postresuciated ideoventricular rythms

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Intensive Care Med (2007) 33:16281632DOI 10.1007/s00134-007-0633-z B R I E F R E P O R T

Min-Shan TsaiChien-Hua HuangHung-Ren Chen

Cheng-Chun HsiehWei-Tien ChangChiung-Yuan HsuMatthew Huei-Ming MaShyr-Chyr ChenWen-Jone Chen

Postresuscitation accelerated idioventricular

rhythm: a potential prognostic factor

for out-of-hospital cardiac arrest survivors

Received: 17 October 2006Accepted: 26 March 2007

Published online: 25 April 2007 Springer-Verlag 2007

M.-S. Tsai C.-H. Huang H.-R. Chen C.-C. Hsieh W.-T. Chang C.-Y. Hsu M. H.-M. Ma S.-C. Chen W.-J. Chen (u)National Taiwan University Hospital andCollege of Medicine, Department ofEmergency Medicine,No. 7 Chung-Shan S. Road, 100 Taipei,Taiwane-mail: [email protected].: +886-2-23562831Fax: +886-2-23223150

C.-H. Huang W.-T. Chang M. H.-M. Ma W.-J. ChenNational Taiwan University Hospital andCollege of Medicine, Division ofCardiology, Department of InternalMedicine,No. 7 Chung-Shan S. Road, 100 Taipei,Taiwan

Abstract Objective: Data are lackingon the relationship between postresus-

citation ECG and outcome in out-of-hospital cardiac arrest (OHCA). Weexamined the prognostic informationthat postresuscitation ECG rhythmcan provide for predicting outcomein OHCA survivors. Methods: Theretrospective observational studyenrolled 56 successfully resuscitatednontraumatic adult OHCA patients.Postresuscitation 12-lead ECGs ofthe enrolled patients were interpretedindependently by two cardiologists.We compared baseline clinical char-

acteristics, CPR process, and outcomein the 8 patients with postresuscitationaccelerated idioventricular rhythm(AIVR, n = 8) and the 48 withoutAIVR. Results: The AIVR grouphad a higher proportion of patientswith coronary artery disease (50%vs. 15%), initial ventricular tachycar-

dia/fibrillation rhythm (50% vs. 8%),and cardiac origin of OHCA (75%

vs. 23%). AIVR patients had longertotal CPR duration (32 vs. 18 min)and higher dose of epinephrine use(10 vs. 3 mg). Postresuscitation AIVRwas associated with an increasedincidence of repeated CPR within1 h after return of spontaneous cir-culation (38% vs. 4%), and lower7-day survival rate (0% vs. 50%).Conclusions: AIVR on postresusci-tation ECG offers a prognostic factorrelated to a higher repeated CPR ratewithin 1 h after return of spontaneous

circulation and a lower 7-day survivalrates in successfully resuscitatedOHCA victims.

Keywords Accelerated idioven-tricular rhythm Postresuscitationelectrocardiogram Out-of-hospitalcardiac arrest

Introduction

Many pre- and in-hospital factors including witnessed col-lapse, collapse-to-resuscitation interval, cardiac index, andneurological findings are associated with survival in pa-tients with out-of-hospital cardiac arrest (OHCA) [16].QRS duration on admission and discharge electrocardiog-raphy (ECG) are reported to predict in-hospital and long-term outcome in resuscitated patients [3]. However, theprognostic implication of postresuscitation ECG rhythm isunclear and information is limited. The objective of thisstudy was to determine the prognostic value of postresus-citation ECG rhythm to predict outcomes for OHCA sur-vivors.

Methods

This retrospective observational study was approvedby the Institutional Review Board and enrolled OHCAsurvivors from the Emergency Department of the NationalTaiwan University Hospital between February and Decem-ber 2005. Eligible patients included nontraumatic adult(> 18 years old) OHCA survivors. Exclusion criterion wasthe absence of analyzable postresuscitation 12-lead ECG.The university hospital is a tertiary-referred center hospi-tal with about 100,000 emergency department visits peryear [1, 7]. The emergency medical service configurationis a fire-based, single-tiered, basic-life-support and defib-rillation system described in our previous studies [8, 9].


