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Abandoning therapeutic hypothermia after cardiac arrest: are real world data compelling enough to question the Targeted Temperature Management trial?
Session:
Posters 4 - Écran 1 - Doença Coronária
Speaker:
Christopher Strong
Congress:
CPC 2019
Topic:
E. Coronary Artery Disease, Acute Coronary Syndromes, Acute Cardiac Care
Theme:
14. Acute Cardiac Care
Subtheme:
14.5 Acute Cardiac Care – Cardiac Arrest
Session Type:
Posters
FP Number:
---
Authors:
Christopher Strong; António Tralhão; Gustavo Da Rocha Rodrigues; Catarina Brízido; Jorge Santos Ferreira; Carlos Aguiar; Miguel Mendes
Abstract
<p><strong>Background: </strong>Until 2013, a growing body of evidence favored the use of therapeutic hypothermia (TH) in comatose survivors after cardiac arrest. Practices changed dramatically after the TTM trial demonstrated no difference between 32-34ºC and 36ºC targets. However, difficulties in avoiding fever during “normothermia” may potentially compromise a 36ºC based strategy. We aimed to assess the impact of not performing hypothermia in real-world conditions.</p> <p><strong>Methods: </strong>Consecutive patients admitted to a cardiac ICU from January 2008 to October 2018 after arrest of presumed cardiac origin and presenting with a Glasgow Coma Scale Score ≤ 8 were identified and divided into two groups (TH: 32-34ºC during 24 hours followed by gradual rewarming and no-TH: fever control). The decision to perform TH was left to the attending physicians. A propensity score (PS) was used to account for baseline imbalances using the variables collected in the TTM trial. Primary endpoints were all-cause mortality and severe disability defined as a cerebral performance category > 2 (range 1-5).</p> <p><strong>Results: </strong>90 patients were identified during the study period, of which 22 underwent TH. Mean patient age was 64 ± 15 years, 78% were male and in 63% of cases the presenting rhythm was shockable. Mean time to return of spontaneous circulation (ROSC) was 25 ±19 minutes, mean lactate was 6.4 ± 4.6 mmol/L and mean pH was 7.24 ± 0.13. After ROSC, the most frequent ECG change was ST-segment elevation (47%). The majority of patients underwent emergent coronary angiography (80%) and PCI was performed in 42 cases. After PS matching, TH (n = 20) and no-TH (n = 20) groups showed no significant difference in clinical characteristics. Mean temperature during the first 48 hours was 33.8ºC (range 33.0 - 36.0ºC) in the TH group and 36.8º C in the non-TH group (range 35 - 37.5ºC) - p < 0.01. Median follow-up in the matched population was 0.8 (IQR 0.2 - 4.4) years. Kaplan-Meier curves (figure) revealed improved survival in hypothermia patients (65 vs. 25%, log-rank p = 0.009). Neurological status at discharge was significantly better in the TH group (70 vs. 30%, p = 0.026).</p> <p><strong>Conclusions: </strong>In a real-world setting, moderate TH may offer a prognostic benefit to patients resuscitated after cardiac arrest. Difficulties in maintaining body temperature below 36ºC may, to some extent, account for the diverging results between our population and patients from the TTM trial.</p>
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