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Out-of-hospital cardiac arrest 1


Out-of-hospital cardiac arrest: current concepts
Aung Myat, Kyoung-Jun Song, Thomas Rea

Lancet 2018; 391: 970–79 Out-of-hospital cardiac arrest (OHCA) is a leading cause of global mortality. Regional variations in reporting
This is the first in a Series of frameworks and survival mean the exact burden of OHCA to public health is unknown. Nevertheless, overall prognosis
three papers about and neurological outcome are relatively poor following OHCA and have remained almost static for the past three
out-of-hospital cardiac arrest
decades. In this Series paper, we explore the aetiology of OHCA. Coronary artery disease remains the predominant
Sussex Cardiac Centre, Brighton cause, but there is a diverse range of other potential cardiac and non-cardiac causes to be aware of. Additionally, we
and Sussex University
Hospitals NHS Trust, Brighton,
describe how investigators and key stakeholders in resuscitation science have formulated specific Utstein data element
UK (A Myat MD); Division of domains in an attempt to standardise the definitions and outcomes reported in OHCA research so that management
Clinical and Experimental pathways can be improved. Finally, we identify the predictors of survival after OHCA and what primary and secondary
Medicine, Brighton and Sussex prevention strategies can be instigated to mitigate the devastating sequelae of this growing public health issue.
Medical School, Brighton, UK
(A Myat); Department of
Emergency Medicine, Seoul Introduction incidence estimates according to person-years of
National University College of Out-of-hospital cardiac arrest (OHCA) is a leading cause EMS-treated OHCA are 34·4 in Europe, 53·1 in North
Medicine and Hospital, Seoul,
of mortality worldwide.1,2 It is defined as the loss of America, 59·4 in Asia, and 49·7 in Australia. Of these
South Korea (K-J Song PhD);
Laboratory of Emergency functional cardiac mechanical activity in association with estimates, the percentage survival to discharge was
Medical Services, Seoul an absence of systemic circulation, occurring outside of a 7·6% in Europe, 6·8% in North America, 3·0% in Asia,
National University Hospital hospital setting. The exact burden of OHCA to public and 9·7% in Australia.2
Biomedical Research Institute,
health is unknown since a considerable number of cases These data not only serve to highlight the extensive
South Korea (K-J Song); and
Division of General Internal are not attended by emergency medical services (EMS) geographical variation in the incidence of OHCA but also
Medicine, Harborview Medical and regional variations are prevalent in both reporting the very poor outcomes that have remained mostly static
Centre, University of systems and survival.3–5 It is estimated that 275 000 people in the past three decades.1–4 However, some cities have
Washington, Seattle, WA, USA
in Europe have all-rhythm cardiac arrest treated by EMS achieved survival in the region of 20–40%.9,10 This
(Prof T Rea MD)
per year, with only 29 000 of those surviving to hospital difference in survival can partly be attributed to varying
Correspondence to:
Dr Aung Myat, Sussex Cardiac discharge.6 In England, 28 729 EMS-treated OHCA cases definitions of OHCA,2 but it is primarily due to a
Centre, Brighton and Sussex were reported in 2014 (ie, 53 cases per 100 000 of the coordinated effort to optimise the effectiveness of the local
University Hospitals NHS Trust, resident population) with only 7·9% surviving to hospital chain of survival.11 By identifying and thereafter improving
Brighton BN2 5BE, UK
discharge.7 In the USA, reports from 35 communities weak links in the local chain of survival, positive outcomes
aung.myat@bsuh.nhs.uk
suggested an incidence of 55 per 100  000 person- have been achieved in several locations.9,12–14
years.8 This incidence would equate to approximately In this review, the first of a three-part Series, we look at
155 000 individuals having an EMS-treated all-rhythm the causes of OHCA. Additionally, we look at how
OHCA per year in the USA.8 Globally, the weighted researchers and key stakeholders in resuscitation science
have attempted to standardise the definitions and
outcomes reported in OHCA research at an international
Search strategy and selection criteria level to better delineate how management pathways can
We searched the Cochrane Library, MEDLINE, PubMed, and be enhanced. Finally, we describe the predictors of
Embase for articles published in English only using a survival after OHCA and what primary and secondary
combination of the search terms “out-of-hospital cardiac prevention strategies can be instigated to mitigate the
arrest”, “sudden cardiac death”, “Utstein”, “bystander devastating sequelae of this growing public health issue.
cardiopulmonary resuscitation”, “dispatcher-assisted
cardiopulmonary resuscitation”, “emergency medical Causes of OHCA
services”, “automated external defibrillator”, “ST-segment The causes of OHCA can be broadly categorised into
elevation”, “chain of survival”, “layperson”, “socio-economic cardiac and non-cardiac causes (panel 1).7,15,16 Most people
status”, “Charlson Comorbidity Index”, “shockable rhythm”, reached by an EMS crew, and in whom resuscitation is
and “cardiac resuscitation centre”. We selected publications considered possible, have a cardiac cause.16 On post-
in the past 10 years, but did not exclude commonly mortem examination of 100 patients who died from
referenced and highly regarded older publications. We also sudden cardiac ischaemia, the investigators showed that
searched the reference lists of articles identified by this 74 cases had coronary thrombus.17 In the 26 patients that
search strategy and selected those we judged relevant. did not have evidence of an intraluminal thrombus,
Review articles and online resources are cited to provide 21 had evidence of plaque fissuring. Similarly, Farb and
readers with more details and references. colleagues18 found acute changes in coronary plaque
morphology (thrombus, plaque disruption, or both) in

