Noritoshi Ito

Duration of Prehospital Resuscitation Efforts After Out-of-Hospital Cardiac Arrest.

Background— During out-of-hospital cardiac arrest, it is unclear how long prehospital resuscitation efforts should be continued to maximize lives saved. Methods and Results— Between 2005 and 2012, we enrolled 282 183 adult patients with bystander-witnessed out-of-hospital cardiac arrest from the All-Japan Utstein Registry. Prehospital resuscitation duration was calculated as the time interval from call receipt to return of spontaneous circulation in cases achieving prehospital return of spontaneous circulation or from call receipt to hospital arrival in cases not achieving prehospital return of spontaneous circulation. In each of 4 groups stratified by initial cardiac arrest rhythm (shockable versus nonshockable) and bystander resuscitation (presence versus absence), we calculated minimum prehospital resuscitation duration, defined as the length of resuscitation efforts in minutes required to achieve ≥99% sensitivity for the primary end point, favorable 30-day neurological outcome after out-of-hospital cardiac arrest. Prehospital resuscitation duration to achieve prehospital return of spontaneous circulation ranged from 1 to 60 minutes. Longer prehospital resuscitation duration reduced the likelihood of favorable neurological outcome (adjusted odds ratio, 0.84; 95% confidence interval, 0.838–0.844). Although the frequency of favorable neurological outcome was significantly different among the 4 groups, ranging from 20.0% (shockable/bystander resuscitation group) to 0.9% (nonshockable/bystander resuscitation group; P<0.001), minimum prehospital resuscitation duration did not differ widely among the 4 groups (40 minutes in the shockable/bystander resuscitation group and the shockable/no bystander resuscitation group, 44 minutes in the nonshockable/bystander resuscitation group, and 45 minutes in the nonshockable/no bystander resuscitation group). Conclusions— On the basis of time intervals from the shockable arrest groups, prehospital resuscitation efforts should be continued for at least 40 minutes in all adults with bystander-witnessed out-of-hospital cardiac arrest. Clinical Trial Registration— URL: http://www.umin.ac.jp/ctr/. Unique identifier: 000009918.

Regional cerebral oxygen saturation monitoring for predicting interventional outcomes in patients following out-of-hospital cardiac arrest of presumed cardiac cause: A prospective, observational, multicentre study

AIM This study investigated the value of regional cerebral oxygen saturation (rSO2) monitoring upon arrival at the hospital for predicting post-cardiac arrest intervention outcomes. METHODS We enrolled 1195 patients with out-of-hospital cardiac arrest of presumed cardiac cause from the Japan-Prediction of Neurological Outcomes in Patients Post-cardiac Arrest Registry. The primary endpoint was a good neurologic outcome (cerebral performance categories 1 or 2 [CPC1/2]) 90 days post-event. RESULTS A total of 68 patients (6%) had good neurologic outcomes. We found a mean rSO2 of 21%±13%. A receiver operating characteristic curve analysis indicated an optimal rSO2 cut-off of ≥40% for good neurologic outcomes (area under the curve 0.92, sensitivity 0.81, specificity 0.96). Good neurologic outcomes were observed in 53% (55/103) and 1% (13/1092) of patients with high (≥40%) and low (<40%) rSO2, respectively. Even without return of spontaneous circulation (ROSC) upon arrival at the hospital, 30% (9/30) of patients with high rSO2 had good neurologic outcomes. Furthermore, 16 patients demonstrating ROSC upon arrival at the hospital and low rSO2 had poor neurologic outcomes. Multivariate analyses indicated that high rSO2 was independently associated with good neurologic outcomes (odds ratio=14.07, P<0.001). Patients with high rSO2 showed favourable neurologic prognoses if they had undergone therapeutic hypothermia or coronary angiography (CPC1/2, 69% [54/78]). However, 24% (25/103) of those with high rSO2 did not undergo these procedures and exhibited unfavourable neurologic prognoses (CPC1/2, 4% [1/25]). CONCLUSION rSO2 is a good indicator of 90-day neurologic outcomes for post-cardiac arrest intervention patients.

Characteristics of regional cerebral oxygen saturation levels in patients with out-of-hospital cardiac arrest with or without return of spontaneous circulation: A prospective observational multicentre study.