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AIVR (n = 8) Non-AIVR (n =48) p

Sex: M/F 7/1 (88%/12%) 25/23 (52%/48%) 0.120Age (years) 76.7 (60.185.9) 78.3 (64.983.9) 0.972Diabetes mellitus 2 (25%) 15 (31%) 1.000Hypertension 2 (25%) 24 (50%) 0.426Coronary artery disease 4 (50%) 7 (15%) 0.024Arrhythmia 1 (13%) 6 (13%) 1.000

Chronic obstructive 1 (13%) 5 (10%) 0.577pulmonary diseaseEnd-stage renal disease 0 (0%) 3 (6%) 1.000Cerebral vascular disease 2 (25%) 10 (21%) 0.639Malignancy 0 (0%) 8 (17%) 0.577Arterial blood gas, median (IQR)

PH 7.11 (6.94 to 7.23) 7.08 (6.96 to 7.22) 0.977PaCO2 (mmHg) 44 (28.5 to 89.4) 67.7 (50.5 to 82.3) 0.209HCO3 (mEq/l) 13.9 (7.8 to 20.3) 21.6 (14.7 to 25.1) 0.051Base excess (mEq/l) 11.5( - 7.7 to 18.1) 9.1( 2.4 to 16.3) 0.253Lactate (mmol/l) 7.63 (5.92 to 9.34) 8.08 (6.29 to 9.83) 0.865White blood cell count 9,150 11,805 0.071

(l1) (7,850 to 11,180) (9,030 to 14,560)Hemoglobin (g/dl) 11.4 (6.4 to 15.6) 11.2 (8.6 to 13.1) 0.935C-reactive protein (mg/dl) 0.77 (0.31 to 1.91) 1.18 (0.28 to 4.45) 0.854Myoglobin (U/l) 183.5 (139 to 488) 109 (78 to 224) 0.062CK-MB (U/l) 44.95 (23.3 to 54) 31.5 (21.1 to 42.9) 0.114Troponin-I (ng/ml) 0.41 (0.17 to 1.07) 0.05 (0 to 0.12) 0.387Blood urea nitrogen (mg/dl) 22.5 (16.9 to 63.3) 24.6 (16.7 to 39.9) 0.905Serum creatinine level (mg/dl) 1.55 (1.2 to 1.9) 1.4 (1.0 to 2.1) 0.802Serum sodium level (mmol/l) 141 (137 to 149) 139 (134 to 146) 0.256Serum potassium level (mmol/l) 5.1 (4.1 to 6.6) 5.4 (4.1 to 6.4) 0.980

Table 1 Comparison of baselineclinical characteristics betweenthe AIVR and non-AIVR groups(CK-MB creatine kinaseisoenzyme MB, IQRinterquartile range)

Fig. 1 Flow chart of the enrolled patients. AIVR Acceleratedidioventricular rhythm; ECG electrocardiography; OHCA out-of-hospital cardiac arrest; ROSC return of spontaneous circulation

OHCA patients received cardiopulmonary resusci-tation (CPR) according to the guidelines establishedby the American Heart Association in 2000. Data onresuscitation were collected according to the Utstein style.Causes of OHCA were classified as cardiac or noncardiac.

To determine the causes of cardiac arrests in OHCAsurvivors we performed repeated laboratory examin-ations and 12-lead ECG, and additional selective exami-nations such as computed tomography scans, transthoracicechocardiography, abdominal ultrasound, and coronaryangiography. The cause of cardiac arrest was determinedby the physician-in-charge and was reviewed by the studyphysicians. The controversy was settled after discussionamong the physicians [10]. Return of spontaneous cir-culation (ROSC) was defined as a palpable pulse withmeasurable blood pressure. None of the enrolled patientsreceived therapeutic hypothermia during resuscitation orafter ROSC.

There were 177 OHCA patients during the studyperiod. Of the 137 nontraumatic adult OHCA patientsROSC was achieved in 65. Excluding four without 12-leadECG (due to ROSC duration that was too short) andfive without analyzable 12-lead ECG (due to inadequatequality), a total of 56 OHCA survivors was included in thestudy (Fig. 1; 32 men, 24 women; age 73.4 14.7 years).Cardiac origin accounted for one-third OHCA causes(n = 17, 30%) and asystole was the most common firstmonitored rhythm (n = 36, 64%). Fifty-five patients (98%)had sustained ROSC, 54 patients (96%) with postresusci-


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OHCA of cardiac origin 6 (75%) 11 (23%) 0.007First monitored rhythm

