In-Hospital Cardiac Arrest Outcomes
Abstract & Commentary
By John P. DiMarco, MD, PhD, Professor of Medicine, Division of Cardiology, University of Virginia, Charlottesville. Dr. DiMarco does research for Medtronic, is a consultant for Medtronic, Novartis, and St. Jude, and is a speaker for Boston Scientific.
Source: Chan PS, et al, for the American Heart Association Get with the Guidelines-Resuscitation investigators. Long-term outcomes in elderly survivors of in-hospital cardiac arrest. N Engl J Med 2013;368:1019-1026.
The Get with the Guidelines-Resuscitation registry is a large, prospective registry of in-hospital cardiac arrests that analyzes data to promote quality improvement. In this paper, Chan and colleagues report the long-term outcomes in Medicare-age patients who suffered an in-hospital cardiac arrest and survived to discharge. The study cohort was drawn from 523 acute care hospitals that submitted data to the Get with the Guidelines-Resuscitation registry between 2000 and 2008. Data were collected on 10,316 Medicare age eligible patients. Of these, approximately 70% could be linked to Medicare claims data for the survival analysis. For patients with cardiac arrests during multiple hospitalizations, only the first event was included. The outcomes of interest were survival and freedom from readmission during the first year after discharge. Multivariable logistic-regression models were used to examine predictors of 1-year survival. The models included patient clinical characteristics, diagnoses, post-arrest neurological status, characteristics of the arrest, and clinical and administrative aspects of the arrest.
There were 6972 survivors of in-hospital cardiac arrests in the cohort. Ventricular fibrillation and pulseless electrical activity were the most common cardiac arrest rhythms. Heart failure, myocardial infarction, and renal infarction were present in 25% of patients. At hospital discharge, 48% of the patients had mild or no neurologic disability with 34% having moderate and 17% either had severe neurologic disability or were in a vegetative state. At discharge, 55% of the patients were transferred to an inpatient skilled nursing or rehabilitation facility, 40% were discharged home, and 5% went to a hospice. Life table analysis showed that the overall rate of survival was 82% at 30 days, 72% at 3 months, 59% at 1 year, and 50% at 2 years. Survival probability decreased with increasing age. Other factors associated with survival were white race, female gender, ventricular fibrillation as the presenting rhythm, and milder post-arrest neurologic disability. Hospital readmission was also common. Sixty-five percent of the patients were readmitted within 1 year after discharge and 76% had been readmitted by 2 years.
The authors conclude that the Get with the Guidelines-Resuscitation Registry provides important data about the outcomes of in-hospital cardiac arrest. If patients survive to discharge, a significant proportion will survive long-term, but repeat hospitalizations will be common.
It has been estimated that in-hospital cardiac arrest occurs with a frequency of about 6.6 per 1000 hospitalized adult patients, with about 50% in intensive care units and 50% in other settings. Since patients with in-hospital cardiac arrest are often already seriously ill, survival to hospital discharge is low, with most studies showing rates of less than 20-25%. However, as shown here, if patients do make it to discharge without severe neurologic damage, long-term survival is possible. This makes improvements in hospital programs to prevent and treat in-hospital cardiac arrest critically important.
The American Heart Association has recently published a position paper on strategies to improve survival after in-hospital cardiac arrest.1 This comprehensive document should be required reading for all cardiologists who provide in-hospital care.
1. Morrison LJ, et al. Strategies for improving survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations: A consensus statement from the American Heart Association. Circulation 2013; 127:1538-1563.