to EMS response, and initial rhythm simi-larly revealed no differences in outcome.
Rescue breathing in out-of-hospital by-stander CPR does not seem to improvesurvival compared to chest compressionsalone, and, given its drawbacks — difficultto perform and potential transmission of infection — it should be abandoned.
— J. Stephen Bohan, MD, MS, FACP,FACEP,
Journal Watch EmergencyMedicine
Svensson L et al. Compression-only CPR or standard CPR in out-of-hospital cardiac arrest.
N Engl J Med
2010 Jul 29; 363:434.
Improving Outcomes of CardiacArrest: Don’t Forget About CPR!
The 2005 AHA resuscitation guidelines,which emphasize high-quality CPR, havehad a positive effect.
In the late 1990s and early 2000s, many predicted that automated external defi-brillators would markedly improve car-diac arrest outcomes; unfortunately, thesehopes were not realized. In 2005, theAmerican Heart Association publishedresuscitation guidelines reemphasizingthe importance of circulatory supportwith properly performed chest compres-sions in addition to defibrillation. Changesfrom previous recommendations includeda compression-to-ventilation ratio of 30:2, ventilation at
10 breaths per minute, anda more-vigorous compression technique.To evaluate the effects of the new guide-lines, investigators compared outcomes in1605 cardiac arrest patients treated ac-cording to the 2005 guidelines and 1641controls treated before guideline imple-mentation in five U.S. emergency medicalservices (EMS) systems.Age, sex, rates of bystander cardio-pulmonary resuscitation (CPR), and timefrom 911 call to arrival of EMS personneldid not differ significantly between the twogroups. The rate of survival to hospital dis-charge was significantly higher in patientstreated after guideline implementationthan in controls (13.1% vs. 10.1%). In pa-tients with ventricular tachycardia or fib-rillation, the rate of survival to dischargewas 32.3% and 20.0%, respectively. Neuro-logical function was also significantly im-proved in survivors treated according to2005 protocols, compared with controls.
Increased emphasis on cardiopulmonary circulation has improved outcomes of car-diac arrest. Yet further improvement islikely to be possible, not only in survivalbut in survival with good neurologicalfunction. The path to improvement will bemultifactorial, including higher rates andquality of bystander CPR and improvedpostarrest treatment.
— Mark S. Link, MD
Aufderheide TP et al. Implementing the 2005 American Heart Association Guidelines improvesoutcomes after out-of-hospital cardiac arrest.
2010 Apr 24; [e-pub ahead of print]. (http://dx.doi.org/10.1016/j.hrthm.2010.04.022)
Microvascular Outcomesin the ACCORD Trial
Intensive glycemic control did not lower theincidence of microvascular adverse outcomes.
In the ACCORD trial, 10,000 patients withtype 2 diabetes (mean age, 62; average du-ration of diabetes, 10 years) were random-ized to receive intensive or standard glyce-mic control; choice of antidiabetic agentswas individualized. The main purpose of ACCORD was to determine whether inten-sive treatment (target glycosylated hemo-globin [HbA
6%) improved car-diovascular outcomes. The trial was haltedafter an average follow-up of 3.5 years,when overall and cardiovascular mortality were significantly higher with intensivethan with standard treatment (
Jul 2008, p. 53, and
N Engl J Med
2008;358:2545). Now, the researchers presentmicrovascular outcomes.The principal composite microvascularoutcome was end-stage renal disease, riseof serum creatinine to >3.3 mg/dL, or needfor photocoagulation or vitrectomy to treatretinopathy. This outcome occurred in simi-lar proportions of patients in the intensiveand standard treatment groups, both duringthe study itself (9%) and after 1.5 additionalyears of follow-up (11%). Although inten-sive treatment appeared to slow the progres-sion of neuropathy, the incidence of a com-posite endpoint that included neuropathy (along with nephropathy and retinopathy)remained similar between groups. Somesecondary endpoints (e.g., incident albu-
Harlan M. Krumholz, MD, SM,
Harold H. Hines, Jr.,Professor of Medicine, Section of CardiovascularMedicine, Yale University School of Medicine,New Haven
Kristin L. Odmark
Massachusetts Medical Society
Howard C. Herrmann, MD,
Professor of Medicine,Director, Interventional Cardiology and CardiacCatheterization Laboratories, University ofPennsylvania Medical Center, Philadelphia
JoAnne M. Foody, MD,
Director, CardiovascularWellness Center, Brigham and Women’s Hospital,Boston
Joel M. Gore, MD,
Edward Budnitz Professorof Cardiovascular Medicine, University ofMassachusetts, Worcester
Mark S. Link, MD,
Associate Professor of Medicine,New England Medical Center and Tufts UniversitySchool of Medicine, Boston
Frederick A. Masoudi, MD, MSPH,
Division ofCardiology, Denver Health Medical Center andAssociate Professor of Medicine, University ofColorado at Denver
Beat J. Meyer, MD,
Associate Professor ofCardiology, University of Bern; Chief, Division ofCardiology, Lindenhofspital, Bern, Switzerland
William T. Abraham, MD,
Professor of Medicine,Chief, Division of Cardiovascular Medicine,The Ohio State University Heart Center, Columbus
Hugh Calkins, MD,
Professor of Medicine andDirector of Electrophysiology, The Johns HopkinsHospital, Baltimore
Kim A. Eagle, MD,
Albion Walter Hewlett Professorof Internal Medicine and Chief of ClinicalCardiology, Division of Cardiology, University ofMichigan Medical Center, Ann Arbor
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Vol. 16 No. 9