Public-Access Defibrillation and Survival after Out-of-Hospital Cardiac Arrest

BACKGROUND The rate of survival after out-of-hospital cardiac arrest is low. It is not known whether this rate will increase if laypersons are trained to attempt defibrillation with the use of automated external defibrillators (AEDs). Full Text of Background... METHODS We conducted a prospective, community-based, multicenter clinical trial in which we randomly assigned community units (e.g., shopping malls and apartment complexes) to a structured and monitored emergency-response system involving lay volunteers trained in cardiopulmonary resuscitation (CPR) alone or in CPR and the use of AEDs. The primary outcome was survival to hospital discharge. Full Text of Methods... RESULTS More than 19,000 volunteer responders from 993 community units in 24 North American regions participated. The two study groups had similar unit and volunteer characteristics. Patients with treated out-of-hospital cardiac arrest in the two groups were similar in age (mean, 69.8 years), proportion of men (67 percent), rate of cardiac arrest in a public location (70 percent), and rate of witnessed cardiac arrest (72 percent). No inappropriate shocks were delivered. There were more survivors to hospital discharge in the units assigned to have volunteers trained in CPR plus the use of AEDs (30 survivors among 128 arrests) than there were in the units assigned to have volunteers trained only in CPR (15 among 107; P=0.03; relative risk, 2.0; 95 percent confidence interval, 1.07 to 3.77); there were only 2 survivors in residential complexes. Functional status at hospital discharge did not differ between the two groups. Full Text of Results... CONCLUSIONS Training and equipping volunteers to attempt early defibrillation within a structured response system can increase the number of survivors to hospital discharge after out-of-hospital cardiac arrest in public locations. Trained laypersons can use AEDs safely and effectively. Full Text of Discussion... Read the Full Article..

Comparative plasma catecholamine and hemodynamic responses to handgrip, cold pressor and supine bicycle exercise testing in normal subjects

Serial hemodynamic and plasma catecholamine responses were compared among 10 healthy men (27 ± 3 years) ( ± 1 standard deviation) during symptom-limited handgrip (33% maximal voluntary contraction for 4.4 ± 1.8 minutes), cold pressor testing (6 minutes) and symptom-limited supine bicycle exercise (22 ± 5 minutes). Plasma catecholamine concentrations were measured by radioenzymatic assays; ejection fraction and changes in cardiac volumes were assessed by equilibrium radionuclide angiography. During maximal supine exercise, plasma norepinephrine and epinephrine concentrations increased three to six times more than during either symptom-limited handgrip or cold pressor testing. Additionally, increases in heart rate, systolic blood pressure, rate-pressure product, stroke volume, ejection fraction and cardiac output were significantly greater during bicycle exercise than during the other two tests. A decrease in ejection fraction of 0.05 units or more was common in young normal subjects during the first 2 minutes of cold pressor testing (6 of 10 subjects) or at symptom-limited handgrip (3 of 10), but never occurred during maximal supine bicycle exercise.The magnitude of hemodynamic changes with maximal supine bicycle exercise was greater, more consistent and associated with much higher sympathetic nervous system activation, making this a potentially more useful diagnostic stress than either handgrip exercise or cold pressor testing

Public-Access Defibrillation and Survival After Out-of-Hospital Cardiac Arrest

Background The rate of survival after out-of-hospital cardiac arrest is low. It is not known whether this rate will increase if laypersons are trained to attempt defibrillation with the use of automated external defibrillators (AEDs). Methods We conducted a prospective, community-based, multicenter clinical trial in which we randomly assigned community units (e.g., shopping malls and apartment complexes) to a structured and monitored emergency-response system involving lay volunteers trained in cardiopulmonary resuscitation (CPR) alone or in CPR and the use of AEDs. The primary outcome was survival to hospital discharge. Results More than 19,000 volunteer responders from 993 community units in 24 North American regions participated. The two study groups had similar unit and volunteer characteristics. Patients with treated out-of-hospital cardiac arrest in the two groups were similar in age (mean, 69.8 years), proportion of men (67 percent), rate of cardiac arrest in a public location (70 percent), and rate of witnessed cardiac arrest (72 percent). No inappropriate shocks were delivered. There were more survivors to hospital discharge in the units assigned to have volunteers trained in CPR plus the use of AEDs (30 survivors among 128 arrests) than there were in the units assigned to have volunteers trained only in CPR (15 among 107; P=0.03; relative risk, 2.0; 95 percent confidence interval, 1.07 to 3.77); there were only 2 survivors in residential complexes. Functional status at hospital discharge did not differ between the two groups. Conclusions Training and equipping volunteers to attempt early defibrillation within a structured response system can increase the number of survivors to hospital discharge after out-of-hospital cardiac arrest in public locations. Trained laypersons can use AEDs safely and effectively

