Tomoaki Natsukawa

Resistance to conventional cardiopulmonary resuscitation in witnessed out-of-hospital cardiac arrest patients with shockable initial cardiac rhythm.

BACKGROUND Shockable initial cardiac rhythm is a key predictor of survival after out-of-hospital cardiac arrest (OHCA). However, not all patients with shockable OHCA achieve return of spontaneous circulation (ROSC) via conventional cardiopulmonary resuscitation (CPR). Therefore, we retrospectively analyzed patients with witnessed OHCA and shockable initial cardiac rhythm to identify the resistance factors for conventional CPR. METHODS We retrospectively analyzed consecutive patients with witnessed OHCA and shockable initial cardiac rhythm who were admitted to our hospital between October 2009 and October 2014. We then compared the baseline characteristics, pre-hospital clinical course, and causes of the cardiopulmonary arrest among patients who achieved ROSC via conventional CPR and patients who did not achieve ROSC via conventional CPR and underwent extracorporeal CPR (ECPR). RESULTS A total of 85 patients achieved ROSC via conventional CPR (non-ECPR group) and 40 patients did not achieve ROSC via conventional CPR and underwent ECPR (ECPR group). Among these 125 patients, 113 had known causes for their cardiopulmonary arrest, including 66 cases (53%) of acute myocardial infarction (AMI). There were no significant differences in the causes of arrest between the non-ECPR and ECPR cases. However, among the 66 cases of AMI (43 non-ECPR and 23 ECPR), the rate of non-recanalization during the initial coronary angiography was significantly higher among the ECPR cases (non-ECPR: 58% vs. ECPR: 87%; p=0.03). CONCLUSIONS The major cause of witnessed OHCA with shockable initial cardiac rhythm was AMI, and resistance to conventional CPR was related to continuous myocardial ischemia.

Association of Epicardial, Visceral, and Subcutaneous Fat With Cardiometabolic Diseases

BACKGROUND Excess of visceral fat is a central factor in the pathogenesis of metabolic syndrome (MetS) and atherosclerosis. However, little is known about how much epicardial fat affects cardiometabolic disorders in comparison with visceral or subcutaneous fat.Methods and Results:Participants suspected as having angina pectoris underwent cardiac computed tomography (CT) imaging. Of them, 374 subjects were analyzed the association of clinical characteristics and CT-based fat distribution measured as epicardial fat volume (EFV), visceral fat area (VFA), and subcutaneous fat area (SFA). EFV was highly associated with VFA (R=0.58). Serum adiponectin was significantly decreased in high VFA subjects (VFA ≥100 cm2) and was also reduced in the high EFV group (EFV ≥80 cm3). Among the low VFA groups, the numbers of subjects with diabetes and coronary atherosclerosis were increased in high EFV group. Among the low EFV groups, the numbers of subjects with diabetes, hyperuricemia, and coronary atherosclerosis were increased among the high VFA subjects. In an age-, sex-, and body mass index (BMI)-adjusted model, EFV was associated with dyslipidemia and MetS, and VFA was significantly associated with hypertension, dyslipidemia, MetS, and coronary atherosclerosis, while SFA was not related with coronary risks and atherosclerosis. CONCLUSIONS Epicardial fat accumulation may be a risk for coronary atherosclerosis in subjects without visceral fat accumulation. Visceral fat is the strongest risk for cardiometabolic diseases among the 3 types of fat depot.

Significant Association of Serum Adiponectin and Creatine Kinase-MB Levels in ST-Segment Elevation Myocardial Infarction.

