We searched the Cochrane Library, MEDLINE, PubMed, and Embase for articles published in English only using a combination of the search terms “out-of-hospital cardiac arrest”, “sudden cardiac death”, “Utstein”, “bystander cardiopulmonary resuscitation”, “dispatcher-assisted cardiopulmonary resuscitation”, “emergency medical services”, “automated external defibrillator”, “ST-segment elevation”, “chain of survival”, “layperson”, “socio-economic status”, “Charlson Comorbidity Index”, “shockable
SeriesOut-of-hospital cardiac arrest: current concepts
Introduction
Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality worldwide.1, 2 It is defined as the loss of functional cardiac mechanical activity in association with an absence of systemic circulation, occurring outside of a hospital setting. The exact burden of OHCA to public health is unknown since a considerable number of cases are not attended by emergency medical services (EMS) and regional variations are prevalent in both reporting systems and survival.3, 4, 5 It is estimated that 275 000 people in Europe have all-rhythm cardiac arrest treated by EMS per year, with only 29 000 of those surviving to hospital discharge.6 In England, 28 729 EMS-treated OHCA cases were reported in 2014 (ie, 53 cases per 100 000 of the resident population) with only 7·9% surviving to hospital discharge.7 In the USA, reports from 35 communities suggested an incidence of 55 per 100 000 person-years.8 This incidence would equate to approximately 155 000 individuals having an EMS-treated all-rhythm OHCA per year in the USA.8 Globally, the weighted incidence estimates according to person-years of EMS-treated OHCA are 34·4 in Europe, 53·1 in North America, 59·4 in Asia, and 49·7 in Australia. Of these estimates, the percentage survival to discharge was 7·6% in Europe, 6·8% in North America, 3·0% in Asia, and 9·7% in Australia.2
These data not only serve to highlight the extensive geographical variation in the incidence of OHCA but also the very poor outcomes that have remained mostly static in the past three decades.1, 2, 3, 4 However, some cities have achieved survival in the region of 20–40%.9, 10 This difference in survival can partly be attributed to varying definitions of OHCA,2 but it is primarily due to a coordinated effort to optimise the effectiveness of the local chain of survival.11 By identifying and thereafter improving weak links in the local chain of survival, positive outcomes have been achieved in several locations.9, 12, 13, 14
In this review, the first of a three-part Series, we look at the causes of OHCA. Additionally, we look at how researchers and key stakeholders in resuscitation science have attempted to standardise the definitions and outcomes reported in OHCA research at an international level to better delineate how management pathways can be enhanced. Finally, we describe the predictors of survival after OHCA and what primary and secondary prevention strategies can be instigated to mitigate the devastating sequelae of this growing public health issue.
Section snippets
Causes of OHCA
The causes of OHCA can be broadly categorised into cardiac and non-cardiac causes (panel 1).7, 15, 16 Most people reached by an EMS crew, and in whom resuscitation is considered possible, have a cardiac cause.16 On post-mortem examination of 100 patients who died from sudden cardiac ischaemia, the investigators showed that 74 cases had coronary thrombus.17 In the 26 patients that did not have evidence of an intraluminal thrombus, 21 had evidence of plaque fissuring. Similarly, Farb and
Predictors of survival after OHCA
Several studies report substantial regional variation in morbidity and mortality after OHCA and point to factors that affect the chances of survival with a favourable neurological outcome.3, 5, 6, 8, 31, 35, 48 Although some predictors are intuitively obvious, the effects of many remain unclear. In the main, predictors of survival after OHCA can be categorised into patient factors, event factors, system factors, and therapeutic factors (panel 2).
Associated comorbid conditions are not always a
Primary and secondary prevention of sudden cardiac arrest
Both the European Society of Cardiology and the American Heart Association/American College of Cardiology/Heart Rhythm Society have published extensive guideline recommendations for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death.72, 73 In the US guideline recommendations, sudden cardiac arrest is defined as the sudden cessation of cardiac activity such that the patient becomes unresponsive, with either persisting gasping respirations or
Conclusion
Although programmatic implementation of established science can improve survival and in turn achieve public health gains, effective implementation can be challenging and must overcome a broad range of barriers that involve training, equipment, administrative and political obstacles, and medical considerations.77 Successful community implementation often requires leadership, teamwork, and accountability to overcome organisation inertia and to introduce lasting change.78 Population-based efforts
Search strategy and selection criteria
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Age and sex-related differences in outcomes of OHCA patients after adjustment for sex-based in-hospital management disparities
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