Duration of cardiopulmonary resuscitation and outcomes for adults with in-hospital cardiac arrest: retrospective cohort study
BMJ 2024; 384 doi: https://doi.org/10.1136/bmj-2023-076019 (Published 07 February 2024) Cite this as: BMJ 2024;384:e076019
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Dear Editor
We read your article “Duration of cardiopulmonary resuscitation and outcomes for adults with in-hospital cardiac arrest: retrospective cohort study” with great interest [1].
It might be beneficial to consider the importance of stratified analysis by race/ethnicity. A previous study has shown that the survival rate and survival to discharge rate after in-hospital cardiac arrest are lower in Black patients compared to White patients [2]. It is known that this discrepancy could be attributed not only to socioeconomic status and cardiovascular risk factors [3,4], but also to pathophysiological differences, including cardiac hypertrophy [5]. Assuming the existence of racial differences, survival probabilities predicted predominantly based on data from White patients (68.5% of the current study) could influence decision-making and resuscitation strategies, and potentially disadvantaging patients of other race/ethnicities. Additional analysis specific to race/ethnicity could help understand and address potential differences and unfairness.
References:
1. Okubo M, Komukai S, Andersen LW, et al. American Heart Association’s Get With The Guidelines—Resuscitation Investigators. Duration of cardiopulmonary resuscitation and outcomes for adults with in-hospital cardiac arrest: retrospective cohort study. BMJ. 2024;384:e076019. doi: 10.1136/bmj-2023-076019. PMID: 38325874.
2. Chan PS, Nichol G, Krumholz HM, et al. American Heart Association National Registry of Cardiopulmonary Resuscitation (NRCPR) Investigators. Racial differences in survival after in-hospital cardiac arrest. JAMA. 2009;302:1195-201. doi: 10.1001/jama.2009.1340. PMID: 19755698.
3. Bosson N, Fang A, Kaji AH, et al. Racial and ethnic differences in outcomes after out-of-hospital cardiac arrest: Hispanics and Blacks may fare worse than non-Hispanic Whites. Resuscitation. 2019;137:29-34. doi: 10.1016/j.resuscitation.2019.01.038. PMID: 30753852.
4. Shah KS, Shah AS, Bhopal R. Systematic review and meta-analysis of out-of-hospital cardiac arrest and race or ethnicity: black US populations fare worse. Eur J Prev Cardiol. 2014;21:619-38. doi: 10.1177/2047487312451815. PMID: 22692471.
5. Deo R, Safford MM, Khodneva YA, et al. Differences in Risk of Sudden Cardiac Death Between Blacks and Whites. J Am Coll Cardiol. 2018;72:2431-2439. doi: 10.1016/j.jacc.2018.08.2173. PMID: 30442286.
Competing interests: No competing interests
Dear Editor,
This study provides useful information to both guide clinicians decision-making in cardiac arrests; and inform patients during advanced decision-making discussions.
A 2023 study by Salleh et al (1) showed that knowledge and experience have little influence on the decision to terminate cardiopulmonary resuscitation (CPR) during cardiac arrest however multiple external factors contribute. This includes family presence, past co-morbidity, age, and circumstance of arrest. The importance of each varies considerably between clinicians, demonstrating the lack of consensus towards futile CPR.
A similar effect is demonstrated in Morgan et al 2002 (2) study examining junior doctor attitudes towards in-hospital cardiac arrest. We can see that a common theme is a lack of early senior input into advanced care planning, which can leave arrest teams in a difficult situation.
When applying this information to the Okubo et al study, we can consider how clinicians individual attitudes may skew this data. The steep decline in survival probability within 0-10 minutes could be explained by clinicians attitudes towards ‘futile’ CPR and inappropriate intervention. It could also falsely lower survival chances in the early stages of CPR. This is covered by the authors statement ‘assuming all decisions on termination of resuscitation were accurate’, however the factors that contribute to termination may shine further light on outcomes for our patients.
Using this information, we can gain two further conclusions.
First, our advanced care planning discussions are vital to high-quality in-hospital care, and these should be personalised to patients. The 22% survival probability is a headline figure, however this is highly variable and clinicians should use individualised predictions.
Secondly, attitudes of cardiac arrest team members towards CPR may confound these results, so examining this fully could aid clinicians in improving their decisions of when CPR is futile.
(1) Salleh NAM et al. Questionnaire Survey Medical Futility and Termination of Resuscitation in Out-of-hospital-cardiac-arrest Patients Presenting to Emergency Department in Hospitals in Klang Valley. Eurasian J Emerg Med 2023;22:146-160.
(2) Morgan R, Westmoreland C. Survey of junior hospital doctors' attitudes to cardiopulmonary resuscitation. Postgrad Med J. 2002 Jul;78(921):413-5.
Competing interests: No competing interests
Re: Questions about the data——Duration of cardiopulmonary resuscitation and outcomes for adults with in-hospital cardiac arrest: retrospective cohort study
Dear Editor,
I am writing to you to clarify the data in this article. The visual abstract showed that there were 384996 participants in the study, however, 348996 patients were included in the results section. I think it is necessary to confirm which one is the real data.
Thank you and best regards.
Yours sincerely,
Qiong Zhang
Competing interests: No competing interests