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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 193-197

Outcome in survivors of out-of-hospital cardiac arrest in a tertiary care center of North India: A prospective observational study


1 Interventional Gastroenterology, Medanta Medicity, Gurgaon, Haryana, India
2 Department of Cardiology, Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute, Ludhiana, Punjab, India
3 Department of Pulmonology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
4 Department of Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Date of Web Publication11-Jan-2019

Correspondence Address:
Dr. Bishav Mohan
Department of Cardiology, Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute, Ludhiana - 141 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_53_18

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  Abstract 

Background: OHCA (out of hospital cardiac arrest) is a leading cause of death in developed countries, outcome of which depends upon various factors. Not much data is available in India, on outcome of OHCA. Thus, this study was conducted to assess various clinical and biochemical parameters in predicting outcome of survivors of out of hospital cardiac arrest. Methods: This prospective study was done in HDHI Unit of DMCH, Ludhiana over a period of 12 months (January, 2016 to December 2016). Patients of OHCA who were revived following CPR were enrolled for the study and outcome in terms of GCPS and NYHA was seen after one month. Results: A total of 542 patients of OHCA presented to the emergency, of which 49 (9.04%) patients were admitted after ROSC following CPR. Of these 49 patients, 18 (36.73%) survived to hospital discharge and 31 (63.26%) expired or took discharge in a critical condition and presumed to be expired. Mean age of patients was 58.06 ± 15.1 years and males constituted 67.35%. Mean time from arrest to hospital was 7.44 ± 6.9 minutes (survivors) compared to 13.23 ± 8.1 minutes (non survivors) (P value = 0.009). Mean duration of stay was more among discharged (P = 0.006). Patients presenting with VF/VT (P = 0.003) as first monitored rhythm compared to asystole (P = 0.004) had better outcome. On multivariate analysis VF, duration of hospital stay, raised urea and creatinine, time from arrest to first help and hospital were predictors of good outcome. Conclusion: Shorter time interval from arrest to reaching the hospital and shockable rhythm were associated with better outcome in patients of OHCA. Duration of CPR (cardiopulmonary resuscitation), age, gender, comorbidities, witnessed arrest and resuscitation attempt by bystander (bystander CPR) did not show any relation in predicting outcome in out of hospital cardiac arrest survivors. Raised urea and creatinine (correctable biochemical parameters) played a significant role in survival was cardiac arrest on way to hospital.

Keywords: Cardiac arrest, favorable parameters, survival outcome


How to cite this article:
Grewal CS, Singh B, Bansal R, Sidhu US, Gupta D, Tandon R, Goyal A, Chhabra ST, Aslam N, Wander GS, Mohan B. Outcome in survivors of out-of-hospital cardiac arrest in a tertiary care center of North India: A prospective observational study. J Pract Cardiovasc Sci 2018;4:193-7

How to cite this URL:
Grewal CS, Singh B, Bansal R, Sidhu US, Gupta D, Tandon R, Goyal A, Chhabra ST, Aslam N, Wander GS, Mohan B. Outcome in survivors of out-of-hospital cardiac arrest in a tertiary care center of North India: A prospective observational study. J Pract Cardiovasc Sci [serial online] 2018 [cited 2019 Jan 16];4:193-7. Available from: http://www.j-pcs.org/text.asp?2018/4/3/193/249936


  Introduction Top


Cardiac arrest (also known as cardiopulmonary arrest or circulatory arrest) is the cessation of normal circulation of the blood due to failure of the heart to contract effectively.[1]

Cardiac arrest is a medical emergency that, in certain situations, is potentially reversible if treated early. Unexpected cardiac arrest sometimes leads to death almost immediately, this is called sudden cardiac death.[1] The treatment for cardiac arrest is cardiopulmonary resuscitation (CPR) to provide circulatory support, followed by defibrillation if a shockable rhythm is present.

It is an important public health problem and often occurs in the out-of-hospital setting in patients without a prior history of heart disease. Very few communities or emergency medical service (EMS) systems report survival rates for out-of-hospital cardiac arrest (OHCA).

In India, very sparse data are available about survival after CPR.[2] As outcome after CPR and its predictors may vary in the Indian population, application of western data to Indian population is not appropriate. Various factors modifying outcome in Indian population may include undiagnosed premorbid conditions, poor EMSs, lack of bystander CPR, inadequate knowledge and skill of resuscitation, and lack of infrastructure to deal with such situations. The financial constraints are also an important factor in India. Another reason is unstructured protocols for cardiac arrest in India.

