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Precise criteria for extracorporeal cardiopulmonary resuscitation (ECPR) are still lacking in patients with out-of-hospital cardiac arrest (OHCA). We aimed to investigate whether adopting our hypothesized criteria for ECPR to patients with refractory OHCA could benefit. This before-after study compared 4.5 years after implementation of ECPR for refractory OHCA patients who met our criteria (Jan, 2015 to May, 2019) and 4 years of undergoing conventional CPR (CCPR) prior to ECPR with patients who met the criteria (Jan, 2011 to Jan, 2014) in the emergency department. The primary and secondary outcomes were good neurologic outcome at 6-months and 1-month respectively, defined as 1 or 2 on the Cerebral Performance Category score. A total of 70 patients (40 with CCPR and 30 with ECPR) were included. For a good neurologic status at 6-months and 1-month, patients with ECPR (33.3%, 26.7%) were superior to those with CCPR (5.0%, 5.0%) (all P s < 0.05). Among patients with ECPR, a group with a good neurologic status showed shorter low-flow time, longer extracorporeal membrane oxygenation duration and hospital stays, and lower epinephrine doses used (all P s < 0.05). The application of the detailed indication before initiating ECPR appears to increase a good neurologic outcome rate.

Indications of extracorporeal cardiopulmonary resuscitation (ECPR) are still debatable, particularly in patients with cancer. Prediction of the prognosis of in-hospital cardiac arrest (IHCA) in patients with cancer receiving ECPR is important given the increasing prevalence and survival rate of cancer. We compared the neurologic outcomes and survival rates of IHCA patients with and without cancer receiving ECPR. Data from the extracorporeal membrane oxygenation registry between 2015 and 2019 were used in a retrospective manner. The primary outcome was 6-month good neurologic outcome, defined as a Cerebral performance category score of 1 or 2. The secondary outcomes were 1- and 3-month good neurologic outcome, and 6-month survival. Among 247 IHCA patients with ECPR, 43 had active cancer. The 6-month good neurologic outcome rate was 27.9% and 32.4% in patients with and without active cancer, respectively ( P  > 0.05). Good neurologic outcomes at 1-month (30.2% vs. 20.6%) and 3-month (30.2% vs. 28.4%), and the survival rate at 6-month (39.5% vs. 36.5%) were not significantly different (all P  > 0.05) Active cancer was not associated with 6-month good neurologic outcome by logistic regression analyses. Therefore, patients with IHCA should not be excluded from ECPR solely for the presence of cancer itself.

The modified accelerated diagnostic protocol (ADP) to assess patients with chest pain symptoms using troponin as the only biomarker (mADAPT), the History, ECG, Age, Risk factors, and Troponin (HEART) pathway, and the Emergency Department Assessment of Chest Pain Rule (EDACS)-ADP, are the three most well-known ADPs for patients with chest pain. These ADPs define major adverse cardiac event (MACE) as components of acute myocardial infarction, revascularization, and death; unstable angina is not included as an endpoint. We performed a single-center prospective observational study comparing the performance of these 3 ADPs for patients with 30-day MACE with and without unstable angina. We hypothesized that these ADPs will have high sensitivities for MACE without unstable angina, a definition used for score derivation studies. However, when unstable angina is included in the MACE, their performances would be lower than the acceptable rate of >99% sensitivity. A total of 1,214 patients were included in the analysis. When unstable angina was not included in the endpoint, sensitivities for MACE were 99.1% (95% confidence interval [CI]: 96.7–99.9%), 99.5% (95% CI: 97.4–100%), and 100% (95% CI: 98.3–100%) for mADAPT, EDACS-ADP, and HEART pathway, respectively. The HEART pathway had the highest proportion of patients classified as low risk (39.2%, 95% CI: 35.8–42.9%), followed by EDACS-ADP (31.3%, 95% CI: 28.2–34.6%) and mADAPT (29.3%, 95% CI: 26.4–32.5%). However, when unstable angina was included in the MACE, sensitivities were 96.6% (95% CI: 94.4–98.1%) for mADAPT, 97.3% (95% CI: 95.3–98.6%) for EDACS-ADP, and 97.3% (95% CI: 95.3–98.6%) for the HEART pathway, respectively. There were 15 false-negative cases with mADAPT, and 12 false-negative cases each for EDACS-ADP and HEART pathway. All three ADPs—mADAPT, EDACS-ADP, and HEART pathway—were similarly accurate in their discriminatory performance for the risk stratification of ED patients presenting with possible ACS when unstable angina was not included in the endpoint. The HEART pathway showed the best combination of sensitivity and proportion of patients that can be classified as safe for early discharge. However, when unstable angina was added to the endpoint, all three ADPs did not show appropriate safety levels and their performances were lower than the acceptable risk of MACE.

