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    Reinforcing the Links in the Chain of Survival. Lambiase Pier D Journal of the American College of Cardiology 10.1016/j.jacc.2017.06.060
    Continuous improvements in "chain of survival" increased survival after out-of-hospital cardiac arrests: a large-scale population-based study. Iwami Taku,Nichol Graham,Hiraide Atsushi,Hayashi Yasuyuki,Nishiuchi Tatsuya,Kajino Kentaro,Morita Hiroshi,Yukioka Hidekazu,Ikeuchi Hisashi,Sugimoto Hisashi,Nonogi Hiroshi,Kawamura Takashi Circulation BACKGROUND:The impact of ongoing efforts to improve the "chain of survival" for out-of-hospital cardiac arrest (OHCA) is unclear. The objective of this study was to evaluate the incremental effect of changes in prehospital emergency care on survival after OHCA. METHODS AND RESULTS:This prospective, population-based observational study involved consecutive patients with OHCA from May 1998 through December 2006. The primary outcome measure was 1-month survival with favorable neurological outcome. Multiple logistic regression analysis was used to assess factors that were potentially associated with better neurological outcome. Among 42,873 resuscitation-attempted adult OHCAs, 8782 bystander-witnessed arrests of presumed cardiac origin were analyzed. The median time interval from collapse to call for medical help, first cardiopulmonary resuscitation, and first shock shortened from 4 (interquartile range [IQR] 2 to 11) to 2 (IQR 1 to 5) minutes, from 9 (IQR 5 to 13) to 7 (IQR 3 to 11) minutes, and from 19 (IQR 13 to 22) to 9 (IQR 7 to 12) minutes, respectively. Neurologically intact 1-month survival after witnessed ventricular fibrillation increased from 6% (6/96) to 16% (49/297; P<0.001). Among all witnessed OHCAs, earlier cardiopulmonary resuscitation (odds ratio per minute 0.89, 95% confidence interval 0.85 to 0.93) and earlier intubation (odds ratio per minute 0.96, 95% confidence interval 0.94 to 0.99) were associated with better neurological outcome. For ventricular fibrillation, only earlier shock was associated with better outcome (odds ratio 0.84, 95% confidence interval 0.80 to 0.88). CONCLUSIONS:Data from a large, population-based cohort demonstrate a continuous increase in OHCA survival with improvement in the chain of survival. The incremental benefit of early advanced care on OHCA survival is also suggested. 10.1161/CIRCULATIONAHA.108.802058
    Implementation of the fifth link of the chain of survival concept for out-of-hospital cardiac arrest. Tagami Takashi,Hirata Kazuhiko,Takeshige Toshiyuki,Matsui Junichiroh,Takinami Makoto,Satake Masataka,Satake Shuichi,Yui Tokuo,Itabashi Kunihiro,Sakata Toshio,Tosa Ryoichi,Kushimoto Shigeki,Yokota Hiroyuki,Hirama Hisao Circulation BACKGROUND:The American Heart Association 2010 resuscitation guidelines recommended adding a fifth link (multidisciplinary postresuscitation care in a regional center) to the previous 4 in the chain of survival concept for out-of-hospital cardiac arrest. Our study aimed to determine the effectiveness of this fifth link. METHODS AND RESULTS:This multicenter prospective cohort study involved all eligible out-of-hospital cardiac arrest patients in the Aizu region (n=1482, suburban/rural, Fukushima, Japan). Proportions of favorable neurological outcomes were evaluated before (January 2006-April 2008) and after (January 2009-December 2010) the implementation of the fifth link. After implementation, all patients were transported directly from the field to the tertiary-level hospital or secondarily from an outlying hospital to the tertiary-level hospital after restoration of circulation. The tertiary hospital provided intensive postresuscitation care, including appropriate hemodynamic and respiratory management, therapeutic hypothermia, and percutaneous coronary intervention. One-month survival with a favorable neurological outcome among all patients treated by emergency medical services providers improved significantly after implementation (4 of 770 [0.5%] versus 21 of 712 [3.0%]; P<0.001). The adjusted odds ratios of favorable neurological outcome were 0.9 (95% confidence interval, 0.7-1.1) for early access to emergency medical care, 3.1 (95% confidence interval, 0.7-14.2) for bystander resuscitation, 14.7 (95% confidence interval, 3.2-67.0) for early defibrillation, 1.0 (95% confidence interval, 1.0-1.1) for early advanced life support, and 7.8 (95% confidence interval, 1.6-39.0) for the fifth link. CONCLUSION:The proportion of out-of-hospital cardiac arrest patients with a favorable neurological outcome improved significantly after the implementation of the fifth link, which may be an independent predictor of outcome. CLINICAL TRIAL REGISTRATION:URL: http://www.apps.who.int/trialsearch. Unique identifier: UMIN000001607. 10.1161/CIRCULATIONAHA.111.086173
    Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival. Strömsöe Anneli,Svensson Leif,Axelsson Åsa B,Claesson Andreas,Göransson Katarina E,Nordberg Per,Herlitz Johan European heart journal AIMS:To describe out-of-hospital cardiac arrest (OHCA) in Sweden from a long-term perspective in terms of changes in outcome and circumstances at resuscitation. METHODS AND RESULTS:All cases of OHCA (n = 59,926) reported to the Swedish Cardiac Arrest Register from 1992 to 2011 were included. The number of cases reported (n/100,000 person-years) increased from 27 (1992) to 52 (2011). Crew-witnessed cases, cardiopulmonary resuscitation prior to the arrival of the emergency medical service (EMS), and EMS response time increased (P < 0.0001). There was a decrease in the delay from collapse to calling for the EMS in all patients and from collapse to defibrillation among patients found in ventricular fibrillation (P < 0.0001). The proportion of patients found in ventricular fibrillation decreased from 35 to 25% (P < 0.0001). Thirty-day survival increased from 4.8 (1992) to 10.7% (2011) (P < 0.0001), particularly among patients found in a shockable rhythm and patients with return of spontaneous circulation (ROSC) at hospital admission. Among patients hospitalized with ROSC in 2008-2011, 41% underwent therapeutic hypothermia and 28% underwent percutaneous coronary intervention. Among 30-day survivors in 2008-2011, 94% had a cerebral performance category score of 1 or 2 at discharge from hospital and the results were even better if patients were found in a shockable rhythm. CONCLUSION:From a long-term perspective, 30-day survival after OHCA in Sweden more than doubled. The increase in survival was most marked among patients found in a shockable rhythm and those hospitalized with ROSC. There were improvements in all four links in the chain of survival, which might explain the improved outcome. 10.1093/eurheartj/ehu240