Capital Do-Re-Mi: A Randomized Trial of Dobutamine Compared to Milrinone in Cardiogenic Shock

Cardiogenic shock (CS) is correlated with substantial morbidity and mortality. Even though a centrepiece of medical treatment is an inotropic support for CS, little evidence exists to lead the selection of inotropic agents in clinical practice. Mathew R, presented a study in a session at American Heart Association Scientific Sessions 2020: A Virtual Experience, which compared inotropic agents dobutamine and milrinone for cardiogenic shock. A double blind randomized controlled trial in which patients with SCAI class B to E shock were assigned to either milrinone or dobutamine for inotropic support. Treatment was titrated based on clinical, biochemical and hemodynamic response as analysed by the treating physician. The primary outcome included a combined endpoint of in hospital mortality, non-fatal MI, stroke, new initiation of renal replacement therapy (RRT), requirement for MCS or cardiac transplant, or cardiac arrest with successful resuscitation. Secondary outcomes were individual components of the primary outcome.

From 192 participants, 49% (47 of 96) of patients in the milrinone arm and 54% (52 of 96) patients in the dobutamine group (RR 0.90, 95% CI of 0.69-1.19, p-value = 0.47) showed no substantial difference in the primary outcome. Also no significant differences were seen in secondary outcomes among milrinone and dobutamine, including in-hospital mortality 37% (35 of 96) vs 43% (41 of 96) (RR 0.85, 95% CI 0.60-1.21, p-value = 0.38) or requirement for RRT 22% (21 of 96) vs 17% (16 of 96) (RR 1.31, 95% CI 0.73-2.36, p-value = 0.36).

No significant difference was shown in the primary composite outcome or in secondary outcomes in this randomized clinical trial of milrinone and dobutamine in CS. Inotropic agent selection could rationally be focused on physician comfort, cost and individual treatment response.


Mechanical, Team-focused, Video-Reviewed Cardiopulmonary Resuscitation Improves Trends in Survival to Discharge and Cardiac Arrest Performance Measures

Cardiac arrest patients of emergency department (ED) exhibited an enhancement in return of spontaneous circulation (ROSC) following implementing a bundle including mechanical, team-focused, video-reviewed cardiopulmonary resuscitation (MTV-CPR). Rolston D, presented in a session at American Heart Association Scientific Sessions 2020: A Virtual Experience, which analysed trends in cardiac arrest outcomes and enhancements in cardiac arrest execution estimates following the implementation of the MTV-CPR intervention. In 2018, ED initiated a new team-focused strategy; utilization of mechanical CPR with nurse guided ACLS; and biweekly video-review of cardiac arrests. The primary outcome of the study was to analyse the annual trend in survival to discharge from 2017 (the year prior to implementing MTV-CPR) via 2019. Secondary outcomes were ROSC and survival to admission. The Cochrane-Armitage test was incorporated to assess annual trends in outcomes over the 3-year study period. It was also sought to measure whether Wilcoxon rank sum and two-sample t-tests provided an increase in cardiac arrest performance measures over the two years of MTV-CPR intervention.

Across the 3-year study period, the groups were similar at baseline. 291 patients were enrolled in the study (96 in 2017, 96 in 2018, and 99 in 2019). Survival to discharge showed improvement from 3.1% in 2017 to 5.2% in 2018 to 10.1% in 2019 (p= 0.043); ROSC exhibited enhancement from 26% to 41.7% to 40.4% (p=0.038); survival to admission went from 19.8% to 25% to 29.3% however was not substantially different (p=0.124). Because of ultrasound, a substantial decrease was seen in time to bed transfer, rhythm determination, mechanical CPR placement, and duration of each chest compression interruption

Application of the MTV-CPR intervention showed enhanced trends in survival to discharge and ROSC in cardiac arrest patients, as well as developments in multiple cardiac arrest performance measures.