Aims: Adiponectin, an adipocyte-specific secretory protein, abundantly exists in the blood stream while its concentration paradoxically decreases in obesity. Hypoadiponectinemia is one of risks of cardiovascular diseases. However, impact of serum adiponectin concentration on acute ischemic myocardial damages has not been fully clarified. The present study investigated the association of serum adiponectin and creatine kinase (CK)-MB levels in subjects with ST-segment elevation myocardial infarction (STEMI). Methods: This study is a physician-initiated observational study and is also registered with the University Hospital Medical Information Network (Number: UMIN 000014418). Patients were admitted to Senri Critical Care Medical Center, given a diagnosis of STEMI, and treated by primary percutaneous coronary intervention (PCI). Finally, 49 patients were enrolled and the association of serum adiponectin, CK-MB, and clinical features were mainly analyzed. Results: Serum adiponectin levels decreased rapidly and reached the bottom at 24 hours after recanalization. Such reduction of serum adiponectin was inversely correlated with the area under the curve (AUC) of serum CK-MB (p = 0.013). Serum adiponectin concentrations were inversely correlated with AUC of serum CK-MB. In multivariate analysis, serum adiponectin concentration on admission (p = 0.002) and collateral (p = 0.037) were significantly and independently correlated with serum AUC of CK-MB. Conclusion: Serum AUC of CK-MB in STEMI subjects was significantly associated with serum adiponectin concentration on admission and reduction of serum adiponectin levels from baseline to bottom. The present study may provide a possibility that serum adiponectin levels at acute phase are useful in the prediction for prognosis after PCI-treated STEMI subjects.

Global Registry of Acute Coronary Events risk score predicts mortality and neurological outcome in out-of hospital cardiac arrest

Purpose: The aim of this study was to assess the usefulness of the Global Registry of Acute Coronary Events (GRACE) risk score in predicting in‐hospital mortality and neurological outcome of patients resuscitated after out‐of‐hospital cardiac arrest (OHCA). Methods: We retrospectively analyzed the data of patients admitted to our hospital between October 2009 and October 2015 with OHCA and shockable initial cardiac rhythm who were resuscitated via conventional cardiopulmonary resuscitation. We calculated the GRACE risk score on admission and assessed its usefulness in predicting in‐hospital mortality and neurological outcome. Results: Among 91 patients, 42 (46%) had acute myocardial infarction (AMI), 19 (21%) died in‐hospital, and 52 (57%) had favorable neurological outcome. Among all the study patients, GRACE risk score was lower in survivors than in non‐survivors (median 211 [interquartile range 176–240] vs. 266 [219–301], p < 0.001, respectively) and in favorable than in unfavorable neurological outcome group (202 [167–237] vs. 242 [219–275], p < 0.001, respectively). Multivariate analysis showed significant association between GRACE risk score and favorable neurological outcome (odds ratio, 0.975; 95% confidence interval, 0.961–0.990). Areas under receiver‐operating characteristic curves, that describe the accuracy of GRACE risk score in predicting in‐hospital mortality and favorable neurological outcome, were both 0.79. Conclusion: GRACE risk score may predict the in‐hospital mortality and neurological outcome associated with resuscitated patients with OHCA and shockable initial cardiac rhythm, regardless of the cause of arrest.

D-dimer predicts bleeding complication in out-of-hospital cardiac arrest resuscitated with extracorporeal membrane oxygenation

Purpose In out‐of‐hospital cardiac arrest (OHCA) patients resuscitated with veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO), known as extracorporeal cardiopulmonary resuscitation (ECPR), bleeding is a common complication. The purpose of this study was to assess the risk factors for bleeding complications in ECPR patients. Methods We retrospectively analyzed the data for OHCA patients admitted to our hospital and resuscitated with ECPR between October 2009 and December 2016. We compared patients with and without major bleeding (i.e. the Bleeding Academic Research Consortium class ≥ 3 bleeding) within 24 h of hospital admission. Patients, whose bleeding complication was not evaluated, were excluded. Results During the study period, 133 OHCA patients were resuscitated with ECPR, of whom 102 (77%) were included. In total, 71 (70%) patients experienced major bleeding. There were significant differences in age (median 65 vs. 50 years, P < 0.001), prior antiplatelet therapy (25% vs. 3%, P = 0.008), hemoglobin (median 11.6 vs. 12.6 g/dL, P = 0.003), platelet count (median 125 vs. 155 × 103/&mgr;L, P = 0.001), and D‐dimer levels on admission (median 18.8 vs. 6.7 &mgr;g/mL, P < 0.001) among patients with and those without major bleeding. Multivariate analysis showed significant associations between major bleeding and D‐dimer levels (odds ratio, 1.066; 95% confidence interval, 1.018–1.116). Area under receiver‐operating characteristic curve, which describes the accuracy of D‐dimer levels in predicting major bleeding, was 0.76 (95% confidence interval, 0.66–0.87). Conclusion D‐dimer levels may predict major bleeding in ECPR patients, suggesting that hyperfibrinolysis may be related to bleeding.

