When is a Cardiac Arrest Non-Cardiac?

Introduction: While the overall survival rate for out-of-hospital cardiac arrest (OHCA) is low, ranging from 5%-10%, several characteristics have been shown to decrease mortality, such as presence of bystander cardiopulmonary resuscitation (CPR), witnessed vs unwitnessed events, and favorable initial rhythm (VF/VT). More recently, studies have shown that modified CPR algorithms, such as chest-compression only or cardio-cerebral resuscitation, can further increase survival rates in OHCA. Most of these studies have included only OHCA patients with "presumed cardiac etiology," on the assumption that airway management is of lesser impact than chest compressions in these patients. However, prehospital personnel often lack objective and consistent criteria to assess whether an OHCA is of cardiac or non-cardiac etiology. Hypothesis/Problem: The relative proportions of cardiac vs non-cardiac etiology in published data sets of OHCA in the peer-reviewed literature were examined in order to assess the variability of prehospital clinical etiology assessment. Methods: A Medline (US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA) search was performed using the subject headings " OHCA" and " Emergency Medical Services" (EMS). Studies were included if they reported prevalence of cardiac etiology among OHCA in the entire patient sample, or in all arms of a comparison study. Studies that either did not report etiology of OHCA, or that excluded all cardiac or non-cardiac etiologies prior to reporting clinical data, were excluded. Results: Twenty-four studies were identified, containing 27 datasets of OHCA which reported the prevalence of presumed cardiac vs non-cardiac etiology. These 27 datasets were drawn from 15 different countries. The prevalence of cardiac etiology among OHCA ranged from 50% to 91%. No obvious patterns were found regarding database size, year of publication, or global region (continent) of origin. Conclusions: There exists significant variation in published rates of cardiac etiology among OHCAs. While some of this variation likely reflects different actual rates of cardiac etiologies in the sampled populations, varying definitions of cardiac etiology among prehospital personnel or varying implementation of existing definitions may also play a role. Different proportions of cardiac vs non-cardiac etiology of OHCA in a sample could result in entirely different interpretations of data. A more specific consensus definition of cardiac etiology than that which currently exists in the Utstein template may provide better guidance to prehospital personnel and EMS researchers in the future.