Juan R. Rey

Hypothermia in Comatose Survivors From Out-of-Hospital Cardiac Arrest Pilot Trial Comparing 2 Levels of Target Temperature

Background— It is recommended that comatose survivors of out-of-hospital cardiac arrest should be cooled to 32° to 34°C for 12 to 24 hours. However, the optimal level of cooling is unknown. The aim of this pilot study was to obtain initial data on the effect of different levels of hypothermia. We hypothesized that deeper temperatures will be associated with better survival and neurological outcome. Methods and Results— Patients were eligible if they had a witnessed out-of-hospital cardiac arrest from March 2008 to August 2011. Target temperature was randomly assigned to 32°C or 34°C. Enrollment was stratified on the basis of the initial rhythm as shockable or asystole. The target temperature was maintained during 24 hours followed by 12 to 24 hours of controlled rewarming. The primary outcome was survival free from severe dependence (Barthel Index score ≥60 points) at 6 months. Thirty-six patients were enrolled in the trial (26 shockable rhythm, 10 asystole), with 18 assigned to 34°C and 18 to 32°C. Eight of 18 patients in the 32°C group (44.4%) met the primary end point compared with 2 of 18 in the 34°C group (11.1%) (log-rank P =0.12). All patients whose initial rhythm was asystole died before 6 months in both groups. Eight of 13 patients with initial shockable rhythm assigned to 32°C (61.5%) were alive free from severe dependence at 6 months compared with 2 of 13 (15.4%) assigned to 34°C (log-rank P =0.029). The incidence of complications was similar in both groups except for the incidence of clinical seizures, which was lower (1 versus 11; P =0.0002) in patients assigned to 32°C compared with 34°C. On the contrary, there was a trend toward a higher incidence of bradycardia (7 versus 2; P =0.054) in patients assigned to 32°C. Although potassium levels decreased to a greater extent in patients assigned to 32°C, the incidence of hypokalemia was similar in both groups. Conclusions— The findings of this pilot trial suggest that a lower cooling level may be associated with a better outcome in patients surviving out-of-hospital cardiac arrest secondary to a shockable rhythm. The benefits observed here merit further investigation in a larger trial in out-of-hospital cardiac arrest patients with different presenting rhythms. Clinical Trial Registration— URL: [http://www.clinicaltrials.gov][1]. Unique identifier: [NCT01155622][2]. # Clinical Perspective {#article-title-25} [1]: http://www.clinicaltrials.gov. [2]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01155622&atom=%2Fcirculationaha%2F126%2F24%2F2826.atomBackground—It is recommended that comatose survivors of out-of-hospital cardiac arrest should be cooled to 32° to 34°C for 12 to 24 hours. However, the optimal level of cooling is unknown. The aim of this pilot study was to obtain initial data on the effect of different levels of hypothermia. We hypothesized that deeper temperatures will be associated with better survival and neurological outcome. Methods and Results—Patients were eligible if they had a witnessed out-of-hospital cardiac arrest from March 2008 to August 2011. Target temperature was randomly assigned to 32°C or 34°C. Enrollment was stratified on the basis of the initial rhythm as shockable or asystole. The target temperature was maintained during 24 hours followed by 12 to 24 hours of controlled rewarming. The primary outcome was survival free from severe dependence (Barthel Index score ≥60 points) at 6 months. Thirty-six patients were enrolled in the trial (26 shockable rhythm, 10 asystole), with 18 assigned to 34°C and 18 to 32°C. Eight of 18 patients in the 32°C group (44.4%) met the primary end point compared with 2 of 18 in the 34°C group (11.1%) (log-rank P=0.12). All patients whose initial rhythm was asystole died before 6 months in both groups. Eight of 13 patients with initial shockable rhythm assigned to 32°C (61.5%) were alive free from severe dependence at 6 months compared with 2 of 13 (15.4%) assigned to 34°C (log-rank P=0.029). The incidence of complications was similar in both groups except for the incidence of clinical seizures, which was lower (1 versus 11; P=0.0002) in patients assigned to 32°C compared with 34°C. On the contrary, there was a trend toward a higher incidence of bradycardia (7 versus 2; P=0.054) in patients assigned to 32°C. Although potassium levels decreased to a greater extent in patients assigned to 32°C, the incidence of hypokalemia was similar in both groups. Conclusions—The findings of this pilot trial suggest that a lower cooling level may be associated with a better outcome in patients surviving out-of-hospital cardiac arrest secondary to a shockable rhythm. The benefits observed here merit further investigation in a larger trial in out-of-hospital cardiac arrest patients with different presenting rhythms. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01155622.

