| 1. |
- Elfwen, Ludvig, et al.
(författare)
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Post-resuscitation myocardial dysfunction in out-of-hospital cardiac arrest patients randomized to immediate coronary angiography versus standard of care
- 2020
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Ingår i: IJC Heart & Vasculature. - : ELSEVIER IRELAND LTD. - 2352-9067. ; 27
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Tidskriftsartikel (refereegranskat)abstract
- Background: Immediate coronary angiography with subsequent percutaneous coronary intervention (PCI) has the potential to reduce post-resuscitation myocardial dysfunction in out-of-hospital cardiac arrest (OHCA) patients. The aim of this study was to see if immediate coronary angiography, with potential PCI, in patients without ST-elevation on the ECG, influenced post-resuscitation myocardial function and cardiac biomarkers.Methods: A secondary analysis of the Direct or Subacute Coronary Angiography in Out-of-Hospital Cardiac Arrest (DISCO) trial (ClinicalTrials.gov ID: NCT02309151). Patients with bystander-witnessed OHCA, without ST-elevations on the ECG were randomly assigned to immediate coronary angiography within two hours of cardiac arrest (n = 38) versus standard-of-care with deferred angiography (n = 40). Outcome measures included left ventricle ejection fraction (LVEF) at 24 h, peak Troponin T levels, lactate clearance and NT-proBNP at 72 h.Results: In the immediate-angiography group, median LVEF at 24 h was 47% (Q1-Q3; 30-55) vs. 46% (Q1-Q3; 35-55) in the standard-of-care group. Peak Troponin-T levels during the first 24 h were 362 ng/L (Q1-Q3; 174-2020) in the immediate angiography group and 377 ng/L (Q1-Q3; 205-1078) in the standard-of-care group. NT-proBNP levels at 72 h were 931 ng/L (Q1-Q3; 396-2845) in the immediate-angiography group and 1913 ng/L (Q1-Q3; 489-3140) in the standard-of-care group.Conclusion: In this analysis of OHCA patients without ST-elevation on the ECG randomized to immediate coronary angiography or standard-of-care, no differences in post-resuscitation myocardial dysfunction parameters between the two groups were found. This finding was consistent also in patients randomized to immediate coronary angiography where PCI was performed compared to those where PCI was not performed.
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| 2. |
- Lagedal, Rickard, et al.
(författare)
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Coronary angiographic findings after cardiac arrest in relation to ECG and comorbidity
- 2020
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Ingår i: Resuscitation. - : Elsevier BV. - 0300-9572 .- 1873-1570. ; 146, s. 213-219
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: The relations between specific ECG patterns and coronary angiographic findings in cardiac arrest patients with different comorbidities are not properly assessed. More evidence is needed to identify patients with the highest risk for acute coronary artery disease as a cause of the cardiac arrest. This study aims to describe the coronary artery findings after cardiac arrest in relation to ECG and comorbidity.Method: A retrospective study of out-of-hospital cardiac arrest patients, with coronary angiography performed within 28 days. ECG on admission, comorbidity, PCI attempts and angiographic findings are described. Data were retrieved from national registries in Sweden.Results: Among 1133 patients with available ECG and angiography information the mean age was 64 years. The rate of shockable rhythm was 79 degrees 0. The total incidence of any significant stenosis in cardiac arrest patients without ST-elevation who underwent coronary angiography within 28 days was 71 degrees 0. The incidence of any stenosis in patients with normal ECG was 62.1 degrees 0 and in patients with LBBB, 59.3 degrees 0. In patients with ST-depression or RBBB, PCI attempts were made in 47.1 degrees 0 and 42.4 degrees 0 respectively, compared with 33.3 degrees 0 in patients with normal ECG. Among patients without ST-elevation, those with diabetes mellitus and those with initial shockable rhythm respectively, 84.8 degrees 0 and 71.5 had at least one significant stenosis.Conclusion: Our study suggests, that evaluation of ECG patterns and comorbidities in out-of-hospital cardiac arrest patients without ST-segment elevation may be important to identify those with a high risk of coronary artery lesions that could benefit from early revascularization.