Among those who survive, survival rates vary substantially between countries due in large part to community differences in the chain of survival. To improve survival after cardiac arrest, care must be optimized at each point along the cardiac arrest continuum including a rapid emergency response, provision of CPR by bystanders, delivery of high-quality chest compressions with minimal interruptions byfirst responders, rapid defibrillation, and optimization of postresuscitation care, including therapeutic hypothermia. OHCA is a leading cause of death infirst world countries. The estimated incidence in the United States is about 1/1000 population per year (15%–20% of all deaths).[3] OHCA is often thefirst presentation of ischemic heart disease. If victims of OHCA can receive immediate and appropriate treatment, they have a 30%–70% chance of survival.[4] There is a paucity of data on survival from OHCA in India. The management of OHCA is presently the only area of prehospital emergency care where there is clear evidence that appropriate intervention leads to improved survival.[5]

In India, there is not much data available on the outcome of OHCA. Therefore, there is a need to collect data on the outcome of CPR and its predictors in an Indian tertiary care hospital.

The proposed study was conducted on patients who had cardiac arrest outside hospital or in the community, presented to the emergency department (ED) and underwent CPR. The patients who were revived and admitted to the hospital were enrolled, and data were collected to study the various clinical and biochemical parameters in predicting the outcome. Various factors studied include age, sex, rhythm at presentation, time of arrest to the hospital, comorbid conditions, mean duration of stay, witnessed or unwitnessed arrest, and location of the arrest.


  Methods Top


Patients

It was a prospective study done in the ED of a high volume tertiary care hospital over a period of 12 months (January 01, 2016–December 31, 2016). The hospital is a located in the main city of Ludhiana (urban town of Punjab) with high intake of patients from most of Punjab and neighboring states. There are two emergency units (1) cardiac emergency unit and (2) medical emergency unit. We conducted our study in patients who were admitted to both the emergencies.

Participants

Patients with OHCA in the community and home who presented to the ED were subjected to CPR as per advanced cardiovascular life support (ACLS) guidelines. Those who survived/were revived after CPR following OHCA were enrolled for the study.

Inclusion criteria

  • Patients having cardiac arrest out of hospital brought to the emergency as defined by the absence of central pulse, for example, carotid pulse[6] and absence of adequate breathing/gasping.


Exclusion criteria

  • Patients revived before coming to the hospital.


Records related to CPR of patients in an ED fulfilling the inclusion criteria were collected. The following parameters were studied to analyze the observations made. The data collection included demographic profile, age, sex, coexisting comorbidities such as hypertension, renal failure, cardiac diseases, pulmonary diseases, and malignancy.

The status of ACLS intervention given after arrest such asfirst monitored rhythm, duration of CPR performed, and number of defibrillation attempted. The outcome was measured in terms of any return of spontaneous circulation,[6] survived (<24 h), survived (>24 h), and health status at discharge and 30 days using cerebral performance categories (CPCs)/New York Heart Association (NYHA) classification as per [Table 1] and [Table 2] respectively.[7],[8] Left against medical advice (LAMA)/expired were counted together.
Table 1: Cerebral performance categories scale

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Table 2: New York heart association classification

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Statistical methods

The data were collected and analyzed. Various statistical variables were collected, and with the use of SPSS, the data were analyzed. The continuous data were compared using either Student's t-tests or Wilcoxon tests. The categorical variables were compared using a Chi-square test and Fisher's exact tests. All probability values were two-sided, and differences with P < 0.05 were considered statistically significant. In order to find the independent predictors, logistic regression analysis was done. The outcome was measured at discharge and after 30 days using the CPC/NYHA classification.


  Results Top


This observational study was carried out over a period of 12 months (January 01, 2016–December 31, 2016) in patients who survived after OHCA by CPR in ED. A total 49 patients were enrolled as per inclusion criteria.

Out of these 49 patients enrolled who were revived after CPR, and admitted, 18 (36.7%) were discharged alive and 13 (26.5%) patients expired and 18 (36.7%) patients took discharge in view of critical condition and ultimately expired [Figure 1]. The mean age of patients who underwent CPR was 58.1 ± 15.1 years. The mean age of patients who were discharged was 53.3 ± 12.2 years and mean age of patients who expired was 60.8 ± 16.1 years with no statistically significant difference (P = 0.06). [Table 3] demonstrates the age distribution of the study population.
Figure 1: Presenting number of patients.