Lack of Racial Diversity in Cardiopulmonary Resuscitation Training Films: A Cross-sectional Analysis

Minorities are less likely to be CPR-trained, and less likely to obtain bystander CPR compared with whites. Blount C, presented in a session at American Heart Association Scientific Sessions 2020: A Virtual Experience, which hypothesized that modern CPR training films exhibit poor racial diversity and hence poor pertinence to minority communities.

350 and 500 films were reviewed using the query “how to do CPR” in Google and YouTube. Exclusion criteria were: pre-2015, non-English, non-instructional, paediatric or animal victims, duplicates, parity, or in-hospital cardiac arrest. For each film, 4 racially-diverse analysers recognised the race of the instructor, rescuer, victim, and manikin as “white” or “non-white.” Films were scored on the basis of 6 aspects of CPR instruction: scene safety, check responsiveness, activate Emergency Medical Services, proper hand position, precise rate, and relevant depth of compressions. Furthermore, the race of characters in CPR training films from the American Heart Association (AHA) and American Red Cross (ARC) were evaluated using one self-identified non-white evaluator.

Total 72 online films meeting with the criteria, 50 utilized a human instructor (76% white); 19 exhibited a human victim (84% white); 70 represented a human rescuer (74% white); and 58 attributed a manikin (95% white) (p<0.0001 for all, white v. non-white). Only 10 of 72 films (14%) instructed hands-only CPR, attributed at least one non-white character, and were of high-quality (>5 aspects of CPR instruction).  Increased level of inter-rater reliability was seen (>0.775). 7 ARC and 7 AHA adult CPR training films (2015 or later) were also reviewed. 4 of 7 AHA films (57%) and 2 of 7 ARC films (29%) attributed at least one non-white character.

Only 10 online high-quality films instructing hands-only CPR which attribute at least one non-white character were recognised. CPR instructional films deriving out of the AHA and ARC exhibited higher racial diversity. Enhanced racial representation is significant in CPR training films to elevate importance to under-trained minority communities.


Socioeconomically Equitable Public Defibrillator Placement Using Mathematical Optimization

Mathematical optimization can be utilized to put automated external defibrillators (AEDs) in locations that augment coverage of out-of-hospital cardiac arrests (OHCAs). However, the degree to which optimization strategies influence the socio-economic equal distribution of AEDs is unclear. Leung KHB, presented in a session at American Heart Association Scientific Sessions 2020: A Virtual Experience, which analysed the effect of socioeconomically equitable distribution of AEDs using mathematical optimization. In Scotland among Jan. 2011 – Sept. 2017, all suspected OHCAs and registered AEDs were incorporated with a recorded location and mapped over the quintiles of the Scottish Index of Multiple Deprivation (SIMD), a national estimate of socioeconomic status. Initially, AEDs were maintained at current locations and modeled placing an equal number of additional AEDs to augment “coverage” (i.e., AED located within 100 m) of suspected OHCAs. A second analysis generated optimal sites for relocating all existing AEDs to develop coverage without further AEDs. The proportion of OHCAs covered in each SIMD quintile under each AED placement strategy were estimated. A difference in coverage levels over all regions of Scotland was examined using a Wilcoxon signed-rank test.

49,692 suspected OHCAs and 1,532 AEDs were recognised. Existing AEDs enclosed 1,384 OHCAs (2.8%), with OHCA coverage peaking in quintile 3 (moderate deprivation), specifying a mismatch with the distribution of suspected OHCA. 10,465 OHCAs (21.1%; p<0.001) were covered by adding an equal number of new AEDs in optimal locations. 9,464 OHCAs (19.0%; p<0.001) were covered with optimal relocation of existing AEDs with no additional units. OHCA coverage receiving either optimization strategy peaked in quintile 1 (highest deprivation), ranging to the OHCA event distribution.

Developing AED placement showed substantial increase in OHCA coverage and superior ranges coverage with OHCA event over SIMD quintiles, enhancing socioeconomic equity of OHCA coverage. Similar coverage to doubling the number of devices could be accomplished by relocating existing AEDs.


