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Outcomes of Patients with Cardiac Arrest with and without COVID-19 in the United States

Published:January 04, 2023DOI:https://doi.org/10.1016/j.ejim.2023.01.004
      Cardiac arrest (CA) remains associated with very high mortality, with only one in ten patients surviving to hospital discharge.[
      • Mitchell OJL
      • Yuriditsky E
      • Johnson NJ
      • et al.
      Coronavirus 2019 In-Hospital Cardiac Arrest (COVID IHCA) Study Group. In-hospital cardiac arrest in patients with coronavirus 2019.
      ,
      • Thapa SB
      • Kakar TS
      • Mayer C
      • Khanal D
      Clinical outcomes of in-hospital cardiac arrest in COVID-19.
      ,
      • Hayek SS
      • Brenner SK
      • Azam TU
      • et al.
      STOP-COVID Investigators. In-hospital cardiac arrest in critically ill patients with COVID-19: multicenter cohort study.
      ] Over the last three years, the widespread prevalence of COVID-19 infection has been associated with a significant parallel rise in the incidence of CA.[
      • Mitchell OJL
      • Yuriditsky E
      • Johnson NJ
      • et al.
      Coronavirus 2019 In-Hospital Cardiac Arrest (COVID IHCA) Study Group. In-hospital cardiac arrest in patients with coronavirus 2019.
      ,
      • Thapa SB
      • Kakar TS
      • Mayer C
      • Khanal D
      Clinical outcomes of in-hospital cardiac arrest in COVID-19.
      ,
      • Hayek SS
      • Brenner SK
      • Azam TU
      • et al.
      STOP-COVID Investigators. In-hospital cardiac arrest in critically ill patients with COVID-19: multicenter cohort study.
      ,
      • Girotra S
      • Chan ML
      • Starks MA
      • Churpek M
      • Chan PS
      American Heart Association Get With the Guidelines–Resuscitation Investigators. Association of COVID-19 Infection With Survival After In-Hospital Cardiac Arrest Among US Adults.
      ] We aimed to assess 1) the incidence of COVID-19 infection in patients hospitalized with cardiac arrest and 2) the impact of concomitant COVID-19 and cardiac arrest on in-hospital mortality in the United States.
      Using the national inpatient sample (NIS) database, we identified all the hospitalizations with cardiac arrest in the year 2020. Clinical characteristics and outcomes were compared between hospitalizations for cardiac arrest with and without concomitant COVID-19. Primary outcome was in-hospital mortality and secondary outcomes were cardiopulmonary resuscitation (CPR) & utilization of mechanical circulatory support. We present data on national estimates using the discharge weights provided by NIS. Categorical variables were compared using chi-square test and continuous variables using the Mann-Whitney U test. Multivariable logistic regression analysis was performed to adjust for patient and hospital characteristics. The statistical analysis was performed using SPSS version 23.0.
      261,430 hospitalizations for cardiac arrest were identified of which 31170 (11.9%) had concomitant COVID-19 infection. Patients with concomitant COVID-19 were more likely to be older, non-caucasians, obese, hypertensive, and diabetic. However, they were less likely to have a history of congestive heart failure, coronary artery disease, valvular disease, and acute myocardial infarction. Sepsis, pulmonary embolism and respiratory failure were more common in COVID-19 cohort. However, non-COVID-19 patients were more likely to have cardiogenic shock. The prevalence of shockable rhythms including ventricular tachycardia (VT) and ventricular fibrillation (VF) was significantly lower in COVID-19 patients.
      In-hospital mortality was significantly higher in COVID-19 group (86.9% vs 63.0%, adjusted odds ratio (aOR): 4.1 (95% confidence interval (CI), 3.8-4.4), p<0.001). CPR (aOR: 0.88 (95% CI, 0.83-0.92), p<0.001) and mechanical circulatory support (aOR: 0.26 (95% CI, 0.19-0.36), p<0.001) were significantly underutilized in COVID-19 cohort . Median length of stay and hospitalization charges were significantly higher in concomitant COVID-19 group.
      Our study is the largest study to assess the incidence and impact of COVID-19 infection in patients with cardiac arrest. Important observations from our study are: 1) Around 12% of all CA patients admitted across the US in the pre-vaccination period had concomitant COVID-19 infection; 2) COVID-19 positive patients who suffered cardiac arrest were four times more likely to die in the hospital as compared with non-COVID-19 patients; 3) CPR and mechanical circulatory support were significantly underutilized in the COVID-19 cohort; and 4) African-americans and Hispanics were disproportionately affected with increased prevalence of concomitant COVID-19 infection.
