Zachary D. Goldberger

Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study

BACKGROUND During in-hospital cardiac arrests, how long resuscitation attempts should be continued before termination of efforts is unknown. We investigated whether duration of resuscitation attempts varies between hospitals and whether patients at hospitals that attempt resuscitation for longer have higher survival rates than do those at hospitals with shorter durations of resuscitation efforts. METHODS Between 2000 and 2008, we identified 64,339 patients with cardiac arrests at 435 US hospitals within the Get With The Guidelines—Resuscitation registry. For each hospital, we calculated the median duration of resuscitation before termination of efforts in non-survivors as a measure of the hospitals overall tendency for longer attempts. We used multilevel regression models to assess the association between the length of resuscitation attempts and risk-adjusted survival. Our primary endpoints were immediate survival with return of spontaneous circulation during cardiac arrest and survival to hospital discharge. FINDINGS 31,198 of 64,339 (48·5%) patients achieved return of spontaneous circulation and 9912 (15·4%) survived to discharge. For patients achieving return of spontaneous circulation, the median duration of resuscitation was 12 min (IQR 6-21) compared with 20 min (14-30) for non-survivors. Compared with patients at hospitals in the quartile with the shortest median resuscitation attempts in non-survivors (16 min [IQR 15-17]), those at hospitals in the quartile with the longest attempts (25 min [25-28]) had a higher likelihood of return of spontaneous circulation (adjusted risk ratio 1·12, 95% CI 1·06-1·18; p<0·0001) and survival to discharge (1·12, 1·02-1·23; 0·021). INTERPRETATION Duration of resuscitation attempts varies between hospitals. Although we cannot define an optimum duration for resuscitation attempts on the basis of these observational data, our findings suggest that efforts to systematically increase the duration of resuscitation could improve survival in this high-risk population. FUNDING American Heart Association, Robert Wood Johnson Foundation Clinical Scholars Program, and the National Institutes of Health.

Are changes in carotid intima-media thickness related to risk of nonfatal myocardial infarction? A critical review and meta-regression analysis

BACKGROUND Carotid intima-media thickness (CIMT) is increasingly being used as a surrogate end point in randomized control trials (RCTs) of novel cardiovascular therapies. However, it remains unclear whether changes in CIMT that result from these therapies correlate with nonfatal myocardial infarction (MI). METHODS We performed a literature search of RCTs from 1990-2009 that used CIMT. Eligible RCTs (1) included quantitative and sequential assessments in CIMT at least 1 year apart and (2) reported nonfatal MI. Across RCTs, random-effects metaregression was employed to correlate differences in mean change in CIMT between treatment and control groups over time with the log odds ratios of developing nonfatal MI during follow-up. RESULTS Overall, we identified 28 RCTs with 15,598 patients. Differences in mean change in CIMT over time between treatment and control groups correlated with developing nonfatal MI during follow-up: for each 0.01 mm per year smaller rate of change in CIMT, the odds ratio for MI was 0.82 (95% CI, 0.69 to 0.96; P = .018). Results were similar in subgroups of RCTs with >1 year follow-up (P = .018) and those with at least 50 subjects in the treatment group (P = .019). However, there was no significant relationship between mean change in CIMT and nonfatal MI in RCTs evaluating statin therapy or those with high CIMTs at baseline (P > .20 in both instances). CONCLUSIONS Less progression in CIMT over time is associated with a lower likelihood of nonfatal MI in selected RCTs; however, these findings were inconsistent at times, suggesting caution in using CIMT as a surrogate end point.

Therapeutic Ranges of Serum Digoxin Concentrations in Patients With Heart Failure

Evidence-based medicine is an evolutionary process, intended to foster and disseminate the best practice guidelines from an ongoing critical analysis of available data. An underaddressed challenge relates to detecting and correcting delays where the evidence supports, but fails to effect, a timely change in practice. An example pertains to serum digoxin concentrations (SDCs) in the treatment of chronic heart failure (HF) because (1) the widely disseminated and used “therapeutic” SDCs for treating HF are not consistently aligned with considerably lower evidence-based values and (2) this discrepancy—a variant of the “clinical inertia” syndrome—may lead to unnecessary exposure of patients to potentially life-threatening toxicities.

Registries to measure and improve outcomes after cardiac arrest.

Purpose of reviewCardiac arrest registries are used to measure and improve the process and outcome of resuscitation care, and can give insight into risk factors, prognosis, and the effectiveness of interventions to mitigate its impact. This review provides an overview of current out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA) registries, with attention to key recent findings and future directions. Recent findingsMajor OHCA registries include the Resuscitation Outcomes Consortium Cardiac Arrest Epistry and Cardiac Arrest Registry to Enhance Survival. Registry data from IHCA largely stem from the US and Canada with Get with the Guidelines-Resuscitation, and the UK with the National Cardiac Arrest Audit. Each registry has strengths and limitations. Important findings include trends in survival, racial disparities in care, and hospital and community-level variations in performance, as well as estimates of the effectiveness of individual interventions. Utstein definitions facilitate uniform reporting of the process and outcome of care, and are currently being updated. Standardization of registry data is an ongoing challenge. SummaryOHCA and IHCA registries are invaluable in advancing our understanding of resuscitation care, as well as variations in international practice. Investigations that compare and contrast outcomes from established and evolving registries will help advance resuscitation science further.

Variations on a theme

A 57-year-old man presented to the emergency department with a 2-week history of progressive dyspnea on exertion, edema of the legs, a nonproductive cough, and scant hemoptysis. He also reported occasional passage of bright red blood from his rectum and intermittent nausea and vomiting during the previous 4 days.

Carotid Intima-Media Thickness as a Surrogate Endpoint

We read with great interest the recently published meta-analysis by Costanzo et al. ([1][1]) investigating whether changes in carotid intima-media thickness (CIMT) affect major cardiovascular endpoints, including cardiovascular-related and all-cause mortality. The study was carefully executed and

Three's Company: An Unusual Clue

D O ous p ugg urs w the n t and c ni and e with o ent w aus c c itive p ona has a s ade. H a or c of c diog right v pir and m mp ssoc dia ( limb l elect varia ed in c (2:1) p a P l RESENTATION his case illustrates how a unique ECG pattern provide nusual clue to the diagnosis in a febrile patient. The p as a 30-year-old African woman who presented to mergency department after suffering 7 days of intermit evers, night sweats, increasing shortness of breath, alaise. She had a sharp, nonradiating chest pain w ying supine, and when she swallowed, she experien onspecific chest discomfort that created a sensation ullness. She denied recent weight loss. Other than nfant daughter, who had had a runny nose 2 weeks e he reported no close sick contacts. The patient, who had immigrated to the United S rom Kenya 12 years previously, worked in homeless ers as a social worker. She had received the B almette Guerin vaccination as a child, and she de xposures to tuberculosis. She reported having a posi urified protein derivative (PPD) tuberculin test in the ut she had not completed treatment for latent tubercul er medications included omeprazole and acetaminoph therwise, her medical history was unremarkable.

A lifetime in the making

Udhay Krishnan, MD Vikas I. Parekh, MD Phuc Nguyen, MD Sara A. Bowling, BA Sanjay Saint, MD, MPH Zachary D. Goldberger, MD Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan. Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, Michigan. 3 VA Health Services Research and Development Center for Excellence and Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan.