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REVIEW
KEYWORDS Summary A large proportion of deaths in the Western World are caused by
Cardiac arrest; ischaemic heart disease. Among these patients a majority die outside hospital due
Treatment; to sudden cardiac death.
Post resuscitation The prognosis among these patients is in general, poor. However, a signicant
proportion are admitted to a hospital ward alive. The proportion of patients who
survive the hospital phase of an out of hospital cardiac arrest varies considerably.
Several treatment strategies are applicable during the post resuscitation care
phase, but the level of evidence is weak for most of them. Four treatments are
recommended for selected patients based on relatively good clinical evidence:
therapeutic hypothermia, beta-blockers, coronary artery bypass grafting, and an
implantable cardioverter debrillator. The patients cerebral function might inu-
ence implementation of the latter two alternatives. There is some evidence for
revascularisation treatment in patients with suspected myocardial infarction. On
pathophysiological grounds, an early coronary angiogram is a reasonable alternative.
Further randomised clinical trials of other post resuscitation therapies are essential.
2005 Elsevier Ireland Ltd. All rights reserved.
A Spanish translated version of the summary of this article appears as Appendix in the online version at
10.1016/j.resuscitation.2005.08.006.
Corresponding author. Tel.: +46 31 3421000; fax: +46 31 827375.
0300-9572/$ see front matter 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.resuscitation.2005.08.006
16 J. Herlitz et al.
Contents
Background ....................................................................................................... 16
Predictors for outcome ........................................................................................... 16
Therapeutic possibilities (Table 1) ................................................................................ 17
Optimizing physiology/general intensive care treatment ......................................................... 17
Body temperature............................................................................................ 17
Indication for hypothermia ............................................................................ 17
Blood pressure ............................................................................................... 17
Indication for optimizing blood pressure ............................................................... 18
Blood glucose ................................................................................................ 18
Indication for optimizing blood glucose ................................................................ 18
Acidbase status............................................................................................. 18
Indication for optimizing acidbase status............................................................. 18
Serum potassium............................................................................................. 18
Indication for optimizing serum potassium ............................................................. 18
Serum magnesium............................................................................................ 18
Indication for optimizing serum magnesium............................................................ 18
Revascularization ................................................................................................. 18
Thrombolysis................................................................................................. 19
Indication for thrombolysis ............................................................................ 19
Percutaneous transluminal coronary intervention ............................................................ 19
Indication for PCI ...................................................................................... 19
Coronary artery bypass grafting (CABG) ...................................................................... 19
Indication for CABG.................................................................................... 19
Anti-arrhythmic therapy .......................................................................................... 19
Implantable cardioverter debrillator (ICD) .................................................................. 19
Indication for ICD ...................................................................................... 20
Beta-blockers ................................................................................................ 20
Indication for beta-blockers ........................................................................... 20
Amiodarone .................................................................................................. 20
Indication for amiodarone ............................................................................. 20
Anticonvulsant therapy ........................................................................................... 20
Indication for anticonvulsants ................................................................................ 20
Conclusion........................................................................................................ 20
References ....................................................................................................... 20
of hospital cardiac arrest. One randomized study Indication for optimizing blood glucose
demonstrated no difference in the neurological Hypo- and hyperglycaemia should be avoided. The
recovery of patients randomised to a mean arterial threshold blood glucose value that should trigger
blood pressure of >100 mmHg versus 100 mmHg insulin therapy is unknown but is likely to be in the
5 min after return of spontaneous circulation. How- range 6.18.0 mmol/l (level of evidence C).
ever, good functional recovery was associated with
a higher blood pressure during the rst 2 h after Acidbase status
return of spontaneous circulation.18 In a similar
study of patients with out-of-hospital ventricular There is no randomized trial evaluating the possible
brillation, Herlitz et al. reported higher mor- benet of treating acidbase disturbances; how-
tality if the systolic blood pressure was below ever, acidosis per se is an adverse prognostic factor
120 mmHg on hospital admission.19 On the other in the post resuscitation phase.4,7
hand, a recent study of survivors of out-of-hospital
cardiac arrest monitored using pulmonary artery Indication for optimizing acidbase status
catheters showed that hypotension and myocar- Undetermined; although avoidance of severe aci-
dial dysfunction is common during the rst 24 h dosis is reasonable (level of evidence C)
but not predictive of survival or neurological
recovery.9 Despite a signicant improvement in
Serum potassium
cardiac index at 24 h, continued vasodilatation
delayed the discontinuation of vasoactive drugs, There is no randomized trial evaluating the value
and the myocardial dysfunction was reversible only of changing serum potassium in post resuscitation
in the survivors.9 Myocardial dysfunction, a result care; however, hyperkalaemia is an adverse prog-
of global myocardial stunning, is well described in nostic factor among these patients.7,12 Whether or
several studies2021 and may be improved by dobu- not this is an epiphenomenon of acidosis or renal
tamine at 5 g/kg/min.2223 insufciency is uncertain.
Indication for optimizing blood pressure
Indication for optimizing serum potassium
Based on the available data, severe hypotension
Based on previous experiences it is reasonable to
and hypertension should be avoided (level of evi-
recommend avoidance of hyperkalaemia and avoid-
dence C).
ance of hypokalaemia (level of evidence C).
