Comparison of outcome of paramedic-witnessed cardiac arrest in patients younger and older than 70 years

doi:10.1016/0002-9149(90)90809-F

The American Journal of Cardiology

Volume 65, Issue 7, 15 February 1990, Pages 453-457

https://doi.org/10.1016/0002-9149(90)90809-F Get rights and content

Abstract

To obtain further information concerning differences in the mechanism of out-of-hospital cardiac arrest between elderly and younger patients, 381 consecutive patients who experienced out-of-hospital cardiac arrest, and whose arrest was witnessed by paramedics, were studied. In 91% of cases the arrest occurred at the time the patient's cardiac rhythm was monitored. Patients were divided into 2 age groups: elderly patients were >70 years (187) and younger patients were <70 years (194). Elderly patients more commonly had a past history of heart failure (25 vs 10%, p < 0.003) and were more commonly taking digoxin (40 vs 20%, p < 0.005) and diuretics (35 vs 25%, p < 0.0004). Before the cardiac arrest, elderly patients were more likely to be complaining of dyspnea (53 vs 40%, p < 0.009), whereas younger patients were more likely to complain of chest pain (27 vs 13%, p < 0.001). Forty-two percent of younger patients demonstrated ventricular fibrillation as the initial out-of-hospital rhythm associated with the arrest, compared to only 22% of elderly patients (p < 0.001). Besides patient age, initial cardiac rhythm varied according to the patient's complaint preceding the arrest. Sixty-eight percent of patients with chest pain demonstrated ventricular fibrillation, whereas only 21% of patients with dyspnea demonstrated ventricular fibrillation. Elderly patients could be as successfully resuscitated as younger patients; however, 24% of younger patients survived, compared to only 10% of elderly patients (p < 0.001). Survival was not only dependent on the patient's age, but was dependent on the patient's complaint preceding arrest and the initial cardiac rhythm associated with the arrest. Sixty-five percent of younger patients complaining of chest pain and demonstrating ventricular fibrillation survived. Even in the elderly patients, 58% survived if their complaint was chest pain and if ventricular fibrillation was their initial out-of-hospital rhythm associated with the cardiac arrest.

References (13)

DD Tresch et al.
Comparison of outcome of resuscitation of out-of-hospital cardiac arrest in persons younger and older than 70 years of age
Am J Cardiol
(1988)
DD Tresch et al.
Should elderly be resuscitated following out-of-hospital cardiac arrest?
Am J Med
(1989)
DD Tresch et al.
Refractory symptomatic ventricular tachycardia and ventricular fibrillation in elderly patients
Am J Med
(1987)
RJ Myerburg et al.
Clinical, electrophysiological and hemodynamic profile of patients resuscitated from prehospital cardiac arrest
Am J Med
(1980)
AAJ Adgey et al.
Management of ventricular fibrillation outside of hospital
Lancet
(1969)
S Goldstein et al.
Analysis of cardiac symptoms preceding cardiac arrest
Am J Cardiol
(1986)

There are more references available in the full text version of this article.

Cited by (55)

