Indirect factors worsened survival of out-of-hospital cardiac arrest during pandemic
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Key takeaways:
- Out-of-hospital cardiac arrests rose 19% during the COVID-19 pandemic.
- Pandemic-related changes in response and care, not COVID-19 itself, likely impacted patient deaths.
Out-of-hospital cardiac arrests rose by 19% during the COVID-19 pandemic in King County, Washington, yet data suggest pandemic-related changes in emergency medical services response and care — not the virus itself — affected survival.
Little is known about how COVID-19 affected out-of-hospital cardiac arrest incidence and outcomes and the increase in out-of-hospital cardiac arrest incidence may be directly attributed to complications of SARS-CoV-2 infection, Jennifer Z. Liu, MPH, of the emergency medical services (EMS) division of Public Health-Seattle & King County, and colleagues wrote in the study background.
Alternatively, the pandemic may affect out-of-hospital cardiac arrest incidence via indirect factors, such as people delaying preventive care or SARS-CoV-2 infection rendering patients with out-of-hospital cardiac arrest more refractory to treatment.
“Alternatively, the pandemic may have produced more generalized challenges independent of patient-specific infection, such as altering societal behaviors or clinical practice, thereby changing out-of-hospital cardiac arrest circumstances or hindering rescuer efforts,” Liu and colleagues wrote in JAMA Network Open. “A better understanding of the potential factors by which COVID-19 may have influenced out-of-hospital cardiac arrest incidence and patient outcomes has important implications for how to best prevent and treat pandemic-related health challenges, specifically out-of-hospital cardiac arrest.”
In a retrospective study conducted in Seattle and King County, Washington, Liu and colleagues analyzed data from 13,081 adults with a nontraumatic out-of-hospital cardiac arrest attended by EMS from 2018 to 2021. The primary outcomes were out-of-hospital cardiac arrest incidence and survival to hospital discharge. Researchers used mediation analysis to determine the percentage change in out-of-hospital cardiac arrest incidence and outcomes between pre-pandemic and pandemic periods that was attributable to acute SARS-CoV-2 infection vs. conventional circumstances and resuscitation care (bystander CPR, early defibrillation and EMS response intervals).
Within the cohort, 5,979 adults were alive when treated by EMS. Among the EMS-treated patients, the median age was 64 years; 64.6% were men and 17.2% survived to hospital discharge.
Patients with out-of-hospital cardiac arrest increased by 19%, from 5,963 during the prepandemic period to 7,118 during the pandemic period, corresponding to an incidence increase from 168.8 per 100,000 person-years to 195.3 events per 100,000 person-years.
Among the EMS-treated patients during the pandemic period, 6.2% were acutely infected with SARS-CoV-2, compared with 3.7% of EMS-attended but untreated patients.
Using a time-series correlation analysis, researchers observed a positive correlation between community SARS-CoV-2 incidence and overall out-of-hospital cardiac arrest incidence (r = 0.27; P = .01), as well as out-of-hospital cardiac arrest incidence with acute SARS-CoV-2 infection (r = 0.43; P < .001).
The survival rate during the pandemic period was lower than that in the pre-pandemic period (15.4% vs. 19.2%). During the pandemic, among those with out-of-hospital cardiac arrest, those with acute SARS-CoV-2 infection had lower likelihood of survival compared with those without acute infection (6.2% vs. 16%). SARS-CoV-2 infection itself accounted for 18.5% of the pandemic survival decline, whereas Utstein Formula for Survival elements mediated 68.2% of the survival decline, according to researchers. The Utstein Formula for Survival is widely recognized as a way of predicting survival from sudden cardiac arrest, employing three elements in hypothesizing potential survival rates: medical science, educational efficiency and local implementation.
“Out-of-hospital cardiac arrest survival was poorer during the pandemic years, largely owing to changes in systemwide Utstein characteristics, as opposed to patient-specific acute SARS-CoV-2 infection,” the researchers wrote. “Overall, the findings underscore the adverse public health consequences from indirect, sometimes unanticipated, effects of the pandemic.”
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