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(Circulation. 2003;107:1948.)
© 2003 American Heart Association, Inc.

Editorial

Cardiac Arrest Outside of a Hospital

How Can We Improve Results of Resuscitation?

Hein J.J. Wellens, MD; Anton P. Gorgels, MD; Hans de Munter, MD

From the Interuniversity Cardiology Institute of the Netherlands, Utrecht (H.J.J.W.); the Department of Cardiology, Academic Hospital Maastricht, Maastricht (A.P.G.); and the Municipal Health Service Maastricht, Maastricht (H.d.M.), The Netherlands.

Correspondence to Hein J.J. Wellens, MD, 21, Henric van Veldekeplein, 6211 TG Maastricht, The Netherlands. E-mail hwellens{at}xs4all.nl

Key Words: Editorials • resuscitation • death, sudden • defibrillation

In the western world, one-fifth of all deaths occur suddenly and unexpectedly,¹ ventricular fibrillation being a frequent mechanism. It happens approximately 300 000 times per year both in the United States and in Europe.² This problem continues to haunt us, for we know that restoring normal heart rhythm by a defibrillation shock not only saves the life of the victim, but is often followed by many years of satisfactory living.

Can We Recognize the Victim Before the Event?

Much effort has been put into recognizing the person at high risk of dying suddenly and is clearer in the case of a previous life-threatening arrhythmia or successful resuscitation from circulatory arrest. In such patients, death from a new arrhythmic episode can be prevented by implanting a defibrillator. Accurate risk stratification is much more difficult in the large group of patients with known heart disease but without a history of a life-threatening arrhythmia.³

Patients characterized by a previous myocardial infarction and poor left ventricular function, with or without non-sustained ventricular arrhythmias, can profit from a defibrillator implant, as shown by studies such as the Multicenter Automatic Defibrillator Implantation Trial-I (MADIT I), the Multicenter Unstable Tachycardia Trial (MUSTT), and MADIT II.^4–6 However, only 10% of sudden cardiac arrest victims have such a high-risk profile.^1,7

The Challenge

The challenge is therefore to improve the outcome of resuscitation in the 90% of patients that we cannot recognize as being at high risk before the event. Of course, risk in the known cardiac patient should be minimized by improving myocardial perfusion and pump function by medical and surgical interventions and other secondary prevention measures. In half of the victims, however, cardiac arrest is the first manifestation of heart disease. That 90% has much less cardiac damage than the 10% with a high risk profile, and they should have a much better life expectancy when successfully resuscitated than the high risk category.

This has been the basis for continuing efforts (unfortunately without much success⁸) to educate the public on seeking immediate help when symptoms suggestive of acute myocardial ischemia occur, and also on performing correctly and rapidly the different steps required for survival in case of cardiac arrest. However, it still remains exceptional to save more than 5% of cardiac arrest victims.⁹ That figure has not changed during a 20-year period.^10,11

Public Access Defibrillation

Although the (semi)automatic external defibrillator (AED) has been available for a long time,¹² only recently has a change in policy and removal made wide application of this device by the layman possible. Placing the AED in public settings and training laymen in their correct use gave new hope and resulted in improved outcome of cardiac resuscitation.^13–18 The key to a successful treatment of circulatory arrest is defibrillation within the short time interval of a few minutes.¹⁹ This means that the AED has to be at the site of the victim within that time. This is a problem when we realize that 80% of cases of circulatory arrest occur at home.¹ Currently ongoing studies are examining the benefit of having a dense network of AEDs in the community, with public access to these devices.

The Home AED

The knowledge that most victims of circulatory arrest have the event at home has been the reason to start studies placing the AED in the home of the patient at risk of dying suddenly. Extensive use of the device at that site has been envisioned.²⁰

However, the home AED has its limitations. Having the device at home means that a person other than the victim must be available, able to diagnose circulatory arrest, and be willing to use the defibrillator.²¹ Unfortunately, 40% of circulatory arrests are unwitnessed,¹ making it usually impossible to restore normal cardiac rhythm within the 6 to 8 golden minutes after the start of arrest.

Shockable Versus Non-Shockable Rhythms

Defibrillation is a life-saving therapy in case of ventricular fibrillation (VF). However, sudden cardiac arrest may also be the consequence of asystole or pulseless electrical activity. Recent studies from both sides of the Atlantic suggest a decreasing incidence of VF as cause of cardiac arrest.^11,22,23 Are victims being seen later after the onset of cardiac arrest or is VF becoming less common in patients with known heart disease who are adequately treated medically and surgically, including with ß-blockade? Insight into these changes is important because it necessitates a rhythm-based approach to cardiac arrest.