Out-of-hospital cardiac arrest with onset witnessed by emergency medical services: Implications for improvement in overall survival
2022, Resuscitation
Citation Excerpt :
High rates of chest pain (21%), dyspnea (28%), and syncope (13%) in witnessed OHCAs of presumed cardiac origin were also reported in a study from Japan, but notably, dyspnea was especially common (41%) among witnessed OHCA of presumed noncardiac etiology.37 In another study, dyspnea was more prevalent in older patients whereas younger patients with EMS-witnessed OHCA were more likely to have chest pain.38 The nature of preceding symptoms presumably varies based on the etiology of cardiac arrest, and this aspect needs further investigation.
Out-of-hospital cardiac arrest (OHCA) remains a major public health problem. Even in high-income countries, survival rates have plateaued in the range of ten percent, stimulating an ongoing interest in developing novel approaches to resuscitation. Emergency Medical Services (EMS)-witnessed OHCAs constitute a subgroup of overall OHCA that occur after the arrival of EMS, leading to rapid initiation of resuscitation and significantly improved survival. In this narrative review we summarize and interpret recent developments in knowledge of EMS-witnessed OHCA regarding prevalence, demographics, location, circumstances, survival outcomes and clinical profile. We examine the possibility of informing novel resuscitation approaches and enhancing mechanistic knowledge by studying EMS-witnessed OHCA, with the goal of improving overall survival from OHCA.
The influence of age and gender on delay to treatment and its association with survival after out of hospital cardiac arrest
2021, American Journal of Emergency Medicine
Position paper for management of elderly patients with pacemakers and implantable cardiac defibrillators: Groupe de Rythmologie et Stimulation Cardiaque de la Société Française de Cardiologie and Société Française de Gériatrie et Gérontologie
2016, Archives of Cardiovascular Diseases
Citation Excerpt :
Symptoms preceding cardiac arrest may differ depending on age. Younger patients frequently complain about chest pain, although older patients report dyspnoea [40]. Independent of age, most patients with chest pain presentation before cardiac arrest have ventricular fibrillation, and patients with dyspnoea more frequently have electromechanical dissociation.
Despite the increasingly high rate of implantation of pacemakers (PMs) and implantable cardioverter defibrillators (ICDs) in elderly patients, data supporting their clinical and cost-effectiveness in this age stratum are ambiguous and contradictory. We reviewed the data regarding the applicability, safety and effectiveness of conventional pacing, ICDs and cardiac resynchronization therapy (CRT) in elderly patients. Although periprocedural risk may be slightly higher in the elderly, the implantation procedure for PMs and ICDs is still relatively safe in this age group. In older patients with sinus node disease, the general consensus is that DDD pacing with the programming of an algorithm to minimize ventricular pacing is preferred. In very old patients presenting with intermittent or suspected atrioventricular block, VVI pacing may be appropriate. In terms of correcting potentially life-threatening arrhythmias, the effectiveness of ICD therapy is similar in older and younger individuals. However, the assumption of persistent ICD benefit in the elderly population is questionable, as any advantageous effect of the device on arrhythmic death may be attenuated by higher total non-arrhythmic mortality. While septuagenarians and octogenarians have higher annual all-cause mortality rates, ICD therapy may remain effective in selected patients at high risk of arrhythmic death and with minimum comorbidities despite advanced age. ICD implantation among the elderly, as a group, may not be cost-effective, but the procedure may reach cost-effectiveness in those expected to live more than 5–7 years after implantation. Elderly patients usually experience significant functional improvement after CRT, similar to that observed in middle-aged patients. Management of CRT non-responders remains globally the same, while considering a less aggressive approach in terms of reinterventions (revision of left ventricular [LV] lead placement, addition of a right ventricular or LV lead, LV endocardial pacing configuration). Overall, physiological age, general status and comorbidities rather than chronological age per se should be the decisive factors in making a decision about device implantation selection for survival and well-being benefit in elderly patients.