Is therapeutic hypothermia a risk factor for stent thrombosis

To the Editor: Pre-clinical and clinical hypothermia trials cooling subjects between 18°C and 33°C have suggested potential deleterious prothrombotic effects [(1)][1]. These data have raised major clinical concerns when considering that a large proportion of cardiac arrest survivors will undergo

Influence of the temperature on the moment of awakening in patients treated with therapeutic hypothermia after cardiac arrest

INTRODUCTION Target temperature management (TTM) has shown to reduce brain damage after an out-of-hospital cardiac arrest (CA), but the time to neurological recovery is not defined yet. We sought to determine the time these patients need to regain consciousness, as well as factors associated with a late post-arrest awakening. METHODS We performed a retrospective analysis of patients cooled to 32-34°C during 24h after CA, who regained neurological responsiveness after rewarming. We measured the time until awakening, defined as obedience to verbal commands. RESULTS We included 163 CA survivors (84.7% male, 60.2 years) who regained consciousness after TTM: target temperature was either 32°C (36.2%), 33°C (56.4%) or 34°C (6.7%). Mean time of awakening was 3.8 days. Thirty-four patients (20.9%) regained neurological responsiveness after 5 days after CA. All of them had been cooled to either 32°C (18 patients) or 33°C (16), and no patient cooled to 34°C awakened after day 5. A lower target temperature was associated with a later awakening (p<0.001). The time to advanced cardiopulmonary resuscitation (CPR) was shorter among the early awakers (p=0.04), but we found no other predictors of an earlier awakening. CONCLUSIONS A high proportion of CA survivors induced to TTM regained consciousness after 5 days, and cooling to a lower target temperature may influence on a late neurological recovery. Therefore, withdrawal of life supporting treatment should be delayed to more than 5 days in patients cooled to 33°C or less. Time to advanced CPR was found to be a predictor of early awakening.

Viabilidad y seguridad del empleo de la ecografía intracoronaria. Experiencia de un centro

Introduccion y objetivos. La ecografia intracoronaria presenta numerosas ventajas en la cuantificacion y caracterizacion de las lesiones coronarias con respecto a la angiografia. Sin embargo, estudios previos han senalado entre un 3,5 y un 11% de complicaciones y un 10–30% de lesiones no abordables mediante esta tecnica. El objetivo de este trabajo es estudiar la incidencia actual de complicaciones con los nuevos modelos de sondas y la viabilidad de la realizacion de esta prueba en un grupo de pacientes consecutivos. Material y metodos. Se analizaron la viabilidad de la exploracion, como el porcentaje de exitos respecto a intentos, y las complicaciones aparecidas en todos los procedimientos en los que se intento utilizar la ultrasonografia intracoronaria entre julio de 1994 y febrero de 1996. Las complicaciones fueron divididas en relacionadas, dudosamente relacionadas y no relacionadas con el estudio ecografico. Resultados Se estudiaron 239 vasos en 209 procedimientos (el 74% intervencionistas) y 139 pacientes. Se logro realizar el estudio ultrasonico en el 100% de los estudios diagnosticos y en el 96% de los intervencionistas. Existieron complicaciones mayores y menores en el 2,4 y en el 10,5% de los procedimientos, respectivamente. Ninguna complicacion mayor estuvo relacionada con la exploracion con ultrasonidos. Tres pacientes presentaron complicaciones menores relacionadas con el dispositivo (1,4%), siempre en estudios basales de procedimientos intervencionistas. Conclusiones La ecografia intracoronaria es una tecnica segura y factible en la gran mayoria de los procedimientos. El menor tamano de las sondas y la mayor experiencia de los operadores han disminuido notablemente las complicaciones, especialmente la mas frecuente hasta ahora, el espasmo coronario. Las complicaciones se asocian a estudios basales de procedimientos intervencionistas y a una menor experiencia del operador.

