Background

Patients with ST-elevation myocardial infarction (STEMI) complicated by an out-of-hospital-cardiac-arrest (OHCA) may vary widely in their probability of dying. Large variation in mortality may have implications for current national efforts to benchmark operator and hospital mortality rates for coronary angiography. We aimed to build a risk-adjustment model of in-hospital mortality among OHCA survivors with concurrent STEMI.

Methods

Within the Cardiac Arrest Registry to Enhance Survival (CARES), we included adults with OHCA and STEMI who underwent emergent angiography within 2 hours of hospital arrival between January 2013 and December 2019. Using multivariable logistic regression to adjust for patient and cardiac arrest factors, we developed a risk-adjustment model for in-hospital mortality and examined variation in patients’ predicted mortality.

Results

Of 2,999 patients (mean age 61.2 ± 12.0, 23.1% female, 64.6% white), 996 (33.2%) died during their hospitalization. The final risk-adjustment model included higher age (OR per 10-year increase, 1.50 [95% CI: 1.39–1.63]), unwitnessed OHCA (OR, 2.51 [1.99–3.16]), initial non-shockable rhythm [OR, 5.66 [4.52–7.13]), lack of sustained pulse for > 20 minutes (OR, 2.52 [1.88–3.36]), and longer resuscitation time (increased with each 10-minute interval) (c-statistic = 0.804 with excellent calibration). There was large variability in predicted mortality: median, 25.2%, inter-quartile-range: 14.0% to 47.8%, 10th-90th percentile: 8.2 % to 74.1%.

Conclusions

In a large national registry, we identified 5 key predictors for mortality in patients with STEMI and OHCA and found wide variability in mortality risk. Our findings suggest that current national benchmarking efforts for coronary angiography, which simply adjusts for the presence of OHCA, may not adequately capture patient case-mix severity.

中文翻译：

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院外心脏骤停和 ST 段抬高心肌梗死患者的风险调整模型

背景

伴有院外心脏骤停 (OHCA) 的 ST 段抬高心肌梗死 (STEMI) 患者的死亡概率可能差异很大。死亡率的巨大差异可能对当前国家对冠状动脉造影术者和医院死亡率进行基准测试的努力产生影响。我们的目的是建立一个 OHCA 幸存者并发 STEMI 的住院死亡率风险调整模型。

方法

在提高生存率的心脏骤停登记处 (CARES) 中，我们纳入了 2013 年 1 月至 2019 年 12 月期间在到达医院 2 小时内接受急诊血管造影的 OHCA 和 STEMI 成人。使用多变量逻辑回归来调整患者和心脏骤停因素，我们开发了住院死亡率的风险调整模型，并检查了患者预测死亡率的变化。

结果

在 2,999 名患者（平均年龄 61.2 ± 12.0，23.1% 女性，64.6% 白人）中，996 人（33.2%）在住院期间死亡。最终的风险调整模型包括更高的年龄（OR 每增加 10 年，1.50 [95% CI: 1.39–1.63]），未见证的 OHCA（OR，2.51 [1.99–3.16]），初始不可电击节律 [OR， 5.66 [4.52–7.13]），脉搏持续时间减少 > 20 分钟（OR，2.52 [1.88–3.36]），复苏时间更长（每 10 分钟间隔增加）（c 统计量 = 0.804，校准良好） . 预测死亡率存在很大差异：中位数，25.2%，四分位数范围：14.0% 至 47.8%，第 10-90 个百分位数：8.2% 至 74.1%。

结论

在一项大型国家登记中，我们确定了 STEMI 和 OHCA 患者死亡率的 5 个关键预测因子，并发现死亡率风险存在很大差异。我们的研究结果表明，目前国家对冠状动脉造影的基准测试（仅根据 OHCA 的存在进行调整）可能无法充分捕捉患者病例组合的严重程度。