Malgré le taux de plus en plus élevé d’implantation de pacemaker (PM) ou de défibrillateurs automatiques implantables (DAI) chez les patients âgés, l’efficacité clinique et le rapport coût/efficacité des prothèses électriques dans cette population restent discutés. Nous discutons ici les données concernant l’applicabilité, la sécurité et l’efficacité de la stimulation conventionnelle, du DAI et de la resynchronisation cardiaque chez les patients âgés. Le risque péri-procédural peut être légèrement plus élevé chez les personnes âgées, mais l’implantation de PM ou de DAI se fait avec une relative sécurité pour ces patients. Chez les patients âgés souffrant d’une maladie du nœud sinusal, un consensus général est que la stimulation double chambre, ainsi que la programmation d’un algorithme pour réduire au minimum la stimulation ventriculaire est préférable. Pour les patients très âgés avec un bloc atrioventriculaire intermittent ou suspecté, la stimulation VVI peut être appropriée. Concernant les arythmies ventriculaires potentiellement mortelles, l’efficacité du traitement par DAI est comparable chez les personnes âgées et les sujets plus jeunes. Toutefois, l’hypothèse d’un bénéfice du DAI dans la population âgée est discutable, car le bénéfice sur la mort arythmique peut être atténué par une mortalité totale ou non rythmique supérieure. Alors que septuagénaires et octogénaires ont des taux annuels plus élevés de mortalité totale, le traitement par DAI peut rester efficace chez certains patients à haut risque de décès par arythmie et avec des comorbidités limitées malgré l’âge avancé. L’implantation de DAI chez les personnes âgées peut avoir un rapport coût/efficacité défavorable à l’échelle de la population totale, mais la procédure est économiquement rentable si l’on considère les patients avec une espérance de vie d’au moins 5–7 ans après l’implantation. Les patients âgés ont habituellement une amélioration fonctionnelle significative après resynchronisation cardiaque par stimulation biventriculaire, similaire à celle observée chez les patients d’âge moyen. La prise en charge des non répondeurs à la resynchronisation reste globalement la même, tout en tenant compte d’une approche moins agressive en termes de ré-interventions (repositionnement de sonde VG, ajout d’une sonde VD ou VG, ou stimulation endocardique VG). Au total, l’âge physiologique, le statut général et les comorbidités (plutôt que l’âge chronologique en soi) devraient être les facteurs décisifs lors de prise de décision pour l’implantation d’une prothèse cardiaque électrique pour un bénéfice en termes de survie et de qualité de vie chez les patients âgés.
The significance of pre-arrest factors in out-of-hospital cardiac arrests witnessed by emergency medical services: A report from the Victorian Ambulance Cardiac Arrest Registry
2015, Resuscitation
Citation Excerpt :
Our multivariable analyses indicate that both prodromal factors and clinical parameters can be used to identify patients who are at increased risk of death following OHCA. The association between pre-arrest factors, arresting rhythm and survival has been attributed to the underlying aetiology of arrest,8,19,20 and may help to differentiate patients who are unlikely to benefit from in-field resuscitation efforts. For instance, patients with chest pain or anginal equivalent symptoms (e.g. arm or shoulder pain) were significantly more likely to experience shockable rhythms on arrest, and almost all achieved ROSC in the field.
The significance of pre-arrest factors in out-of-hospital cardiac arrests (OHCA) witnessed by emergency medical services (EMS) is not well established. The purpose of this study was to assess the association between prodromal symptoms and pre-arrest clinical observations on the arresting rhythm and survival in EMS witnessed OHCA.
Between 1st January 2003 and 31st December 2011, 1056 adult EMS witnessed arrests of a presumed cardiac aetiology were identified from the Victorian Ambulance Cardiac Arrest Registry. Pre-arrest prodromal features and clinical characteristics were extracted from the patient care record. Backward elimination logistic regression was used to identify pre-arrest factors associated with an initial shockable rhythm and survival to hospital discharge.
