 days. RESULTS Of 534 recruited patients, 512 were included in the analysis. The qSOFA was improved at 3 h (ΔqSOFA < 0) in 287 (55%) patients. Overall in-hospital mortality was 27%: 44% when ΔqSOFA greater than 0, 36% when ΔqSOFA = 0, and 18% when ΔqSOFA less than 0. A positive ΔqSOFA was independently associated with reduced in-hospital mortality (adjusted hazard ratio of 0.48, 95% confidence interval: 0.34-0.68). After modeling qSOFA kinetics in the first 3 h, there was a significant difference in adjusted slopes between patients who died and those who survived (0.15, 95% confidence interval: 0.09-0.22, P < 0.001). CONCLUSION In patients with suspected infection presenting to the ED with a qSOFA of 2 or higher, the early change in qSOFA is a strong independent predictor of mortality.

Considerable apprehension often surrounds the issue of sudden cardiovascular arrest (SCA) during physical activity, especially that related to sexual intercourse. Sex-related SCA (SxSCA) has been mainly investigated through forensic studies, and epidemiological data are scarce.1 A comparison of the characteristics and outcomes of SxSCA with other SCAs may allow a better understanding of this dramatic condition. The Paris-SDEC registry (Paris-Sudden Death Expertise Center) has been described previously.2 In brief, it is an ongoing, prospective, population-based study in Paris and its suburbs (population 6.7 million). Since May 2011, every case of out-of-hospital SCA aged ≥18 years has been captured, and systematic information has been gathered. Appropriate institutional review boards approved the investigation with waiver of informed consent. Utstein templates and medical records were reviewed by 2 cardiologists. Data from all patients with SCA alive at hospital admission were analyzed. SxSCA was defined as any SCA occurring during coitus or within the following hour, and its characteristics were compared with SCA occurring during other physical activities (exercise-non SxSCA), and at rest (sedentary), as well. All patients admitted alive with a normal coronary angiogram and clinical evidence for a neurological issue systematically underwent a computed …

The safety of the pulmonary embolism rule-out criteria (PERC), an 8-item block of clinical criteria aimed at ruling out pulmonary embolism (PE), has not been assessed in a randomized clinical trial.To prospectively validate the safety of a PERC-based strategy to rule out PE.A crossover cluster-randomized clinical noninferiority trial in 14 emergency departments in France. Patients with a low gestalt clinical probability of PE were included from August 2015 to September 2016, and followed up until December 2016.Each center was randomized for the sequence of intervention periods. In the PERC period, the diagnosis of PE was excluded with no further testing if all 8 items of the PERC rule were negative.The primary end point was the occurrence of a thromboembolic event during the 3-month follow-up period that was not initially diagnosed. The noninferiority margin was set at 1.5%. Secondary end points included the rate of computed tomographic pulmonary angiography (CTPA), median length of stay in the emergency department, and rate of hospital admission.Among 1916 patients who were cluster-randomized (mean age 44 years, 980 [51%] women), 962 were assigned to the PERC group and 954 were assigned to the control group. A total of 1749 patients completed the trial. A PE was diagnosed at initial presentation in 26 patients in the control group (2.7%) vs 14 (1.5%) in the PERC group (difference, 1.3% [95% CI, -0.1% to 2.7%]; P = .052). One PE (0.1%) was diagnosed during follow-up in the PERC group vs none in the control group (difference, 0.1% [95% CI, -∞ to 0.8%]). The proportion of patients undergoing CTPA in the PERC group vs control group was 13% vs 23% (difference, -10% [95% CI, -13% to -6%]; P .001). In the PERC group, rates were significantly reduced for the median length of emergency department stay (mean reduction, 36 minutes [95% CI, 4 to 68]) and hospital admission (difference, 3.3% [95% CI, 0.1% to 6.6%]).Among very low-risk patients with suspected PE, randomization to a PERC strategy vs conventional strategy did not result in an inferior rate of thromboembolic events over 3 months. These findings support the safety of PERC for very low-risk patients presenting to the emergency department.clinicaltrials.gov Identifier: NCT02375919.

International audience; Background: Lesbians, gays, and bisexual people (LGB) present high levels of suicidal ideation. The disclosure of sexual orientation is a stressful experience which presents a high suicide risk. Research has not paid sufficient attention to stress during this disclosure in order to understand suicide among LGB people. The aims of this study were to investigate: (1) the characteristics of stress during this revelation, more precisely cognitive appraisal, emotions, and coping; and (2) associations between these characteristics and suicidal ideation. Method: A total of 200 LGB young adults answered the ``Stressful situation assessment questionnaire'', focusing on the most stressful disclosure of sexual orientation they have ever experienced. Results: Avoidance coping is a good predictor of suicidal ideation, and mediates the association between primary appraisal (risk ``Harm myself and others'') and suicidal ideation. Conclusions: Our study illustrates the need to better understand stress during the disclosure of sexual orientation to prevent and care for suicide risk among LGB young adults.

Aim Due to collapse and cardiopulmonary resuscitation (CPR) maneuvers, major traumatic injuries may complicate the course of resuscitation for out-of-hospital cardiac arrest patients (OHCA). Our goals were to assess the prevalence of these injuries, to describe their characteristics and to identify predictive factors. Methods We conducted an observational study over a 9-year period (2007–2015) in a French cardiac arrest (CA) center. All non-traumatic OHCA patients admitted alive in the ICU were studied. Major injuries identified were ranked using a functional two-level scale of severity (life-threatening or consequential) and were classified as CPR-related injuries or collapse-related injuries, depending of the predominant mechanism. Factors associated with occurrence of a CPR-related injury and ICU survival were identified using multivariable logistic regression. Results A major traumatic injury following OHCA was observed in 91/1310 patients (6.9%, 95%CI: 5.6, 8.3%), and was classified as a life-threatening injury in 36% of cases. The traumatic injury was considered as contributing to the death in 19 (21%) cases. Injuries were related to CPR maneuvers in 65 patients (5.0%, (95%CI: 3.8, 6.1%)). In multivariable analysis, age [OR 1.02; 95%CI (1.00, 1.04); p = 0.01], male gender [OR 0.53; 95%CI (0.31, 0.91); p = 0.02] and CA occurring at home [OR 0.54; 95%CI (0.31, 0.92); p = 0.02] were significantly associated with the occurrence of a CPR-related injury. CPR-related injuries were not associated with the ICU survival [OR 0.69; 95%CI (0.36, 1.33); p = 0.27]. Conclusions Major traumatic injuries are common after cardiopulmonary resuscitation. Further studies are necessary to evaluate the interest of a systematic traumatic check-up in resuscitated OHCA patients in order to detect these injuries.

Although guidelines on post-resuscitation care recommend the use of short-acting agents for sedation during targeted temperature management (TTM) after cardiac arrest (CA), the potential advantages of this strategy have not been clinically demonstrated.We compared two sedation regimens (propofol-remifentanil, period P2, vs midazolam-fentanyl, period P1) among comatose TTM-treated CA survivors. Management protocol, apart from sedation and neuromuscular blockers use, did not change between the two periods. Baseline severity was assessed with Cardiac-Arrest-Hospital-Prognosis (CAHP) score. Time to awakening was measured starting from discontinuation of sedation at the end of rewarming. Awakening was defined as delayed when it occurred after more than 48 h.460 patients (134 in P2, 326 in P1) were included. CAHP score did not significantly differ between P2 and P1 (P = 0.93). Sixty percent of patients awoke in both periods (81/134 vs. 194/326, P = 0.85). Median time to awakening was 2.5 (IQR 1-9) hours in P2 vs. 17 (IQR 7-60) hours in P1. Awakening was delayed in 6% of patients in P2 vs. 29% in P1 (p 0.001). After adjustment, P2 was associated with significantly lower odds of delayed awakening (OR 0.08, 95% CI 0.03-0.2; P 0.001). Patients in P2 had significantly more ventilator-free days (25 vs. 24 days; P = 0.007), and lower catecholamine-free days within day 28. Survival and favorable neurologic outcome at discharge did not differ across periods.During TTM following resuscitation from CA, sedation with propofol-remifentanil was associated with significantly earlier awakening and more ventilator-free days as compared with midazolam-fentanyl.

International audience; Trajectories of gender identity were examined from Grade 6 (Mage = 11.9 years) to Grade 9 in European French (n = 570) and North African French (n = 534) adolescents, and gender and ethnic group differences were assessed in these trajectories. In Grade 6, boys of both ethnic groups reported higher levels of gender typicality and felt pressure for gender conformity than girls. European French girls and boys and North African French girls reported decreasing gender typicality from Grade 6 to Grade 9, whereas North African French boys did not change. Felt pressure decreased among girls, did not change in European French boys, and increased in North African French boys. Ethnic and gender differences in gender identity development are discussed.