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Table 3: Age distribution of subjects

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Of 49 patients who survived after cardiac arrest, 33 (67.35%) were male and 16 (32.65%) were female. There was no statistically significant difference (P = 0.13) in gender distribution between patients who survived and did not survive. Diabetes (55.1%) and hypertension (44.9%) were the most common comorbidities among patients in our study. Cardiac diseases (32.7%) were the third most common illness. The clinical characteristics of the study population have been tabulated in [Table 4].
Table 4: Clinical and laboratory characteristics of the study population

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Compared to the patients who expired, the mean blood urea (78.9 ± 77.4 vs. 47.5 ± 33.2; P = 0.04) and serum creatinine levels (2.9 ± 2.1 vs. 1.9 ± 1.5; P = 0.04) were significantly higher among discharged patients. The comparison of various biochemical and hematological parameters between discharged and expired patients has been shown in [Table 4].

Compared to discharged patients (6.2 ± 4.7 min), mean duration of time of arrest tofirst help was significantly longer among expired patients (12.1 ± 8.0 min) with a P = 0.009. Similarly, the mean time lag from arrest to hospital among expired patients (13.2 ± 8.1 min) was significantly longer than those of discharged patients (7.4 ± 4.8 min) with the P = 0.009. Mean duration of stay of patients who were discharged alive was longer than those who expired (34.9 ± 39.9 days vs. 4.2 ± 3.6 days; P = 0.006). Early presentation to the hospital was associated with better survival outcome, and those patients had a longer hospital stay. We also recorded the location of cardiac arrest, and the results showed statistically better outcome among the patients who had a cardiac arrest on the way to the hospital as compared to the patients who had a cardiac arrest at home, in other terms presented earlier. Very few patients (n = 5) with arrest were witnessed by health-care personnel and had no statistically significant relation. Most of the patients in the study (n = 39) presented without attempted resuscitation and had no significant survival compared with patients in whom CPR was attempted. Nine patients presented with shockable rhythm and had statistically significant survival outcome compared to others. While the majority of the patients presented with asystole. [Table 5] shows the comparison of various factors determining the outcome of the study.
Table 5: Comparison of the factors determining the outcome of the study group

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Ten patients had a favorable outcome at discharge and 30 days. The rest of the eight patients had a poor neurological outcome. Out of these eight patients, six patients were bedridden due to severe cerebral disability, and two patients were in a vegetative state. In terms of the NYHA score majority of the patients who survived and recuperated (n = 7) had NYHA Class-II symptoms [Table 6]. In multivariate regression analysis of factors determining mortality, the shockable rhythm ventricular tachycardia increased urea, and duration of hospital stay were found to be independent predictors of good outcome among the enrolled patients. Asystole at the time of presentation and cardiac arrest at home were associated with poor outcome in our study [Table 7].
Table 6: Distribution of subjects according to outcome score

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Table 7: Independent predictors of outcome on multivariate regression analysis

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  Discussion Top


This observational study was conducted over a period of 1 year (January 01, 2016–December 31, 2016) on patients admitted to the emergency room. The outcome was studied among survivors after CPR in patients of OHCA who were admitted to emergency. In-hospital mortality among survivors of OHCA was found to be 63.3%. Similar studies have been conducted and are underway in many western world countries. Over decades, various studies have shown a very poor outcome of OHCA patients.[9],[10],[11],[12] The survival to hospital discharge of the patients who got revived of the OHCA was less, ranging between 8% and 10% in major parts of the world.[13] Some of the centers have a better survival rate, probably attributed to bystander CPR, easy and quick access to health-care facilities, and better EMS. This study was performed in Northern part of India. A study by Krishna et al. observed the survival rate to hospital admission was 32.5%, the survival rate to hospital discharge was 8.8% and with good CPC neurological status was 3.8%.[14] A recent study by Joshi had studied the incidence and outcome of both in-hospital and OHCA patients. They have found the survival rate of 10.38% at 1-year follow-up.[15]

This study highlighted the different modes of presentation among OHCA patients in the Indian scenario. Most of the patients in our study did not receive any bystander CPR, had different comorbidities and were mostly brought to the hospital on their private vehicles. The data from the western world suggests that the majority of the patients reached the hospital in an ambulance accompanied by an EMSs crew.[16] EMS needs to be strengthened to improve the outcome of OHCA.

In our study compared to western data, early presentation to the hospital, shockable rhythm had a statistically significant favorable outcome. Patients who had raised urea and creatinine (most of the chronic kidney disease patients) had a statistically significant favorable outcome. The likely reason for this could be because of the correctable factors like hyperkalemia or metabolic acidosis which reverse by various medical interventions.

