Specialized ‘cardiac arrest center’ does not improve survival after resuscitation: ARREST
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Key takeaways:
- Ambulances should take cardiac arrest patients not experiencing MI to their nearest emergency department.
- There was no 30-day survival difference between patients transferred to the ED vs. a specialized center.
Adults in the U.K. quickly transferred to a specialized cardiac arrest center after resuscitated cardiac arrest were no less likely to die at 30 days than patients transferred to their closest ED, researchers reported.
Early bystander CPR, early defibrillation and advanced in-hospital care all improve survival after a sudden cardiac arrest, yet only about 10% of patients with out-of-hospital cardiac arrest survive to leave the hospital, Simon R. Redwood, MBBS, MD, FRCP, FACC, FSCAI, professor of interventional cardiology, honorary consultant cardiologist and director of the cardiac cath labs at Guy’s and St Thomas’ NHS Foundation Trust, said during a press conference at the European Society of Cardiology Congress. Researchers have proposed the concept of a “cardiac arrest center” as a way of improving those outcomes, Redwood said, with acute cardiac care including a 24/7 cath lab, advanced critical care, neuro-prognostication and rehab.
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“There are overwhelming registry data to suggest that these cardiac arrest centers improve outcomes,” Redwood said during the press conference. “In fact, if you look at the nonrandomized registry data, there is a 30% absolute difference in mortality.”
Because of those data, officials with the International Liaison Committee on Resuscitation called for a randomized trial to generate more robust evidence, Redwood said.
30-day mortality data similar
For the ARREST study, Redwood, Tiffany Patterson, PhD, and colleagues analyzed data from 862 adults who experienced return of spontaneous circulation after out-of-hospital cardiac arrest without a confirmed MI on ECG from 2018 to 2022. The mean age of patients was 63 years; 32% were women and 50% had symptoms before their cardiac arrest. London Ambulance Service staff randomly assigned patients at the scene of their cardiac arrest to expedited delivery to the cardiac catheter laboratory at one of seven cardiac arrest centers in London or standard of care, with delivery to the geographically closest ED at one of 32 London hospitals. Masking of the ambulance staff who delivered the interventions and those reporting treatment outcomes in hospital was not possible.
The primary outcome was all-cause mortality at 30 days, with safety outcomes (neurological) analyzed in the intention-to-treat population.
The findings were simultaneously published in The Lancet.
Redwood noted that 20 participants withdrew from the cardiac arrest center group and 19 withdrew from the standard care group due to lack of consent or unknown mortality status, leaving 411 participants in the cardiac arrest center group and 412 in the standard care group for the primary analysis.
Among 822 participants with available data, the primary endpoint of 30-day mortality occurred in 63% of participants in the cardiac arrest center group and 63% in the standard care group (unadjusted RR for survival = 1; 95% CI, 0.9-1.11; P = .96).
Neurological outcomes were similar in both groups at discharge and 3 months; 2% of patients in the cardiac arrest center group and 1% of patients in the standard care group experienced serious adverse events, none of which were deemed related to the intervention, Redwood said.
“This study does not support transportation of cardiac arrest patients direct to a cardiac arrest center in London; they should go to their nearest emergency department,” Redwood said. “These results may allow better allocation of resources elsewhere.”
Greater ‘focus on the basics’ needed
In a related editorial published in The Lancet, Carolina Malta Hansen, MD, of the division of cardiology at Copenhagen University in Denmark, and colleagues wrote that prioritizing a minimum standard of care at local hospitals caring for people who experience out-of-hospital cardiac arrest is at least as important as ensuring high-quality care or advanced treatment at tertiary centers.
“How hospital care and follow-up can improve recovery is another important area to study,” Malta Hansen and colleagues wrote. “This trial also calls for more focus on the basics, including efforts to increase bystander cardiopulmonary resuscitation and early defibrillation, aspects of care that are currently being assessed in two ongoing clinical trials and are most strongly associated with improved survival, when coupled with high-quality prehospital care with trained staff and short response times.”
References:
- Hansen CM, et al. Lancet. 2023;doi:10.1016/S0140-6736(23)01560-x.
- Patterson T, et al. Lancet. 2023;doi:10.1016/S0140-6736(23)01351-x.
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Patterson T, et al. Hot line 5. Presented at: European Society of Cardiology Congress; Aug. 25-28, 2023; Amsterdam (hybrid meeting).
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