Understanding Why Differences in the Provision of Bystander Cpr Exist for Women Versus Men: Does the Sex of the Rescuer Matter?

Women who endure an out of hospital cardiac arrest receive bystander cardiopulmonary resuscitation (bCPR) less frequently as compared to men. Shelton S, presented in a session at American Heart Association Scientific Sessions 2020: A Virtual Experience, which analysed if there were differences in prospective deterrents to arranging CPR if the rescuer was a man or a woman. Participants were surveyed through Amazon’s Mechanical Turk, a national crowdsourcing platform, to examine why women acquire less bCPR as compared to men based on the sex of the rescuer. The participants were asked to rank five themes previously recognised. Eligible participants were ≥18 years, US residents, and correctly described CPR. Participants were requested to rank the 5 following themes if the sex of the rescuer was unrecognised sex, male, and female: 1) Rescuers are anxious to injure or hurt women; 2) Rescuers might have a misunderstanding that women don’t endure cardiac arrest; 3) Rescuers are anxious to be charged with sexual assault or sexual harassment; 4) Rescuers have a concern of touching women or that the touch might be improper; 5) Rescuers anticipated that women are “faking it” or being “overdramatic.”

Total 576 participants were analysed, and 520 responses were formally examined. The respondents were 42.3% female, 74.2% Caucasian, 10.4% African American, and 6.7% Hispanic. A statistical model that having the mode of the rankings was used to analyse a “consensus” ranking, bringing separate results for each of the classes of rescuer. This procedure discovered that the modal ranking for respondents questioned about a female rescuer was Hurt/Injure, Touch, Overdramatic, Misconception, Sexual Assault/Harassment. By contrast, the modal ranking was found to be Touch, Sexual Assault/Harassment, Hurt/Injure, Misconception, Overdramatic when respondents were questioned about a male rescuer. The modal ranking was similar to that for the male rescuer question when the sex of the rescuer was not recognised.

A difference in response was seen based on the sex of the rescuer while examining the public as to why women acquire less-bystander CPR as compared to men. Participants demonstrated that a male rescuer would prospectively be inhibited by fears of accusation of sexual assault/harassment or improper touch, although female rescuers would be more discouraged because of fears of causing physical injury or harm.


Chest Molding in Extended Cardiopulmonary Resuscitation

Cardiopulmonary resuscitation (CPR) is an assertive method that may change features of the patient. Limited clinical data relating to applied forces and depth responses has been released, especially in increasingly prevalent extended CPR sessions. Russell JK, presented in a session at American Heart Association Scientific Sessions 2020: A Virtual Experience, which examined synchronous force and depth records to explore how chests mold work in the course of extended CPR.

Chest molding, featured as reduction in stiffness from its initial value, will elevate as CPR progresses. In out-of-hospital resuscitations attended by a single EMS agency (TVFR, Tigard, Oregon) in 2013 via 2017, force and acceleration signals were drawn from CPR monitors utilized in adult cases of continuous compression CPR. The depth and velocity were estimated from acceleration, and recognised chest compressions automatically where descending velocity crossed 25mm/s and force consequently surpassed 5 kg-f. Series were described as sequences without pauses surpassing 2 minutes. An initial series lasting at least 10 minutes was evaluated. Stiffness as force/depth at peak compression velocity was measured. A molding in 5 minute blocks of CPR was measured as 100*(1- stiffness block/stiffness minute 1), by medians as stiffness which was not evenly allocated. A Kruskal-Wallis ANOVA was used to examine dependence of molding on CPR duration. From 616 available cases, 478 showed initial CPR series >= 10 minutes’ duration, incorporating 997,254 compressions. 152 cases showed >= 30 minutes of initial CPR series duration, and 48 cases showed >= 40 minutes. 61 minutes was the longest initial series.

Chest molding enhanced firmly via the first 25 minutes of CPR, and elevated thereafter (p < 0.001). Median molding was 20% at >= 25 minutes. The implications of decreasing stiffness affirm additional examination.


