G.
PETTINATI - DIVISIONE DI CARDIOLOGIA - OSPEDALE F.FERRARI - CASARANO
Sudden
cardiac death remains a world-wide health problem. More than 1000 such
deaths occur daily in the United States (1); most are secondary to
ventricular fibrillation (VF). Unfortunately, only about 5% of victims
survive. Sudden cardiac death is the most common "accidental"
death in the US.A combined total of all airline, automobile, and
drowning deaths would nor equal the number of accidental or unexpected
sudden cardiac deaths.
In
European countries many studies (2) about out hospital cardiac arrest
reported overall survival after hospital discharge among 8%. Maastricht
Study (1993-97) : 517
patient with out hospital cardiac arrest received a RCP an 36% of case,
time of first aid was 6,5 minutes, overall survival was 6,2 %. Goteborg
Study: (1981-93): 3714 patients with out hospital cardiac arrest; time
of first aid was 7,3" and survival 9%. An follow up mortality was
21% after 1 year, 56% after 5 years and 16% presented other cardiac
arrest on following 3 years. Lisboa Study (1990-95): 1250 patients with
out hospital cardiac arrest; time of first aid was 9,2" and overall
survival 11,9%. Firenze Study 328 patients with out hospital, time of
first aid 8',0" and overall survival 6,5%. In USA the data are
various. In retrospective review of 2043 out hospital cardiac
arrest in King Counthy, Washington, Cummins (3) reported that 18% of
patients survived to hospital discharge. In an analysis of 352 witnessed
pre hospital cardiac arrest in Miami 67 patients (19%) survived to
discharge (4). Two other studies in over 6000 patients in Chicago and
New York reported dismal survival rate of
2 % on 1,4% respectively (5-6). The different survival rate was
depending from many factors as
call of emergency medical service, witnessed
versus unwitnessed arrest, bystander initiated CPR (7). It's
important to note that in hospital cardiac arrest varies tremendously
among studies but average about 15% - 20%. In a 10 years study by
Peatfield (8) that excluded ICU and CCU there were 1063 in hospital
cardiac arrest 93 patients (8,7%) were discharged alive and only 2,1 %
on the general wards. Similarly, Saklayen (9) reported a survival rate
of 15% after in hospital cardiac arrest in their meta analysis of 113
published reports including
26095 patients. On the all studies
the outcome and long term follow up of the survivors never is
reported.
The
key issue in successfully treating sudden cardiac death is early
defibrillation. "The sooner the better" is never more true
than with defibrillation of VF. In various settings, if defibrillation
is applied immediately or very early, such as in the cardiac
catheterisation laboratory or or cardiac rehabilitation centres, a
survival rate of 90% is possible and should be expect (11). The American
Heart Association has stated, "it is essential to integrate the
concept of early
defibrillation into an effective emergency cardiac care system".
The natural extension to these statements has been consider expanding
the boundaries of first responders to include the lay public, the public
access defibrillation.
The
increased availability of automatic external defibrillators should
result in earlier defibrillation, leading to better outcome from cardiac
arrest (12). It was happening during last five years. An important
report from Seattle, Washington, examined the "public"
location in cardiac arrest. These investigators again confirmed that
most cardiac arrest occur in the home (76%); only 16% occur in public
sites. The most common public location for cardiac arrest was Seattle
Tacoma Airport, with seven cardiac arrests each year. Penitentiaries
were the second most common location. Shopping malls had 0,7
arrests each year, and sporting arenas
during major events 0,4 each year. Other less frequent locations
included hotels, government offices, schools, and churches. White of the
Mayo Clinic in Rochester, Minnesota (13), reported his results on police
initiated defibrillation. He has equipped the Rochester police
department with automatic external defibrillators, reasoning that as the
police often arrive first at an emergency, some of these could include
cardiac arrest. Forty one of 108 patients having a cardiac arrest were
first shocked by the police. Spontaneous circulation was restored
without additional advance cardiac life support in 14 patients (34%).
These patients were long term survivors. Among patients in whom
spontaneous circulation could not be restored before arrival of the
paramedics and who needed further advanced cardiac life support only 22%
were long term survivors. The survival rate when police deliver the firs
shock is 49% compared with 43% when paramedics initiate early
defibrillation. Mosesso (14) reported on a similar type of project in
the suburbs of Pittsburgh, Pennsylvania. A historical control was used
during which time the police were not equipped with automatic external
defibrillators. The time from emergency call to delivery of the first
shock was 11,8 minutes during the control period. After the police were
equipped with automatic external defibrillators that time dropped to 8,7
minutes (p < 0,0001). Restoration of spontaneous circulation improved
from 36% to 52% (p < 0,03), and survival more than doubled from 6% to
14% (p = 0,01). When the police arrived first during the control years
only 3% of patients with cardiac arrest survived. A survival rate
of 26% has been achieved since the police were issued with automatic
external defibrillators (p < 0,05).
