Søholm Helle, Kjaergaard Jesper, Bro-Jeppesen John, Hartvig-Thomsen Jakob, Lippert Freddy, Køber Lars, Nielsen Niklas, Engsig Magaly, Steensen Morten, Wanscher Michael, Karlsen Finn Michael, Hassager Christian
From the Department of Cardiology 2142, The Heart Centre (H.S., J.K., J.B.-J., J.H.-T., L.K., C.H.), Department of Anesthesiology (M.S.), and Department of Thoracic Anesthesiology, The Heart Centre (M.W.), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Emergency Medical Services, Copenhagen, The Capital Region of Denmark (F.L.); Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden (N.N.); Department of Anesthesiology, Gentofte University Hospital, Hellerup, Denmark (M.E.); and Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark (F.M.K.).
Circ Cardiovasc Qual Outcomes. 2015 May;8(3):268-76. doi: 10.1161/CIRCOUTCOMES.115.001767. Epub 2015 May 5.
Studies have found higher survival rates after out-of-hospital cardiac arrest and admission to tertiary heart centers. The aim was to examine the level-of-care at tertiary centers compared with nontertiary hospitals and the association with outcome after out-of-hospital cardiac arrest.
Consecutive out-of-hospital cardiac arrest patients (n=1078) without ST-segment-elevation myocardial infarction admitted to tertiary centers (54%) and nontertiary hospitals (46%) were included (2002-2011). Patient charts were reviewed focusing on level-of-care and comorbidity. Survival to discharge differed significantly with 45% versus 24% of patients discharged alive (P<0.001), and after adjustment for prognostic factors admissions to tertiary centers were still associated with lower 30-day mortality (hazard ratio, 0.78 [0.64-0.96; P=0.02]), independent of comorbidity. The adjusted odds of predefined markers of level-of-care were higher in tertiary centers: admission to intensive care unit (odds ratio [OR], 1.8 [95% confidence interval, 1.2-2.5]), temporary pacemaker (OR, 6.4 [2.2-19]), vasoactive agents (OR, 1.5 [1.1-2.1]), acute (<24 hours) and late coronary angiography (OR, 10 [5.3-22] and 3.8 [2.5-5.7]), neurophysiological examination (OR, 1.8 [1.3-2.6]), and brain computed tomography (OR, 1.9 [1.4-2.6]), whereas no difference in therapeutic hypothermia was noted. Patients at tertiary centers were more often consulted by a cardiologist (OR, 8.6 [5.0-15]), had an echocardiography (OR, 2.8 [2.1-3.7]), and survivors more often had implantable cardioverter defibrillator's implanted (OR, 2.1 [1.2-3.6]).
Admissions to tertiary centers were associated with significantly higher survival after out-of-hospital cardiac arrest in patients without ST-segment-elevation myocardial infarction in the Copenhagen area even after adjustment for prognostic factors including comorbidity. Level-of-care seems higher in tertiary centers both in the early phase, during the intensive care unit admission, and in the workup before discharge. The varying level-of-care may contribute to the survival difference; however, differences in comorbidity do not seem to matter significantly.
研究发现，院外心脏骤停后入住三级心脏中心的患者生存率更高。本研究旨在比较三级中心与非三级医院的医疗护理水平，以及院外心脏骤停后其与预后的关系。
纳入2002年至2011年期间连续收治的院外心脏骤停患者（n = 1078例），这些患者均无ST段抬高型心肌梗死，其中54%入住三级中心，46%入住非三级医院。回顾患者病历，重点关注医疗护理水平和合并症情况。出院生存率有显著差异，三级中心和非三级医院分别有45%和24%的患者存活出院（P < 0.001）。在对预后因素进行调整后，入住三级中心的患者30天死亡率仍然较低（风险比，0.78 [0.64 - 0.96；P = 0.02]），且与合并症无关。三级中心在医疗护理水平的预定义指标方面调整后的优势比更高：入住重症监护病房（优势比[OR]，1.8 [95%置信区间，1.2 - 2.5]）、使用临时起搏器（OR，6.4 [2.2 - 19]）、使用血管活性药物（OR，1.5 [1.1 - 2.1]）、急性（<24小时）和晚期冠状动脉造影（OR，10 [5.3 - 22]和3.8 [2.5 - 5.7]）、神经生理学检查（OR，1.8 [1.3 - 2.6]）以及脑部计算机断层扫描（OR，1.9 [1.4 - 2.6]），而在治疗性低温方面未发现差异。三级中心的患者更常由心脏病专家会诊（OR，8.6 [5.0 - 15]），接受超声心动图检查（OR，2.8 [2.1 - 3.7]），存活患者更常植入植入式心脏复律除颤器（OR，2.1 [1.2 - 3.6]）。
在哥本哈根地区，即使对包括合并症在内的预后因素进行调整后，无ST段抬高型心肌梗死的院外心脏骤停患者入住三级中心后的生存率仍显著更高。三级中心在早期、重症监护病房住院期间以及出院前检查阶段的医疗护理水平似乎更高。不同的医疗护理水平可能导致了生存差异；然而，合并症的差异似乎并不显著。
