Trends in treated ventricular fibrillation out-of-hospital cardiac arrest: A 17-year population-based study

doi:10.1016/j.hrthm.2004.04.017

Heart Rhythm

Volume 1, Issue 3, September 2004, Pages 255-259

https://doi.org/10.1016/j.hrthm.2004.04.017 Get rights and content

Abstract

Objectives

The aims of this study were to describe the trends of ventricular fibrillation (VF) out-of-hospital cardiac arrest in Rochester, Minnesota, since 1985 and to determine coexistent trends in implantable cardioverter defibrillator (ICD) placement and termination of potentially lethal ventricular arrhythmias that might explain, at least in part, a declining incidence trend.

Background

The incidence of VF out-of-hospital cardiac arrest treated by emergency medical services (EMS) personnel has declined over the past decade. Because VF out-of-hospital cardiac arrest occurs primarily in the setting of severe coronary artery disease, primary and secondary prevention strategies may account in part for the decline. In particular, ICD use in large primary and secondary prevention clinical trials in patients at high risk of sudden death has demonstrated that these devices improve survival.

Methods

All residents of the City of Rochester, Minnesota, who presented with a VF out-of-hospital cardiac arrest from 1985 to 2002, identified and treated by EMS, were included in the study. In addition, residents of the City of Rochester who received their first ICD implant from 1989 to 2002 were identified. From the ICD records, general demographics, etiology of heart disease, comorbid medical disease, and indication for ICD placement were abstracted. Follow-up data obtained from this population included ICD shocks, the underlying rhythm disturbance, and death.

Results

The overall incidence of EMS-treated VF out-of-hospital cardiac arrest in Rochester during the study period was 17.1 per 100,000 [95% confidence interval (CI) 15.1–19.4]. The incidence has decreased significantly (P < 0.001) over the study period: 1985–1989: 26.3/100,000 (95% CI 21.0–32.6), 1990–1994: 18.2/100,000 (95% CI 14.1–23.1), 1995–1999: 13.8/100,000 (95% CI 10.4–17.9), 2000–2002: 7.7/100,000 (95% CI 4.7–11.9). One hundred ten patients received an ICD. The placement of ICDs also has increased dramatically over the past 10 years: 1990–1994: 5.0/100,000 to 2000–2002: 20.7/100,000 (P < 0.001). ICDs terminated VF or fast ventricular tachycardia (<270 ms) in 22 patients. Termination of these potentially fatal arrhythmias has shown a trend toward an increase over the study period: 1990–1994: 1.1/100,000 to 2000–2002: 3.5/100,000 (P = 0.06).

Conclusions

The incidence of VF out-of-hospital cardiac arrest is declining. In contrast, the rates of ICD placement and ICD termination of ventricular tachycardia or VF are markedly increasing. Sudden death preventive strategies are multifactorial. These observations suggest that ICD termination of potentially lethal ventricular arrhythmias may contribute to the lower incidence of VF out-of-hospital cardiac arrest.

Section snippets

Background

Sudden cardiac death remains a major cause of mortality in the Western world and typically reflects underlying severe coronary artery disease.1, 2 However, since the late 1960s, the mortality from coronary artery disease in the United States has decreased.3, 4, 5 Cardiovascular mortality is substantially influenced by out-of-hospital sudden death, which likewise has decreased over time.3, 6

Ventricular fibrillation (VF) is the most common initial rhythm in out-of-hospital cardiac arrest in many

Methods

The study was approved by the Mayo Clinic Institutional Review Board for Human Subject Research. All patients with an out-of-hospital cardiac arrest between January 1985 and December 2002 who received defibrillation of VF by EMS (police officers/firefighters/paramedics) in the City of Rochester, Minnesota (population 85,806; 2000 census) were evaluated in the study. After determination of a cardiac arrest, first-responding personnel, primarily police officers or paramedics (Gold Cross Ambulance