The Weak Links in the Chain of Survival and How to Correct Them

Although after cardiac arrest, time to successful resuscitation can be prolonged by CPR, ideally the time interval between collapse by VF and defibrillation should not exceed 5 to 6 minutes.²⁴ Several conditions should be fulfilled to reach that goal (Table 1). The first step is to make the time interval between collapse and call for help as short as possible. This requires a bystander who quickly overcomes the paralysis that occurs when one witnesses cardiac arrest. Currently, even with a bystander trained in CPR, it easily takes 1 minute to confirm circulatory arrest. That is the time required to call emergency medical services. It takes on average 2 minutes after the call comes in for trained responders to be sent to the scene.

View this table: [in this window] [in a new window]   TABLE 1. Weak Links in the Chain of Survival

The dispatch time can be shortened by having a special telephone number other than 911 in the United States and 112 in Europe that is exclusively used for a cardiac emergency.¹⁷ Time between collapse and defibrillation can also be shortened by having a sufficient number of AEDs and a dense network of "cardiac arrest watchers" in the community. These are people living in the neighborhood who can be alarmed when cardiac arrest occurs.

What Else Is Needed?

A major breakthrough in improving results of cardiac resuscitation could come from developing an apparatus specifically geared toward minimizing the time between collapse and the resuscitation effort, one that requires continuous registration of vital signs, such as cardiac rhythm or arterial pulsations with prompt recognition of circulatory arrest. This will reduce the time to come to the correct diagnosis by giving an audible alarm to attract bystanders in the home and in situations where there are no witnesses. The location of the victim should be transmitted to the nearest site of an AED in the community and to the emergency medical services, resulting in a marked reduction in time required for diagnosis and dispatch.

The device should also have a clock that allows for precise identification of the time of collapse and subsequent intervention, providing information that is essential for decision making in the individual victim. This point was recently stressed by Weisfeldt and Becker²⁵ in their 3-phase time-sensitive model, which indicated that optimal treatment of cardiac arrest might be phase-specific. In the electrical phase, which lasts approximately 4 minutes, early defibrillation is required. In the next phase, the circulatory phase (4 to 10 minutes after cardiac arrest), oxygen delivery should precede attempts to restore normal rhythm by defibrillation. In the last phase, the metabolic phase (starting approximately 10 minutes after cardiac arrest), Weisfeldt and Becker suggested investigating the value of interventions such as controlled reperfusion after treatment with apoptosis inhibitors and external cooling.

Wearing the device will also indicate that the person wants to be resuscitated, a question one cannot answer in case of an anonymous victim. A reliable device, one able to continuously register artifact-free vital signs, probably requires intracutaneous or subcutaneous sensors. Vital signs should be transmitted to a wearable receiver able to analyze them and sound an alarm in case of circulatory arrest and to transmit the location of the victim. Recently, the PULSE initiative was published, in which a detailed description was given of scientific priorities and strategic planning for resuscitation research and life-saving therapies.²⁶ However, little attention was given to the importance of developing a wearable, reliable device as described above. The development of such a device, some necessary features of which are shown in Table 2, will be a real challenge. But, as shown in the Figure, it may give us a new opportunity to speed up the chain of survival, resulting in a reduction of sudden deaths outside the hospital. It might also allow us to apply more phase-specific therapies according to time elapsed after cardiac arrest. If we could bring the overall success rate of a resuscitation attempt after a cardiac arrest from 5% to 25%, an additional 70 000 lives will be saved yearly, both in the United States and in Europe.

View this table: [in this window] [in a new window]   TABLE 2. Technical Challenges in the Development of a Cardiac Arrest Device

View larger version (27K): [in this window] [in a new window]   Time intervals during the current approach to resuscitation compared with the use of a monitoring device that recognizes cardiac arrest, sounds an alarm, and transmits the location of the victim directly to the first responder or the AED in the community and advanced life support. SCA indicates sudden cardiac arrest.

Conclusion

Increasing public awareness of the frequency of sudden cardiac arrest and rapid access to an AED is likely to lead to a higher success rate of resuscitation attempts. However, a real breakthrough requires the development of a device that recognizes cardiac arrest, sounds an alarm, and transmits the location of the victim, shortening the time interval of the different steps in the chain of survival.

Footnotes

The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.

References

1. De Vreede-Swagemakers JJ, Gorgels AP, Dubois-Arbouw WJ, et al. Out-of-hospital cardiac arrest in the 1990’s: a population based study in the Maastricht area on incidence, characteristics and survival. J Am Coll Cardiol. 1997; 30: 1500–1505.[Abstract]
   
2. Priori SG, Aliot E, Blomstrom-Lundqvist C, et al. Task Force on Sudden Cardiac Death of the European Society of Cardiology. Eur Heart J. 2001; 22: 1374–1450.[Free Full Text]
   
3. Eisenberg MJ. Risk stratification for arrhythmic events: are the bangs worth the bucks? N Engl J Med. 2001; 344: 1304–1313.[Free Full Text]
   
4. Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmias. N Engl J Med. 1996; 335: 1933–1940.[Abstract/Free Full Text]
   
5. Buxton AE, Lee KL, Fisher JD, et al. A randomized study of the prevention of sudden death in patients with coronary heart disease. N Engl J Med. 1999; 341: 1882–1890.[Abstract/Free Full Text]
   
6. Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002; 346: 877–883.[Abstract/Free Full Text]
   
7. Myerburg RJ, Castellanos A. Cardiac arrest and sudden cardiac death. In: Braunwald E, Zipes DP, Libby P, eda. Heart Disease: A Textbook of Cardiovascular Medicine. 6th edition. Philadelphia, Pa: WB Saunders Company; 2001: 890–931.
   