The median age was 73.0 years, 690 (65.3%) were male, and the rhythm of arrest was shockable in 465 (44.0%) cases. The most commonly reported prodromal symptoms prior to arrest were chest pain (48.8%), dyspnoea (41.8%) and altered consciousness (37.8%). An unrecordable systolic blood pressure was observed in 34.4%, a respiratory rate <13 or >24 min⁻¹ was present in 43.1%, and 45.5% had a Glasgow coma score <15. In the multivariable analysis, the following pre-arrest factors were significantly associated with survival: age, public location, aged care facility, chest pain, arm or shoulder pain, dyspnoea, dizziness, vomiting, ventricular tachycardia, pulse rate, systolic blood pressure, respiratory rate, Glasgow coma score, aspirin and inotrope administration.
Pre-arrest factors are strongly associated with the arresting rhythm and survival following EMS witnessed OHCA. Potential opportunities to improve outcomes exist by way of early recognition and management of patients at risk of OHCA.
Clinical predictors of outcome in survivors of out-of-hospital cardiac arrest treated with hypothermia
2012, Cor et Vasa
Citation Excerpt :
Over the past-half century, many interventions improved the rate of restoration of spontaneous circulation (ROSC) but without impacting long-term survival [3]. During this period, major indicators for increased survival rate have not changed: younger age, VF/VT as initial rhythm, witnessed cardiac arrest, bystander cardiopulmonary resuscitation (CPR), and time elapsed to ROSC [7–9]. During the past few years, new pre-hospital and in-hospital therapeutic approaches have been introduced to improve outcome.
Out-of-hospital cardiac arrest (OHCA) is a leading cause of death and severe neurological disability. The objective of this study was to identify clinical predictors of early neurological outcome in survivors of OHCA managed according to recent recommendations for OHCA care.
Data from survivors of OHCA, admitted to a tertiary cardiac intensive care unit and treated with hypothermia in a 22 months period (n=46, age 60±13 years, 74% males) were retrospectively evaluated. At 1-month follow-up, patients were classified according to the best achieved Glasgow–Pittsburgh cerebral performance categories (CPC 1–5) and factors affecting the outcome were analysed.
At 1-month follow-up, 23 patients (50%) had favourable outcome (CPC 1–2), while 23 patients (50%) had poor outcome (CPC 3–5), including 19 with in-hospital death (41% of total). Patients with good outcome were younger (55±13 years vs. 66±10 years; P=0.003), had more often myocardial infarction as the cause of arrest (63% vs. 30%; P=0.018) and ventricular fibrillation/tachycardia as an initial rhythm (78% vs. 39%; P=0.007). Both groups differed by lactate level on admission (4.0±4.6 vs. 7.3±4.1 mmol/l, P=0.02), after 12 h (2.5±1.1 vs. 4.3±3.2 mmol/l, P=0.04) and after 24 h (1.9±1.2 vs. 3.2±1.9 mmol/l, P=0.04). Logistic regression revealed the following independent outcome predictors: age, acute myocardial infarction and admission lactate level.
Favourable outcome was observed in a half of OHCA survivors. Young age, acute myocardial infarction as underlying aetiology of cardiac arrest, and low lactate level on admission were the best predictors of favourable outcome.
Five-year survival of patients after out-of-hospital cardiac arrest depending on age
2011, Archives of Gerontology and Geriatrics
Patient's age belongs to the independent prognostic factors of patients after out-of-hospital cardiac arrest (OHCA). This study aimed to evaluate the influence of age on 5-year survival in professionally cardio-pulmonary resuscitated patients with “primary cardiac” etiology OHCA. In this analysis of prospective multi-centric study, from April 1, 2002 until August 31, 2004, a total of 560 patients were included (aged 16–97 years) from the East Bohemian region, for whom a professional cardio-pulmonary resuscitation for OHCA was attempted. In the age subgroup <70 years there were 307 patients and in the age subgroup ≥70 years there were 253 patients. Of the subgroup <70 years, 29 patients (10%) survived to year 5 (58% from the 50 patients surviving to day 30), and in the subgroup ≥70 years, we had 4 patients surviving to year 5 (2%) (29% from the 14 patients surviving to day 30), respectively (Fisher‘s exact test; comparison in the all resuscitated patients: p < 0.001, in the population surviving to day 30: p = 0.071). In conclusion, there was a trend towards a worse outcome in 5-year survival following OHCA in the patients aged ≥70 years. Nevertheless, these data support that prognosis OHCA of elders is not associated with universal dismal outcome.

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Comparison of outcome of paramedic-witnessed cardiac arrest in patients younger and older than 70 years

Abstract

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