Hypothermia in Comatose Survivors From Out-of-Hospital Cardiac Arrest

Background— It is recommended that comatose survivors of out-of-hospital cardiac arrest should be cooled to 32° to 34°C for 12 to 24 hours. However, the optimal level of cooling is unknown. The aim of this pilot study was to obtain initial data on the effect of different levels of hypothermia. We hypothesized that deeper temperatures will be associated with better survival and neurological outcome. Methods and Results— Patients were eligible if they had a witnessed out-of-hospital cardiac arrest from March 2008 to August 2011. Target temperature was randomly assigned to 32°C or 34°C. Enrollment was stratified on the basis of the initial rhythm as shockable or asystole. The target temperature was maintained during 24 hours followed by 12 to 24 hours of controlled rewarming. The primary outcome was survival free from severe dependence (Barthel Index score ≥60 points) at 6 months. Thirty-six patients were enrolled in the trial (26 shockable rhythm, 10 asystole), with 18 assigned to 34°C and 18 to 32°C. Eight of 18 patients in the 32°C group (44.4%) met the primary end point compared with 2 of 18 in the 34°C group (11.1%) (log-rank P =0.12). All patients whose initial rhythm was asystole died before 6 months in both groups. Eight of 13 patients with initial shockable rhythm assigned to 32°C (61.5%) were alive free from severe dependence at 6 months compared with 2 of 13 (15.4%) assigned to 34°C (log-rank P =0.029). The incidence of complications was similar in both groups except for the incidence of clinical seizures, which was lower (1 versus 11; P =0.0002) in patients assigned to 32°C compared with 34°C. On the contrary, there was a trend toward a higher incidence of bradycardia (7 versus 2; P =0.054) in patients assigned to 32°C. Although potassium levels decreased to a greater extent in patients assigned to 32°C, the incidence of hypokalemia was similar in both groups. Conclusions— The findings of this pilot trial suggest that a lower cooling level may be associated with a better outcome in patients surviving out-of-hospital cardiac arrest secondary to a shockable rhythm. The benefits observed here merit further investigation in a larger trial in out-of-hospital cardiac arrest patients with different presenting rhythms. Clinical Trial Registration— URL: [http://www.clinicaltrials.gov][1]. Unique identifier: [NCT01155622][2]. # Clinical Perspective {#article-title-25} [1]: http://www.clinicaltrials.gov. [2]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01155622&atom=%2Fcirculationaha%2F126%2F24%2F2826.atomBackground—It is recommended that comatose survivors of out-of-hospital cardiac arrest should be cooled to 32° to 34°C for 12 to 24 hours. However, the optimal level of cooling is unknown. The aim of this pilot study was to obtain initial data on the effect of different levels of hypothermia. We hypothesized that deeper temperatures will be associated with better survival and neurological outcome. Methods and Results—Patients were eligible if they had a witnessed out-of-hospital cardiac arrest from March 2008 to August 2011. Target temperature was randomly assigned to 32°C or 34°C. Enrollment was stratified on the basis of the initial rhythm as shockable or asystole. The target temperature was maintained during 24 hours followed by 12 to 24 hours of controlled rewarming. The primary outcome was survival free from severe dependence (Barthel Index score ≥60 points) at 6 months. Thirty-six patients were enrolled in the trial (26 shockable rhythm, 10 asystole), with 18 assigned to 34°C and 18 to 32°C. Eight of 18 patients in the 32°C group (44.4%) met the primary end point compared with 2 of 18 in the 34°C group (11.1%) (log-rank P=0.12). All patients whose initial rhythm was asystole died before 6 months in both groups. Eight of 13 patients with initial shockable rhythm assigned to 32°C (61.5%) were alive free from severe dependence at 6 months compared with 2 of 13 (15.4%) assigned to 34°C (log-rank P=0.029). The incidence of complications was similar in both groups except for the incidence of clinical seizures, which was lower (1 versus 11; P=0.0002) in patients assigned to 32°C compared with 34°C. On the contrary, there was a trend toward a higher incidence of bradycardia (7 versus 2; P=0.054) in patients assigned to 32°C. Although potassium levels decreased to a greater extent in patients assigned to 32°C, the incidence of hypokalemia was similar in both groups. Conclusions—The findings of this pilot trial suggest that a lower cooling level may be associated with a better outcome in patients surviving out-of-hospital cardiac arrest secondary to a shockable rhythm. The benefits observed here merit further investigation in a larger trial in out-of-hospital cardiac arrest patients with different presenting rhythms. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01155622.

