Correspondence
Time to Defibrillation after In-Hospital Cardiac Arrest
N Engl J Med 2008; 358:1631-1634April 10, 2008
- Article
To the Editor:
The study of the time to defibrillation after in-hospital cardiac arrest, reported by Chan et al. (Jan. 3 issue),1 showed strikingly higher mortality among hospitalized patients with ventricular fibrillation or pulseless ventricular tachycardia when defibrillation was delayed. In an accompanying editorial, Saxon observes that underlying medical conditions in hospitalized patients contribute to their lower survival rate as compared with the rate among persons who have heart attacks in public areas.2
Actually, health differences contribute so greatly to the discrepancy that the survival-rate comparison is highly misleading as a critique of hospital performance. Consider only patients who underwent swift defibrillation: in the studies Saxon cites, the rate of survival until hospital discharge was 79% for persons in airports who underwent defibrillation within 5 minutes3 and 74% for those in casinos who underwent defibrillation within 3 minutes.4 By contrast, the survival rate for hospitalized patients who underwent defibrillation within 2 minutes was only 39%.
Given the popular media's propensity to misinterpret and sensationalize (e.g., “People who suffer cardiac arrest are more likely to survive if they are in a casino or airport than if they are in a hospital”),5 it should be emphasized that population differences render comparison of survival rates between hospitalized patients and others inappropriate.
5 ReferencesYves R. Chretien, A.M.
Harvard University, Cambridge, MA 02138
chretien@stat.harvard. edu 1
Chan PS, Krumholz HM, Nichol G, Nallamothu BK, American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators
Full Text | Web of Science | Medline2
Saxon LA . Survival after tachyarrhythmic arrest -- what are we waiting for? N Engl J Med 2008;358:77-79
Full Text | Web of Science | Medline3
Caffrey SL ,Willoughby PJ ,Pepe PE ,Becker LB . Public use of automated external defibrillators. N Engl J Med 2002;347:1242-1247
Full Text | Web of Science | Medline4
Valenzuela TD ,Roe DJ ,Nichol G ,Clark LL ,Spaite DW ,Hardman RG . Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med 2000;343:1206-1209
Full Text | Web of Science | Medline5
Maugh TH II. Study finds hospitals slow to defibrillate: researchers say they are riskier than a casino in event of cardiac arrest. Los Angeles Times. January 3, 2008:A8.
To the Editor:
Chan et al. report that black race is a significant predictor of delayed defibrillation for in-hospital cardiac arrest. As the authors note, further research is needed, given that reasons for the disturbing racial disparities are not “intuitively obvious.” A recent report on an analysis of out-of-hospital cardiac arrest makes the point that contributing factors are complex but potentially identifiable.1 Statements on knowledge gaps and clinical research priorities for cardiopulmonary resuscitation do not currently include investigation of these recurring trends.2,3 This prioritization is needed for alignment with national goals to eliminate health disparities.4
4 ReferencesMegan Coylewright, M.D., M.P.H.
Johns Hopkins Hospital, Baltimore, MD 21231
coyle@jhmi.edu 1
Galea S ,Blaney S ,Nandi A , et al. Explaining racial disparities in incidence of and survival from out-of-hospital cardiac arrest. Am J Epidemiol 2007;166:534-543
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Gazmuri RJ ,Nadkuri VM ,Nolan JP , et al. Scientific knowledge gaps and clinical research priorities for cardiopulmonary resuscitation and emergency cardiovascular care identified during the 2005 International Consensus Conference on ECC [corrected] and CPR science with treatment recommendations: a consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian Resuscitation Council, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, and the New Zealand Resuscitation Council), the American Heart Association Emergency Cardiovascular Care Committee, the Stroke Council, and the Cardiovascular Nursing Council. Circulation 2007;116:2501-2512[Erratum, Circulation 2007;116:following 2512, 2008;117(5):e155.]
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Becker LB ,Weisfeldt ML ,Weil MH , et al. The PULSE initiative: scientific priorities and strategic planning for resuscitation research and life saving therapies. Circulation 2002;105:2562-2570
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Department of Health and Human Resources, Office of Disease Prevention and Health Promotion. Healthy People 2010. (Accessed March 21, 2008, at http://www.healthypeople.gov/.)
To the Editor:
The graded association between increasing time to defibrillation and lower survival rates after in-hospital cardiac arrest, reported by Chan et al., raises two questions. First, was defibrillation performed earlier because of earlier recognition of well-known abnormal physiological variables that precede cardiac arrest?1 This may lead to the development of new real-time automated monitoring systems integrating several vital signs, such as heart rate, blood pressure, oxygen saturation, skin temperature, and breathing rate. Such noninvasive devices may detect critical events earlier and trigger timely intervention by medical emergency teams.2
Second, in how many cases was defibrillation performed earlier with automated external defibrillators (AEDs), especially among nonmonitored inpatients? In the accompanying editorial, Saxon wonders whether placing an AED in every patient's room could be beneficial for survival. The answer is probably yes, and costly, but meanwhile, should we recommend the placement of AEDs at least in every inpatient ward as a start to improve the outcome of in-hospital cardiac arrest, as is recommended nowadays in France?
