Sergio Timerman

Left Ventricular Systolic Function and Outcome After In-Hospital Cardiac Arrest

Background— The effect of prearrest left ventricular ejection fraction (LVEF) on outcome after cardiac arrest is unknown. Methods and Results— During a 26-month period, Utstein-style data were prospectively collected on 800 consecutive inpatient adult index cardiac arrests in an observational, single-center study at a tertiary cardiac care hospital. Prearrest echocardiograms were performed on 613 patients (77%) at 11±14 days before the cardiac arrest. Outcomes among patients with normal or nearly normal prearrest LVEF (≥45%) were compared with those of patients with moderate or severe dysfunction (LVEF <45%) by &khgr;2 and logistic regression analyses. Survival to discharge was 19% in patients with normal or nearly normal LVEF compared with 8% in those with moderate or severe dysfunction (adjusted odds ratio, 4.8; 95% confidence interval, 2.3 to 9.9; P<0.001) but did not differ with regard to sustained return of spontaneous circulation (59% versus 56%; P=0.468) or 24-hour survival (39% versus 36%; P=0.550). Postarrest echocardiograms were performed on 84 patients within 72 hours after the index cardiac arrest; the LVEF decreased 25% in those with normal or nearly normal prearrest LVEF (60±9% to 45±14%; P<0.001) and decreased 26% in those with moderate or severe dysfunction (31±7% to 23±6%, P<0.001). For all patients, prearrest &bgr;-blocker treatment was associated with higher survival to discharge (33% versus 8%; adjusted odds ratio, 3.9; 95% confidence interval, 1.8 to 8.2; P<0.001). Conclusions— Moderate and severe prearrest left ventricular systolic dysfunction was associated with substantially lower rates of survival to hospital discharge compared with normal or nearly normal function.

Global health and emergency care: a resuscitation research agenda--part 1.

At the 2013 Academic Emergency Medicine global health consensus conference, a breakout session on a resuscitation research agenda was held. Two articles focusing on cardiac arrest and trauma resuscitation are the result of that discussion. This article describes the burden of disease and outcomes, issues in resuscitation research, and global trends in resuscitation research funding priorities. Globally, cardiovascular disease and trauma cause a high burden of disease that receives a disproportionately smaller research investment. International resuscitation research faces unique ethical challenges. It needs reliable baseline statistics regarding quality of care and outcomes; data linkages between providers; reliable and comparable national databases; and an effective, efficient, and sustainable resuscitation research infrastructure to advance the field. Research in resuscitation in low- and middle-income countries is needed to understand the epidemiology, infrastructure and systems context, level of training needed, and potential for cost-effective care to improve outcomes. Research is needed on low-cost models of population-based research, ways to disseminate information to the developing world, and finding the most cost-effective strategies to improve outcomes.

Use of demonstrably effective therapies in the treatment of acute coronary syndromes: comparison between different Brazilian regions. Analysis of the Brazilian Registry on Acute Coronary Syndromes (BRACE).