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51 of 90 hearts examined following sudden cardiac death.


In a landmark angiographic study, more than 70% of Panel 1: Recognised causes of out-of-hospital cardiac arrest
84 consecutive survivors of OHCA had clinically Cardiac causes
significant coronary artery disease shown on their • Ischaemic heart disease
immediate coronary angiography.19 Nearly 50% of the • Acute myocardial infarction
cohort was also found to have coronary artery occlusion. • Non-atherosclerotic disease of the coronary arteries
Of note, features such as chest pain or ST-segment • Lethal arrhythmia without ischaemic heart disease
elevation were shown to be poor predictors of coronary • Wolff-Parkinson-White syndrome
occlusion. In patients with no obvious non-cardiac cause • Long QT syndrome
of OHCA, a study showed at least one significant coronary • Brugada syndrome
artery lesion in 70% of patients, 96% with ST-segment • Catecholaminergic polymorphic ventricular tachycardia
elevation on their electrocardiograph and 58% without • Cardiomyopathy
ST-segment elevation.20 A retrospective single-centre • Acute on chronic heart failure
study of 72 consecutive survivors of OHCA also found • Acute heart failure secondary to valvular heart disease
64% of survivors had angiographic evidence of coronary • Myocarditis
artery disease (≥one lesion with >50% stenosis).21 Only • Dilated cardiomyopathy
38%, however, had angiographic and clinical evidence • Left ventricular non-compaction cardiomyopathy
of an acute coronary syndrome due to either an acute • Hypertrophic cardiomyopathy
occlusion (17%) or an irregular lesion suggestive of • Arrhythmogenic right ventricular cardiomyopathy
ruptured plaque or thrombus (25%).21 These findings • Other infiltrative or inflammatory myocardial disease,
emphasise the difficulty in identifying patients with or both
ongoing myocardial ischaemia in the setting of OHCA. • Valvular heart disease
An excess of circulating catecholamines, electrolyte • Congenital heart disease
derangement, hypothermia, and brain injury can all • Presumed cardiac origin (unknown or unobtainable cause)
cause ST-segment deviation, making a definitive
diagnosis of acute myocardial infarction problematic. Non-cardiac causes
The evidence would suggest OHCA of a presumed • Trauma
cardiac origin is usually triggered by coronary plaque • Malignancy
rupture (leading to acute occlusion) or fissuring, • Non-traumatic bleeding
fragmentation, and embolisation of thrombus.18 Up to • Gastrointestinal
80% of individuals who have sudden cardiac death • Gynaecological
have coronary heart disease, the prevalence for both • Cerebrovascular
increasing with age and being more common in men • Acute aortic dissection
than in women.22 In an analysis7 of the OHCA Outcomes • Asphyxia
Project in England (a prospective registry structured and • Submersion (near drowning)
maintained in accordance with the Utstein guideline • Hanging
for resuscitation registries), the investigators reported that • Hypoxia
80% of cases were due to a cardiac cause. The caveat being • Pneumonia
all cases reported as unknown (13%) or unobtainable (5%) • Asthma or chronic obstructive pulmonary disease
were also presumed to have a cardiac origin. • Carbon monoxide poisoning
The consequences of OHCA can be devastating. The • Pulmonary embolism
aftermath of such life-changing events is brought into • Drug overdose
sharper focus if the patient with OHCA was a seemingly • Hypoglycaemia
fit and healthy athlete, young adult, or child. The • Hypothermia
incidence of sudden cardiac death in athletes can range • Epilepsy
from one in 23 000 to one in 200 000 athletes per year, • Septic shock
depending on the methods used to identify cases, • Dehydration and malnutrition
inclusion and exclusion criteria, and what populations are The causes are not listed in order of frequency and the list is not intended to be
being studied.23 In a retrospective analysis of the Rescu exhaustive.
Epistry database of consecutive OHCA attended by EMS
in a specific area of Ontario, Canada, investigators found
the incidence of sudden cardiac death during participation between 35 and 45 years, coronary artery disease was the
in competitive sports to be 0·76 cases per 100 000 athlete- most frequent underlying pathology.24 In a similar but
years.24 The principal causes of sudden cardiac death in prospective study25 of children and young adults aged
this population were stratified by age group. In those 1–35 years, 490 cases of sudden cardiac death were
younger than 35 years, structural heart and primary identified from centres in Australia and New Zealand.
arrhythmic causes were most common. In those aged The cause of death was unexplained in 40% of these cases

