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Emphasis on chest compressions improved survival in nonshockable cardiac arrest patients
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Use of guidelines-based CPR that focus on chest compressions appeared to improve short- and long-term survival in patients with out-of-hospital cardiac arrest who will not benefit from a defibrillator shock, recent data suggest.
In 2005, the American Heart Association updated its guidelines to recommend more chest compressions with fewer interruptions — a change that continued in the 2010 guidelines.
Peter J. Kudenchuk, MD, professor of medicine at the University of Washington, and colleagues performed a retrospective cohort study of 3,960 patients with nontraumatic out-of-hospital cardiac arrest resulting from an initial nonshockable rhythm treated by emergency medical service providers from King County, Washington throughout a 10-year period. They compared survival rates of a 5-year control period during which the 2000 AHA guidelines for CPR were used with those from a 5-year intervention period during which the 2005 guidelines prioritizing chest compressions were used.
From the control period to the intervention period, 1-month survival improved from 4.1% to 6.2% and 1-year survival from 2.7% to 4.9%. Similarly, researchers found increases in hospital discharge (4.6% vs. 6.8%) and return of spontaneous circulation (27% vs. 34%), as well as more favorable neurological outcomes (3.4% vs. 5.1%).
After adjustment for potential confounders, results linked the intervention period with improved ORs of:
- 1.5 (95% CI, 1.29-1.74) for return of spontaneous circulation;
- 1.53 (95% CI, 1.14-2.05) for hospital survival;
- 1.56 (95% CI, 1.11-2.18) for favorable neurological status;
- 1.54 (95% CI, 1.14-2.1) for 1-month survival; and
- 1.85 (95% CI, 1.29-2.66) for 1-year survival.
“Now, for the first time, we have seen a treatment that improves survival specifically in [patients who experience out-of-hospital cardiac arrest],” Kudenchuk said in a press release. “And that treatment is simply providing the more intense, quality CPR recommended in the new guidelines. You could save 2,500 more lives each year in North America alone by implementing these changes.”
Perspective
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Andrew E. Epstein, MD
Out-of-hospital cardiac arrest (OHCA) survival from shockable arrhythmias (ventricular tachycardia and ventricular fibrillation) can be improved by implementing American Heart Association resuscitation guideline changes that include increasing the proportion of time devoted to chest compression relative to ventilation, eliminating "stacked" shocks, doubling the time between rhythm evaluations and de-emphasizing mouth-to-mouth breathing. However, nonshockable rhythms are now the predominant presentation of OHCA and portend a poor prognosis, and the optimal management strategy for these rhythms has been uncertain. This paper shows that despite worse outcomes for these patients compared to those with shockable rhythms, the application of CPR using current guidelines actually benefits OHCA victims with nonshockable rhythms affording a >50% improved chance for hospital survival with favorable neurological status, and an 85% greater chance for 1-year survival compared to historical controls. These observations should provide reassurance that CPR, regardless of the rhythm at presentation, should be applied and that the simple presence of a nonshockable rhythm should not preclude attempts for resuscitation focusing on chest compression.
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