Spectral analysis-based risk score enables early prediction of mortality and cerebral performance in patients undergoing therapeutic hypothermia for ventricular fibrillation and comatose status

BACKGROUND Early prognosis in comatose survivors after cardiac arrest due to ventricular fibrillation (VF) is unreliable, especially in patients undergoing mild hypothermia. We aimed at developing a reliable risk-score to enable early prediction of cerebral performance and survival. METHODS Sixty-one out of 239 consecutive patients undergoing mild hypothermia after cardiac arrest, with eventual return of spontaneous circulation (ROSC), and comatose status on admission fulfilled the inclusion criteria. Background clinical variables, VF time and frequency domain fundamental variables were considered. The primary and secondary outcomes were a favorable neurological performance (FNP) during hospitalization and survival to hospital discharge, respectively. The predictive model was developed in a retrospective cohort (n = 32; September 2006-September 2011, 48.5 ± 10.5 months of follow-up) and further validated in a prospective cohort (n = 29; October 2011-July 2013, 5 ± 1.8 months of follow-up). RESULTS FNP was present in 16 (50.0%) and 21 patients (72.4%) in the retrospective and prospective cohorts, respectively. Seventeen (53.1%) and 21 patients (72.4%), respectively, survived to hospital discharge. Both outcomes were significantly associated (p < 0.001). Retrospective multivariate analysis provided a prediction model (sensitivity = 0.94, specificity = 1) that included spectral dominant frequency, derived power density and peak ratios between high and low frequency bands, and the number of shocks delivered before ROSC. Validation on the prospective cohort showed sensitivity = 0.88 and specificity = 0.91. A model-derived risk-score properly predicted 93% of FNP. Testing the model on follow-up showed a c-statistic ≥ 0.89. CONCLUSIONS A spectral analysis-based model reliably correlates time-dependent VF spectral changes with acute cerebral injury in comatose survivors undergoing mild hypothermia after cardiac arrest.

Refibrinólisis con r-tpa por trombosis de prótesis mitral tras un infarto agudo de miocardio

Presentamos un paciente de 62 anos portador de protesis mitral que fue ingresado con un infarto anterior y tratado con r-tPA. Unos dias despues desarrollotrombosis de la protesis con aparicion de insuficiencia cardiaca. El enfermo se considero como de alto riesgo quirurgico, y fue tratado conexito con una nueva dosis de r-tPA, desapareciendola insuficiencia cardiaca y la imagen ecocardiografica de trombosis protesica.

Long-term neurological outcomes in out-of-hospital cardiac arrest patients treated with targeted-temperature management

BACKGROUND This study aimed to assess long-term cognitive and functional outcomes in out-of-hospital cardiac arrest (OHCA) patients treated with targeted-temperature management, investigate the existence of prognostic factors that could be assessed during initial admission and evaluate the usefulness of classic neurological scales in this clinical scenario. METHODS Patients admitted due to OHCA from August 2007 to November 2015 and surviving at least one year were included. Each patient completed a structured interview focused on the collection of clinical, social and demographic data. All available information in clinical records was reviewed and a battery of neurocognitive and psychometric tests was performed. RESULTS Seventy-nine patients were finally included in the analysis. Forty-three patients (54.4%) scored below the usual cut-off points for the diagnosis of mild cognitive impairment, even though most of these deficits went unnoticed when patients were assessed using CPC and modified Rankin scale. Nineteen (24%) developed certain degree of impairment in their attention capacity and executive functions. A significant proportion developed new memory-related disorders (43%), depressive symptoms (17.7%), aggressive/uninhibited behavior (12.7%) and emotional lability (8.9%). A greater number of weekly hours of intellectual activity and a qualified job were independent protective factors for the development of cognitive impairment. However, being older at the time of the cardiac arrest was identified as a poor prognostic factor. CONCLUSIONS There is a high prevalence of long-term cognitive deficits and functional limitations in OHCA survivors. Most commonly used clinical scales in clinical practice are crude and lack sensitivity to detect most of these deficits.

Dataset regarding baseline and follow-up characteristics of out-of-hospital cardiac arrest patients focused on neurological outcomes

This data article contains the data related to the research article entitled “Long-term neurological outcomes in out-of-hospital cardiac arrest patients treated with targeted-temperature management” (Caro-Codón et al., 2018). In this dataset, we report details regarding the flow chart of the included patients and the specific exclusion criteria. We also include information on the difference between the patients who attended the structured personal interview (and therefore were finally included in the study) and those who did not attend. Neuropsychiatric and functional data before and after cardiac arrest are also reported. Finally, we list all the “de novo” focal neurological deficits identified after cardiac arrest in the related population.

Response to Letter Regarding Article, “Hypothermia in Comatose Survivors From Out-of-Hospital Cardiac Arrest: Pilot Trial Comparing 2 Levels of Target Temperature”

We thank Kagawa et al for their comments and appreciate their interest in our work.1 We agree with them that there are many possible factors that could influence the results of our pilot study. All of these factors could not be controlled in our study. Kagawa et al, based on the results of their retrospective study,2 consider that the relative risk of favorable neurological outcomes is 0.90 with a time interval of 1 minute from collapse to return of …