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| 3. |
- Lagedal, Rickard, 1981-
(författare)
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Coronary angiography after out-of-hospital cardiac arrest
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Out-of-hospital cardiac arrest (OHCA) is a common cause of death with a survival rate of 10% in Sweden. The chance of survival depends on rapid recognition, high quality cardiopulmonary resuscitation and post-resuscitation care including searching and treating the cause of the arrest. Ischaemic cardiac disease including acute coronary artery occlusions is the most common cause of OHCA. Acute coronary artery lesions can be diagnosed and treated with coronary angiography and subsequent PCI. This thesis analyses various aspects of coronary angiography after OHCA. Paper I+II describes the rational, protocol and the results from the pilot phase (n=117) of a randomized multicentre clinical trial. We compared a strategy of immediate coronary angiography in patients successfully resuscitated after OHCA with a strategy without immediate coronary angiography. We did not reach the stipulated time of 120 minutes from first medical contact to angiography, but our study strategy was feasible. No major unexpected safety issues were reported. The main phase of the study could therefore be started with only minor changes from the pilot phase protocol. In a registry study of 1133 patients (Paper III) coronary angiographic findings were compared with ECG and comorbidities in unconscious patients after OHCA. In patients without ST-elevation, the rate of PCI attempts was higher in patients with ST-depression (47%) and in patients with ECG classified as “other findings” (45%) compared to patients with normal ECG (33%), OR 1.78 (CI 1.13-2.82) and OR 1.65 (CI 1.04-2.61), respectively. When analysing patients without ST-elevation, no difference in PCI rates were found between the comorbidity groups and neither between patients with shockable compared to non-shockable initial ECG rhythm. Paper IV is a registry study (n=3906) analysing the impact of patient income on the probability to receive early coronary angiography after OHCA. When dividing patients into income quarters and adjusting for confounders, increasing income was associated with higher rates of early coronary angiography. Thirty-six percent of patients in the highest income quarter received early angiography compared to fifteen percent in the lowest income quarter, OR 1.64 (1.27-2.11). Adding potential mediators to explain this finding gradually decreased the difference, and the main explanatory factor for this difference was that higher income is associated with higher rates of shockable ECG rhythm. 30-day survival was also higher in the highest income quarter compared to the lowest income group in the fully adjusted analysis, OR 1.51 (CI 1.22-1.89).
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| 4. |
- Lagedal, Rickard, et al.
(författare)
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Income is associated with the probability to receive early coronary angiography after out-of-hospital cardiac arrest
- 2020
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Ingår i: Resuscitation. - : Elsevier. - 0300-9572 .- 1873-1570. ; 156, s. 35-41
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: Low socioeconomic status has been associated with worse outcome after cardiac arrest. This study aims to investigate if patients income influences the probability to receive early coronary angiography in out-of-hospital cardiac arrest (OHCA) patients.Methods: In this nationwide retrospective observational study, 3906 OHCA patients admitted alive and registered in the Swedish Registry for Cardiopulmonary Resuscitation were included. Individual data on income and educational level, prehospital parameters, coronary angiography results and comorbidity were linked from SWEDEHEART and other national registers.Results: Patients were divided into quarters depending on their income level. In the unadjusted model there was a strong correlation between income level and rate of early coronary angiography where 35.5% of patients in the highest income quarters received early angiography compared to 15.4% in the lowest income quarters. When adjusting for educational level, sex, age, comorbidity and hospital type, there were still higher chance of receiving early coronary angiography with increasing income, OR 1.31 (CI 1.01-1.68) and 1.67 (CI 1.29-2.16) for the two highest income quarters respectively compared to the lowest income quarter. When adding potential mediators to the model (first recorded ECG rhythm by the EMS, location, response time, bystander cardiopulmonary resuscitation and if the arrest was witnessed) no difference in early angiography related to income level where found. The main mediator was first recorded ECG rhythm.Conclusion: Income level is associated with the probability to undergo early coronary angiography in OHCA patients. This association seems to be mediated by the initial ECG rhythm.