Chest Compression Pause Duration is Associated with Worse Survival Outcomes Following Pediatric In-hospital Cardiac Arrest

Lauridsen KG, presented in a session at American Heart Association Scientific Sessions 2020: A Virtual Experience, which hypothesized that longer maximum duration of Chest Compression (CC) pauses was correlated with poorer survival and neurological outcomes.

This was a cohort review of all pediatric In-hospital Cardiac Arrest (IHCA) indexes (<18 years of age) ≥ 1 min in Pediatric Resuscitation Standard (PediRES-Q) from July 2015 to December 2019. Multivariate logistic regression with mixed effects and stable standard deviations was used to evaluate the relationship of 5-sec intervals of the longest length of CC pause with survival and neurological outcomes. Favourable neurological outcome was described as Pediatric Cerebral Performance Category (PCPC) at release ≤ 3 or no change from baseline. The IHCA index was 371: median [Q1,Q3] age 2.6 [0.6,9.4] years, female 46%, shock rhythm 13%, CPR period 23 [9.47] min. The median time of the longest pause was 17 [8.27] sec. Each 5 sec rise in the longest period of CC pause was correlated with 6% lower chances of survival with a favourable neurological outcome, even after age change, defibrillation, intubation, extracorporeal cardiopulmonary resuscitation (CPR), disease category, hypotension as arrest etiology, CC depth, and site clustering (aOR 0.94 [95% CI:0.88-0.99], p=0.04). Analysis controlling the same variables demonstrated the correlation of the longest period of delay with lower chances of survival to hospital discharge (aOR 0.94[95% CI: 0.90-0.99, p=0.02) and the return of spontaneous circulation (aOR 0.91 [(95% CI: 0.86-0.96], p=0.001).

Longest duration of CC pause is correlated with favourable neurological outcome, survival to hospital discharge, and restoration to spontaneous circulation after pediatric IHCA, even when controlling for established confounders and clustering by location. Each 5 sec. increase in the longest length of CC pause was correlated with a 6% decrease in survival with a favourable neurological outcome.


Disparities in Out of Hospital Cardiac Arrest Care and Outcomes in Texas

Huebinger R, presented in a session at American Heart Association Scientific Sessions 2020: A Virtual Experience, which analysed ethnic and socio-economic inequalities in Out of Hospital Cardiac Arrest Care (OHCA) treatment and results in Texas. There are variations in OHCA treatment and results in the census tract in Texas.

Texas-Cardiac Arrest Registry to Improve Survival (CARES) data from 13 emergency medical services (EMS) agencies delivering services in 15 counties to approximately 30% of the state population was examined. All adult (>=18year) OHCAs from 1/1/14 to 12/31/18 with complete details were included. Using census tract info, it was stratified that in-racial/ethnic census tract categories: >50% non-Hispanic/Latin white, >50% black and >50% Hispanic/Latin. It was stratified in communities above and below the median for socio-economic characteristics: household income, jobs and high school graduation. Results were described as spectator CPR rates, public spectator AED use, and hospital discharge survival. Using mixed models, the relation between outcomes and neighbourhood (1) racial/ethnic categories and (2) socioeconomic categories were studied. Data on 18,487 OHCAs from 1,727 census tracts is included. Relative to white neighbourhoods, black neighbourhoods had slightly lower rates of AED bystander use (OR 0.3, CI 0.1-0.9), and Latino neighbourhoods had lower rates of CPR bystander use (OR 0.7, CI0.6-0.8), AED bystander use (OR 0.4, CI 0.3-0.6) and hospital discharge survival (OR 0.9, CI 0.8-0.98). Lower income was correlated with a lower rate of CPR bystander (OR 0.8, CI 0.7-0.8), bystander use of AED (OR 0.5, 0.4-0.8), and hospital discharge survival (OR 0.6, CI 0.5-0.9). Lower high school graduation was associated with lower rates of CPR bystander (OR 0.8, CI 0.7-0.9) and AED bystander use (OR 0.6, CI 0.4-0.9). High unemployment was correlated with lower rates of CPR bystander (OR 0.9, CI 0.8-0.94) and AED bystander use (OR 0.7, CI 0.5-0.99).

