Wardhere, Abdirahman

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) using venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a promising strategy for refractory cardiac arrest. However, the role of left ventricular (LV) unloading during ECPR remains uncertain. Methods: We queried the United States National Inpatient Sample (2016-2021) to identify adult patients with out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA) who received ECPR. Patients were stratified based on the use of either VA-ECMO only or VA-ECMO with intra-aortic balloon pump (IABP) or VA-ECMO with Impella (ECPELLA) for ventricular unloading. Multivariable logistic regression was used to compare in-hospital outcomes between the groups. Results: Among 6,915 patients receiving ECPR, VA-ECMO alone was used in 5,145 (74.4%), VA-ECMO-IABP in 809 (11.7%), and ECPELLA in 961 (13.9%). The LV unloading groups more frequently presented with ventricular tachycardia/fibrillation (61.1% and 72.4% vs. 43.9%, both p<0.01), while the VA-ECMO only group more often presented with pulseless electrical activity/asystole (56.1% vs. 38.9% and 27.6%, both p<0.01). In IHCA patients, ECPELLA was associated with 50% lower odds of in-hospital mortality compared to VA-ECMO alone (adjusted odds ratio [aOR] 0.50, 95% CI 0.31-0.81, p<0.01). No significant difference was found in OHCA patients. VA-ECMO-IABP was not associated with a mortality benefit vs. VA-ECMO alone in either OHCA or IHCA (Figure 1). Cardiovascular complications were significantly higher in both LV unloading groups compared to the VA-ECMO only group in OHCA subgroup (90% and 95% vs. 73.3%, both p<0.01) while IHCA subgroup only showed higher significant rates in ECPELLA compared to VA-ECMO alone (89.3% vs. 81%, p=0.04) (Figure 2). After adjustment for potential confounders, VA-ECMO-IABP (aOR 2.79, 95% CI 1.02-7.60, p=0.04) and ECPELLA (aOR 6.92, 95% CI 2.09-22.94, p<0.01) were associated with significantly higher odds of cardiovascular complications compared to VA-ECMO alone among OHCA patients, but not among IHCA patient. There were no statistically significant differences in neurologic, renal, and hematologic complications between the three groups in either OHCA or IHCA patients (Figure 3). Conclusion: In this nationwide study, LV unloading with ECPELLA was associated with improved survival in IHCA patients but not in OHCA patients compared to VA-ECMO alone. The addition of IABP to VA-ECMO was not associated with a mortality benefit.

Background: In-hospital cardiac arrest (IHCA) is associated with significant morbidity and mortality. The relationships of race/ethnicity and sex to outcomes and treatment patterns among patients with IHCA remain poorly understood. Methods: We conducted a retrospective cohort study using the National Inpatient Sample database from 2016 to 2020 to identify adult patients with IHCA and compare in-hospital outcomes stratified by race/ethnicity (White, Black, Hispanic) and sex. The primary outcome was in-hospital mortality. Secondary outcomes included rates of in-hospital procedures. Multivariable logistic regression was used to adjust for potential confounders. Results: Among 207,770 patients with IHCA, 26.6% had ventricular tachycardia/fibrillation (VT/VF) and 73.4% had pulseless electrical activity (PEA)/asystole. In the VT/VF subgroup, Black males (aOR 1.42, 95% CI 1.21-1.66), Black females (aOR 1.25, 95% CI 1.05-1.50), and Hispanic females (aOR 1.30, 95% CI 1.01-1.66) had higher odds of mortality compared to White males (Figure 1). In the PEA/asystole subgroup, Black males (aOR 1.25, 95% CI 1.11-1.39) and Hispanic males (aOR 1.22, 95% CI 1.07-1.40) had higher odds of mortality, while White females had lower odds (aOR 0.88, 95% CI 0.82-0.94) compared to White males (Figure 2). Black patients were less likely to receive percutaneous coronary intervention (aOR 0.53, 95% CI 0.43-0.66 for males; aOR 0.54, 95% CI 0.42-0.69 for females) and coronary artery bypass grafting (aOR 0.50, 95% CI 0.30-0.82 for males; aOR 0.47, 95% CI 0.27-0.81 for females) compared to White males in VT/VF arrests. Additionally, Black males had the highest adjusted odds of renal replacement therapy in VT/VF arrests (aOR 1.47, 95% CI 1.21-1.80), while Hispanic males had the highest adjusted odds in PEA/asystole arrests (aOR 1.49, 95% CI 1.27-1.74) compared to White males. The remaining outcomes of interest in both VT/VF and PEA/asystole arrests are shown in Figure 1 and Figure 2 respectively. Conclusion: Significant racial/ethnic and sex disparities exist in outcomes and treatment patterns among patients with IHCA, with differences observed in both VT/VF and PEA/asystole subgroups. Targeted efforts and further studies are needed to better understand and address these disparities and improve outcomes in these severely ill patients.

Background In‐hospital cardiac arrest (IHCA) is associated with significant morbidity and mortality. The relationships between race and ethnicity and sex on outcomes and treatment patterns among patients with IHCA remain poorly understood. Methods and Results We conducted a retrospective study using the National (Nationwide) Inpatient Sample (NIS) database from 2016 to 2020 to identify adult patients with IHCA and examine the associations between in‐hospital outcomes and race and ethnicity (White, Black, Hispanic) and sex. The primary outcome was in‐hospital mortality. Secondary outcomes included rates of in‐hospital procedures. Multivariable logistic regression analysis was used to adjust for potential confounders. Among 207 770 patients with IHCA, 26.6% had ventricular tachycardia/ventricular fibrillation and 73.4% had pulseless electrical activity/asystole. For ventricular tachycardia/ventricular fibrillation arrest, Black men (adjusted odds ratio [aOR], 1.42 [95% CI, 1.21–1.66]), Black women (aOR, 1.25 [95% CI, 1.05–1.50]), and Hispanic women (aOR, 1.30 [95% CI, 1.01–1.66]) had higher odds of mortality compared with White men (corresponding adjusted risk ratios [aRRs], 1.10 [CI, 1.06–1.14], 1.06 [95% CI, 1.02–1.11], and 1.08 [95% CI, 1.01–1.14], respectively). In the pulseless electrical activity/asystole arrest subgroup, Black men (aOR, 1.25 [95% CI, 1.11–1.39]) and Hispanic men (aOR, 1.22 [95% CI, 1.07–1.40]) had higher odds of mortality (corresponding aRRs, 1.04 [95% CI, 1.02–1.06] and 1.04 [95% CI, 1.01–1.06], respectively). Black patients with IHCA were less likely to receive percutaneous coronary intervention, coronary artery bypass grafting, and mechanical circulatory support compared with White men. Conclusions Significant racial and ethnic and sex disparities exist in outcomes and treatment patterns among patients with IHCA. Targeted efforts and further studies are needed to better understand and address these disparities and improve outcomes.