      These findings highlight the immense burden of COVID-19 infection on our society. Patients with COVID-19 who suffered a CA were more likely to have a non-shockable rhythm. Since we noted a higher incidence of pulmonary embolus (PE) and consequent respiratory failure in this population, hypoxia was probably the most common underlying mechanism behind CA in these patients. The results of our study suggests that in patients with CA and COVID-19, the care of the underlying infection is of paramount importance. Employing a protocol that utilizes a lower threshold to anticoagulate COVID-19 patients and also prioritizes the use of advanced treatment options early in the disease course for high risk patients may help in preventing a significant proportion of CA in these patients. In addition, these findings also highlight the challenges in taking care of COVID-19 patients with CA. Delays to performing chest compression due to the time needed to take appropriate precautions, hesitation from medical staff due to the concern of acquiring the infection, and the low utilization of MCS devices contribute to the suboptimal outcome noted in this group. With the possibility of further mutations and COVID surges, hospital systems should be prepared with a protocol that includes the use of automated chest compression devices, prioritizes early intubation, and also make personal protective equipment easily accessible in order to provide optimal and timely care to these patients.
      The results of our study need to be interpreted within the context of the following limitations. First is the use of retrospective administrative database which utilizes ICD codes instead of adjudication. Second, we were unable to determine the timing of cardiac arrest using this database. Third, this data provides information only during the pre-vaccination period. Furthermore, due to the retrospective nature of our study, the effect of unmeasured covariates on the primary outcome cannot be assessed. Table 1, Table 2
      Table 1Characteristics of patients who had cardiac arrest (CA) with and without concomitant COVID-19 infection
      CharacteristicsCA with concomitant COVID-19 infection N= 31170 (11.92%)CA without concomitant COVID-19 infection N=230260 (88.08%)P value
      Age (Median)6765<0.001
      Female39.4042.17<0.001
      Race<0.001
      White41.0061.35
      Black23.8820.24
      Hispanic25.3011.06
      Coronary artery disease24.4532.60<0.001
      Prior myocardial infarction4.766.88<0.001
      Hypertension75.3868.38<0.001
      Peripheral artery disease5.058.82<0.001
      Diabetes mellitus53.7438.50<0.001
      Hyperlipidemia41.7436.65<0.001
      Congestive heart failure29.4842.89<0.001
      COPD22.4326.19<0.001
      Valvular disease5.7610.86<0.001
      End stage renal disease10.1410.480.064
      STEMI1.966.37<0.001
      NSTEMI5.739.47<0.001
      Sepsis38.4828.38<0.001
      Pulmonary Embolism5.103.27<0.001
      Ventricular tachycardia9.4613.75<0.001
      Ventricular fibrillation6.2912.77<0.001
      Left heart catheterization1.3612.21<0.001
      Percutaneous coronary intervention0.676.27<0.001
      Coronary artery bypass surgery0.031.37<0.001
      Acute kidney injury63.4651.82<0.001
      ESRD on dialysis0.130.04<0.001
      Respiratory failure72.6266.68<0.001
      RF requiring mechanical Ventilation53.2951.98<0.001
      Cardiogenic Shock2.826.92<0.001
      Abbreviations: CA- cardiac arrest; COPD- chronic obstructive pulmonary disease; STEMI- ST-segment elevation myocardial infarction; NSTEMI- non-ST-segment elevation myocardial infarction; ESRD- end stage renal disease; RF- respiratory failure
      Table 2Outcomes of patients who had cardiac arrest (CA) with and without concomitant COVID-19 infection
      OutcomesCA with concomitant COVID-19 infection N= 31170 (11.92%)CA without concomitant COVID-19 infection N=230260 (88.08%)P value
      Died86.9463.03<0.001
      Adjusted OR4.10 (3.82-4.41)Reference<0.001
      CPR38.8537.72<0.001
      Adjusted OR0.88 (0.84-0.92)Reference<0.001
      MCSD0.672.89<0.001
      Adjusted OR0.26 (0.19-0.36)Reference<0.001
      LOS (Median)138<0.001
      Total Charges (Median)$230839$181332.91<0.001
      Abbreviations: OR: odds ratio; CPR: cardiopulmonary resuscitation; MCSD: mechanical circulatory support device; LOS: length of stay
      In this nationwide study of patients with cardiac arrest in the US, 12% were found to have concomitant COVID-19 infection. The presence of an active COVID-19 infection was associated with worse in-hospital outcomes after CA compared to those without the viral infection. Enhanced efforts are required to optimize the delivery of advanced cardiac life support (ACLS), assess for coagulopathy, and to aggressively treat the underlying infection in order to improve the outcomes of this high risk group.

      Funding source

      None

      Declaration of Competing Interest

      The authors declare no conflicts of interest

      Acknowledgements

      None

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