BACKGROUND: Little is known in our country about regional differences in the treatment of acute coronary disease. OBJECTIVE: To analyze the behavior regarding the use of demonstrably effective regional therapies in acute coronary disease. METHODS: A total of 71 hospitals were randomly selected, respecting the proportionality of the country in relation to geographic location, among other criteria. In the overall population was regionally analyzed the use of aspirin, clopidogrel, ACE inhibitors / AT1 blocker, beta-blockers and statins, separately and grouped by individual score ranging from 0 (no drug used) to 100 (all drugs used). In myocardial infarction with ST elevation (STEMI) regional differences were analyzed regarding the use of therapeutic recanalization (fibrinolytics and primary angioplasty). RESULTS: In the overall population, within the first 24 hours of hospitalization, the mean score in the North-Northeast (70.5 ± 22.1) was lower (p <0.05) than in the Southeast (77.7 ± 29.5), Midwest (82 ± 22.1) and South (82.4 ± 21) regions. At hospital discharge, the score of the North-Northeast region (61.4 ± 32.9) was lower (p <0.05) than in the Southeast (69.2 ± 31.6), Midwest (65.3 ± 33.6) and South (73.7 ± 28.1) regions; additionally, the score of the Midwest was lower (p <0.05) than the South region. In STEMI, the use of recanalization therapies was highest in the Southeast (75.4%, p = 0.001 compared to the rest of the country), and lowest in the North-Northeast (52.5%, p <0.001 compared to the rest of the country). CONCLUSION: The use of demonstrably effective therapies in the treatment of acute coronary disease is much to be desired in the country, with important regional differences.BACKGROUND Little is known in our country about regional differences in the treatment of acute coronary disease. OBJECTIVE To analyze the behavior regarding the use of demonstrably effective regional therapies in acute coronary disease. METHODS A total of 71 hospitals were randomly selected, respecting the proportionality of the country in relation to geographic location, among other criteria. In the overall population was regionally analyzed the use of aspirin, clopidogrel, ACE inhibitors / AT1 blocker, beta-blockers and statins, separately and grouped by individual score ranging from 0 (no drug used) to 100 (all drugs used). In myocardial infarction with ST elevation (STEMI) regional differences were analyzed regarding the use of therapeutic recanalization (fibrinolytics and primary angioplasty). RESULTS In the overall population, within the first 24 hours of hospitalization, the mean score in the North-Northeast (70.5 ± 22.1) was lower (p <0.05) than in the Southeast (77.7 ± 29.5), Midwest (82 ± 22.1) and South (82.4 ± 21) regions. At hospital discharge, the score of the North-Northeast region (61.4 ± 32.9) was lower (p <0.05) than in the Southeast (69.2 ± 31.6), Midwest (65.3 ± 33.6) and South (73.7 ± 28.1) regions; additionally, the score of the Midwest was lower (p <0.05) than the South region. In STEMI, the use of recanalization therapies was highest in the Southeast (75.4%, p = 0.001 compared to the rest of the country), and lowest in the North-Northeast (52.5%, p <0.001 compared to the rest of the country). CONCLUSION The use of demonstrably effective therapies in the treatment of acute coronary disease is much to be desired in the country, with important regional differences.

Effect of amiodarone on haemodynamics during cardiopulmonary resuscitation in a canine model of resistant ventricular fibrillation

OBJECTIVE Amiodarone has been shown to be superior to both placebo and lidocaine in improving survival to hospital admission for victims of out-of-hospital refractory ventricular fibrillation. Concern had been expressed about the known vasodilatatory effects of amiodarone if given without precedent vasoconstrictive medications. The haemodynamic effects of intravenous amiodarone administered during ongoing CPR have not been systemically investigated. Our intention was to verify if amiodarone alone produced significantly lower resuscitation haemodynamics than did either adrenaline (epinephrine) alone or the combination of amiodarone and adrenaline. DESIGN Prospective, randomized, comparative study. SETTING Research laboratory of a medical school. SUBJECTS Thirty mongrel dogs. INTERVENTIONS After 8 min of untreated VF, defibrillation was attempted once at 3 J/kg and external chest compressions and ventilation started. Those animals resistant to the defibrillation attempt were randomized, ten to an adrenaline (0.02 mg/kg) group, ten to an amiodarone (5 mg/kg) group, and ten to a group receiving a combination of both drugs. MEASUREMENTS AND MAIN RESULTS Aortic systolic and diastolic, and coronary perfusion pressures were all significantly lower in the group receiving amiodarone alone than in the other two groups. Amiodarone combined with adrenaline produced pressures during CPR similar to adrenaline alone. CONCLUSION Amiodarone can be safely administered simultaneously in combination with adrenaline and such a combination results in similar haemodynamic support as adrenaline alone. Amiodarone administered alone produces significantly lower coronary perfusion pressure than when combined with adrenaline.