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| 5. |
- Lindgren, Erik, 1972-
(författare)
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Cardiac Arrest – mechanical chest compressions, gender differences and coronary angiography
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Cardiac arrest is a major health problem with over 6000 cases of out-of-hospital cardiac arrest (OHCA) and 2500 cases of in-hospital cardiac arrest (IHCA) per year in Sweden. Survival are low. Many factors affect the chances of survival, including effective cardiopulmonary resuscitation and optimal post resuscitation care. These thesis involve these areas. Paper I+II describe a randomized clinical trial (n=2589). We compared a novel CPR algorithm with defibrillations during ongoing chest compressions delivered with a mechanical chest compression device and manual CPR according to guidelines. We found no difference in 4-hour survival, 23.6% with mechanical CPR and 23.7% with manual CPR. The vast majority of survivors in both groups had good neurological outcomes by 6 months. Paper III is a registry study (n=1498). We investigated impact of gender in performance and findings of early coronary angiography (CAG) and percutaneous coronary intervention (PCI), comorbidity and outcome among OHCA victims with an initially shockable rhythm. We found no difference between men and women in rates of ST-elevation/left bundle branch block (LBBB), 40% vs. 38% or rates of CAG, 45% vs. 40%. Among patients without ST-elevation/LBBB more men than women had CAG followed by PCI, 59% vs. 42% (P=0.03) and more advanced coronary artery disease. We found no association between gender and use of early CAG. Paper IV is a retrospective observational single centre study (n=423) of ICU treated victims of cardiac arrest. OHCA and IHCA were compared regarding comorbidity, characteristics of the arrest, treatment including CAG and CAG findings and outcome. OHCA patients had less preexisting comorbidity, lower rates of bystander CPR 71% vs 100% (p<0.001) and longer time to return of spontaneous circulation, 20 vs 10 minutes (p<0.001). OHCA patients more often had a shockable first rhythm, 47% vs 13% (p<0.001) and CA without any obvious non-cardiac origin, 77% vs 50% (p<0.001). OHCA patients more often underwent early CAG, 52% vs 25% (p<0.001) but no difference in rates of subsequent PCI or angiogram with at least one significant stenosis was seen. OHCA and IHCA did not differ in 30-days survival, 42% vs 41% or 1-year survival, 39% vs 33%
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| 6. |
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| 7. |
- Lipcsey, Miklós, et al.
(författare)
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Endotoxin removal in septic shock with the Alteco LPS adsorber was safe but showed no benefit compared to placebo in the double-blind randomized controlled trial-the asset study
- 2020
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Ingår i: Shock. - : Ovid Technologies (Wolters Kluwer Health). - 1073-2322 .- 1540-0514. ; 54:2, s. 224-231
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Tidskriftsartikel (refereegranskat)abstract
- Purpose: Lipopolysaccharides (LPS) are presumed to contribute to the inflammatory response in sepsis. We investigated if extracorporeal Alteco LPS Adsorber for LPS removal in early gram-negative septic shock was feasible and safe. Also, effects on endotoxin level, inflammatory response, and organ function were assessed.Methods: A pilot, double-blinded, randomized, Phase IIa, feasibility clinical investigation was undertaken in six Scandinavian intensive care units aiming to allocate 32 septic shock patients with abdominal or urogenital focus on LPS Adsorber therapy or a Sham Adsorber, therapy without active LPS binding. The study treatment was initiated within 12 h of inclusion and given for 6 h daily on first 2 days. LPS was measured in all patients.Results: The investigation was terminated after 527 days with eight patients included in the LPS Adsorber group and seven in the Sham group. Twenty-one adverse effects, judged not to be related to the device, were reported in three patients in the LPS Adsorber group and two in the Sham group. Two patients in the Sham group and no patients in the LPS Adsorber group died within 28 days. Plasma LPS levels were low without groups differences during or after adsorber therapy. The changes in inflammatory markers and organ function were similar in the groups.Conclusions: In a small cohort of patients with presumed gram-negative septic shock, levels of circulating endotoxin were low and no adverse effects within 28 days after LPS adsorber-treatment were observed. No benefit compared with a sham device was seen when using a LPS adsorber in addition to standard care.