Pearls and perils of an implantable defibrillator trial using a common control: implications for the design of future studies

Abstract Aims Implantable defibrillators are considered life-saving therapy in heart failure (CHF) patients. Surprisingly, the recent Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) reached an opposing conclusion from that of numerous other trials about their survival benefit in patients with advanced CHF. A critical analysis of common control trial design may explain this paradoxical finding, with important implications for future studies. Methods and Results Common control trials compare several intervention groups to a single rather than separate control groups. Though potentially requiring fewer patients than trials using separate controls, variation in the common control group will influence all comparisons and creates correlations between findings. During subgroup analyses, this dependency of outcomes may increase belief in the presence of a real subgroup effect when, in fact, it should increase skepticism. For example, a high (r = 0.92), statistically unlikely (p = 0.052) correlation between comparisons was observed across the subgroups reported in SCD-HeFT. Such concordance between amiodarone and a defibrillator across subgroups was unexpected, given how much the effects of these treatments significantly differed from one another in the main study. This suggests the study's subgroup findings (specifically the absence of benefit from defibrillators in advanced CHF) were not necessarily a consequence of treatment; more likely, they resulted from variation in what the treatments were compared against, the common control. Conclusion Common control trials can be more efficient than other designs, but induce dependence between treatment comparisons and require cautious interpretation.</p

Superimposed hazard ratios for subgroups of patients treated with amiodarone or a defibrillator, compared to the common control in SCD-HeFT

The figure was created by superimposing the hazard ratios with confidence intervals reported in SCD-HeFT from the left portion of Figure 5 (depicting amiodarone versus placebo) upon those on the right (defibrillator therapy versus placebo) as shown in the circular inset (see text for specific construction). Dots with solid (or dashed) horizontal lines represent the hazard ratio and confidence intervals for the effect of treatment with a defibrillator (or amiodarone) versus the common control on outcome. The vertical dotted line represents the alignment of the hazard ratios for the topmost subgroup defined by each variable. Subgroups with discordant treatment effects are highlighted as green text. Abbreviations: ft = feet; LVEF = left ventricular ejection fraction. (Copyright 2005, Massachusetts Medical Society [5]. All rights reserved. Adapted with permission.).<p><b>Copyright information:</b></p><p>Taken from "Pearls and perils of an implantable defibrillator trial using a common control: implications for the design of future studies"</p><p>http://www.trialsjournal.com/content/9/1/24</p><p>Trials 2008;9():24-24.</p><p>Published online 2 May 2008</p><p>PMCID:PMC2397377.</p><p></p

Depiction of a trial using a common control design testing the same clinical question as one with 2 separate controls (shown in figure 1)

The corresponding study-wide alpha (α) and beta (β) calculations are depicted below the design. The designated relative samples sizes are those for maximum efficiency. In the common control design shown, the active treatments of amiodarone and a defibrillator are compared against a common control, which is administered an oral placebo. The most efficient allocation of patients to these treatments and the common control is in the ratio of 1:1:√2.<p><b>Copyright information:</b></p><p>Taken from "Pearls and perils of an implantable defibrillator trial using a common control: implications for the design of future studies"</p><p>http://www.trialsjournal.com/content/9/1/24</p><p>Trials 2008;9():24-24.</p><p>Published online 2 May 2008</p><p>PMCID:PMC2397377.</p><p></p

Influence of coronary bypass surgery on subsequent outcome of patients resuscitated from out of hospital cardiac arrest

AbstractThe effect of coronary bypass surgery on recurrent cardiac arrest was estimated in 265 patients resuscitated from out of hospital cardiac arrest between 1970 and 1988. From this cohort, 85 patients (32%) underwent coronary bypass surgery after recovery from cardiac arrest and 180 patients (68%) were treated medically. A multivariate Cox analysis was used to estimate the effect of coronary bypass surgery on subsequent survival after adjusting for effects of age, prior cardiac history, ejection fraction, year of the event, history of angina, antiarrhythmic drug use and whether the arrest was related to acute myocardial infarction.The use of coronary bypass surgery had a significant effect in reducing the incidence of subsequent cardiac arrest daring follow-up study (risk ratio [RR] 0.48, 95% confidence interval [CI] 0.24 to 0.97, p < 0.04). There was also a trend consistent with a reduction in total cardiac mortality (RR 0.65, 95% CI 0.39 to 1.10, p = 0.10). These findings suggest that coronary bypass surgery may reduce the incidence of sudden death in suitable patients resuscitated from an episode of ventricular fibrillation