University of Pittsburgh School of Medicine, United States.
Department of Emergency Medicine, University of Pittsburgh School of Medicine, United States.
Resuscitation. 2018 Sep;130:33-40. doi: 10.1016/j.resuscitation.2018.06.024. Epub 2018 Jun 22.
Cardiac arrest etiology is often assigned according to the Utstein template, which differentiates medical (formerly "presumed cardiac") from other causes. These categories are poorly defined, contain within them many clinically distinct etiologies, and are rarely based on diagnostic testing. Optimal clinical care and research require more rigorous characterization of arrest etiology.
We developed a novel system to classify arrest etiology using a structured chart review of consecutive patients treated at a single center after in- or out-of-hospital cardiac arrest over four years. Two reviewers independently reviewed a random subset of 20% of cases to calculate inter-rater reliability. We used X and Kruskal-Wallis tests to compare baseline clinical characteristics and outcomes across etiologies.
We identified 14 principal arrest etiologies, and developed objective diagnostic criteria for each. Inter-rater reliability was high (kappa = 0.80). Median age of 986 included patients was 60 years, 43% were female and 71% arrested out-of-hospital. The most common etiology was respiratory failure (148 (15%)). A minority (255 (26%)) arrested due to cardiac causes. Only nine (1%) underwent a diagnostic workup that was unrevealing of etiology. Rates of awakening and survival to hospital discharge both differed across arrest etiologies, with survival ranging from 6% to 60% (both P < 0.001), and rates of favorable outcome ranging from 0% to 40% (P < 0.001). Timing and mechanism of death (e.g. multisystem organ failure or brain death) also differed significantly across etiologies.
Arrest etiology was identifiable in the majority cases via systematic chart review. "Cardiac" etiologies may be less common than previously thought. Substantial clinical heterogeneity exists across etiologies, suggesting previous classification systems may be insufficient.
心脏骤停的病因通常根据乌斯滕模板进行分配，该模板将病因分为医学（以前称为“推定心脏”）和其他原因。这些类别定义不明确，包含许多临床上明显不同的病因，并且很少基于诊断测试。最佳的临床护理和研究需要更严格地描述骤停的病因。
我们开发了一种新的系统，通过对在一家中心接受治疗的连续患者进行结构化图表回顾，来对骤停病因进行分类。两位评审员独立地对随机抽取的 20％病例进行回顾，以计算组内可靠性。我们使用 X 和 Kruskal-Wallis 检验来比较不同病因的基线临床特征和结局。
我们确定了 14 种主要的骤停病因，并为每种病因制定了客观的诊断标准。组内可靠性很高（kappa=0.80）。纳入的 986 名患者的中位年龄为 60 岁，43％为女性，71％在院外发生骤停。最常见的病因是呼吸衰竭（148 例（15％））。只有少数（255 例（26％））因心脏原因发生骤停。只有 9 例（1％）进行了未揭示病因的诊断性检查。不同病因的觉醒率和存活至出院均不同，存活率从 6％到 60％不等（均 P<0.001），预后良好率从 0％到 40％不等（P<0.001）。不同病因的死亡时间和机制（例如多系统器官衰竭或脑死亡）也存在显著差异。
通过系统图表审查可以识别大多数病例的骤停病因。“心脏”病因可能比以前认为的要少。病因之间存在明显的临床异质性，表明以前的分类系统可能不足。