Utilização de terapêuticas comprovadamente úteis no tratamento da coronariopatia aguda: comparação entre diferentes regiões brasileiras. Análise do Registro Brasileiro de Síndromes Coronarianas Agudas (BRACE - Brazilian Registry on Acute Coronary Syndromes)

BACKGROUND: Little is known in our country about regional differences in the treatment of acute coronary disease. OBJECTIVE: To analyze the behavior regarding the use of demonstrably effective regional therapies in acute coronary disease. METHODS: A total of 71 hospitals were randomly selected, respecting the proportionality of the country in relation to geographic location, among other criteria. In the overall population was regionally analyzed the use of aspirin, clopidogrel, ACE inhibitors / AT1 blocker, beta-blockers and statins, separately and grouped by individual score ranging from 0 (no drug used) to 100 (all drugs used). In myocardial infarction with ST elevation (STEMI) regional differences were analyzed regarding the use of therapeutic recanalization (fibrinolytics and primary angioplasty). RESULTS: In the overall population, within the first 24 hours of hospitalization, the mean score in the North-Northeast (70.5 ± 22.1) was lower (p <0.05) than in the Southeast (77.7 ± 29.5), Midwest (82 ± 22.1) and South (82.4 ± 21) regions. At hospital discharge, the score of the North-Northeast region (61.4 ± 32.9) was lower (p <0.05) than in the Southeast (69.2 ± 31.6), Midwest (65.3 ± 33.6) and South (73.7 ± 28.1) regions; additionally, the score of the Midwest was lower (p <0.05) than the South region. In STEMI, the use of recanalization therapies was highest in the Southeast (75.4%, p = 0.001 compared to the rest of the country), and lowest in the North-Northeast (52.5%, p <0.001 compared to the rest of the country). CONCLUSION: The use of demonstrably effective therapies in the treatment of acute coronary disease is much to be desired in the country, with important regional differences.BACKGROUND Little is known in our country about regional differences in the treatment of acute coronary disease. OBJECTIVE To analyze the behavior regarding the use of demonstrably effective regional therapies in acute coronary disease. METHODS A total of 71 hospitals were randomly selected, respecting the proportionality of the country in relation to geographic location, among other criteria. In the overall population was regionally analyzed the use of aspirin, clopidogrel, ACE inhibitors / AT1 blocker, beta-blockers and statins, separately and grouped by individual score ranging from 0 (no drug used) to 100 (all drugs used). In myocardial infarction with ST elevation (STEMI) regional differences were analyzed regarding the use of therapeutic recanalization (fibrinolytics and primary angioplasty). RESULTS In the overall population, within the first 24 hours of hospitalization, the mean score in the North-Northeast (70.5 ± 22.1) was lower (p <0.05) than in the Southeast (77.7 ± 29.5), Midwest (82 ± 22.1) and South (82.4 ± 21) regions. At hospital discharge, the score of the North-Northeast region (61.4 ± 32.9) was lower (p <0.05) than in the Southeast (69.2 ± 31.6), Midwest (65.3 ± 33.6) and South (73.7 ± 28.1) regions; additionally, the score of the Midwest was lower (p <0.05) than the South region. In STEMI, the use of recanalization therapies was highest in the Southeast (75.4%, p = 0.001 compared to the rest of the country), and lowest in the North-Northeast (52.5%, p <0.001 compared to the rest of the country). CONCLUSION The use of demonstrably effective therapies in the treatment of acute coronary disease is much to be desired in the country, with important regional differences.

Aliança Internacional dos Comitês de Ressuscitação (ILCOR): papel nas novas diretrizes de ressuscitação cardiopulmonar e cuidados cardiovasculares de emergência 2005-2010

Resuscitation, sudden cardiac, emergency cardiovascular care.in January 2005. The proceedings of this meeting provided material for regional consensus organizations to write their own resuscitation guidelines.The creation of ILCOR established a unique opportunity for international collaboration in the development of guidelines and training programs on resuscitation over the past fifteen years. A short summary of the important aspects and the progress of the organization, which has become the authoritative voice on the scientific consensus behind national and international resuscitation guidelines, is presented below.