Blood glucose
Serum magnesium
An infusion of glucose and insulin improves cere-
bral outcome after asphyxial cardiac arrest in rats24 Hypomagnesaemia is associated with adverse out-
and in an intervention study with glucose infu- come in critically ill patients30,31 and may have
sion before complete cerebral ischaemia in mon- a role in mitigating neurological injury; however,
keys, lower blood glucose levels were associated there is no randomization trial evaluating magne-
with better outcome.25 Intensive insulin therapy sium in post-resuscitation care.
improves outcome among surgical patients in the
intensive care unit.26 A recent trial of insulin ther- Indication for optimizing serum magnesium
apy in critically ill patients indicated that con- Avoid hypomagnesaemia (level of evidence C).
trol of glucose levels, with a target level of less
than 8.0 mmol/l, rather than the dose of exoge-
nous insulin therapy accounts for the improved Revascularization
survival.27
In the DIGAMI I study,28 the infusion of glucose A post mortem study of 82 cardiac arrest victims
and insulin followed by long-term insulin improved in Finland, indicated that coronary artery disease
long-term outcome among diabetic patients with was the cause of the arrest in 78%32 ; furthermore,
acute myocardial infarction; however, this has coronary thrombi are found frequently in patients
not been conrmed in the more recent DIGAMI after sudden cardiac death.33 Acute changes in
2 study.29 The latter study did, however, demon- coronary plaque morphology are found in 4086%
strate that elevation of blood glucose is an inde- cardiac arrest survivors, and in 1564% in autopsy
pendent predictor for an adverse outcome among studies.34
diabetic patients with a threatened myocardial Immediate coronary angiography among sur-
infarction.29 vivors of out of hospital cardiac arrest showed a
Post resuscitation care 19
coronary occlusion in 48% of cases; not all patients arrest, 26% of 85 patients undergoing CABG had car-
had an ECG-pattern indicating such a nding.35 diac arrest or died versus 62% among 180 who were
on medication without surgery.
Thrombolysis When adjusting for differences at baseline, CABG
was associated with a signicant reduction in the
There are limited data on the impact of throm- risk of a new cardiac arrest, but not death.40
bolysis on survival during the post resuscitation Randomized clinical trials4143 and meta-
period. An observational study of relatively few analysis44 have shown that among patients with
patients (n = 69) showed a survival benet for angina pectoris and a left main stenosis or three
thrombolysis36 : the mortality was 13 of 33 (39%) vessel coronary artery disease, CABG will improve
among those receiving thrombolysis versus 24 of survival.
36 (67%) in those who did not. The difference was
in deaths attributed to cardiac, rather than neu- Indication for CABG
rological causes.36 Similar ndings are reported Coronary artery bypass grafting is indicated in the
from Finland,10 Sweden,19 Great Britain37 and post resuscitation phase for patients with left main
Germany.38 Although bleeding has been reported stenosis or triple vessel coronary artery disease if
in a few cases,37,38 thrombolysis seems to cause the cardiac arrest was thought to be caused by
few side-effects, even when given in the prehos- ischaemic heart disease (level of evidence A or C
pital setting.10 depending on interpretation).
brillation as well as patients with haemodynami- in patients with a history of severe ventricular
cally unstable ventricular tachycardia and patients arrhythmias.
with reduced left ventricular function, syncope and
inducible ventricular tachycardia.48 Six hundred
and fty-nine patients were assigned randomly to Anticonvulsant therapy
treatment with an ICD or with amiodarone. At 5
years a non-signicant reduction in the risk of death Seizures occur after cardiac arrest in up to
was observed with the ICD (8.3% per year) com- 3040% of cases6061 and are associated with
pared with 10.2% per year in the amiodarone group a worse outcome.4,6061 Early prevention and
(a relative risk reduction of 20%). treatment of seizures is advocated although the
A meta-analysis of the three trials showed a sig- scientic evidence for this strategy is weak;
nicant reduction in death from any cause with an the link between seizures and outcome may be
ICD with a summary hazard ratio of 0.72 (95% con- causative or simply an epiphenomenon. Anticon-
dence interval 0.600.87; p = 0.0006).49 The ICD vulsants such as thiopental and especially pheny-
extended survival by a mean of 4.4 months during toin are neuroprotective,6264 but a clinical trial of
a follow up period of 6 years. Patients with a left thiopental after cardiac arrest showed no benet.65
ventricular ejection fraction 35% derived signif- Further clinical studies are required.
icantly more benet from ICD therapy than those
with better left ventricular function.
Indication for anticonvulsants
Indication for ICD The indication for anticonvulsants is undetermined,
The balance of evidence favours ICD-therapy over although treatment of seizures is reasonable (level
anti-arrhythmic medical therapy (level of evidence of evidence C).
A or B).
Beta-blockers Conclusion
Beta-blockers reduced total mortality (particularly Several treatment strategies are applicable dur-
sudden death) among patients with myocardial ing the post resuscitation care phase, but the
infarction50 and/or heart failure5153 and are asso- level of evidence is weak for most of them.
ciated with improved survival in cardiac arrest Four treatments are recommended for selected
registries.12,54,55 patients based on relatively good clinical evidence:
therapeutic hypothermia, beta-blockers, coronary
Indication for beta-blockers artery bypass grafting, and an implantable car-
The indications for beta-blockers are (1) Known or dioverter debrillator. The patients cerebral func-
recent myocardial infarction and/or heart failure tion might inuence implementation of the lat-
(level of evidence A or C); (2) cardiac arrest of pre- ter two alternatives. There is some weak evidence
sumed cardiac aetiology (level of evidence B). for revascularisation treatment in patients with
suspected myocardial infarction. On pathophysio-
Amiodarone logical grounds, an early coronary angiogram is a
reasonable alternative. Further randomised clini-
The two largest trials evaluating patients at risk cal trials of other post resuscitation therapies are
of sudden death both showed that amiodarone essential.
reduced arrhythmic deaths but not the total
deaths.5657 Meta-analysis from all 13 randomised
controlled trials of amiodarone (89% after myocar- References
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