Department of Medicine, University of California, Irvine School of Medicine, Orange, CA, USA; Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.
Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri-Kansas City, Kansas City, MO, USA.
Resuscitation. 2022 Feb;171:41-47. doi: 10.1016/j.resuscitation.2021.12.021. Epub 2021 Dec 27.
Patients with ST-elevation myocardial infarction (STEMI) complicated by an out-of-hospital-cardiac-arrest (OHCA) may vary widely in their probability of dying. Large variation in mortality may have implications for current national efforts to benchmark operator and hospital mortality rates for coronary angiography. We aimed to build a risk-adjustment model of in-hospital mortality among OHCA survivors with concurrent STEMI.
Within the Cardiac Arrest Registry to Enhance Survival (CARES), we included adults with OHCA and STEMI who underwent emergent angiography within 2 hours of hospital arrival between January 2013 and December 2019. Using multivariable logistic regression to adjust for patient and cardiac arrest factors, we developed a risk-adjustment model for in-hospital mortality and examined variation in patients' predicted mortality.
Of 2,999 patients (mean age 61.2 ± 12.0, 23.1% female, 64.6% white), 996 (33.2%) died during their hospitalization. The final risk-adjustment model included higher age (OR per 10-year increase, 1.50 [95% CI: 1.39-1.63]), unwitnessed OHCA (OR, 2.51 [1.99-3.16]), initial non-shockable rhythm [OR, 5.66 [4.52-7.13]), lack of sustained pulse for > 20 minutes (OR, 2.52 [1.88-3.36]), and longer resuscitation time (increased with each 10-minute interval) (c-statistic = 0.804 with excellent calibration). There was large variability in predicted mortality: median, 25.2%, inter-quartile-range: 14.0% to 47.8%, 10th-90th percentile: 8.2 % to 74.1%.
In a large national registry, we identified 5 key predictors for mortality in patients with STEMI and OHCA and found wide variability in mortality risk. Our findings suggest that current national benchmarking efforts for coronary angiography, which simply adjusts for the presence of OHCA, may not adequately capture patient case-mix severity.
患有 ST 段抬高型心肌梗死（STEMI）并发院外心脏骤停（OHCA）的患者其死亡率可能存在较大差异。死亡率的巨大差异可能对当前国家基准测试冠状动脉造影术操作人员和医院死亡率的努力产生影响。我们旨在建立一个并发 STEMI 的 OHCA 幸存者院内死亡率的风险调整模型。
在心脏骤停注册研究以提高生存率（CARES）中，我们纳入了在 2013 年 1 月至 2019 年 12 月期间到达医院后 2 小时内接受紧急血管造影的患有 OHCA 和 STEMI 的成年人。我们使用多变量逻辑回归调整患者和心脏骤停因素，为院内死亡率制定风险调整模型，并检查患者预测死亡率的变化。
在 2999 名患者中（平均年龄 61.2 ± 12.0 岁，23.1%为女性，64.6%为白人），996 名（33.2%）患者在住院期间死亡。最终的风险调整模型包括年龄较大（每增加 10 岁，OR 为 1.50 [95%CI：1.39-1.63]）、无人见证的 OHCA（OR，2.51 [1.99-3.16]）、初始非冲击性节律（OR，5.66 [4.52-7.13]）、无持续脉搏>20 分钟（OR，2.52 [1.88-3.36]）和复苏时间较长（每增加 10 分钟间隔）（C 统计量为 0.804，校准效果极好）。死亡率的预测存在很大差异：中位数为 25.2%，四分位距为 14.0%至 47.8%，第 10 百分位数至第 90 百分位数为 8.2%至 74.1%。
在一个大型的国家注册中心，我们确定了 STEMI 和 OHCA 患者死亡的 5 个关键预测因素，并发现死亡率的风险存在很大差异。我们的研究结果表明，当前国家基准测试冠状动脉造影术的努力，仅根据 OHCA 的存在进行调整，可能无法充分捕捉患者病例组合的严重程度。