Background: Early risk stratification is crucial due to septic patients’ heterogeneity. Serum albumin level may reflect the severity of sepsis and host status. This study aimed to evaluate the prognostic ability of the initial sequential organ failure assessment (SOFA) score alone and combined with serum albumin levels for predicting 28-day mortality in patients with septic shock. Methods: We conducted an observational study using a prospective, multicenter registry of septic shock patients between October 2015 and May 2022 from 12 emergency departments in the Korean Shock Society and the results were validated by examining those from the septic shock cohort in Asan Medical Center. The primary outcome was 28-day mortality. The area under the receiver operating characteristic (ROC) curve was used to compare the predictive values of SOFA score alone and SOFA score combined with serum albumin level. Results: Among 5805 septic shock patients, 1529 (26.3%) died within 28 days. Mortality increased stepwise with decreasing serum albumin levels (13.6% in albumin ≥3.5, 20.7% in 3.5–3.0, 29.7% in 3.0–2.5, 44.0% in 2.5–2.0, 56.4% in <2.0). The albumin SOFA score was calculated by adding the initial SOFA score to the 4 points assigned for albumin levels. ROC analysis for predicting 28-day mortality showed that the area under the curve for the albumin SOFA score was 0.71 (95% CI 0.70–0.73), which was significantly higher than that of the initial SOFA score alone (0.68, 95% CI: 0.67–0.69). Conclusions: The combination of the initial SOFA score with albumin can improve prognostic accuracy for patients with septic shock, suggesting the albumin SOFA score may be used as an early mortality stratification tool.

Current guidelines recommend the use of the updated Diamond–Forrester (DF) method and Coronary Artery Disease (CAD) Consortium models to assess the pretest probability of obstructive CAD. The present study aimed to compare the performance of these models among patients with chest pain evaluated in an emergency department (ED). We compared three scores (DF, CAD consortium basic, and clinical) among 1247 consecutive patients with chest pain who underwent coronary computed tomographic angiography (CTA). Invasive angiography was performed to confirm the stenosis for those who showed obstructive CAD on CTA, if clinically indicated. Primary outcome was the presence of obstructive CAD (≧50% stenosis). Overall, 426 (34.2%) patients were diagnosed with obstructive CAD. The expected prevalence of CAD was underestimated by the CAD consortium clinical model (23.4%) and overestimated by the DF model (53.1%). For the prediction of obstructive CAD, the CAD consortium clinical model had superior area under the receiver-operating curve (0.754), followed by the CAD consortium basic (0.736), and finally, the DF model (0.718). Whereas the CAD consortium models more accurately classified patients without any CAD or nonobstructive CAD as low-risk patients, the DF model more accurately classified high-risk patients with obstructive CAD. The net reclassification improvement of CAD consortium basic and clinical models were 24.7% and 27.9%, respectively. Compared with the DF model, the CAD consortium clinical model appears to improve the prediction of low-risk patients with <15% probability of having obstructive CAD. However, this model needs caution when using in high-risk population.