8. Goldberg RJ, Garwitz JH, Gore JM. Duration of, and temporal trends (1994–1997) in pre-hospital delay in patients with acute myocardial infarction. Arch Intern Med. 1999; 159: 2142–2147.
   
9. Eisenberg MS, Mengert TJ. Cardiac resuscitation. N Engl J Med. 2001; 344: 1304–1313.[Free Full Text]
   
10. Nichol G, Stiell IG, Laupacis A, et al. A cumulative meta-analysis of the effectiveness of defibrillator-capable emergency medical services for victims of out-of-hospital cardiac arrest. Ann Emerg Med. 1999; 34: 517–552.[CrossRef][Medline] [Order article via Infotrieve]
    
11. Herlitz J, Andersson E, Bang A, et al. Experiences from treatment of out-of-hospital cardiac arrest during 17 years in Goteborg. Eur Heart J. 2000; 21: 1251–1258.[Abstract/Free Full Text]
    
12. Cummins RO, Eisenberg MS, Bergner L, et al. Automatic external defibrillation: evaluation of its role in the home and in emergency medical services. Ann Emerg Med. 1984; 13: 798–801.[CrossRef][Medline] [Order article via Infotrieve]
    
13. Weisfeldt ML, Kerber RE, McGoldrick RP, et al. Public access defibrillation: a statement for healthcare professionals from the American Heart Association Task Force on the automatic external defibrillator. Circulation. 1995; 92: 2763–2772.[Free Full Text]
    
14. Page RL, Joglar JA, Kowal RC, et al. Use of automated external defibrillators by a U. S. airline. N Engl J Med. 2000; 343: 1210–1216.[Abstract/Free Full Text]
    
15. Valenzuela TD, Roe DJ, Nichol G, et al. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med. 2000; 343: 1206–1209.[Abstract/Free Full Text]
    
16. Marenco JP, Wang PJ, Link MS, et al. Improving survival from sudden cardiac arrest: the role of the automated external defibrillator. JAMA. 2001; 285: 1193–1200.[Abstract/Free Full Text]
    
17. Myerburg RJ, Fenster J, Velez M, et al. Impact of community-wide police car deployment of automated external defibrillators on survival from out-of-hospital cardiac arrest. Circulation. 2002; 106: 1058–1064.[Abstract/Free Full Text]
    
18. Capucci A, Aschieri D, Piepoli MF, et al. Tripling survival from sudden cardiac arrest via early defibrillation without traditional education in cardiopulmonary resuscitation. Circulation. 2002; 106: 1065–1070.[Abstract/Free Full Text]
    
19. Eisenberg MS, Bergner L, Hallstrom A. Cardiac resuscitation in the community: importance of rapid provision and implications of program planning. JAMA. 1979; 241: 1905–1907.[Abstract]
    
20. Eisenberg MS. Is it time for over-the-counter defibrillators? JAMA. 2000; 284: 1435–1438.[Free Full Text]
    
21. Chen MA, Eisenberg MS, Meischke H. Impact of in-home defibrillators on post myocardial infarction patients and their significant others: an interview study. Heart Lung. 2002; 31: 173–185.[CrossRef][Medline] [Order article via Infotrieve]
    
22. Kuisma M, Repo J, Alaspaa A. The incidence of out-of-hospital ventricular fibrillation in Helsinki, Finland from 1994–1999. Lancet. 2001; 358: 473–474.[CrossRef][Medline] [Order article via Infotrieve]
    
23. Cobb LA, Fahrenbruch CE, Olsufka M, et al. Changing incidence of out-of-hospital ventricular fibrillation, 1980–2000. JAMA. 2002; 288: 308–313.[Free Full Text]
    
24. Holmberg M, Holmberg S, Herlitz J. Factors modifying the effect of bystander cardiopulmonary resuscitation on survival in out-of-hospital cardiac arrest patients in Sweden. Eur Heart J. 2001; 22: 511–519.[Abstract/Free Full Text]
    
25. Weisfeldt ML, Becker LB. Resuscitation after cardiac arrest: a 3-phase time-sensitive model. JAMA. 2002; 288: 3035–3038.[Free Full Text]
    
26. Becker LB, Weisfeldt ML, Weil MH, et al. The PULSE initiative: scientific priorities and strategic planning for resuscitation research and life saving therapies. Circulation. 2002; 105: 2562–2570.[Free Full Text]
    

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