2 ReferencesSorraya Chabbouh, M.D.
Sebastien Ghiglione, M.D.
Alexandre Mignon, M.D., Ph.D.
Hôpital Cochin, 75014 Paris, France
alexandre.mignon@cch. aphp. fr 1
Herlitz J ,Bang A ,Aune S ,Ekstrom L ,Lundstrom G ,Holmberg S . Characteristics and outcome among patients suffering in-hospital cardiac arrest in monitored and non-monitored areas. Resuscitation 2001;48:125-135
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Tarassenko L ,Hann A ,Young D . Integrated monitoring and analysis for early warning of patient deterioration. Br J Anaesth 2006;97:64-68
CrossRef | Web of Science | Medline
To the Editor:
Chan and colleagues report delayed defibrillation in 30% of hospitalized patients with cardiac arrest due to pulseless ventricular tachycardia or ventricular fibrillation, leading to poor outcomes. The editorial by Saxon emphasizes the need for early detection and defibrillation as central components of efforts to improve survival and further stresses the use of automated detection algorithms to detect and treat ventricular arrhythmias. These recommendations are consistent with our institution's experience with AEDs and manual defibrillators in AED mode.1 Implementation of a program encouraging early defibrillation led to a 14-fold increase in survival to discharge among patients with cardiac arrest due to ventricular tachycardia or ventricular fibrillation1 and contributed to the statement by the American Heart Association that “AEDs should be considered for the hospital setting as a way to facilitate early defibrillation.”2 Currently, we are conducting a prospective, randomized clinical trial assessing the role of continuous monitoring by automated external cardioverter–defibrillators (AECDs) in patients with in-hospital cardiac arrest.3 The use of AEDs and AECDs may address the delay in recognition and treatment of ventricular tachycardia or ventricular fibrillation in cases of in-hospital cardiac arrest.
Bakhtiar Ali, M.D.
Atlanta Veterans Affairs Medical Center, Decatur, GA 30033Samuel C. Dudley, Jr., M.D., Ph.D.
University of Illinois at Chicago, Chicago, IL 60612A. Maziar Zafari, M.D., Ph.D.
Emory University School of Medicine, Atlanta, GA 30322
azafari@emory.edu Dr. Zafari reports receiving grants from Cardiac Science. No other potential conflict of interest relevant to this letter was reported.
3 References1
Zafari AM ,Zarter SK ,Heggen V , et al. A program encouraging early defibrillation results in improved in-hospital resuscitation efficacy. J Am Coll Cardiol 2004;44:846-852
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2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care
Web of Science3
Ali B ,Bloom HL ,Veledar E , et al. Automated external cardioversion defibrillation monitoring in telemetry patients. Circulation 2007;116:Suppl II:II-927
CrossRef | Web of Science
To the Editor:
The finding that delayed defibrillation leads to a poorer outcome is intuitively obvious, and the authors do not offer any suggestions for avoiding it. The suggestion in the accompanying editorial that all hospitalized patients undergo continuous electrocardiographic monitoring seems impractical and will lead to many false alarms.
The study's real take-home message, however, is the bleak prognosis for patients with in-hospital cardiac arrest. After extrapolation for patients with missing data, only 11% of the total group of 6789 patients in this “good-risk” group with ventricular tachycardia or ventricular fibrillation survived with “no major disability.” Moreover, the adverse effects of defibrillation included a prolongation of hospitalization without survival in 27% of the group and survival with disability of a moderate-to-severe degree or even a persistent vegetative state in 23% of the patients.
Considering these dismal results, as well as the commotion, disruption of normal hospital routines, and emotional turmoil for staff, families, and other patients — not to mention the significant expense — one wonders whether, overall, attempted resuscitation in the hospital, except possibly for a few prespecified patients, does not do more harm than good.
Mayer Bassan, M.D.
11 Windmill St., 94110 Jerusalem, Israel
mayer_bassan@yahoo.co. uk Author/Editor Response
We agree with Chretien that comparisons of patients who have in-hospital cardiac arrest with those who have out-of-hospital cardiac arrest are inappropriate. There are distinct differences in the causes of cardiac arrest between these populations, making such comparisons misleading. Coylewright notes the growing literature on racial and ethnic disparities in survival after cardiac resuscitation. We agree that this area should be a priority for further investigation. In fact, the National Registry of Cardiopulmonary Resuscitation (NRCPR) is currently examining the extent to which racial and ethnic differences in defibrillation times may be explained by hospital-level characteristics and resources available to minorities.