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at autopsy, in whom a structurally normal heart was


Utstein domains • Population served
• System description
found.25 In this study, the annual incidence of sudden
• Cardiac arrests attended cardiac death was calculated to be 1·3 cases per
• Resuscitation attempted 100 000 people. When stratified according to age group,
• Resuscitation not attempted
the highest incidence (3·2 cases per 100 000 people per
System year) was found in the category of those aged 31–35 years.
• Resuscitation algorithms followed Again, coronary artery disease was the most common
• Do not attempt resuscitation legislation cause discovered here. Younger age and sudden cardiac
• Termination of resuscitation rules
• Prehospital ECG activity death occurring at night were independently associated
• Dispatch software with unexplained sudden cardiac death. Less common
• Data quality activities
causes were inherited cardiomyopathies (eg, dilated,
hypertrophic, and arrhythmogenic right ventricular),
Dispatch • Dispatcher-identified cardiac arrest myocarditis, and aortic dissection.
• Dispatcher CPR instructions Sudden cardiac death in athletes, young adults, and
children can be regarded as relatively uncommon but it
• Age is incumbent on those managing young survivors of
• Sex OHCA to be mindful of the causes prevalent in these
• Cause
• Location particular groups. Indeed, there is widespread consensus,
• Witnessed cardiac arrest including recommendations from the American Heart
• Bystander CPR or use of automated external
defribillator
Association and European Society of Cardiology, that
• First monitored cardiac rhythm young athletes should have cardiovascular screening
Patient before participation in competitive sports. A more
detailed synopsis of sudden cardiac death in the young
• Comorbidities
• Independent living
and non-cardiac causes of OHCA is beyond the scope of
For more on the Cardiac Risk • ST-segment elevation on ECG this review; we recommend the work done by the Cardiac
in the Young charity see • Implantable cardioverter defibrillator
https://www.c-r-y.org.uk
Risk in the Young charity in the UK for further reading.
• Ventricular assist device

