Bradycardia During Targeted Temperature Management: An Early Marker of Lower Mortality and Favorable Neurologic Outcome in Comatose Out-of-Hospital Cardiac Arrest Patients
Bradycardia During Targeted Temperature Management: An Early Marker of Lower Mortality and Favorable Neurologic Outcome in Comatose Out-of-Hospital Cardiac Arrest Patients
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DOI：
10.1097/ccm.0000000000001390
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发表时间：
2016-02-01
影响因子：
8.8
通讯作者：
Kjaergaard, Jesper
中科院分区：
文献类型：
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作者：
Thomsen, Jakob Hartvig;Nielsen, Niklas;Kjaergaard, Jesper
目的：心动过缓在目标温度管理期间很常见，可能是对较低体温的生理反应，最近在较小的观察性研究中与院外心脏骤停后的良好结局相关。本研究试图在接受33 ℃目标温度管理治疗的患者的大型多中心队列中证实这一发现，并探索对36 ℃目标温度管理的反应。设计：前瞻性随机研究的事后分析。设置：10个国家的36个ICU。患者：我们研究了447（目标温度管理= 33 ℃）和430（目标温度管理= 36 ℃）具有可用心率数据的昏迷院外心脏骤停患者，在2010年至2013年的目标温度管理试验中随机分配。干预措施：在33摄氏度和36摄氏度进行目标温度管理。测量和主要结果：终点为180天死亡率和不利的神经功能（脑功能分类3-5）。在随机分组后12、20和28小时，根据目标温度和目标温度管理期间的最低心率（< 50、50-59和60次/分钟[参考]）对患者进行分层。在33 ℃组中，分别有132例（30%）和131例（29%）记录到心率低于50次/分钟和50-59次/分钟。粗180天死亡率随最低心率增加而增加（< 50次/min = 32%，50-59次/min = 43%，60次/min = 60%; p（对数秩）< 0.0001）。心动过缓小于50次/分与180天死亡率较低独立相关（风险比（调整后）= 0.50 [0.34-0.74; p < 0.001]）和不良神经学结局的几率较低（比值比（校正）= 0.38 [ 0.21-0.68; p < 0.01]）在调整潜在混杂因素的模型中，包括年龄，初始节律，恢复自主循环的时间，入院时乳酸含量相似的，虽然不太强，较低的心率和良好的结果，发现在36 ℃的目标温度管理治疗的患者的独立关联。结论：这项研究证实了心动过缓和较低的死亡率和良好的神经功能的结果在一个大的队列昏迷的院外心脏骤停患者治疗的目标温度管理在33 ℃。因此，在33 ℃的目标温度管理期间心动过缓可能是有利结果的新的早期标志。
Objectives: Bradycardia is common during targeted temperature management, likely being a physiologic response to lower body temperature, and has recently been associated with favorable outcome following out-of-hospital cardiac arrest in smaller observational studies. The present study sought to confirm this finding in a large multicenter cohort of patients treated with targeted temperature management at 33 degrees C and explore the response to targeted temperature management targeting 36 degrees C.Design: Post hoc analysis of a prospective randomized study.Setting: Thirty-six ICUs in 10 countries.Patients: We studied 447 (targeted temperature management = 33 degrees C) and 430 (targeted temperature management = 36 degrees C) comatose out-of-hospital cardiac arrest patients with available heart rate data, randomly assigned in the targeted temperature management trial from 2010 to 2013.Interventions: Targeted temperature management at 33 degrees C and 36 degrees C.Measurements and Main Results: Endpoints were 180-day mortality and unfavorable neurologic function (cerebral performance category 3-5). Patients were stratified by target temperature and minimum heart rate during targeted temperature management (< 50, 50-59, and 60 beats/min [reference]) at 12, 20, and 28 hours after randomization. Heart rates less than 50 beats/min and 50-59 beats/min were recorded in 132 (30%) and 131 (29%) of the 33 degrees C group, respectively. Crude 180-day mortality increased with increasing minimum heart rate (< 50 beats/min = 32%, 50-59 beats/min = 43%, and 60 beats/min = 60%; p(log-rank) < 0.0001). Bradycardia less than 50 beats/min was independently associated with lower 180-day mortality (hazard ratio(adjusted) = 0.50 [0.34-0.74; p < 0.001]) and lower odds of unfavorable neurologic outcome (odds ratio(adjusted) = 0.38 [ 0.21-0.68; p < 0.01]) in models adjusting for potential confounders including age, initial rhythm, time to return of spontaneous circulation, and lactate at admission. Similar, albeit less strong, independent associations of lower heart rates and favorable outcome were found in patients treated with targeted temperature management at 36 degrees C.Conclusions: This study confirms an independent association of bradycardia and lower mortality and favorable neurologic outcome in a large cohort of comatose out-of-hospital cardiac arrest patients treated by targeted temperature management at 33 degrees C. Bradycardia during targeted temperature management at 33 degrees C may thus be a novel, early marker of favorable outcome.