Survival After Ventricular Fibrillation Cardiac Arrest in the Sao Paulo Metropolitan Subway System: First Successful Targeted Automated External Defibrillator (AED) Program in Latin America.

Background Targeted automated external defibrillator (AED) programs have improved survival rates among patients who have an out‐of‐hospital cardiac arrest (OHCA) in US airports, as well as European and Japanese railways. The Sao Paulo (Brazil) Metro subway carries 4.5 million people per day. A targeted AED program was begun in the Sao Paulo Metro with the objective to improve survival from cardiac arrest. Methods and Results A prospective, longitudinal, observational study of all cardiac arrests in the Sao Paulo Metro was performed from September 2006 through November 2012. This study focused on cardiac arrest by ventricular arrhythmias, and the primary endpoint was survival to hospital discharge with minimal neurological impairment. A total of 62 patients had an initial cardiac rhythm of ventricular fibrillation. Because no data on cardiac arrest treatment or outcomes existed before beginning this project, the first 16 months of the implementation was used as the initial experience and compared with the subsequent 5 years of full operation. Return of spontaneous circulation was not different between the initial 16 months and the subsequent 5 years (6 of 8 [75%] vs. 39 of 54 [72%]; P=0.88). However, survival to discharge was significantly different once the full program was instituted (0 of 8 vs. 23 of 54 [43%]; P=0.001). Conclusions Implementation of a targeted AED program in the Sao Paulo Metro subway system saved lives. A short interval between arrest and defibrillation was key for good long‐term, neurologically intact survival. These results support strategic expansion of targeted AED programs in other large Latin American cities.

Outcomes of patients with trauma and intraoperative cardiac arrest

BACKGROUND Although the occurrence of intraoperative cardiac arrest is rare, it is a severe adverse event with a high mortality rate. Trauma patients have additional causes for intraoperative arrest, and we hypothesised that the survival of trauma patients who experienced intraoperative cardiac arrest would be worse than nontrauma patients who experienced intraoperative cardiac arrest. OBJECTIVES The aim of the present study was to compare the outcomes of trauma and nontrauma patients after intraoperative cardiac arrest. METHODS In a tertiary university hospital and trauma centre, the intraoperative cardiac arrest cases were evaluated from January 2007 to December 2009, excluding patients submitted to cardiac surgery. Data were prospectively collected using the Utstein-style. Outcomes among the patients with trauma were compared to the patients without trauma. RESULTS We collected data from 81 consecutive intraoperative cardiac arrest cases: 32 with trauma and 49 without trauma. Patients in the trauma group were younger than the patients in the nontrauma group (44±23 vs. 63±17, p<0.001). Hypovolaemia (63% vs. 35%, p=0.022) and metabolic/hydroelectrolytic disturbances (41% vs. 2%, p<0.001) were more likely to cause the cardiac arrest in the trauma group. The first documented arrest rhythm did not differ between the groups, and pulseless electrical activity was the most prevalent rhythm (66% vs. 53%, p=0.698). The return of spontaneous circulation (47% vs. 63%, p=0.146) and survival to discharge with favourable neurological outcome (16% vs. 14%, p=0.869) did not differ between the two groups. CONCLUSIONS The outcomes did not differ between patients with trauma and nontrauma intraoperative cardiac arrest.