Progress in resuscitation outcomes with the Utstein


• Response time framework
• Defibrillation time
• Pharmacotherapy Although prevention is a key strategy in the drive to
• Targeted temperature management reduce the incidence of OHCA, many events occur among
• Coronary reperfusion attempted
those without clinical heart disease or warning symptoms,
making prevention an incomplete strategy to address this
Process • Airway control growing public health challenge. Therefore, initiatives
• Number of shocks administered aimed at optimising the quality and performance of
• Timing of drugs
• Quality of CPR resuscitation provide a complimentary and necessary
• Manual versus automated CPR pathway to reduce overall mortality.
• Targeted oxygenation and ventilation therapy
• pH, lactate, and glucose
The continual evolution of resuscitation science is
• ECG regularly captured within clinical guidelines through an
• Blood pressure control: ECMO or IABP evidence-based process involving international experts.26
• Hospital type or volume, or both
• Neuro-prognostication The science indicates that a successful resuscitation
attempt requires a coordinated team of rescuers that
include laypeople, emergency dispatchers, first responders,
• A return of spontaneous circulation
• Survival to discharge
EMS, and hospital providers. For the best chances of
• Survival at 30 days survival, the team must deploy a time-sensitive series of
• Cerebral performance category therapies. Derived from scientific understanding, these
therapies are described by the metaphor of “links in the
Outcome
• Cause of death chain of survival”, which highlight the interdependent
• Treatment withdrawal elements of early OHCA recognition and call for
• Transport to hospital
• Organ donation help, early cardiopulmonary resuscitation (CPR), early
• Quality-of-life measures defibrillation, expert advanced cardiac life support, and
• Patient-reported outcome measures expert post-resuscitation care.12,13,27–29
Core elements • Survival at 12 months
Supplemental elements Despite scientific advancement, temporal improvement
in outcome across population-based settings has been
Figure 1: Utstein data element domains for out-of-hospital cardiac arrest
ECG=electrocardiograph. CPR=cardiopulmonary resuscitation.
inconsistent.2 Appreciating the challenges of scientific
ECMO=extracorporeal membrane oxygenation. IABP=intra-aortic balloon pump. discovery and community translation, a multidisciplinary
group of key stakeholders convened at the Utstein Abbey

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in Norway in 1990 to develop and define standard data


elements and definitions that could provide the
framework for resuscitation research and quality Medical Educational Local
× × implementation = Survival
improvement.30 The Utstein data elements include science efficiency

measures of demographics, prehospital and hospital


care, and outcome organised to feature bystander-
witnessed shockable cardiac arrest. The Utstein data Figure 2: The Utstein formula to improve survival after out-of-hospital
definitions and presentation template have been refined cardiac arrest
over time through expert review and consensus, and
continue to provide the common framework to evaluate Targeted training
resuscitation process and care (figure 1).31
The Utstein data elements are the foundation for Social media and technology
clinical research. These elements consistently predict
survival and so inform research efforts as important School-based training
covariates that can help explain outcome relationships.1
However, the Utstein elements collectively do not fully Dispatcher telephone CPR

