Martin J. Arron

Predicting survival from in-hospital CPR - Meta-analysis and validation of a prediction model

Objective: To better clarify patient factors that predict survival from in-hospital cardiopulmonary resuscitation (CPR), using two methods: 1) meta-analysis and 2) validation of a prediction model, the pre-arrest morbidity (PAM) index.Design: Meta-analysis of previously published studies by standard techniques. Retrospective chart review of validation sample.Setting: University-affiliated teaching hospital.Patients/participants: Meta-analytic sample of 21 previous studies from 1965–1989. The validation sample consisted of all patients surviving resuscitation from the authors’ hospital during the period September 1986 to January 1991. A matched sample of patients who did not survive from the same time period was used as the comparison group.Interventions: None.Measurements and main results: The strongest negative predictors of survival, by meta-analysis, were renal failure (r=0.088, p<0.0002), cancer (r=0.08, p<0.0002), and age more than 60 years (r=0.063, p<0.006). Sepsis (r=0.046, p<0.02), recent cerebrovascular accident (CVA) (r=0.038, p<0.04), and congestive heart failure (CHF) class III/IV (r=0.036, p<0.05) were weaker negative predictors. Presence of acute myocardial infarction (AMI) was a significant positive predictor of survival (r=0.15, p<0.0001). The PAM score was highly predictive of survival in a logistic regression model (p<0.0003, R2=9.6%). No patient who survived to discharge had a PAM score higher than 8.Conclusion: Meta-analysis reveals that the most significant negative predictors of survival from CPR are renal failure, cancer, and age more than 60 years, while AMI is a significant positive predictor. The PAM index is a useful method of stratifying probability of survival from CPR, especially for those patients with high PAM scores, who have essentially no chance of survival.

ST segment depression detected by continuous electrocardiography in patients with acute ischemic stroke or transient ischemic attack.

Forty percent of patients with a history of ischemic stroke or transient ischemic attack (TIA) have concomitant coronary artery disease. ST segment depression, detected by continuous electrocardiography, is associated with increased cardiac morbidity and mortality in patients with known coronary artery disease. While electrocardiographic changes have been associated with acute stroke, the etiology and significance of these changes remain unclear. In this pilot study we report the prevalence of ST segment depression and ventricular arrhythmias in patients with acute ischemic stroke or TLA monitored by continuous electrocardiography. Clinical predictors of ST segment depression and ventricular arrhythmia are also identified. Methods Consecutive patients presenting with acute ischemic stroke or TLA were enrolled within 72 hours of hospital admission and monitored by continuous electrocardiography for 48 hours. The electrocardiographic results were analyzed for periods of ST segment depression and ventricular arrhythmias. Results Of 51 patients with ischemic stroke or TIA, 15 (29%) had episodes of ST segment depression (95% confidence interval, 15% to 43%), and 18 (35%) had ventricular arrhythmias (95% confidence interval, 21% to 49%). In logistic regression analysis, increasing age (P<.02) and a left-sided neurological event (P<.01) were significant predictors of ST segment depression. Increasing numbers of atherosclerotic risk factors, a history of cardiac disease, and increasing or decreasing mean arterial pressure were not predictive of ST segment depression. Conclusions Patients with acute ischemic stroke or TIA have a 29% prevalence of ST segment depression within the first 5 days after their event. In comparison, the prevalence of ST depression is 2.5% to 8% in asymptomatic adults and 43% to 60% in patients with symptomatic coronary artery disease. The association of ST segment depression with left-sided neurological events suggests that the electrocardiographic changes are in part neurologically mediated. Further study is necessary to better define the brain-heart interaction and to determine whether ST segment depression in patients with ischemic stroke or TLA reflects underlying coronary artery disease.

Prognostic Significance of ST-Segment Depression on Continuous Electrocardiography in Patients with Acute Ischemic Neurologic Events

Patients with a history of ischemic stroke or transient ischemic attack (TIA) are at significant risk of cardiac death. This study reports the prognostic significance of ST-segment depression and ventricular tachycardia on continuous electrocardiography in 48 consecutive patients hospitalized with an acute ischemic stroke or TIA. Thirty-one percent of patients had episodes of asymptomatic ST-segment depression and 6% had transient ventricular tachycardia on continuous electrocardiographic monitoring. At a mean follow-up of 13 months, 19% had experienced a cardiac outcome, and 19% met criteria for a neurologic outcome. Cardiac and neurologic outcomes, including death, were not significantly different in patients with and without ST-segment depression on continuous electrocardiography. Cardiac outcomes occurred in 13% of patients with ST-segment depression and in 21% of patient without ST-segment depression (p = 0.52). However, ventricular tachycardia was associated with a higher rate of cardiac death (33% vs. 2%, p < 0.01). Only 27% of patients subsequently found to have coronary artery disease had ST-segment depression by continuous electrocardiography. In contrast to patients with coronary artery disease, ST-segment depression on continuous electrocardiography is not associated with poorer outcome among patients with acute ischemic stroke or TIA.