Minority and poor communities face significant and unacceptable inequalities in the response and results of OHCA. These data provide a significant opportunity for focused resuscitation training and enhancement of quality.


Racial Disparities in Management and Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction

Subramaniam A, presented in a session at American Heart Association Scientific Sessions 2020: A Virtual Experience, which hypothesized that racial minorities, would have poorer results with Acute Myocardial Infarction-Cardiac Arrest (AMI-CA) relative to white patients. AMI admissions with concomitant diagnosis of CA were reported from the National Inpatient Sample during 2012-2017. Race has been categorized as white, black and others (Hispanic, Asian or Pacific Islander, Native American, Others). Racial disparities in in-hospital mortality were the primary outcome. Secondary results included racial disparities in invasive procedures and hospitalization characteristics. In the study period, 3,504,225 AMI admissions were reported, of which 182,750 (5.2%) were complicated by CA. 74.8% were white, 10.7% were black, and 14.5% were of other races. Black and other AMI-CA race admissions received unusual early coronary angiography (41.4% vs. 50.2% vs. 52.8%), coronary angiography (61.9% vs. 70.2% vs. 73.1%), percutaneous coronary intervention (PCI) (44.6% vs. 53.0% vs. 58.1%), coronary artery bypass graft surgery (CABG) and mechanical circulatory assistance relative to white and other races. The mean time to coronary angiography was the highest between blacks (3.4 ± 4.2 days) and the lowest among whites (3.0 ± 3.7 days). Black and other races had slightly higher unadjusted mortality, but in a multivariate logistic regression study with the white race referred, the black race was correlated with lower in-hospital mortality (OR 0.95 [95% CI 0.91-0.99]; p=0.007) while the other races had higher in-hospital mortality (OR 1.11 [95% CI 1.08-1.15]; p<0.001) relative to the white race. AMI-CA admissions to the black community had longer hospital stays, higher rates of palliative care, less regular use of Do-Not-Resuscitate (DNR) status, and less discharges to the home. Admissions of other races had higher DNR status and higher hospitalization costs relative to whites and blacks.

Significant ethnic differences occur in in-hospital mortality between CA-complicated AMI admissions. Further quantitative and qualitative research on the equal treatment of racial minorities with AMI-CA is required to resolve this gap.


Survival after Out-of-hospital Cardiac Arrest: The Role of Urban-rural Residence and Demographic Factors

Abbott EE, presented in a session at American Heart Association Scientific Sessions 2020: A Virtual Experience which examined the relationship between urban-rural residential county designation and post-OHCA survival to assess whether the ethnic makeup of county and community health metrics lead to better OHCA outcomes.

Using age-eligible Medicare fee-for-service claims data from January 2013 to December 2014, reported OHCA patients with ICD-9-CM diagnosis code 427.5 and determined release survival and 30 days. Additional data sources included the 2013 National Center for Health Statistics (NCHS) urban-rural classification, US Census data and County Health Rankings. Mixed logistic regression was used to assess the relationship of OHCA and NCHS categorized residence outcomes for age, sex and ethnicity, county ethnic composition, poverty level, and community health initiatives. 256,107 cases of OHCA were found with an average age of 78.7 (SD 8.5) years, 22.8% non-white, 47.5% female. Overall release survival was 21.8 % and 30-day survival was 15.1 %. Patients living in the most rural areas had an improved probability of initial survival (aOR1.1, CI 1.0-1.1), but were correlated with lower survival at 30 days (aOR 0.9, CI 0.8-0.9). The non-white race of patients living in the majority of non-white counties was correlated with a substantial decrease in the probability of survival at 30 days (7% and 11% respectively).