predict outcome, indicating that additional measures


Community training programmes
influence prognosis.32 The Utstein elements often assess
a binary base category but often do not have the fidelity to Figure 3: Examples of complimentary bystander CPR programmes
measure quality. For example, bystander CPR is typically CPR=cardiopulmonary resuscitation.
a yes or no variable. The quality of CPR is not routinely
measured. Yet the effectiveness of chest compressions CPR, school-based training, smart geospatial technology
during CPR incorporates specific characteristics relating to activate community rescuers, and focused training
to compression depth, release, rate, and timing.28,29,33 efforts directed at high-risk groups.38–41 Each strategy can
Thus, promising strategies for scientific discovery often increase knowledge and action for bystander CPR but
define or evaluate the qualitative and quantitative requires translation from scientific understanding to
components of the categorical Utstein elements. organised action. In communities that effectively use
Equally as important to serving as the platform for these strategies, bystander CPR can be provided for more
scientific discovery, the Utstein elements also provide than three quarters of patients with OHCA.42
a common framework for emergency systems to Therefore, emergency systems require approaches
systematically and consistently measure resuscitation that can translate science into actionable and often
care. The approach has enabled comparison within and pragmatic programmes (table).43 For example, inter­
across emergency systems, and in turn highlighted the national experience highlights the potential of effective
marked disparity in OHCA survival. Survival varies up quality improvement involving telephone CPR. A series
to ten times across systems as supported by multiple of studies from around the world reveal a notable
peer-review investigations, highlighting the opportunity increase in bystander CPR and improvement in survival
to improve public health by achieving current best with implementation of dispatcher-directed telephone
practices across more communities.3,5,34,35 CPR, whereby dispatchers help identify cardiac arrest
Indeed, the Utstein forum recognised the reality that and coach CPR.44–47 The emergency medical dispatcher
scientific understanding does not uniformly translate to is the principal link between the general public and
community success, and so they published a formula for the EMS system in the prehospital setting. Therefore,
system survival (figure 2). The formula recognises that highly trained dispatchers play a pivotal role in guiding
community translation to achieve best practices must pair bystanders through what is the most time-critical period
medical science with educational efficiency and local in cardiac arrests. Not only do they attempt to create a
implementation.36 Each of these domains was recognised by calmer environment more conducive to establishing an
the 2015 Academy of Sciences Report, which endorsed the informed diagnosis upon which to act, their skill lies in
need for a multipronged strategy for resuscitation progress the ability to ensure bystander CPR, and defibrillation
that included scientific discovery and community translation, if appropriate, is delivered in the most effective way.
the latter built upon programmatic quality improvement to Implementation is just the beginning and must be
systematically measure and improve care.37 supported by quality evaluation, incorporating process
A prime example is the provision of early CPR by measurement with a focus on improvement. This process
laypeople before the arrival of professional rescuers. can be motivated by performance goals. With the potential
There is a range of complimentary programme strategies for widespread survival gains through improvements in
that collectively enable a community to achieve best education and implementation, resuscitation stakeholders
practices in early bystander CPR (figure 3). These again convened in 2015 at the Utstein Abbey and in 2016
programmes are derived from peer-review evidence and in Copenhagen, Denmark, to discuss strategies that can
support efforts to provide community training, telephone positively affect care and outcome at the community level.

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Stakeholder Programme description


Cardiac arrest registry Community, telecommunication A registry acts as measurement tool that enables data-driven assessment of the emergency system so that
centre, EMS, and hospital implementation and improvement efforts can be benchmarked, directed, and refined
Telephone CPR Community, telecommunication Telecommunicators facilitate cardiac arrest identification and coach layperson CPR using a directed approach that
centre, and EMS prioritises cardiac arrest identification and care; quality improvement with use of audio review enables case-specific
feedback and evaluation of performance metrics
High-performance EMS CPR EMS High-quality CPR metrics can be achieved by combining individual CPR skills and coordinated team choreography that
incorporates local EMS operations, staffing, equipment, and logistics
Rapid dispatch Telecommunication centre and EMS Telecommunicators immediately dispatch EMS for certain initial descriptions such as unconscious, difficulty breathing,
chest pain, and seizure, which might represent or develop into cardiac arrest, and then complete caller interview and action
Measurement of professional EMS and hospital Programmes that provide case-specific review provide the basis to review and improve individual and team performance;
rescuer cardiac arrest care review can include team debriefing or objective review of CPR performance generated through real-time recording of care;
this review includes measurement of guideline-directed CPR metrics for benchmarking
AED programme for first Community, telecommunication Programmes of public access and law enforcement defibrillation can achieve early defibrillation, but must incorporate
responders centre, and EMS local understanding of the geographical distribution of risk and the logistics of public service response
Smart technologies for CPR Community, telecommunication Interconnected technology provides the potential for real-time arrest geolocation, proximal layperson notification,
and AED centre, and EMS nearby AED locations, and just-in-time CPR instruction; collectively, a well integrated system with community
participation can mobilise community responders
Mandatory CPR and AED Community and EMS Mandated and volunteer programmes of CPR and AED training involve a variety of settings such as schools, work places,
training community organisations, and targeted populations; training approaches use a range of formats and mediums to achieve
competency
Hospital care Hospital Hospital programmes of targeted temperature management, coronary revascularisation, and supportive critical care
with deferred prognostication provide a composite to assess best practices; successful hospitals often use as standard
practice this composite as part of a standing programmatic strategy that might establish best practice; performance
review and feedback provides for benchmarking and improvement
Culture of excellence Telecommunication centre, EMS, System measurement and reporting that engages all stakeholders, informs ongoing quality improvement, and establishes
and hospital accountability; the framework produces commitment to professional excellence and an expectation of success