Indication for mild therapeutic hypothermia based on an initial Glasgow Coma Scale motor score

Although neurological evaluation using the Glasgow Coma Scale motor score is mandatory for post-cardiac arrest patients, further study is required to determine if this score can be used as an indicator for mild therapeutic hypothermia. Although the current study conducted by Natsukawa et al. presents interesting data, there are some critical issues regarding study design, selection bias, and interpretation of study results that should be pointed out.

Low-flow time is associated with a favorable neurological outcome in out-of-hospital cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation

Propose: The aim of this retrospective study was to investigate the prognostic factors in extracorporeal cardiopulmonary resuscitation (ECPR) patients and to assess their accuracy as predictors of a favorable neurological outcome. Materials and methods: Between October 2009 and December 2017, we retrospectively analyzed witnessed out‐of‐hospital cardiac arrest patients who were admitted to our hospital and resuscitated with ECPR. We compared the baseline characteristics, pre‐hospital clinical course, arrest causes, and blood samples on admission for the favorable and unfavorable outcome groups. Results: Among the 135 patients included, 22 (16%) had a favorable neurological outcome. Low‐flow time was shorter (median 38 vs. 48 min, p < 0.001) in the favorable neurological outcome group; in multiple logistic analyses, low‐flow time was significantly associated with a favorable neurological outcome (odds ratio, 0.88; 95% confidence interval, 0.82–0.94). The area under the receiver‐operating characteristic curve of low‐flow time was 0.80 (95% confidence interval, 0.70–0.89), and the cut‐off value of 58 min corresponded to a sensitivity of 0.25 and a specificity of 1.0. Conclusions: In ECPR patients, low‐flow time was significantly associated with a favorable neurological outcome, and ECPR should be performed within 58 min of the low‐flow time.

Impact of extracorporeal cardiopulmonary resuscitation on outcomes of elderly patients who had out-of-hospital cardiac arrests: a single-centre retrospective analysis

Objectives Little is known about the effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for elderly patients who had out-of-hospital cardiac arrest (OHCA). The aim of this study was to examine the impact of age on outcomes among patients who had OHCA treated with ECPR. Design Single-centre retrospective cohort study. Setting A critical care centre that covers a population of approximately 1 million residents. Participants Patients who had consecutive OHCA aged ≥18 years who underwent ECPR from 2005 to 2013. Primary and secondary outcome measures Primary outcomes were 1 month neurologically favourable outcomes and survival. To determine the association between advanced age and each outcome, we fitted multivariable logistic regression models using: (1) age as a continuous variable and (2) age as a categorical variable (<50 years, 50–59 years, 60–69 years and ≥70 years). Results Overall, 144 patients who had OHCA who underwent ECPR were eligible for our analyses. The proportion of neurologically favourable outcomes was 7%, while survival was 19% in patients who had OHCA. After the adjustment for potential confounders, while advanced age was non-significantly associated with neurologically favourable outcomes (adjusted OR 0.96 (95% CI 0.91 to 1.01), p=0.08), the association between advanced age and the poor survival rate was significant (adjusted OR 0.96 (95% CI 0.93 to 0.99), p=0.04). Additionally, compared with age <50 years, age ≥70 years was non-significantly associated with poor neurological outcomes (adjusted OR 0.08 (95% CI 0.01 to 1.00), p=0.051), whereas age ≥70 years was significantly associated with worse survival in the adjusted model (adjusted OR 0.14 (95% CI 0.03 to 0.80), p=0.03). Conclusions In our analysis of consecutive OHCA data from a critical care hospital in an urban area of Japan, we found that advanced age was associated with the lower rate of 1-month survival in patients who had OHCA who underwent ECPR. Although larger studies are required to confirm these results, our findings suggest that ECPR may not be beneficial for patients who had OHCA aged ≥70 years.

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