Temporal trends in out-of-hospital cardiac arrest with an initial non-shockable rhythm in Singapore

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Abstract

Aim

Out-of-hospital cardiac arrest (OHCA) with an initial non-shockable rhythm is the predominant form of OHCA in adults. We evaluated its 10-year trends in epidemiology and management in Singapore.

Methods

Using the national OHCA registry we studied the trends of 20,844 Emergency Medical Services-attended adult OHCA from April 2010 to December 2019. Survival to hospital discharge was the primary outcome. Trends and outcomes were analyzed using linear and logistic regression, respectively.

Results

Incidence rates of adult OHCAs increased during the study period, driven by non-shockable OHCA. Compared to shockable OHCA, non-shockable OHCAs were significantly older, had more co-morbidities, unwitnessed and residential arrests, longer no-flow time, and received less bystander cardiopulmonary resuscitation (CPR) and in-hospital interventions ( p < 0.001). Amongst non-shockable OHCA, age, co-morbidities, residential arrests, no-flow time, time to patient, bystander CPR and epinephrine administration increased during the study period, while presumed cardiac etiology decreased ( p < 0.05). Unlike shockable OHCA, survival for non-shockable OHCA did not improve ( p < 0.001 for trend difference). The likelihood of survival for non-shockable OHCA significantly increased with witnessed arrest (adjusted odds ratio (aOR) 2.02) and bystander CPR (aOR 3.25), but decreased with presumed cardiac etiology (aOR 0.65), epinephrine administration (aOR 0.66), time to patient (aOR 0.93) and age (aOR 0.98). Significant two-way interactions were observed for no-flow time and residential arrest with bystander CPR (aOR 0.96 and 0.40 respectively).

Conclusion

The incidence of non-shockable OHCA increased between 2010 and 2019. Despite increased interventions, survival did not improve for non-shockable OHCA, in contrast to the improved survival for shockable OHCA.

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Most cited references 27

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A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation

Mary Charlson, Peter Pompei, Kathy Ales … (1987)

The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.

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Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies.

Jocelyn Berdowski, Robert A Berg, Jan Tijssen … (2010)

The aim of this investigation was to estimate and contrast the global incidence and outcome of out-of-hospital cardiac arrest (OHCA) to provide a better understanding of the variability in risk and survival of OHCA. We conducted a review of published English-language articles about incidence of OHCA, available through MEDLINE and EmBase. For studies including adult patients and both adult and paediatric patients, we used Utstein data reporting guidelines to calculate, summarize and compare incidences per 100,000 person-years of attended OHCAs, treated OHCAs, treated OHCAs with a cardiac cause, treated OHCA with ventricular fibrillation (VF), and survival-to-hospital discharge rates following OHCA. Sixty-seven studies from Europe, North America, Asia or Australia met inclusion criteria. The weighted incidence estimate was significantly higher in studies including adults than in those including adults and paediatrics for treated OHCAs (62.3 vs 34.7; P<0.001); and for treated OHCAs with a cardiac cause (54.6 vs 40.8; P=0.004). Neither survival to discharge rates nor VF survival to discharge rates differed statistically significant among studies. The incidence of treated OHCAs was higher in North America (54.6) than in Europe (35.0), Asia (28.3), and Australia (44.0) (P<0.001). In Asia, the percentage of VF and survival to discharge rates were lower (11% and 2%, respectively) than those in Europe (35% and 9%, respectively), North America (28% and 6%, respectively), or Australia (40% and 11%, respectively) (P<0.001, P<0.001). OHCA incidence and outcome varies greatly around the globe. A better understanding of the variability is fundamental to improving OHCA prevention and resuscitation. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

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Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.

Gavin D Perkins, Ian Jacobs, Vinay Nadkarni … (2015)

Utstein-style guidelines contribute to improved public health internationally by providing a structured framework with which to compare emergency medical services systems. Advances in resuscitation science, new insights into important predictors of outcome from out-of-hospital cardiac arrest, and lessons learned from methodological research prompted this review and update of the 2004 Utstein guidelines. Representatives of the International Liaison Committee on Resuscitation developed an updated Utstein reporting framework iteratively by meeting face to face, by teleconference, and by Web survey during 2012 through 2014. Herein are recommendations for reporting out-of-hospital cardiac arrest. Data elements were grouped by system factors, dispatch/recognition, patient variables, resuscitation/postresuscitation processes, and outcomes. Elements were classified as core or supplemental using a modified Delphi process primarily based on respondents' assessment of the evidence-based importance of capturing those elements, tempered by the challenges to collect them. New or modified elements reflected consensus on the need to account for emergency medical services system factors, increasing availability of automated external defibrillators, data collection processes, epidemiology trends, increasing use of dispatcher-assisted cardiopulmonary resuscitation, emerging field treatments, postresuscitation care, prognostication tools, and trends in organ recovery. A standard reporting template is recommended to promote standardized reporting. This template facilitates reporting of the bystander-witnessed, shockable rhythm as a measure of emergency medical services system efficacy and all emergency medical services system-treated arrests as a measure of system effectiveness. Several additional important subgroups are identified that enable an estimate of the specific contribution of rhythm and bystander actions that are key determinants of outcome.

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Author and article information

Contributors

Shir Lynn Lim

Journal

Journal ID (nlm-ta): Resusc Plus

Journal ID (iso-abbrev): Resusc Plus

Title: Resuscitation Plus

Publisher: Elsevier

ISSN (Electronic): 2666-5204

Publication date PMC-release: 13 September 2023

Publication date Collection: December 2023

Publication date (Electronic): 13 September 2023

Volume: 16

Electronic Location Identifier: 100473

Affiliations

[a ]Department of Cardiology, National University Heart Centre, Singapore

[b ]Yong Loo Lin School of Medicine, National University of Singapore, Singapore

[c ]Pre-hospital and Emergency Research Center, Duke-NUS Medical School, Singapore

[d ]Cardiovascular Research Institute, National University Heart Centre, Singapore

[e ]Department of Emergency Medicine, Singapore General Hospital, Singapore

[f ]Health Services Research Unit, Singapore General Hospital, Singapore

[g ]Military Medicine Institute, Singapore Armed Forces Medical Corps, Singapore

[h ]Emergency Department, National University Hospital, Singapore

[i ]Health Services and Systems Research, Duke-NUS Medical School, Singapore

Author notes

[* ]Corresponding author at: Department of Cardiology, National University Heart Centre, 1E Kent Ridge Road, NUHS Tower Block, Singapore 119228, Singapore. mdclims@ 123456nus.edu.sg

[1]

The members of the Singapore PAROS Investigators are listed in Acknowledgement at the end of the article.

Article

Publisher Item ID: S2666-5204(23)00116-9 Publisher ID: 100473

DOI: 10.1016/j.resplu.2023.100473

PMC ID: 10506095

PubMed ID: 37727148

SO-VID: e98ad512-a997-43d3-8a89-f5e982f73892

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Temporal trends in out-of-hospital cardiac arrest with an initial non-shockable rhythm in Singapore

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Most cited references 27

A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation

Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies.

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