低い目標体温もしくは冷却期間の延長は心停止後の昏睡状態の患者の予後を改善するか？

広島大学(Hiroshima University)博士(医学)Doctor of Philosophy in Medical Sciencedoctora

Usefulness of brain natriuretic peptide for predicting left atrial appendage thrombus in patients with unanticoagulated nonvalvular persistent atrial fibrillation

AbstractBackgroundThe CHADS2 scoring system is simple and widely accepted for predicting thromboembolism in patients with nonvalvular atrial fibrillation (NVAF). Although congestive heart failure (CHF) is a component of the CHADS2 score, the definition of CHF remains unclear. We previously reported that the presence of CHF was a strong predictor of left atrial appendage (LAA) thrombus. Therefore, the present study aimed to elucidate the relationship between LAA thrombus and the brain natriuretic peptide (BNP) level in patients with unanticoagulated NVAF.MethodsThe study included 524 consecutive patients with NVAF who had undergone transesophageal echocardiography to detect intracardiac thrombus before cardioversion between January 2006 and December 2008, at Hiroshima City Asa Hospital. The exclusion criteria were as follows: paroxysmal atrial fibrillation, unknown BNP levels, prothrombin time international normalized ratio ≥2.0, and hospitalization for systemic thromboembolism.ResultsReceiver operating characteristic analysis yielded optimal plasma BNP cut-off levels of 157.1pg/mL (area under the curve, 0.91; p<0.01) and 251.2pg/mL (area under the curve, 0.70; p<0.01) for identifying CHF and detecting LAA thrombus, respectively. Multivariate analyses demonstrated that a BNP level >251.2pg/mL was an independent predictor of LAA thrombus (odds ratio, 3.51; 95% confidence interval, 1.08–10.7; p=0.046).ConclusionsIn patients with unanticoagulated NVAF, a BNP level >251.2pg/mL may be helpful for predicting the incidence of LAA thrombus and may be used as a surrogate marker of CHF. The BNP level is clinically useful for the risk stratification of systemic thromboembolism in patients with unanticoagulated NVAF

Predictors of favourable outcome after in-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation: A systematic review and meta-analysis

Aims To identify the predictors of survival to discharge in adults resuscitated with extracorporeal cardiopulmonary resuscitation (ECPR) following in-hospital cardiac arrest (IHCA). Methods MEDLINE and ISI Web of Science were searched for eligible studies. Pooled Odds Ratio (OR) and Pooled Mean Difference (PMD) for each predictor were calculated. The quality of evidence (QOE) was evaluated according to the GRADE guidelines. Results Eleven studies were included totalling 856 patients. Of these, 324 (37.9%) survived to discharge. Good neurological outcome (Cerebral Performance Category 1 or 2) occurred in 222/263 (84.4%) survivors. Survival was associated with significantly higher odds of an initial shockable rhythm (OR 1.65; 95% confidence interval [95%CI] 1.05\ue2\u80\u932.61; p = 0.03), shorter low-flow time (PMD \ue2\u88\u9217.15 [\ue2\u88\u9220.90, \ue2\u88\u9213.40] min; p < 0.00001), lower lactate levels both immediately before ECPR start (PMD \ue2\u88\u924.12 [\ue2\u88\u926.0,\ue2\u88\u922.24] mmol/L; p < 0.0001) and on ICU admission (PMD \ue2\u88\u924.13 [\ue2\u88\u926.38, \ue2\u88\u921.88] mmol/L; p < 0.0003), lower SOFA score (PMD \ue2\u88\u921.71 [\ue2\u88\u922.93, \ue2\u88\u920.50]; p = 0.006) and lower creatinine levels within 24 h after ICU admission (PMD \ue2\u88\u920.37 [\ue2\u88\u920.54, \ue2\u88\u920.19] mg/dl; p < 0.00001). No significant association was found between survival and age, gender, or cardiac vs. non-cardiac aetiology. The overall QOE was low or very low. Conclusions In adult IHCA treated with ECPR a shockable initial rhythm, a lower low-flow time, lower blood lactate levels before ECPR start or on ICU admission, and a lower SOFA score or creatinine levels in the first 24 h after ICU admission were associated with a higher likelihood of survival. These factors could help identifying patients who are eligible for ECPR