EMS=Emergency medical services. CPR=cardiopulmonary resuscitation. AED=automated external defibrillator.

Table: Programmes designed to operationalise scientific understanding

The consequence was the call for a Global Resuscitation what might be expected from an ideal model. Nevertheless,
Alliance. The mission of the alliance is to accelerate comorbidity was shown to be the most powerful predictor
community implementation of effective resuscitation of survival from OHCA due to ventricular fibrillation.49 In
programmes designed to be synergistic with current addition to a larger number of pre-existing conditions
scientific guideline groups. being inversely associated with odds of survival to hospital
discharge, the deleterious effect of the chronic condition–
Predictors of survival after OHCA outcome association is further exacerbated by the response
Several studies report substantial regional variation in time of EMS. Investigators found that the odds ratio (OR)
morbidity and mortality after OHCA and point to factors of survival was 0·72 (95% CI 0·59–0·88) for each
that affect the chances of survival with a favourable additional comorbidity when response time was 8 min
neurological outcome.3,5,6,8,31,35,48 Although some predictors compared with an OR of 0·95 (0·79–1·14) after a 3-min
are intuitively obvious, the effects of many remain EMS response, suggesting that the relationship between
unclear. In the main, predictors of survival after OHCA chronic condition count and survival might be modified
can be categorised into patient factors, event factors, by response interval.50 It is both intuitive and appropriate,
system factors, and therapeutic factors (panel 2). therefore, to appreciate that baseline comorbidity (espec­
Associated comorbid conditions are not always a direct ially cardiac disease) is likely to influence survival, and
cause of cardiac arrest, but refer collectively to chronic or recognition of this factor might assist with prognostication
acute disease states that a patient had prior to having an decisions for patients with OHCA.51–53
event. A comorbidity index based on the existence of heart Taken together, there is an assumption that increasing
failure, myocardial infarction, use of heart medications, age and comorbid conditions act in tandem to attenuate
diabetes, hypertension, chest pain, chronic pulmonary the chances of a positive outcome after OHCA. Some, but
disease, gastrointestinal disorders, cancer, and other not all, studies have observed independent and distinct
chronic conditions in conjunction with the development associations between the burden of comorbidity, age, and
of recent symptoms 2 days before out-of-hospital outcome.54 A retrospective observational cohort study of
ventricular fibrillation has been used to determine non-traumatic OHCA admissions to the University of
whether such factors would affect survival.49 Despite using Michigan Emergency Department found age, but not the
this index relative to a comprehensive set of predictors of Charlson Comorbidity Index, to be significantly associated
survival, the investigators could only account for 25% of with less favourable neurological outcomes after adjusting

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Panel 2: Factors associated with survival following OHCA