Accurate risk stratification for obstructive coronary artery disease (CAD) and major cardiac adverse events (MACE) is important in emergency departments. We compared six established chest pain risk scores (the HEART score, CAD basic model, CAD clinical model, TIMI, GRACE, uDF) for prediction of obstructive CAD and MACE. Patients who presented to the emergency department with chest pain or symptoms of suspected CAD and underwent coronary computed tomographic angiography were analyzed. The primary endpoint was adverse outcomes including the presence of obstructive CAD (≥50% stenosis) and the occurrence of MACE within 6 weeks. We compared the risk scores by the area under the receiver-operating characteristic curve (AUC) and calculated their respective net reclassification index (NRI). Adverse outcomes occurred in 285 (28.4%) out of the 1002 patients included. For the prediction of adverse outcomes, the AUC of the HEART score (0.792) was superior to those of the CAD clinical model (0.760), CAD basic model (0.749), TIMI (0.749), uDF (0.703), and GRACE (0.653). In terms of the NRI, the HEART score significantly improved the reclassification abilities of the uDF (0.39), GRACE score (0.27), CAD basic model (0.11), TIMI (0.10), and CAD clinical model (0.08) (all P < 0.05). The HEART score also had the highest negative predictive value as well (0.893). The HEART score was superior to other cardiac risk scores in predicting both obstructive CAD and MACE. However, due to the high false-negative rate (11%) of the HEART score, its use for identifying low-risk patients should be considered with caution.

Newly updated guidelines suggest brain computed tomography for out-of-hospital cardiac arrest survivors to identify a neurologic cardiac arrest cause. We hypothesized that the “pseudo-subarachnoid hemorrhage” (p-SAH) sign in cardiac arrest survivors is associated with poor outcome. We retrospectively evaluated the registries of 2 tertiary hospitals, identifying 836 adult (≥18 years) patients achieving return of spontaneous circulation after out-of-hospital cardiac arrest. Among them, 398 patients with brain computed tomography within 6 hours after return of spontaneous circulation and received targeted temperature management from 2009 to 2014 were included. Clinical characteristics and outcomes of patients with and without p-SAH were compared. The prevalence of p-SAH sign was 8.0%. The p-SAH group more frequently had asystole as first rhythm and nonwitnessed arrest, predominantly resulting from asphyxia (56.3%). Targeted temperature management characteristics were not different between groups, although the p-SAH cohort had worse neurologic outcomes at discharge (100% vs 67.2%; P < .001). Pseudo-subarachnoid hemorrhage had 11.5% sensitivity, 100% specificity, 100% positive predictive value, and 32.8% negative predictive value for poor neurologic outcome. Pseudo-subarachnoid hemorrhage sign might be one of the simple methods to identify poor neurologic outcome early. However, further prospective studies will be needed to clarify the clinical implication of the p-SAH sign. •“Pseudo-subarachnoid hemorrhage” (p-SAH) sign was rarely seen on early brain computed tomography in out-of-hospital cardiac arrest survivors.•All patients with p-SAH had poor neurologic outcome despite targeted temperature management.•p-SAH may be one of the simple methods of neuroprognostication in cardiac arrest survivors.