Results

From 1985 to 2002, the overall incidence of VF out-of-hospital cardiac arrest treated by EMS in the City of Rochester was 17.1/100,000 [95% confidence interval (CI) 15.1–19.4]. The incidence decreased significantly (P < 0.001) over the study period: 1985–1989: 26.3/100,000 (95% CI 21.0–32.6), 1990–1994: 18.2/100,000 (95% CI 14.1–23.1), 1995–1999: 13.8/100,000 (95% CI 10.4–17.9), 2000–2002: 7.7/100,000 (95% CI 4.7–11.9). The annual numbers of cardiac arrests in Rochester from 1985 to 2002 are

Discussion

In Rochester, Minnesota, the incidence of EMS-treated VF has declined significantly since 1985. This trend in a smaller city with an ongoing study of out-of-hospital cardiac arrest parallels reports from Seattle, Washington,10 Helsinki, Finland,7 and Sweden.9, 11 These studies did not investigate the potential causes of this declining trend. The population-based data reported here expand on these prior reports by first demonstrating an overall decline in EMS-treated VF out-of-hospital cardiac

Conclusion

In this population-based study of City of Rochester residents, the incidence of EMS-treated VF out-of-hospital cardiac arrest declined during the study period from 1985 to 2002. Because this has been reported by other investigators in large populations as well, it appears that VF out-of-hospital cardiac arrest is declining in frequency. In contrast, the rate of ICD placement and ICD termination of VT or VF are markedly increasing. The cause of the declining incidence of VF out-of-hospital