In our study, we noted the various other factors which could have affected the outcome of survival among OHCA patients but could not have any statistically significant association with outcome. This study was thefirst of its kind where the outcome was measured among OHCA population in an Indian scenario where we had tried to figure out the basic lacunae in the chain of survival following cardiac arrest. The hospital stay was longer among survivors. This is due to delayed recovery of the patients having severe neurological complications.

As per the American Heart Association statistics updated on December 12, 2012, there was a 9.5% survival rate. In comparison, in our study, there was a similar (9.04%) survival rate. The reason for this could be that most of the patients who came to the emergency were from nearby localities and peripheral district. Another reason could be that a lesser number of people took the initiative to bring the OHCA patients to the tertiary care. In the Indian scenario, most of the OHCA patients are taken to the local medical care providers. Thus, in our study selected population was enrolled, and the outcome was measured.

In conclusion, the main aim of our study was to come up with a data of Indian patients who present to the hospitals after OHCA and highlight the differences in the chain of survival and factors which affect the outcome among them. The survival outcome of most patients had a poor neurological status. This neurological status mostly depends on the proper chain of survival. Therefore, there is a need to have a proper cardiac arrest registry in the community. The outcome in survivors of OHCA can be further improved if the chain of survival link is maintained and effective emergency ambulance services with a trained emergency medical team are provided. There is also a need to bring awareness and knowledge among the common people regarding the bystander CPR.

There is a need to do further large-scale studies, so that, data can be collected and various predictors and ways to improve outcomes among OHCA survivors can be implemented. This would serve to benefit the Indian population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Jameson JN, Dennis LK, Harrison TR, Braunwald E, Fauci AS, Hauser SL, et al. Harrison's Principles of Internal Medicine. New York: McGraw-Hill Medical Publishing Division; 2005.  Back to cited text no. 1
    
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Rajaram R, Rajagopalan RE, Pai M, Mahendran S. Survival after resuscitation in an urban Indian hospital. Natl Med J India 1999;12:51-5.  Back to cited text no. 2
    
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Becker LB, Smith DW, Rhodes KV. Incidence of cardiac arrest: A neglected factor in evaluating survival rates. Ann Emerg Med 1993;22:86-91.  Back to cited text no. 3
    
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Larson MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac arrest. Ann Emerg Med 1993;22:1652-8.  Back to cited text no. 4
    
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Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency cardiac care committee and subcommittees, American Heart Association. Part I. Introduction. JAMA 1992;268:2171-83.  Back to cited text no. 5
    
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Jacobs IG, Oxer HF. A review of pre-hospital defibrillation by ambulance officers in Perth, Western Australia. Med J Aust 1990;153:662-4.  Back to cited text no. 6
    
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Safar P. Resuscitation after brain ischemia. In: Grenvik A, Safar P, editors. Brain Failure and Resuscitation. New York: Churchill Livingstone; 1981. p. 155-84.  Back to cited text no. 7
    
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The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown and Co.; 1994. p. 253-6.  Back to cited text no. 8
    
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Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: A systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010;3:63-81.  Back to cited text no. 9
    
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Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies. Resuscitation 2010;81:1479-87.  Back to cited text no. 10
    
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Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 2008;300:1423-31.  Back to cited text no. 11
    
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Zive D, Koprowicz K, Schmidt T, Stiell I, Sears G, Van Ottingham L, et al. Variation in out-of-hospital cardiac arrest resuscitation and transport practices in the resuscitation outcomes consortium: ROC epistry-cardiac arrest. Resuscitation 2011;82:277-84.  Back to cited text no. 12
    
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McNally B, Robb R, Mehta M, Vellano K, Valderrama AL, Yoon PW, et al. Out-of-hospital cardiac arrest surveillance – Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 01, 2005 – December 31, 2010. MMWR Surveill Summ 2011;60:1-19.  Back to cited text no. 13
    
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Krishna CK, Showkat HI, Taktani M, Khatri V. Out of hospital cardiac arrest resuscitation outcome in North India-CARO study. World J Emerg Med 2017;8:200-5.  Back to cited text no. 14
    
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Joshi M. A prospective study to determine the circumstances, incidence and outcome of cardiopulmonary resuscitation in a referral hospital in India, in relation to various factors. Indian J Anaesth 2015;59:31-6.  Back to cited text no. 15
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Engdahl J, Holmberg M, Karlson BW, Luepker R, Herlitz J. The epidemiology of out-of-hospital “sudden” cardiac arrest. Resuscitation 2002;52:235-45.  Back to cited text no. 16
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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