Local hospital may be sufficient for non-ST-elevation out-of-hospital cardiac arrest

medwireNews: Results of the randomized ARREST trial show that patients resuscitated after an out-of-hospital cardiac arrest (OHCA) who do not have ST-segment elevation are perhaps best treated at the closest emergency hospital rather than being transported to a specialist cardiac arrest center. The clinical trial, conducted exclusively in London, UK, showed no difference in survival between the two strategies, with 63% of patients in each group dying by the 30-day primary assessment endpoint The unadjusted risk ratio (RR) was 1.0 for all-cause mortality at 30 days, and there was also no difference when all-cause mortality was assessed again at 3 months (RR=1.02). “We show that delivery of patients to the nearest emergency department after presumed cardiac arrest without ST elevation is a reasonable approach and has similar outcomes as delivery to a tertiary centre in the UK health-care setting,” Tiffany Patterson (Guy’s and St Thomas’ NHS Foundation Trust, London) and co-investigators report in The Lancet. The findings, which were simultaneously presented at the ESC Congress 2023 in Amsterdam, the Netherlands, also showed no difference in neurologic outcomes between the two approaches either at 30-day discharge or at 3 months, say the researchers. The results contrast to those of a prior meta-analysis, they acknowledge, but the team points out that the meta-analysis was of observational studies and that, to their knowledge, ARREST is the first randomized trial in this area and meets an unmet need for such trials, as highlighted by the International Liaison Committee on Resuscitation. Commenting on the findings, Carolina Malta Hansen (Copenhagen University, Denmark) and associates say that the lack of survival advantage with the transportation of patients to specialty cardiac arrest centers “is surprising and important, since this complex and critically ill population would be expected to benefit from centres with more expertise.” Altogether 827 people who had been resuscitated after an OHCA were included in the intention-to-treat population. Patients were assessed for inclusion by the London Ambulance staff attending to them and then an advanced paramedic practitioner at the central dispatch desk used a secure system to randomly allocate 414 patients to be taken directly to one of seven hospitals with specialist cardiac centers and 413 to one of 28 geographically close hospitals. As the ambulance staff had to then drive the patient to the allocated hospital for treatment, this was an open-label trial. While that “might have influenced in-hospital treatment strategies and the assessment of neurological outcomes,” say the commentators, “the outcome of mortality is unlikely to have been affected by ascertainment bias.” But they add that “although mortality is the most important outcome, quality of life might be equally important for many patients, and it is possible that long-term recovery could be enhanced with care at a specialised centre.” Getting to the specialist center took an average of 7 minutes longer than transfer to the nearest hospital (84 vs 77 minutes), but once there, patients were more likely to receive coronary angiography (56 vs 37%) and to receive this faster (median 2.3 vs 5.7 hours), be admitted to intensive care (80 vs 69%) and receive hemodynamic (72 vs 62%), ventilatory (86 vs 76%), and renal (11 vs 8%) support. “It could be that basic high-quality critical care, which exists at the local London hospitals, is all that matters to optimise survival,” suggest the commentators, adding that “[i]t would be a mistake to conclude the trial results apply to regions where local hospitals provide a lower quality of care than those in this trial.” The trial does show, however, that while there was no survival benefit, there was also “no harm in transferring patients to the specialised centres in London, with modest transportation delays,” note Hansen et al. They say: “Prioritising a minimum standard of care at local hospitals caring for this population is at least as important as ensuring high-quality care or advanced treatment at tertiary centres.” Hospital care and follow-up, bystander cardiopulmonary resuscitation, and early defibrillation might also influence survival “when coupled with high-quality prehospital care with trained staff and short response times,” Hansen and colleagues conclude. medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2023 Springer Healthcare Ltd, part of the Springer Nature Group ESC Congress 2023; Amsterdam, the Netherlands: 25–28 August Lancet 2023; doi:10.1016/S0140-6736(23)01351-X Lancet 2023; doi:10.1016/S0140-6736(23)01560-X

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Local hospital may be sufficient for non-ST-elevation out-of-hospital cardiac arrest

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