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Of the 1544 shockable OHCAs (incidence 12.6%) included, 97.6% had VF and 2.4% had pVT. VF showed better outcomes than pVT. Predictors for both outcomes (SOD; CPC 1–2) were chronological change (adjusted odds ratio [aOR]: 1.133; 1.176), younger age (aOR: 0.973; 0.967), shorter response time (aOR: 0.998; 0.999), shorter scene time (aOR: 0.999; 0.999), witnessed collapse (aOR: 1.668; 1.670), and bystander cardiopulmonary resuscitation (BCPR) (aOR: 1.448; 1.576). Predictors for only SOD were public location (aOR: 1.450) and successful prehospital defibrillation (aOR: 3.374). The use of the supraglottic airway was associated with adverse outcomes. Chronologically with system interventions, BCPR rate, the proportion of shockable OHCA, and improved neurological outcomes increased over time.
The incidence of shockable OHCA remained low in Asian community. VF showed better outcomes than pVT. Over time, the incidence of shockable rhythm, BCPR rate and patient outcomes did improve with health system interventions. The number of prehospital defibrillations did not predict outcomes.
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We performed a cohort investigation of all non-traumatic, VF OHCA in the Cardiac Arrest Registry to Enhance Survival from 1/1/2013-12/31/2018 among EMS agencies that treated > = 100 VF OHCA. We evaluated sample size and survival with the addition of the new VF populations. We used Pearson coefficient to assess whether there was a correlation of agency-specific survival outcomes between the current Utstein population and unwitnessed and EMS-witnessed VF OHCA.
A total of 107 EMS agencies treated 38,836 VF arrests: 22,918 current Utstein, 11,297 unwitnessed VF, and 4621 EMS-witnessed VF OHCA. Overall, survival was 29.8% (11,567/38,836): 33.9% (7774/22,918) among current Utstein, 17.2% (1942/11,297) among unwitnessed VF, and 40.1% (1851/4621) among EMS-witnessed VF. For agency-specific survival outcome, the Pearson correlation was 0.52 between the current Utstein population versus combined unwitnessed and EMS-witnessed groups. For survival with Cerebral Performance Category 1–2, the Pearson correlation was 0.61.
Expanding the Utstein population to include unwitnessed and EMS-witnessed VF OHCA achieves a simpler, more inclusive case definition that minimizes variability in case determination and increases the number of survivors and eligible population by ∼50%, while still achieving a distinguishing metric of system-specific performance.
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We aimed to assess temporal changes in the incidence of OHCAs of presumed cardiac and non-cardiac aetiologies.
We conducted a retrospective cohort study of OHCAs in Victoria, Australia between 2000−2017. Annual adjusted incidence rates in presumed cardiac and non-cardiac OHCA were calculated with 95% confidence intervals (95% CI), assuming a Poisson distribution. Annual percent changes in the adjusted rates were calculated from Poisson regression models.
During an 18-year period, 90,688 emergency medical service (EMS)-attended OHCAs were included. Of those, 64,422 (71.0%) were of presumed cardiac and 26,266 (29.0%) were of non-cardiac aetiology. Over the 18-year period, there was a 12.6% (95% CI: 10.8%, 14.4%) relative decline in presumed cardiac events and this was driven largely by a reduction in cases with an initial shockable rhythm (23.4%; 95% CI: 19.8%, 27.0%) and cases in patients aged 65−79 years (48.6%; 95% CI: 45.0%, 50.4%). Conversely, there was a 28.8% (95% CI: 27.0%, 32.4%) relative increase in non-cardiac events over the 18-year period, and this was driven by an increase in initial pulseless electrical activity events (93.6%; 95% CI: 86.4%, 100.8%) and cases in patients aged ≥80 years (93.6%; 95% CI: 86.4%, 100.8%). Precipitating events with the largest 18-year increase in incidence were non-traumatic exsanguination (115.2%; 95% CI: 95.4%, 133.2%), respiratory (66.6%; 95% CI: 59.4%, 73.8%), and neurological (63.0%; 95% CI: 50.4%, 77.4%).
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Prior research suggests that the proportion of a shockable initial rhythm in out-of-hospital cardiac arrest (OHCA) declined during the last decades. This study aims to investigate if this decline is still ongoing and explore the relationship between location of OHCA and proportion of a shockable initial rhythm as initial rhythm.
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A total of 19,054 OHCA cases were included. Overall, the total proportion of cases with a shockable initial rhythm decreased from 42% to 37% (P < 0.01) from 2006 to 2015. When stratified according to location, the proportion of cases with a shockable initial rhythm decreased for OHCAs at a residential location (34% to 27%; P = 0.03), while the proportion of a shockable initial rhythm was stable among OHCAs in public locations (59%–57%; P = 0.2). During the last years of the study period (2011–2015), the overall proportion of a shockable initial rhythm remained stable (38%–37%; P = 0.45); this was observed for both residential and public OHCA.
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Original-clinicalsTrends in treated ventricular fibrillation out-of-hospital cardiac arrest: A 17-year population-based study

Abstract

Objectives

Background

Methods

Results

Conclusions

Section snippets

Background

Methods

Results

Discussion

Conclusion

J Am Coll Cardiol

Lancet

J Clin Epidemiol

Ann Emerg Med

Resuscitation

Epidemiology of sudden deathinsights from the Framingham Study

Cardiovasc Clin

Sudden cardiac death in the United States, 1989 to 1998

Circulation

Recent trends in acute coronary heart diseasemortality, morbidity, medical care, and risk factors. The Minnesota Heart Survey Investigators

N Engl J Med

Trends in the incidence of myocardial infarction and in mortality due to coronary heart disease, 1987 to 1994

N Engl J Med

Coronary heart disease death and sudden cardiac deatha 20-year population-based study

Am J Epidemiol

Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation

N Engl J Med

Experiences from treatment of out-of-hospital cardiac arrest during 17 years in Goteborg

Eur Heart J

Changing incidence of out-of-hospital ventricular fibrillation, 1980–2000

JAMA

Decrease in the occurrence of ventricular fibrillation as the initially observed arrhythmia after out-of-hospital cardiac arrest during 11 years in Sweden

Original-clinicals
Trends in treated ventricular fibrillation out-of-hospital cardiac arrest: A 17-year population-based study