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| 8. |
- Riva, Gabriel, et al.
(författare)
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Survival after dispatcher-assisted cardiopulmonary resuscitation in out-of-hospital cardiac arrest
- 2020
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Ingår i: Resuscitation. - : Elsevier BV. - 0300-9572 .- 1873-1570. ; 157, s. 195-201
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Tidskriftsartikel (refereegranskat)abstract
- AimStrategies to increase provision of bystander CPR include mass education of laypersons. Additionally, programs directed at emergency dispatchers to provide CPR instructions during emergency calls to untrained bystanders have emerged. The aim of this study was to evaluate the association between dispatcher-assisted CPR (DA- CPR) and 30-day survival compared with no CPR or spontaneously initiated CPR by lay bystanders prior to emergency medical services in out of hospital cardiac arrest (OHCA).MethodsNationwide observational cohort study including all consecutive lay bystander witnessed OHCAs reported to the Swedish Register for Cardiopulmonary Resuscitation in 2010–2017. Exposure was categorized as: no CPR (NO-CPR), DA-CPR and spontaneously initiated CPR (SP-CPR) prior to EMS arrival. Propensity-score matched cohorts were used for comparison between groups. Main Outcome was 30-day survival.ResultsA total of 15 471 patients were included and distributed as follows: NO-CPR 6440 (41.6%), DA-CPR 4793 (31.0%) and SP-CPR 4238 (27.4%). Survival rates to 30 days were 7.1%, 13.0% and 18.3%, respectively. In propensity-score matched analysis (DA-CPR as reference), NO-CPR was associated with lower survival (conditional OR 0.61, 95% CI 0.52–0.72) and SP-CPR was associated with higher survival (conditional OR 1.21 (95% CI 1.05–1.39).ConclusionsDA-CPR was associated with a higher survival compared with NO-CPR. However, DA-CPR was associated with a lower survival compared with SP-CPR. These results reinforce the vital role of DA-CPR, although continuous efforts to disseminate CPR training must be considered a top priority if survival after out of hospital cardiac arrest is to continue to increase.
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| 9. |
- Stattin, Karl, et al.
(författare)
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Inadequate prophylactic effect of low-molecular weight heparin in critically ill COVID-19 patients
- 2020
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Ingår i: Journal of critical care. - : Elsevier BV. - 0883-9441 .- 1557-8615. ; 60, s. 249-252
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Tidskriftsartikel (refereegranskat)abstract
- PURPOSE: The aim of this study was to investigate potential markers of coagulopathy and the effects of thromboprophylaxis with low-molecular-weight heparin (LMWH) on thromboelastography (TEG) and anti-factor Xa in critically ill COVID-19 patients.MATERIAL AND METHODS: We conducted a prospective study in 31 consecutive adult intensive care unit (ICU) patients. TEG with and without heparinase and anti-factor Xa analysis were performed. Standard thromboprophylaxis was given with dalteparin (75-100 IU/kg subcutaneously).RESULTS: Five patients (16%) had symptomatic thromboembolic events. All patients had a maximum amplitude (MA) > 65 mm and 13 (42%) had MA > 72 mm at some point during ICU stay. Anti-factor Xa activity were below the target range in 23% of the patients and above target range in 46% of patients. There was no significant correlation between dalteparin dose and anti-factor Xa activity.CONCLUSIONS: Patients with COVID-19 have hypercoagulability with high MA on TEG. The effect of LMWH on thromboembolic disease, anti-factor Xa activity and TEG was variable and could not be reliably predicted. This indicates that standard prophylactic doses of LMWH may be insufficient. Monitoring coagulation and the LMWH effect is important in patients with COVID-19 but interpreting the results in relation to risk of thromboembolic disease poses difficulties.
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