AHA: Regional systems may increase survival from out-of-hospital cardiac arrest

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Many more people could survive out-of-hospital cardiac arrest (OOHCA) if regional systems of cardiac resuscitation care were established, according to an American Heart Association (AHA) policy statement published Jan. 14 in Circulation.

In addition, the statement proposes establishing specialized cardiac resuscitation centers in hospitals similar to the regional stroke, heart attack and trauma centers that already exist.

During a cardiac arrest, the heart is unable to pump blood, usually because of abnormal electrical signals within the heart. Many cardiac arrests are due to ventricular fibrillation, the uncoordinated contraction or trembling of the ventricles, according to the AHA. Death usually follows within minutes unless the victim receives immediate cardiopulmonary resuscitation (CPR). CPR can keep a small amount of blood circulating until a device called an automated external defibrillator (AED) can shock the heart to try to stop ventricular fibrillation.

About 295,000 people in the U.S. are treated for OOHCA each year. If deaths due to OOHCA were separated from deaths due to other cardiovascular causes, it would be the third-leading cause of death, according to the statement.

“Currently, survival rates after cardiac arrest vary by as much as 500 percent from city to city, largely because many regions lack a well coordinated approach to treating people who suffer out-of-hospital cardiac arrest,” said lead author Graham Nichol, MD, professor of medicine at the University of Washington in Seattle and director of the University of Washington-Harborview Center for Prehospital Emergency Care.

In areas that have implemented systems of care, such as Seattle and King County, Wash., as many as 40 percent of people who have ventricular fibrillation survive to hospital discharge, compared with an average survival-to-discharge rate of 7.9 percent for emergency medical services (EMS)-treated cardiac arrest throughout North America, according to the statement.

“[R]egional systems of care have had a significant impact on outcomes for people who suffer life-threatening traumatic injury or heart attack,” Nichol said. “It is time to do for people who suffer cardiac arrest what we did for people who suffer heart attack or trauma.”

The statement said that treatments and strategies to care for patients after cardiac arrest include:
  • Therapeutic hypothermia;
  • Coronary angiography and PCI;
  • Early stabilization of blood circulation and vital signs;
  • Ability to manage re-arrest;
  • Reliable estimation of survival (especially considering the effects of therapeutic hypothermia – such as delay in resuming normal brain function and blood chemistry); and
  • Electrophysiology studies prior to discharge and treat patients with lethal arrhythmias.

“These interventions are complex or require special experience and expertise to ensure their success,” wrote the statement authors. “Cardiac resuscitation centers could develop expertise in using these interventions, contribute to research and knowledge of their effectiveness, and function as training centers for post-cardiac arrest care.”

According to the statement, the proposed essential elements of regional systems of care for OOHCA are:
  • Medical direction for EMS and hospital to work together in developing a plan;
  • External certification (not self-designation);
  • Field triage of patients with return of spontaneous circulation to route appropriate patients for angioplasty;
  • Plan for and treatment of re-arrest;
  • Continuous quality improvement plan to monitor, report and set goals to improve outcomes; and
  • Reimbursement plan for participation.