Admission predictors of in-hospital mortality and subsequent long-term outcome in survivors of ventricular fibrillation out-of-hospital cardiac arrest: a population-based study.
BACKGROUND
Survival following out-of-hospital cardiac arrest (OHCA) from ventricular fibrillation (VF) is poor and dependent on a rapid emergency response system. Improvements in emergent early response have resulted in a higher percentage of patients surviving to admission. However, the admission variables that predict both short- and long-term survival in a region with high discharge survival following OHCA require further study in order to identify survivors at subsequent highest risk.


METHODS
All patients with OHCA arrest in Olmsted County Minnesota between 1990 and 2000 who received defibrillation of VF by emergency services were included in the population-based study. Baseline patient admission characteristics in survivor and nonsurvivor groups were compared. Survivors to hospital discharge were prospectively followed to determine long-term survival.


RESULTS
Two hundred patients suffered a VF arrest. Of these patients, 145 (73%) survived to hospital admission (7 died within the emergency department) and 79 (40%) were subsequently discharged. Sixty-six (83%) were male, with an average age of 61.9 +/- 15.9 years. Univariate predictors of in-hospital mortality included call-to-shock time (6.6 vs. 5.5 min, p = 0.002), a nonwitnessed arrest (75.4 vs. 92.4%, p = 0.008), in-field use of epinephrine (27.8 vs. 93.4%, p < 0.001), age (68.1 vs. 61.9 years, p = 0.017), hypertension (36.1 vs. 14.1%, p = 0.005), ejection fraction (32.4 vs. 42.4, p = 0.012), and use of digoxin (34.9 vs. 12.7%, p = 0.002). Of all these variables, hypertension [hazard ratio (HR) 4.0, 95% CI 1.1-14.1, p = 0.03], digoxin use (HR 4.5, 95% CI 1.3-15.6, p = 0.02), and epinephrine requirement (HR 62.0, 95% CI 15.1-254.8, p < 0.001) were multivariate predictors of in-hospital mortality. Nineteen patients (24%) had died prior to the survey follow-up. Five patients experienced a cardiac death, resulting in a 5-year expected cardiac survival of 92%. Multivariate variables predictive of long-term mortality include digoxin use (HR 3.02, 95% CI 1.80-5.06, p < 0.001), hypertension (HR 2.06, 95% CI 2.12-3.45, p = 0.006), and call-to-shock time (HR 1.18, 95% CI 1.01-1.38, p = 0.038).


CONCLUSIONS
A combined police/fire/EMS defibrillation program has resulted in an increase of patients surviving to hospital admission after OHCA. This study confirms the need to decrease call-to-shock times, which influence both in-hospital and long-term mortality. This study also identifies the novel demographic variables of digoxin and hypertension, which were also independent risk factors of increased in-hospital and long-term mortality. Identification of these variables may provide utility in identifying those at high-risk of subsequent mortality after resuscitation.
Department of Internal Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
Thomas J
TJ
Bunch
Colin P
CP
West
Douglas L
DL
Packer
Michael S
MS
Panutich
Roger D
RD
White
D000368:Aged; D000369:Aged, 80 and over; D000889:Anti-Arrhythmia Agents / Q000008:administration & dosage; D004077:Digoxin / Q000008:administration & dosage; D004554:Electric Countershock; D004632:Emergency Medical Services; D005260:Female; D006323:Heart Arrest / Q000209:etiology / Q000401:mortality* / Q000628:therapy; D017052:Hospital Mortality; D006801:Humans; D006973:Hypertension / Q000150:complications; D008297:Male; D008875:Middle Aged; D010343:Patient Admission; D011237:Predictive Value of Tests; D012107:Research Design; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome; D014693:Ventricular Fibrillation / Q000150:complications / Q000401:mortality* / Q000628:therapy
D000889:Anti-Arrhythmia Agents; D004077:Digoxin