CCR-Newsletter-Banner

 

 

 American Heart Association Meeting Update / November 18th 2013

 

Welcome

Hello Rob

Welcome to a supplementary Critical Care Reviews Newsletter, bringing you the major research presented a few hours ago at the American Heart Association Conference in Dallas.

 

New England Journal of Medicine:     Out-of-Hospital Cardiac Arrest

Nielsen and colleagues completed a randomized, parallel group study, comparing targeted temperature management of 33°C (n=473) with 36°C (n=466) in 950 unconscious adults (939 analyzed) after out-of-hospital cardiac arrest of presumed cardiac cause, and found:

  1. no difference in all cause mortality at trial end
    • 33°C group:  50%
    • 36°C group:  48% 
    • hazard ratio with a temperature of 33°C 1.06; 95% CI 0.89 to 1.28; P=0.51
  2. no difference in mortality or poor neurological function at 180 days
    • 33°C group:  54% 
    • 36°C group:  52% 
    • risk ratio 1.02; 95% CI 0.88 to 1.16; P=0.78
  3. using the modified Rankin scale, the comparable rate was 52% in both groups
    • risk ratio 1.01; 95% CI 0.89 to 1.14; P=0.87
  4. analyses adjusted for known prognostic factors were similar

Full Text:  Nielsen. Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. N Engl J Med 2013;epublished November 17th

 

Journal of the American Medical Association:     Out-of-Hospital Cardiac Arrest

Kim et al completed a randomized, parallel group, controled trial, comparing standard care plus prehospital cooling (up to 2 L 4°C 0.9% saline) with standard care alone, in 1,359 cardiac arrest patients following return of spontaneous circulation, and found:

  1. cooling decreased mean core temperature by time of hospital arrival, compared with the control group:
    • ventricular fibrillation patients (n=583):  1.20 °C (95% CI −1.33 °C to −1.07 °C)
    • non ventricular fibrillation patients (n=776): 1.30 °C (95% CI −1.40 °C to −1.20 °C)
    • reduced the time to achieve a temperature of less than 34°C by about 1 hour compared with the control group
  2. no difference in survival to hospital discharge between intervention and control groups among patients with
    • VF patients (P=0.69)
      • cooling: 62.7% (95% CI 57.0%-68.0%)
      • control: 64.3% (95% CI 58.6%-69.5%) 
    • non VF patients (P=0.30)
      • cooling: 19.2% (95% CI 15.6%-23.4%) 
      • control: 16.3% (95% CI 12.9%-20.4%) 
  3. no difference in neurological status of full recovery or mild impairment at discharge 
    • VF patients (P=0.69)
      • cooling: 57.5% [(95% CI 51.8%-63.1%)
      • control: 61.9% (95% CI 56.2%-67.2%)
    • non VF patients (P=0.30)
      • cooling: 14.4% (95% CI 11.3%-18.2%)
      • control: 13.4% (95% CI10.4%-17.2%)
  4. cooling was associated with
    • increased rearrest in the field (P=0.008)
      • cooling: 26% (95% CI 22%-29%)
      • control: 21% (95% CI 18%-24%)
    • increased diuretic use 
    • increased pulmonary edema on first chest radiograph, which resolved within 24 hours after admission

Full Text:  Kim. Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest:  A Randomized Clinical Trial. JAMA 2013;epublished November 17th

 

Journal of the American Medical Association:     Cardiopulmonary Resuscitation

Rubertsson et al performed an international, multicenter randomized trial comparing mechanical chest compressions (LUCAS Chest Compression System) combined with defibrillation during ongoing compressions (n = 1,300) with manual CPR according to guidelines (n = 1,289) in 2,589 patients with out-of-hospital cardiac arrest, and found:

  1. no difference in four-hour survival
    • mechanical CPR:  23.6%
    • manual CPR:       23.7%
    • risk difference –0.05%; 95% CI –3.3% to 3.2%; P > 0.99
  2. no difference in survival with a Cerebral Performance Category score of 1 or 2 
    • intensive care unit discharge
      • mechanical CPR:  7.5% 
      • manual CPR        6.4%
      • risk difference     1.18%; 95% CI –0.78% to 3.1% 
    • hospital discharge
      • mechanical CPR:  8.3%
      • manual CPR:       7.8%
      • risk difference     0.55%; 95% CI –1.5% to 2.6%
    • at 1 month
      • mechanical CPR:  8.1%
      • manual CPR:       7.3%
      • risk difference     0.78%; 95% CI, –1.3% to 2.8%
    • at 6 months
      • mechanical CPR:  8.5%
      • manual CPR:       7.6%
      • risk difference     0.86%; 95% CI –1.2% to 3.0%
  3. in survivors at 6 months with a Cerebral Performance Category score of 1 or 2
    • mechanical CPR:  99%
    • manual CPR:       94%

Full Text:  Rubertsson. Mechanical Chest Compressions and Simultaneous Defibrillation vs Conventional Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac ArrestThe LINC Randomized Trial. JAMA 2013;epublished November 17th

 

? Not Published Yet:     Nitrates in Acute Myocardial Infarction

Siddiqi and colleagues undertook an international, four centre randomized, interventional, safety/efficacy trial, comparing IV sodium nitrite (70 μmoles) with placebo over 5 minutes just before primary PCI in 229 patients with acute ST elevation myocardial infarction, and found:

  1. no difference in infarct size as a proportion of myocardial area at risk
    • at 6 - 8 days  (P=0.31)
      • nitrite:     22%
      • placebo:  20%    
    • at 6 months:
      • nitrite:    12% 
      • placebo: 14%
  2. no significant differences at 6-8 days or 6 months in
    • left ventricular ejection fraction
    • end systolic volume index
    • infarct size at 6 months
    • troponin
    • plasma creatine kinase

Summary Slide:  Siddiqi. Nitrites in Acute Myocardial Infarction (NIAMI) trial.

 

Journal of the American Medical Association:     Stroke Blood Pressure Control

He et al performed a randomized, multicentre, single-blind trial in 4,071 patients with nonthrombolysed ischemic stroke within 48 hours of onset and elevated systolic blood pressure, comparing antihypertensive treatment (aimed at lowering systolic blood pressure by 10% to 25% within the first 24 hours, achieving blood pressure less than 140/90 mm Hg within 7 days, and maintaining this level during hospitalization; n = 2,038) with discontinuation of all antihypertensive medications (control) during hospitalization (n = 2,033), and found:

  1. a larger reduction in mean systolic blood pressure within 24 hours with antihypertensive therapy
    • antihypertensive group:  166.7 mm Hg to 144.7 mm Hg (−12.7%)
    • control group:  165.6 mm Hg to 152.9 mm Hg (−7.2%)
    • difference −5.5% (95% CI −4.9 to −6.1%); absolute difference −9.1 mm Hg (95% CI −10.2 to −8.1); P  < 0.001
  2. lower mean systolic blood pressure at day 7with antihypertensive therapy
    • antihypertensive group137.3 mm Hg
    • control group:  146.5 mm Hg
    • difference −9.3 mm Hg (95% CI −10.1 to −8.4); P < 0.001
  3. no difference in primary outcome (combination of death and major disability at 14 days or hospital discharge)
    • antihypertensive group: 683 events
    • control group:  681 events
    • odds ratio 1.00 (95% CI 0.88 to 1.14); P = 0.98
  4. no difference in secondary composite outcome of death and major disability at 3-month posttreatment follow-up
    • 500 events
    • 502 events
    • odds ratio 0.99 (95% CI, 0.86 to 1.15); P =0 .93
Full Text:  He. Effects of Immediate Blood Pressure Reduction on Death and Major Disability in Patients With Acute Ischemic Stroke:  The CATIS Randomized Clinical Trial. JAMA 2013;epublished November 17th
 
 

 

I hope you find these brief summaries and links useful.


Until this weekend

Rob

Search