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What is the association between the coronavirus disease 2019 (COVID-19) pandemic and out-of-hospital cardiac arrest (OHCA) outcomes in the US?
This registry study found that rates of return of spontaneous circulation were 18% lower overall than before the pandemic, including 11% to 15% lower in communities with low COVID-19 mortality. Rates of survival to discharge were 17% lower, primarily in communities with moderate to high COVID-19 mortality, and incidence of OHCA was higher, but largely in communities with high COVID-19 mortality.
The outcomes of OHCA were worse during the first weeks of the COVID-19 pandemic in the US, and this was observed not only in areas with high case-fatality rates but also ones with lower rates.
Recent reports from communities severely affected by the coronavirus disease 2019 (COVID-19) pandemic found lower rates of sustained return of spontaneous circulation (ROSC) for out-of-hospital cardiac arrest (OHCA). Whether the pandemic has affected OHCA outcomes more broadly is unknown.
To assess the association between the COVID-19 pandemic and OHCA outcomes, including in areas with low and moderate COVID-19 disease burden.
Design, Setting, and Participants
This study used a large US registry of OHCAs to compare outcomes during the pandemic period of March 16 through April 30, 2020, with those from March 16 through April 30, 2019. Cases were geocoded to US counties, and the COVID-19 mortality rate in each county was categorized as very low (0-25 per million residents), low (26-100 per million residents), moderate (101-250 per million residents), high (251-500 per million residents), or very high (>500 per million residents). As additional controls, the study compared OHCA outcomes during the prepandemic period (January through February) and peripandemic period (March 1 through 15).
The COVID-19 pandemic.
Main Outcomes and Measures
Sustained ROSC (≥20 minutes), survival to discharge, and OHCA incidence.
A total of 19 303 OHCAs occurred from March 16 through April 30 in both years, with 9863 cases in 2020 (mean [SD] age, 62.6 [19.3] years; 6040 men [61.3%]) and 9440 in 2019 (mean [SD] age, 62.2 [19.2] years; 5922 men [62.7%]). During the pandemic, rates of sustained ROSC were lower than in 2019 (23.0% vs 29.8%; adjusted rate ratio, 0.82 [95% CI, 0.78-0.87]; P < .001). Sustained ROSC rates were lower by between 21% (286 of 1429 [20.0%] in 2020 vs 305 of 1130 [27.0%] in 2019; adjusted RR, 0.79 [95% CI, 0.65-0.97]) and 33% (149 of 863 [17.3%] in 2020 vs 192 of 667 [28.8%] in 2019; adjusted RR, 0.67 [95% CI, 0.56-0.80]) in communities with high or very high COVID-19 mortality, respectively; however, rates of sustained ROSC were also lower by 11% (583 of 2317 [25.2%] in 2020 vs 740 of 2549 [29.0%] in 2019; adjusted RR, 0.89 [95% CI, 0.81-0.98]) to 15% (889 of 3495 [25.4%] in 2020 vs 1109 of 3532 [31.4%] in 2019; adjusted RR, 0.85 [95% CI, 0.78-0.93]) in communities with very low and low COVID-19 mortality. Among emergency medical services agencies with complete data on hospital survival (7085 total patients), survival to discharge was lower during the pandemic compared with 2019 (6.6% vs 9.8%; adjusted RR, 0.83 [95% CI, 0.69-1.00]; P = .048), primarily in communities with moderate to very high COVID-19 mortality (interaction P = .049). Incidence of OHCA was higher than in 2019, but the increase was largely observed in communities with high COVID-19 mortality (adjusted mean difference, 38.6 [95% CI, 37.1-40.1] per million residents) and very high COVID-19 mortality (adjusted mean difference, 28.7 [95% CI, 26.7-30.6] per million residents). In contrast, there was no difference in rates of sustained ROSC or survival to discharge during the prepandemic and peripandemic periods in 2020 vs 2019.
Conclusions and Relevance
Early during the pandemic, rates of sustained ROSC for OHCA were lower throughout the US, even in communities with low COVID-19 mortality rates. Overall survival was lower, primarily in communities with moderate or high COVID-19 mortality.
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Accepted for Publication: October 16, 2020.
Published Online: November 14, 2020. doi:10.1001/jamacardio.2020.6210
Corresponding Author: Paul S. Chan, MD, MSc, Saint Luke’s Mid America Heart Institute, 4401 Wornall Rd, Kansas City, MO 64111 (email@example.com).
Author Contributions: Dr Chan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Chan, Girotra, McNally.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Chan.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Tang, Al-Araji.
Obtained funding: McNally.
Administrative, technical, or material support: Al-Araji, McNally.
Conflict of Interest Disclosures: Dr Chan has received funding support from the American Heart Association, which currently helps to fund the Cardiac Arrest Registry to Enhance Survival (CARES) registry. Dr Nallamothu reported being a principal investigator or co-investigator on research grants from the National Institutes of Health, VA Health Services Research and Development Service, and the American Heart Association; receiving compensation as editor-in-chief of Circulation: Cardiovascular Quality & Outcomes, a journal of the American Heart Association; and being a coinventor on US utility patent No. US 9,962,124 as well as a provisional patent application (54423) that use software technology with signal processing and machine learning to automate the reading of coronary angiograms, held by the University of Michigan and licensed to AngioInsight, Inc, in which Dr Nallamothu holds ownership shares and receives consultancy fees. The University of Michigan also has filed patents on Dr Nallamothu’s behalf on the use of computer vision for imaging applications in gastroenterology, with technology elements licensed to Applied Morphomics Inc, in which he have no relationship or stake. No other disclosures were reported.
Funding/Support: Dr Chan is supported by grant 1R01HL123980 from the National Heart Lung and Blood Institute. The Cardiac Arrest Registry to Enhance Survival (CARES) was funded by the Centers for Disease Control and Prevention from 2004 through 2012. The program is now supported through private funding from the American Red Cross, the American Heart Association, and in-kind support from Stryker Physio-Control and Emory University. Dr McNally is supported by grant funding from CARES and serves as executive director of the program.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Meeting Presentation: This paper was presented at the American Heart Association Scientific Sessions 2020; November 14, 2020; virtual conference.
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