Little is known about the long-term outcomes in elderly survivors of in-hospital cardiac arrest. We determined rates of long-term survival and readmission among survivors of in-hospital cardiac arrest and examined whether these outcomes differed according to demographic characteristics and neurologic status at discharge.
We linked data from a national registry of inpatient cardiac arrests with Medicare files and identified 6972 adults, 65 years of age or older, who were discharged from the hospital after surviving an in-hospital cardiac arrest between 2000 and 2008. Predictors of 1-year survival and of readmission to the hospital were examined.
One year after hospital discharge, 58.5% of the patients were alive, and 34.4% had not been readmitted to the hospital. The risk-adjusted rate of 1-year survival was lower among older patients than among younger patients (63.7%, 58.6%, and 49.7% among patients 65 to 74, 75 to 84, and ≥85 years of age, respectively; P<0.001), among men than among women (58.6% vs. 60.9%, P=0.03), and among black patients than among white patients (52.5% vs. 60.4%, P=0.001). The risk-adjusted rate of 1-year survival was 72.8% among patients with mild or no neurologic disability at discharge, as compared with 61.1% among patients with moderate neurologic disability, 42.2% among those with severe neurologic disability, and 10.2% among those in a coma or vegetative state (P<0.001 for all comparisons). Moreover, 1-year readmission rates were higher among patients who were black, those who were women, and those who had substantial neurologic disability (P<0.05 for all comparisons). These differences in survival and readmission rates persisted at 2 years. At 3 years, the rate of survival among survivors of in-hospital cardiac arrest was similar to that of patients who had been hospitalized with heart failure and were discharged alive (43.5% and 44.9%, respectively; risk ratio, 0.98; 95% confidence interval, 0.95 to 1.02; P=0.35).
Among elderly survivors of in-hospital cardiac arrest, nearly 60% were alive at 1 year, and the rate of 3-year survival was similar to that among patients with heart failure. Survival and readmission rates differed according to the demographic characteristics of the patients and neurologic status at discharge. (Funded by the American Heart Association and the National Heart, Lung, and Blood Institute.).
"Furthermore, there is a trend to increasing rates of combined CABG and valve surgery , and it is not clear what impact valve surgery would have on the predictive value of cTnI. This study does not tell us about the long-term outcome of patients with elevated cTnI, which would be an important point for future research considering the poor long-term outcomes of those suffering in-hospital cardiac arrest . Further investigation is required to determine whether those patients with elevated cTnI would benefit from having their surgery delayed or brought forward in order to reduce surgical risk. "
[Show abstract][Hide abstract] ABSTRACT: Background
Cardiac troponins are frequently measured as part of the pre-operative work-up of patients prior to coronary artery bypass graft surgery (CABG). The utility of measuring these levels in elective patients, and the clinical implication of an abnormal result are unclear. The following study investigates the relationship between cardiac troponin I (cTnI) measured as part of a routine pre-operative work-up and outcomes following CABG.
From January 2010 to December 2012, 378 patients underwent isolated, elective CABG and had cTnI measured prospectively, as part of their pre-operative work-up. Patients were divided into normal (Group I) and elevated (Group II) cTnI groups. Pre-operative, operative and post-operative data were obtained from our institution's prospectively collected database.
Elevated cTnI was present in 47 patients (12.4%) pre-operatively. Intra-operative variables did not differ between the elevated cTnI and control groups. Both 30-day mortality (Group I: 0.9% v Group II: 6.4%, p = 0.03) and cardiac arrest (Group I: 1.5% v Group II: 8.5%, p = 0.01) were significantly more frequent in the elevated cTnI group. In multivariable analysis, elevated cTnI remained a predictor for cardiac arrest (OR 5.8, 95% CI 1.2–29.2).
Patients presenting for elective CABG frequently have elevated cTnI on pre-operative work-up. These patients may be at a greater risk of 30-day mortality and cardiac arrest. Routine pre-operative measurement of cTnI may alert clinicians to a higher operative risk.
[Show abstract][Hide abstract] ABSTRACT: It is not known if aggressive postresuscitation care, including therapeutic hypothermia and percutaneous coronary intervention, benefits cardiac arrest survivors more than 75 years old. We compared treatments and outcomes of patients at six regional percutaneous coronary intervention centers in the United States to determine if aggressive care of elderly patients was warranted.
Retrospective evaluation of registry data.
Six interventional cardiology centers in the United States.
Six hundred and twenty-five unresponsive cardiac arrest survivors aged 18-75 were compared with 129 similar patients aged more than 75.
Cardiac arrest survivors aged more than 75 had more comorbidities (3.0 ± 1.6 vs 2.0 ± 1.6, p < 0.001), but were matched to younger patients in initial heart rhythm, witnessed arrests, bystander cardiopulmonary resuscitation, and total ischemic time. Patients aged more than 75 frequently underwent therapeutic hypothermia (97.7%), urgent coronary angiography (44.2%), and urgent percutaneous coronary intervention (24%). They had more sustained hyperglycemia (70.5% vs 59%, p = 0.015), less postcooling fever (25.2% vs 35.2%, p = 0.03), were more likely to have do-not-resuscitate orders (65.9% vs 48.2%, p < 0.001), and undergo withdrawal of life support (61.2% vs 47.5%, p = 0.005). Good functional outcome at 6 months (Cerebral Performance Category 1-2) was seen in 27.9% elderly versus 40.4% younger patients overall (p = 0.01) and in 44% versus 55% (p = 0.13) of patients with an initial shockable rhythm. Of 35 survivors more than 75 years old, 33 (94.8%) were classified as Cerebral Performance Category 1 or 2 at (mean) 6.5-month follow-up. In multivariable logistic regression modeling, age more than 75 was significantly associated with outcome only when the presence of a do-not-resuscitate order was excluded from the model.
Elderly patients were more likely to have do-not-resuscitate orders and to undergo withdrawal of life support. Age was independently associated with outcome only when correction for do-not-resuscitate status was excluded, and functional outcomes of elderly survivors were similar to younger patients. Exclusion of patients more than 75 years old from aggressive care is not warranted on the basis of age alone.
Critical care medicine 10/2013; 42(2). DOI:10.1097/CCM.0b013e3182a26ec6 · 6.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To summarize the current literature on racial and gender disparities in critical care and the mechanisms underlying these disparities in the course of acute critical illness.
MEDLINE search on the published literature addressing racial, ethnic, or gender disparities in acute critical illness, such as sepsis, acute lung injury, pneumonia, venous thromboembolism, and cardiac arrest.
Clinical studies that evaluated general critically ill patient populations in the United States as well as specific critical care conditions were reviewed with a focus on studies evaluating factors and contributors to health disparities.
Study findings are presented according to their association with the prevalence, clinical presentation, management, and outcomes in acute critical illness.
This review presents potential contributors for racial and gender disparities related to genetic susceptibility, comorbidities, preventive health services, socioeconomic factors, cultural differences, and access to care. The data are organized along the course of acute critical illness.
The literature to date shows that disparities in critical care are most likely multifactorial involving individual, community, and hospital-level factors at several points in the continuum of acute critical illness. The data presented identify potential targets as interventions to reduce disparities in critical care and future avenues for research.
Critical care medicine 10/2013; 41(12). DOI:10.1097/CCM.0b013e3182a84a43 · 6.31 Impact Factor
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