ObjectiveSepsis-induced myocardial dysfunction (SIMD) can involve both the left and right ventricles. However, the characteristics and outcomes across various manifestations of SIMD remain unknown.MethodsThis was a retrospective cohort study using a prospective registry of septic shock from January 2011 and April 2017. Patients with clinically presumed cardiac dysfunction underwent echocardiography within 72 hours after admission and were enrolled (n=778). SIMD was classified as left ventricle (LV) systolic/diastolic and right ventricle (RV) dysfunction, which were defined based on the American Society of Echocardiography criteria. The primary outcome was 28-day mortality.ResultsOf the 778 septic shock patients who underwent echocardiography, 270 (34.7%) showed SIMD. The median age was 67.0 years old, and the male was predominant (57.3%). Among them, 67.3% had LV systolic dysfunction, 40.7% had RV dysfunction and 39.3% had LV diastolic dysfunction. Although serum lactate level and sequential organ failure assessment score were not significantly different between groups, SIMD group showed higher troponin I (0.1 vs 0.1 ng/mL; p=0.02) and poor clinical outcomes, including higher 28-day mortality (35.9 vs 26.8%; p<0.01), longer intensive care unit length of stay (5 vs 2 days; p<0.01) and prolonged mechanical ventilation (9 vs 4 days; p<0.01). Multivariate analysis showed that isolated RV dysfunction was an independent risk factor of 28-day mortality (OR 2.26, 95% CI 1.04 to 4.91).ConclusionsOne-third of patients with septic shock showed various myocardial dysfunctions. LV systolic dysfunction was common; however, only RV dysfunction was associated with short-term mortality.

The diagnosis of acute pulmonary embolism (PE) in trauma patients is challenging. This study evaluated the diagnostic value of simplified Wells and simplified revised Geneva scores to predict PE in femur fracture patients in emergency department (ED). All consecutive adult patients with femur fractures and elevated D-dimer levels (>0.5μg/mL) who underwent CTPA within 72h of injury from January 2010 to December 2014 were included. The simplified Wells and simplified revised Geneva scores were applied to evaluate the clinical probability of PE. Among 519 femur fracture patients, 446 patients were finally included, and 23 patients (5.2%) were diagnosed with acute PE. The median values of simplified Wells and simplified revised Geneva scores [0 (IQR: 0–1) vs. 0 (IQR: 0–0), P=0.23; 3 (IQR: 2–4) vs. 3 (IQR: 2–3), P=0.48] showed no differences between the PE (n=23) and non-PE (n=423) groups. Using the simplified Wells score, 98% of the patients were categorized into the “PE unlikely” group. The sensitivity, specificity, positive predictive value, and negative predictive value of the simplified revised Geneva score (≥3 points) for the diagnosis of PE were 74%, 35%, 6%, and 96%, respectively. In femur fracture patients with elevated D-dimer levels, the simplified Wells and simplified revised Geneva scores have limited predictive value. However, the simplified revised Geneva score of <3 points may be possibly used as a diagnostic tool.

We developed a modified cardiovascular (CV) Sequential Organ Failure Assessment (SOFA) score using an emergency department-based cohort data, incorporating norepinephrine equivalent dose and lactate to represent current clinical practice patterns for vasopressor utilization and the diagnostic significance of lactate, respectively. In this study, we sought to validate this modified CV-SOFA score in intensive care unit patients with suspected infection using the Marketplace for Medical Information in Intensive Care (MIMIC)-IV database. This was a retrospective study that utilized data from the MIMIC-IV database. Modified CV/total SOFA score and original CV/total SOFA score were compared for predicting in-hospital mortality. Area under the receiver operating characteristic curve (AUROC) and the calibration curve were employed to evaluate discrimination and calibration, respectively. A total of 29,618 ICU patients with suspected infections was analyzed. The in-hospital mortality rate was 12.4% (n = 3,675). Modified CV-SOFA score (AUROC 0.667; 95% confidence interval [CI] 0.657–0.677 vs. 0.663; 95% CI 0.654–0.673; p = 0.283) and modified total SOFA score (0.784 [95% CI 0.776–0.793] vs. 0.785 [95% CI 0.777–0.793], p = 0.490) did not differ significantly from the original CV-SOFA score and original total SOFA score, respectively. The calibration curve of the original CV-SOFA score was inferior to that of the modified CV-SOFA score. The modified CV- and total SOFA scores were better calibrated than the original CV- and total SOFA scores, but their discriminative performance was not significantly different. Further studies of the modified CV-SOFA score in different settings and populations are required to assess the generalizability of this score.