Factors that can affect survival outcomes • Community CPR training
Patient related • Public access defibrillation
• Age Therapeutic related
• Sex • Pharmacotherapy
• Ethnicity • Impedance threshold device for CPR
• Comorbidity • CPR adjuncts
• Diet • Compression only CPR
• Obesity • Airway management
• Medications • Targeted temperature control
• Socioeconomic status • Quality of in-hospital care
• Genetic determinants • Distance to invasive heart centre
Event related • Immediate coronary angiography for all patients with
• Symptoms before collapse OHCAs on admission to hospital
• Location at time of event
Factors shown to have a strong relationship with survival
• Time of the day
outcomes
• Witness status (bystander, EMS, no witness, or unknown)
Patient related
• Decision to begin resuscitation
• Age
• Bystander CPR
• Ethnicity
• Cause of cardiac arrest
• Comorbidity
• Type of heart rhythm
• Socioeconomic status
• Use of on-scene AED
Event related
System related
• Type of heart rhythm
• Time to CPR
• Witness status
• Quality of CPR
• Bystander CPR
• Time to defibrillation
• Agonal breathing
• Interaction of CPR and defibrillation
• Type of EMS system System related
• System size • Time to CPR
• Number of responders • Time to defibrillation
• Ratio of paramedics to population • Interaction of CPR and defibrillation
• Dispatcher-assisted telephone CPR • Dispatcher-assisted telephone CPR
• Quality of EMS care Therapeutic related
• Ongoing medical quality improvement • No therapeutic-related factors have shown a clear association
• Organisational structure and culture with positive outcome after OHCA
• Administrative support
• Quality of training EMS=emergency medical service. CPR=cardiopulmonary resuscitation. AED=automated
external defibrillator. OHCA=out-of-hospital cardiac arrest.

for important covariates. Each decade of life was shown to witnessed by EMS. The investigators found that for every
reduce the odds of a positive outcome by 21%.55 Analysis CAN$100 000 increment in the value of the property in
of the Amsterdam Resuscitation Study, a prospective which the event took place, the chances of receiving
registry of all-cause OHCA, also observed no significant bystander CPR increased (OR 1·07, 95% CI 1·01–1·14;
association between the Charlson Comorbidity Index and p=0·03).57 Similarly, in Taiwan a study of non-traumatic
cardiac arrest outcomes in people older than 70 years.56 In OHCA found the OR of receiving bystander CPR in low-
effect, resuscitation-related factors and not the extent of socioeconomic status areas was 0·72 (95% CI 0·60–0·88)
comorbidity were shown to determine outcome after after adjusting for multiple confounders.58 Real estate
OHCA in older patients. Age, therefore, should be value was again used as the surrogate of socioeconomic
regarded as an independent predictor of prognosis status. There was a significant difference in the proportion
rather than simply seen as a surrogate marker for an of bystander CPR in administrative districts of low
accumulation of comorbidity.55 socioeconomic status versus high socioeconomic status
Socioeconomic status is an important predictor of (14·5% vs 19·6%; p<0·01).58 The racial composition of a
survival. A secondary analysis of the Ontario Prehospital neighbourhood in which an OHCA event occurs, the
Advanced Life Support study looked at OHCA of cardiac educational background of the individual succumbing to
origin occurring in a single residential dwelling, not OHCA, the median household income, and level of social