Among recipients of Medicare, release survival after OHCA was higher if they lived in a non-urban region but did not continue for 30 days. OHCA patients living in the majority of non-white counties were slightly less likely to survive initial hospitalization and 30 days after discharge. Further research is required to elucidate these inequalities and to assess if there are modifiable health factors at the county level that could lead to the improvement of OHCA survival.


Telephone-assisted Cardiopulmonary Resuscitation May Overcome Ethnic and Age Variation Observed in Bystander CPR

Blewer AL, presented in a session at American Heart Association Scientific Sessions 2020: A Virtual Experience, which determines whether the provision of Telephone-assisted Cardiopulmonary Resuscitation (T-CPR) could result in racial, gender and age differences seen in the B-CPR. It was believed that the provision of T-CPR would increase the Bystander CPR (B-CPR) and reduce ethnic differences.

A retrospective analysis of adult, non-traumatic out-of-hospital cardiac arrest (OHCA) from the Singapore Registry (4/2010-12/2016) was performed. Variation in B-CPR by race, gender and older age, stratified by receipt of T-CPR, was measured. Differences using descriptive statistics and multivariable logistic regression accounting for confounding have been investigated. From 2010 to 2016, the Singapore register comprised 12,546 OHCA cases. Excluding trauma, EMS and medical facility arrests, 7,997 incidents were analysed. Of these the average age was 66±19 and 65% were male. B-CPR was administered in 53% of the occurrences, while T-CPR was administered in 30% of the occurrences. In a univariate study, female gender was correlated with variance in B-CPR if T-CPR was not given (F: 29 % vs M: 35 %, p<0.01) and the provision of T-CPR decreased this variation (p=0.17), but this correlation was not observed in a multivariate logistic regression. When correcting for uncertainty, ethnicity was correlated with variance in B-CPR if T-CPR was not given (p<0.01), whereas the provision of T-CPR decreased this variation (p=0.50). In addition, increased older age was correlated with a decreased probability of B-CPR if T-CPR was not given (OR: 0.99 (0.98-0.99), p<0.01), but this variation was not observed with the provision of T-CPR (p=0.50).

T-CPR changed the identified differences in B-CPR seen in ethnicity and increased age, but did not change the differences seen in gender when correcting for other covariates. These results can help inform public policy and methods to reduce variance and increase B-CPR.


Time for a Change: Use of Doppler Ultrasound for Pulse Checks in Cardiac Arrest Patients

Cohen A, presented in a session at American Heart Association Scientific Sessions 2020: A Virtual Experience, which hypothesized that the Doppler ultrasound obtained by the pulse, is more reliable than manual palpation for arterial pulse detection in CA patients.

This was a prospective retrospective study of non-traumatic CA patients at North Shore University Hospital. During the pulse search, both the femoral Doppler waveform and the manual femoral pulse were recorded simultaneously. These values were compared to the waveform of the arterial line, which acted as the gold standard. The presence or absence of a pulse, as well as the arterial line measurement, was recorded during each pulse check. The sensitivity, precision and accuracy of the manual palpation and the Doppler ultrasound determination of the presence of the pulse were measured. A total of 23 patients have been registered. The sensitivity of the Doppler ultrasound pulse detection was 0.82 (95% CI: 0.72, 0.93) with a specificity of 1.00 (95% CI: 1.00, 1.00) and a precision of 0.88 (95% CI: 0.78, 0.94). The sensitivity and precision of the manual pulse palpation was 0.27 (95% CI: 0.15, 0.40) and 0.90 (95% CI: 0.78, 1.00), respectively, with an accuracy of 0.46 (95% CI: 0.34, 0.58).

Assessing the existence of pulse in the management of cardiac arrest patients is a crucial phase in the Advanced Cardiovascular Life Support algorithm. These preliminary findings indicate that Doppler ultrasound has a higher sensitivity and specificity for pulse detection in CA patients and highlights the inaccuracy of manual pulse palpation. These preliminary results may lead to a shift in the practice of pulse tests, which would favour the use of Doppler ultrasound. Further data is required to determine which readings of blood pressure are compatible with perfusable rhythm.