Asystole 3 (38%) 33 (69%) 0.118

Pulseless electrical activity 1 (13%) 11 (23%) 0.672Ventricular tachycardia/fibrillation 4 (50%) 4 (8%) 0.010Prehospital events

Witnessed collapse 6 (75%) 29 (60%) 0.649Prehospital intubation 2 (25%) 16 (33%) 1.000Prehospital CPR duration, median (min; IQR) 9 (2 to 13) 5 (2 to 15.5) 0.818AED defibrillation 3 (38%) 5 (10%) 0.078

In-hospital eventsIn-hospital CPR duration, median (min; IQR) 22.5 (7 to 37) 11.5 (7 to 16.5) 0.025Vasopressin use 1 (13%) 7 (15%) 1.000Total epinephrine dose, median (mg; IQR) 10 (6 to 14) 3 (2 to 5) 0.000In-hospital defibrillation, median (no. IQR) 1.5 (0 to 3) 0 (0 to 1) 0.091

Return of spontaneous circulationTotal CPR duration, median (min; IQR) 32 (20 to 42) 18 (12 to 26) 0.029Systolic blood pressure, median (mmHg; IQR) 118 (74 to 132) 121 (87 to 149.5) 0.412Diastolic blood pressure, median (mmHg; IQR) 67.5 (55 to 91) 59 (49 to 76) 0.542

Table 2 The comparison ofresuscitation events between theAIVR and non-AIVR groups(AED automated externaldefibrillator, CPRcardiopulmonary resuscitation,OHCA out-of-hospital cardiacarrest)

tation shock defined as the need for vasopressor therapyto maintain systolic blood pressure over 90 mmHg, 24patients (43%) survived more than 7 days, and 14 (25%)patients survived to hospital discharge. There were 27patients with sinus rhythm, 12 with atria fibrillation/flutter,8 with accelerated idioventricular rhythm (AIVR), 5 withmultifocal atrial rhythm, and 4 with junctional rhythm.

In survivors 12-lead ECG was routinely obtainedwithin minutes after ROSC and interpreted independentlyby two cardiologists. AIVR was defined as a ventricular

ectopic rhythm with more than three consecutive beatsand a rate between 50 and 120 bpm [11, 12]. SustainedROSC was deemed to have occurred when chest compres-sions were not required for 20 min. Repeated CPR wasconsidered when chest compression was needed within1 h after the first ROSC. One-day survival was definedas patients surviving more than 1 day after ROSC, andthe 3-day and 7-day survival had similar definitions. Thehospital discharge was defined as patients survival up todischarge, including to home or a nursing home.

Patients were divided into two groups: those withAIVR (n = 8, including those whose postresuscitation12-lead ECG showed AIVR) and those without (n = 48).Baseline clinical characteristics of the two groups arepresented in Table 1. The groups were compared withSPSS software (release 10.0; SPSS, Chicago, Ill., USA).Median and quartiles are used to describe numericvariables. The Mann-Whitney U test was used for the

comparison of groups and 2 test was for comparisonof proportions. Survival curves were determined by theKaplan-Meier method and compared by the log-rank test.A p-value less than 0.05 was regarded as statisticallysignificant.

Results

The AIVR group comprised a higher proportion ofpatients with coronary artery disease (CAD; 50% vs.15%, p = 0.024; Table 1). and during resuscitation thehad a higher proportion of cardiac origins of OHCAcauses (75% vs. 23%, p = 0.007) and initial ventriculartachycardia/fibrillation (50% vs. 8%, p = 0.01). AIVRpatients also had longer in-hospital CPR duration (22.5vs. 11.5 min, p = 0.025), longer total CPR duration (32

vs. 18 min, p = 0.029), and higher total epinephrine dose(10 vs. 3 mg, p< 0.0001; Table 2). Fewer patients with

Fig.2 Survival curves in those with and those without acceleratedidioventricular rhythm (AIVR)


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Sustained ROSC 7 (88%) 48 (100%) 0.143Repeated CPR within 1 h 3 (38%) 2 (4%) 0.0171-day survival 3 (38%) 30 (63%) 0.1733-day survival 2 (25%) 27 (56%) 0.1047-day survival 0 (0%) 24 (50%) 0.007Hospital discharge 0 (0%) 14 (29%) 0.083

Table 3 Comparison ofoutcomes between the AIVR andnon-AIVR groups (CPRcardiopulmonary resuscitation;ROSC return of spontaneouscirculation)

postresuscitation sinus rhythm suffered repeated CPR (0%vs. 17%, p = 0.031). Patients with postresuscitation AIVRhad increased incidence of repeated CPR (38% vs. 4%,p = 0.017) and lower 7-day survival rate (0% vs. 50%,p = 0.007; Table 3). No patient was discharged alive in theAIVR group (0% vs. 29%, p = 0.083). The comparisonof survival curves between these two groups is shown inFig. 2.