An
interesting report was presented by the St John Ambulance Brigade London,
UK - a 2300 volunteer lay public first responder provider group (15). In
the past five years, since automatic external defibrillators were
introduced, 17 patients with cardiac arrest have been defibrillated.
Spontaneous circulation was restored in 14 patients. Twelve of the 17
were long term survivors. This is an astounding record of
out-of-hospital success. Quantas Airline's experiences (16) of
defibrillation (n = 21), six on the aircraft and 15 in the terminal,
shows that automatic external defibrillators delivered an appropriate
shock to all patients with VF. VF was terminated by defibrillator shock
in 20 patients. Six of 21 patients had excellent long term outcome.
Few
months ago, Pepper published the WIMAS experiences (West Yorkshire
Ambulance Service) (17). Aim of study
was explore the current use of secondary preventive treatment in
survivors of out of hospital cardiac arrest without myocardial
infarction (primary ventricular fibrillation) in West Yorkshire, and
assess the implications of recent studies on the benefits of implantable
cardioverter-defibrillators (AICD) in this context. Design was
retrospective analysis of
an ambulance service based database of outcome after resuscitation of
out of hospital cardiac arrest, and the Leeds AICD implantation
database. Main outcome measures mortality, rate of referral for
specialist investigation, antiarrhythmic treatment. Twelve month
mortality following successful discharge after primary VF arrest was
15%. Of 53 patients with primary VF/VT, 29 apparently did not see a
cardiologist during the initial admission. Amiodarone was the most
widely used anthiarrhythmic agent. Six patients (15%) received an AICD.
During the same period 22 patients from the same catchment area received
an AICD following an in hospital cardiac arrest.
Mortality
among survivors of non infarct related prehospital cardiac arrest
remains significant, with few patients being referred for specialist
investigation. The implementation of recent guidelines on AICD use in
cardiac arrest survivors would have resulted in anapproximate 60%
increase in the total numbers of the defibrillators implanted in the
West Yorkshire area.
Survived
patients to TV-VF cardiac arrest have high
risk of fatal recidivist. CIDS Study (22) (Canadian Implantable
Defibrillators Study) CASH Study (21) (Cardiac Arrest Study Hanburg) and
AVID study (18) concluded that
implantable cardiovertitor defibrillators (ICD) patients
have bigger preventive than pharmacological drug patients. AVID Study strongly documented improvement of
outcome of ICD patients versus drug patients about secondary preventive
of sudden death. Particularly AVID Study focused 2674 TV-FV patients,
1868 (70%) out hospital and 866 (30%) in hospital cardiac arrest
patients. Immediate and long term mortality rate (Kaplan Meyer) was
smaller for out hospital than in hospital patients with relative risk
greatest 1,6 for in hospital patients. The cause of this surprising
results are 1) in hospital patients have more concomitant disease and
were very seriously ill, 2)
survival rate of out hospital cardiac arrest is depending from sites,
emergency medical system, public organisation, 43% in Seattle, 0,8% in
afro-american people of Chicago (19). Particularly it's important to
note that two years out-hospital survival 83,1% is same than ICD
patients (81,6%) on the AVID Study. It means that results that depends
from one variable (ICD) should be dependent from other variable (site of
FV) (20)
In
conclusion we can enphatize
three points:
1)
AVID
Study (ICD better than drugs) should be very important but not absolute
message: other factors should cause poor outcome of survivors.
2)
An
optimal organisation of territorial emergency medical system can improve
immediate but not long term prognosis, because perhaps many survivors
did not see a cardiologist during initial admission in hospital. A
larger use of ICD should do
it?
3)
The site where the life threatening arrhythmias occurs should be
considered independent risk factor planning future trials about cardiac
arrest and mortality.
References
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Cummins R. Et Alt
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Survival Rrom Sudden Cardiac Arrest
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Of Hospital Cardiac Arrest In The 1990 In The Mediterranean Area.
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Of Mespe- "Progress In Biomedical Research". Cardiostim -
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Bebruary 6, 1999 P. 51
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Survival
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