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deprivation have all been shown to predict outcome survival, it has been proposed that regional systems of
after OHCA.59–63 These analyses also serve to emphasise care should be established to allow concentration of
the importance of early and effective bystander CPR best practice in managing patients with OHCA.48,69
(regardless of witness status), along with early de­ Similar successful programmes have improved pro­
fibrillation, in the context of OHCA survival.10,14,42 Areas of vider experience and patient outcomes following life-
low socioeconomic status consistently have the lowest threatening traumatic injury.70
rates of bystander CPR and defibrillation compared with However, the establishment of a robust cardiac
those of high socioeconomic status.60,61 These findings resuscitation centre infrastructure will require extensive
have wide-ranging implications on where to concentrate interhospital cooperation, which might be a challenge in
public health resources, none more so than when some health-care systems. Additionally, in remote
decisions regarding the optimal deployment of automated areas, the potential delays in transport might not allow
external defibrillators have to be made. These issues are direct transfer to a cardiac resuscitation centre. Recent
further amplified when basic life support training is data have suggested this increase in transport time does
considered in the context of low-income and middle- not detract from the net gain in survival achieved
income countries.64 after admission to an invasive heart centre and regional
It is well established that a shockable rhythm, such performance of acute coronary angiography where
as ventricular fibrillation or ventricular tachycardia, is indicated.71
a strong predictor of survival.1 The strength of the
association is greatest in locations where early bystander Primary and secondary prevention of sudden
defibrillation is viable. Conversely, non-shockable cardiac arrest
rhythms, such as asystole and pulseless electrical activity, Both the European Society of Cardiology and the American
are associated with the lowest survival.1 Furthermore, Heart Association/American College of Cardiology/Heart
shockable rhythm conversion from initially non- Rhythm Society have published extensive guideline
shockable rhythms, especially asystole, is associated with recommendations for the manage­ment of patients with
an increased rate of prehospital return of spontaneous ventricular arrhythmias and the prevention of sudden
circulation, survival to hospital discharge, 1 month cardiac death.72,73 In the US guideline recommendations,
survival, and 1 month favourable neurological outcome.65 sudden cardiac arrest is defined as the sudden cessation
Younger age, male gender, witnessed cardiac arrest, short of cardiac activity such that the patient becomes un­
response time, and underlying cardiac disease increase responsive, with either persisting gasping respirations or
the likelihood of conversion to a shockable rhythm.66 absence of any respiratory movements, and no signs of
Early and effective CPR also delays the degradation of circulation. The most common consequence of sudden
tachyarrhythmias to asystole.1 cardiac arrest is sudden cardiac death. In this context,
There are few studies on the relationship between primary prevention constitutes therapies to reduce the
population density and survival after OHCA. However, it risk of sudden cardiac death in individuals who are at risk
would appear intuitive to assume that lower bystander but have not yet had a cardiac arrest or life-threatening
CPR and longer EMS response times would be a factor in arrhythmia.72 Secondary prevention constitutes therapies
larger geographical regions where the population is more to reduce the risk of sudden cardiac death in patients
widely distributed. In a study of the Swedish Cardiac who have already had a cardiac arrest or life-threatening
Arrest Register, ambulance response time was indeed arrhythmia.72 An implantable cardioverter defibrillator is
more protracted in less-populated areas (p<0·0001). the mainstay of treatment for both primary and secondary
There was, however, no significant association between prevention of sudden cardiac death in patients with
population density and survival to 1 month after OHCA.67 either ischaemic or non-ischaemic cardiomyopathy. The
Conversely, a study of the Victorian Ambulance Cardiac key determinant for intervention common to all those
Arrest Registry of all OHCA of presumed cardiac cause potentially eligible for a device is a life expectancy greater
found population density to be independently associated than 1 year.73 Supplementary pharmacotherapy and the
with survival.68 Indeed, when compared with very increasing importance of radiofrequency catheter ablation
low-density populations, the odds of survival increased of sympto­ matic premature contractions or ventricular
to 1·88 (95% CI 1·15–3·07) in low-density areas, 2·49 tachycardia, refractory to medical therapy, also underscore
(1·55–4·02) in medium-density areas, 3·47 (2·20–5·48) these current guidelines. The value of screening of family
in high-density areas, and 4·32 (2·67–6·99) in very high- members of patients with sudden cardiac death and risk
density areas.68 stratification for those with structural heart disease or
Patients presenting with OHCA are a heterogeneous inherited primary arrhythmia syndromes have also been
group that requires a multifaceted approach to care. emphasised.72,73 Education on warning symptoms such as
Effective post-resuscitation care cannot readily be chest pain and dyspnoea, typically ignored by patients
provided by all hospitals because of a paucity of and relatives, should also be noted as a potential short-
appropriate facilities and expertise. Because this fifth term prevention strategy in those at risk of sudden
link in the chain of survival contributes profoundly to cardiac arrest.74,75 We recommend the European and US

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AM and K-JS declare no competing interests. TR has received after out-of-hospital cardiac arrest: insights from the PROCAT
research grants from the American Heart Association, the Laerdal (Parisian Region Out of hospital Cardiac ArresT) registry.
Circ Cardiovasc Intewrv 2010; 3: 200–07.
Foundation, the Life Sciences Foundation, Medtronic Philanthropy,
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