Key Points:
- Sudden cardiac death causes a fifth of all deaths in industrialized countries, but survival to hospital discharge remains low.
- Transfer to a specialized, cath-lab capable cardiac arrest center may expedite care of patients with an ischemic cause of arrest.
- This multicenter randomized trial compared transfer to a specialized cardiac arrest center with the nearest ED in patients with a resuscitated out-of-hospital cardiac arrest (OHCA). The primary endpoint was 30-day all-cause mortality.
- There were no differences in the primary endpoint of all-cause mortality between the two transportation strategies, nor any difference in the secondary endpoints of 3-month mortality and neurological outcome.
Sudden cardiac death causes 20% of all deaths in industrialized countries. While early bystander CPR and early defibrillation improve survival, only 1:10 patients experiencing an out-of-hospital cardiac arrest (OHCA) survive to leave hospital. In a breaking presentation at the 2023 ESC Congress today, Dr. Simon Redwood and his team presented “Expedited Transfer to a Cardiac Arrest Centre for non-ST Elevation OHCA,” or the ARREST study. These results were also simultaneously published in The Lancet.
The ARREST study (NCT03872960) was a randomized, open label, multicenter trial (conducted across 22 hospitals in London, UK) of adult patients who were successfully resuscitated from an out-of-hospital cardiac arrest. Patients were then randomized to either be transported to their nearest ED or the nearest cath-lab capable Cardiac Arrest Center. Key exclusion criteria were the presence of STEMI, a DNR order, suspected pregnancy, or presumed non-cardiac cause. The primary endpoint was 30-day all-cause mortality.
A total of 862 patients were enrolled, of whom 431 (50%) were randomly assigned to a cardiac arrest center and 431 (50%) to standard of care. After some participants were withdrawn, 411 and 412 respectively were included in the primary analysis. The mean age was 63, and 32% were women. Half of the patients had symptoms preceding their arrest, and 55% had a shockable rhythm. Expectedly, there was a longer duration of time from arrest to hospital arrival in the cardiac arrest center group (84 mins vs 77 mins). There were no differences in the primary endpoint of all-cause mortality at 30 days, with a 63% mortality in each group (RR 1.00, 95% CI 0.90-1.11, p=0.96). There were also no significant differences in death at 3 months (65% in the cardiac arrest center group and 64% in the standard care group) or neurological outcome between groups. On subgroup analysis, there was interaction with age (p for interaction=0.0029); patients age <57 had reduced 30-day all-cause mortality in the cardiac arrest center group (RR 0.76, 95% CI 0.60-0.97) whereas patients age 57-71 had increased all-cause mortality (RR 1.28, 95% CI 1.05-1.56).
When discussing the clinical implications of the study at the ESC Congress press conference, Dr. Redwood stated: “This study does not support transportation of cardiac arrest patients directly to a cardiac arrest center in London….they should go to their nearest ED….these results may allow better allocation of resources elsewhere.”