Análise do atendimento intra-hospitalar de eventos simulados de fibrilação ventricular/taquicardia ventricular

OBJECTIVE To analyze the time intervals between the beginning of the Ventricular Fibrilation/Ventricular Taquicardia (VF/VT) and the main procedures made. METHODS Twenty VF/VT simulations were performed and filmed in a hospital environment, using a static mannequin, on random days at random times. All teams had the same level of skills. The times (in sec.) related to basic life support (BLS) - arrival of the team (AT), confirmation of the arrest (CAT), beginning of the CPR (IT) and the times related to the advanced life support (ALS) - 1st defibrillation (DT), 1st dose of adrenalin (AT) and orotracheal intubation (OTIT). The variables were analyzed and compared in two groups: intensive care unit (ICU) and wards with telemetry (TLW). RESULTS The results in both groups was in that order (GW x ICU ) - AT (70.2+38.7 x 38.6+49.2); CCA (89.4+57.1 x 71+63.9); SC (166.8+81.1 x 142+66.2); FD (282.5+142.8 x 108.4+52.5); FE (401.4+161.7 x 263.3+122.8) e OI (470.3+150.6 x 278.8+98.8). Shows the comparison of the average times between the two groups. CONCLUSION The differences noted in relation to DT, AT and OTIT favorable to ICU are associated to the facility of performance of the ALS maneuvers in such environment. The BLS-related times were similar in both groups, which reinforce the need for the use of semi-automatic defibrillators, even in a hospital environment.

Therapeutic hypothermia after sudden cardiac arrest: Endothelial function evaluation

Therapeutic hypothermia (TH) is now part of the treatment trategy for patients successfully resuscitated after cardiac arrest nce it was demonstrated to improve neurologic outcome and ncrease survival rates.1 TH is associated with several cardiovasular effects. There is a decrease in heart rate and cardiac index and n increase in mean blood pressure and systemic vascular resisance. A variety of arrhythmias may be induced by hypothermia. owever, it is unknown whether vascular reactivity is impaired uring TH after cardiac arrest. We describe an evaluation of endothelium function in a case f an out-of-hospital survivor of cardiac arrest submitted to TH. uring hypothermia and after rewarming brachial flow-dependent asodilation was evaluated. The patient was a 39-year-old male atient victim of ventricular fibrillation who had been resuscitated t home after 20 min and remained comatose after the resumption f spontaneous circulation (ROSC). At hospital admission, Glasgow oma Scale was 8. Cardiovascular risk stratification was performed. lectrocardiography showed sinus rhythm with diffuse repolarzation abnormalities. Angiographic study revealed no coronary bstructive lesions and moderate diffuse left ventricular dysfuncion. Patient was admitted to the ICU and general management of ost-cardiac arrest care was initiated, including TH for 24 h. After ecovery, electrophysiological testing was performed and revealed entricular fibrillation triggered by the use of propafenone. An mplantable cardioverter-defibrillator was indicated. Patient was ischarged from the hospital without neurological sequelae. Using noninvasive approach, with high-resolution ultrasound, we meaured brachial artery diameter and brachial artery blood flow elocity at rest and during reactive hyperemia (RH) after a 5in occlusion of the brachial artery with a blood pressure cuff2,3 Fig. 1) in two moments: first at temperature of 32.6 ◦C, after the ooling period, and second at 37.1 ◦C, after rewarming. After the timuli of RH, the % increases in brachial diameter, peak blood ow and mean blood flow during hypothermia were 20.8 ± 2.3%, 41.3 ± 14.9% and 416.7 ± 14.3%, respectively. After rewarming, hese changes expressed as % were: 8.9 ± 3.5%, 84.5 ± 14.2% and 28.6 ± 18.9%, respectively. Flow-dependent vasodilation, that is econdary to endothelial NO release during RH, was maintained uring TH suggesting an intact endothelial function. ROSC after prolonged whole-body ischemia and subsequent eperfusion that happens after successful cardiopulmonary resusitation is a complex pathological process. The post-cardiac rrest syndrome is a multiple disorder process that causes brain njury, myocardial dysfunction and systemic ischemia/reperfusion esponse, including coagulation disorders, adrenal dysfunction, assive inflammation and microcirculatory impairment.4 The icrocirculatory function is abnormal in post-resuscitation period 4