Discussion

This study found that postresuscitation AIVR is associatedwith a higher repeated CPR rate and a lower 7-day survivalrate in successfully resuscitated OHCA victims. AIVR isusually considered as a benign rhythm [1113]. It can beseen in any kind of heart disease [11, 13] and even in pa-tients without apparent heart disease [11]. In those receiv-ing thrombolytic therapy for myocardial infarct AIVR isregarded as a sign of successful reperfusion without satis-factory sensitivity [14, 15]. In our study, however, postre-suscitation AIVR was associated with worse outcome. No

patient with postresuscitation AIVR in the study survivedhospital discharge.Cardiac arrest patients with initial pulseless idioven-

tricular rhythm or asystole usually have less chance ofgaining ROSC and thus have a higher mortality rate [2].Concerning postresuscitation ECG Spaulding et al. [16]reported that ECG was poor in predicting acute coronary-artery occlusion in OHCA survivors. Immediate coronaryangiography could help accurate diagnosis and improvesurvival in selected patients. In contrast, increased QRSduration after resuscitation is reported to be associatedwith increased long-term mortality and implantablecardioverter-defibrillator shocks in ventricular fibrillationOHCA survivors [3]. In addition, idioventricular rhythm orAIVR was considered as a frequent terminal electrocardio-graphic change in human hearts [17]. To our knowledge,no published study has addressed the correlation betweenpostresuscitation AIVR and outcomes in cardiac arrests.Although it has been previously considered as a benignarrhythmia, AIVR was associated in our study with poorprognosis. Our findings suggest a different viewpointabout AIVR for postresuscitation victims.

The reason why AIVR patients had poorer out-come may be attributed to their longer CPR duration.

Longer CPR duration may result in more myocardialinjury. It is reasonable to hypothesize that longer CPRduration is associated with increased myocardial in- jury and damage to supraventricular pacemakers. Thedysfunction of supraventricular pacemakers thereforemay lead into a takeover of the ventricular pace-maker, which accelerates with increased automaticityunder the effect of epinephrine during resuscitation. How-ever, it was difficult in our study to determine whether

AIVR is due to the prolonged CPR duration itself or pre-existing heart diseases (which resulted in prolonged CPR).In addition to prolonged CPR, higher epinephrine dose inthe AIVR group may be another reason for poor prognosis.Epinephrine has been proven to significantly increase theseverity of postresuscitation myocardial dysfunction anddecrease survival duration in resuscitated rodents [18].

Another interesting finding is that the OHCA in theAIVR group was more often of cardiac origin, which waspreviously associated with better outcomes than those withnoncardiac origin [19]. In the setting of acute myocardialinfarct AIVR has not been found to be associated withan increase incidence of ventricular fibrillation [20].

However, in our study the AIVR group had higher per-centages of patients with CAD and initial ventriculartachycardia/fibrillation rhythm. These findings suggestthat supraventricular pacemakers are more likely to bedamaged in OHCA patients with underlying CAD. Moreextensive studies are necessary to clarify this finding.

There are several limitations in our study. First, theexclusion of patients having too short a ROSC duration toundergo a 12-lead ECG, and who are at higher risk of pooroutcome restricts our results to patients with longer ROSCduration. Secondly, the cause of cardiac arrest was mostlydetermined clinically rather than pathologically [16].Finally, the patient number is small, and larger-scalestudies are needed to establish the relationships betweenthe postresuscitation ECG rhythm and outcomes in OHCAsurvivors.

Based on the finding of the present study we concludethat postresuscitation AIVR is prognostic factor related toa higher repeated CPR rate within 1 h after ROSC anda lower 7-day survival rate in initially successfully resusci-tated OHCA victims. However, since the number of pa-tients included is small, further studies are necessary todetermine the relationships between the ECG rhythm andoutcomes in OHCA survivors.


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