Chabbouh and colleagues question whether prompt defibrillation was associated with earlier recognition of changes in physiological variables or the use of AEDs. We were unable to answer the first issue directly in our analysis, but we agree that identifying clinical deterioration before an in-hospital cardiac arrest has tremendous appeal. Indeed, this is the rationale for rapid response1 and medical emergency2 teams, which 46% of NRCPR hospitals currently use. Regarding the second issue, 37% of NRCPR hospitals currently have AEDs available in non–intensive care areas. However, only an isolated handful of these hospitals used medical emergency teams or AEDs before 2005, the last year for inclusion of patients in our study cohort. Ali and colleagues raise similar points and note their own institutional experience with the use of continuous monitoring systems and AEDs. Their initial findings seem promising, and we look forward to the results of their ongoing clinical trial.
Finally, Bassan argues that outcomes of in-hospital cardiac arrests are so poor, in general, that resuscitation attempts often do more harm than good, “except possibly for a few prespecified patients.” Although we agree that survival in this high-risk population is limited overall, we disagree that efforts to improve resuscitation are futile. In fact, we believe the key message of our analysis was that defibrillation times, which are potentially modifiable through quality-improvement efforts, are important determinants of outcomes in this population. In addition, the potential benefits associated with prompt defibrillation are actually large when absolute differences in survival to hospital discharge are considered: 39.3% for patients treated within 2 minutes as compared with 22.2% among those treated later (i.e., a number needed to treat of 6) (Table 1Table 1
Absolute Difference in Survival to Discharge According to the Time to Defibrillation).2 ReferencesPaul S. Chan, M.D.
Mid-America Heart Institute, Kansas City, MO 64111
pchan@cc-pc.com Graham Nichol, M.D., M.P.H.
Harborview Center for Prehospital Emergency Care, Seattle, WA 98104Brahmajee K. Nallamothu, M.D., M.P.H.
University of Michigan Medical School, Ann Arbor, MI 481091
Sharek PJ ,Parast LM ,Leong K , et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children's hospital. JAMA 2007;298:2267-2274
CrossRef | Web of Science | Medline2
Bellomo R ,Goldsmith D ,Uchino S , et al. A prospective before-and-after trial of a medical emergency team. Med J Aust 2003;179:283-287
Web of Science | Medline
Author/Editor Response
Chretien takes exception to my comparison of survival rates between patients with in-hospital cardiac arrest and those with out-of-hospital cardiac arrest. He suggests that my comments provide fodder for inappropriate media attention to the issue. In one sense, he is right. I was quoted by the New York Times as saying that I was more likely to survive a cardiac arrest in Nordstrom's (where I happened to be standing at the time of the interview) than in some hospital settings.1 However, I believe that media attention to this issue is not only appropriate but also necessary and positive. Hospitals and physicians are responsible for resuscitating patients after arrests from ventricular tachycardia or ventricular fibrillation in the timeliest way possible. Technologies that reduce delays in defibrillation, such as automated detection algorithms and AEDs, do exist and have been validated in out-of-hospital settings. Why not adopt these technologies and processes for hospitalized patients? There is nothing wrong with the media spotlight if it brings attention and pressure for positive change.
Chabbouh and colleagues agree that automated algorithms help identify patients in distress earlier and that AEDs should play an important role in in-hospital defibrillation. In fact, Ali and colleagues have used AEDs in the hospital setting, improving survival, and continue to work to reduce defibrillation times. I apologize for not citing their work in my editorial.2 Finally, Bassan wonders whether aggressive and potentially costly efforts to reduce defibrillation times for all hospitalized patients will produce meaningful survival benefits. Rationing resuscitation attempts for hospitalized patients who have ventricular tachycardia or ventricular fibrillation without advance directives is nihilistic and pessimistic. If prompt resuscitation is feasible in a casino and an airport, we can do it in a hospital. In general, people are capable of understanding that survival of hospitalized patients will not be as favorable as survival of those with an arrest in a public place. Our responsibility as physicians lies with giving each individual patient the best chance at survival, and that means early defibrillation with the best technologies available.
2 ReferencesLeslie A. Saxon, M.D.
University of Southern California, Los Angeles, CA 900331
Grady D. Hospitals slow in heart cases, research finds. New York Times. January 3, 2008.
2
Ali B ,Bloom HL ,Veledar E , et al. Automated external cardioversion defibrillation monitoring in telemetry patients. Circulation 2007;116:Suppl II:II-927
CrossRef | Web of Science
