Minneapolis Heart Institute, Minneapolis, Minnesota.
Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.
JAMA Netw Open. 2018 Nov 2;1(7):e184511. doi: 10.1001/jamanetworkopen.2018.4511.
Despite evidence that therapeutic hypothermia improves patient outcomes for out-of-hospital cardiac arrest, use of this therapy remains low.
To determine whether the use of therapeutic hypothermia and patient outcomes have changed after publication of the Targeted Temperature Management trial on December 5, 2013, which supported more lenient temperature management for out-of-hospital cardiac arrest.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort was conducted between January 1, 2013, and December 31, 2016, of 45 935 US patients in the Cardiac Arrest Registry to Enhance Survival who experienced out-of-hospital cardiac arrest and survived to hospital admission.
Calendar time by quarter year.
Use of therapeutic hypothermia and patient survival to hospital discharge.
Among 45 935 patients (17 515 women and 28 420 men; mean [SD] age, 59.3 [18.3] years) who experienced out-of-hospital cardiac arrest and survived to admission at 649 US hospitals, overall use of therapeutic hypothermia during the study period was 46.4%. In unadjusted analyses, the use of therapeutic hypothermia dropped from 52.5% in the last quarter of 2013 to 46.0% in the first quarter of 2014 after the December 2013 publication of the Targeted Temperature Management trial. Use of therapeutic hypothermia remained at or below 46.5% through 2016. In segmented hierarchical logistic regression analysis, the risk-adjusted odds of use of therapeutic hypothermia was 18% lower in the first quarter of 2014 compared with the last quarter of 2013 (odds ratio, 0.82; 95% CI, 0.71-0.94; P = .006). Similar point-estimate changes over time were observed in analyses stratified by presenting rhythm of ventricular tachycardia or ventricular fibrillation (odds ratio, 0.89; 95% CI, 0.71-1.13, P = .35) and pulseless electrical activity or asystole (odds ratio, 0.75; 95% CI, 0.63-0.89; P = .001). Overall risk-adjusted patient survival was 36.9% in 2013, 37.5% in 2014, 34.8% in 2015, and 34.3% in 2016 (P < .001 for trend). In mediation analysis, temporal trends in use of hypothermia did not consistently explain trends in patient survival.
In a US registry of patients who experienced out-of-hospital cardiac arrest, the use of guideline-recommended therapeutic hypothermia decreased after publication of the Targeted Temperature Management trial, which supported more lenient temperature thresholds. Concurrent with this change, survival among patients admitted to the hospital decreased, but was not mediated by use of hypothermia.
尽管有证据表明治疗性低温可改善院外心脏骤停患者的预后，但该疗法的应用仍然很低。
确定在 2013 年 12 月 5 日发表的靶向温度管理试验（Targeted Temperature Management trial）之后，治疗性低温的使用和患者预后是否发生了变化，该试验支持更宽松的院外心脏骤停的温度管理。
设计、地点和参与者：这是一项回顾性队列研究，在 2013 年 1 月 1 日至 2016 年 12 月 31 日期间，对经历院外心脏骤停并存活至入院的 45935 名美国心脏骤停登记处（Cardiac Arrest Registry to Enhance Survival）患者进行了研究，这些患者存活至入院。
按季度划分的日历时间。
治疗性低温的使用和患者的存活率至出院。
在 45935 名经历院外心脏骤停并存活至 649 家美国医院入院的患者中（17515 名女性和 28420 名男性；平均[SD]年龄为 59.3[18.3]岁），研究期间总体上使用治疗性低温的比例为 46.4%。在未调整的分析中，在 2013 年 12 月发表靶向温度管理试验后，治疗性低温的使用从 2013 年最后一个季度的 52.5%下降到 2014 年第一季度的 46.0%。通过 2016 年，治疗性低温的使用仍保持在 46.5%或以下。在分段分层逻辑回归分析中，与 2013 年最后一个季度相比，2014 年第一季度使用治疗性低温的风险调整优势比降低了 18%（优势比，0.82；95%CI，0.71-0.94；P = .006）。在按室性心动过速或室颤（优势比，0.89；95%CI，0.71-1.13，P = .35）和无脉性电活动或心搏停止（优势比，0.75；95%CI，0.63-0.89，P = .001）的节律分层分析中，也观察到类似的时间点变化。整体风险调整后的患者存活率在 2013 年为 36.9%，2014 年为 37.5%，2015 年为 34.8%，2016 年为 34.3%（趋势 P < .001）。在中介分析中，低温治疗使用率的时间趋势并不能一致解释患者生存率的趋势。
在美国经历院外心脏骤停的患者登记处中，在发表支持更宽松温度阈值的靶向温度管理试验后，指南推荐的治疗性低温的使用减少了。与此变化同时发生的是，入院患者的生存率下降，但这并不是由低温治疗使用率下降导致的。