AIM Our study aimed at filling the fundamental knowledge gap on the characteristics of regional brain oxygen saturation (rSO2) levels in out-of-hospital cardiac arrest (OHCA) patients with or without return of spontaneous circulation (ROSC) upon arrival at the hospital for estimating the quality of cardiopulmonary resuscitation and neurological prognostication in these patients. METHODS We enrolled 1921 OHCA patients from the Japan - Prediction of Neurological Outcomes in Patients Post-cardiac Arrest Registry and measured their rSO2 immediately upon arrival at the hospital by near-infrared spectroscopy using two independent forehead probes (right and left). We also assessed the percentage of patients with a good neurological outcome (defined as cerebral performance categories 1 or 2) 90 days post cardiac arrest. RESULTS After 90 days, 79 (4%) patients had good neurological outcomes and a median lower rSO2 level of 15% (15-20%). Compared to patients without ROSC upon arrival at the hospital, those with ROSC had significantly higher rSO2 levels (56% [39-65%] vs. 15% [15-17%], respectively; P<0.01), and significantly correlated right- and left-sided regional brain oxygen saturation levels (R=0.94 vs. 0.66, respectively). In both groups, the percentage of patients with a good 90-day neurological outcome increased significantly in proportion to their rSO2 levels upon arrival at the hospital (P<0.01). CONCLUSION Our data indicate that measuring rSO2 levels might be effective for both monitoring the quality of resuscitation and neurological prognostication in patients with OHCA.

Lower Proportional Pulse Pressure at Hospital Arrival is Related to Lower Left Ventricular Ejection Fraction in Acute Decompensated Heart Failure

The patients of heart failure (HF) have been increasing as elderly population increasing. The pathophysiology of HF in the elderly is different from that in the young. We aimed this study to clarify the hypothesis that prognostic indicators between elderly and young patients with HF would be different. We enrolled 345 patients with HF (age, 68613 years; male sex, 60%). They were followed up for 17613 months. Re-hospitalization by HF was set as an outcome, and was seen in 67 cases. We divided the patients into two groups by 75 years old: 130 cases in the elderly and 215 cases in the young. The elderly group had more frequent female, lower body mass index, higher ejection fraction, lower left ventricular end-diastolic dimension, lower MMSE score, lower DBP and higher pulse pressure than the young group. In Cox regression analysis adjusting for covariates, nocturnal DBP [Hazard ratio (HR)50.95, 95%CI 0.92-0.99, p!0.01] was a significant predictor of HF re-hospitalization in the elderly group. In the young group, significant prognostic factors were BNP [HR52.67, 1.72-4.15, p!0.01], prior HF hospitalization [HR51.20, 95%CI 1.02-1.41, p50.03], and nocturnal SBP [HR50.97, 0.95-1.00, p!0.01). In conclusion, the indicators of HF re-hospitalization between the elderly and the young patients were different. These results reflect different pathophysiological mechanisms of HF by the age group.

IMPACT OF SINGLE INTRACORONARY NICORANDIL ADMINISTRATION ON MICROCIRCULATORY DISTURBANCE AFTER SUCCESSFUL PRIMARY PERCUTANEOUS INTERVENTION IN ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION

Background: Index of Microcirculatory Resistance (IMR) is an on-site parameter for the assessment of microcirculatory disturbance after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). High IMR has been shown to be a predictor of poor left ventricular (LV) function recovery. We sought to investigate the effects of intracoronary nicorandil administration after primary PCI on microvascular injury and chronic phase LV function.

DISTAL PROTECTION CAN PRESERVE INDEX OF MICROCIRCULATORY RESISTANCE IN PATIENTS WITH ST-SEGMENT ELEVATION ANTERIOR WALL MYOCARDIAL INFARCTION

Authors: Noritoshi Ito, Shinsuke Nanto, Yasuji Doi, Hirotaka Sawano, Daisaku Masuda, Shizuya Yamashita, Mai Hatano, Daisuke Tonomura, Yuma Kurozumi, Tomoaki Natsukawa, Yusuke Ito, Kazuyuki Oka, Jiro Ooba, Taizo Hasegawa, Makoto Kobayashi, Hiroshi Ichiyanagi, Koji Akashi, Koichi Otsuya, Shoji Kaibe, Ken-ichiro Okada, Yasuyuki Hayashi, Tatsuro Kai, Toru Hayashi, Osaka Saiseikai Senri Hospital, Suita, Japan, Osaka University Graduate School of Medicine, Suita, Japan