Postarrest Steroid Use May Improve Outcomes of Cardiac Arrest Survivors

Min-Shan Tsai, MD, PhD; Po-Ya Chuang, MHA; Chien-Hua Huang, MD, PhD; Chao-Hsiun Tang, PhD; Ping-Hsun Yu, MD; Wei-Tien Chang, MD, PhD; Wen-Jone Chen, MD, PhD

Disclosures

Crit Care Med. 2019;47(2):167-175. 

In This Article

Results

The underlying characteristics, CPR events, and socioeconomic status of the enrolled patients are shown in Table 1. When compared with patients in the nonsteroid group, a higher percentage of patients in the steroid group had chronic obstructive pulmonary disease (COPD), asthma, adrenal insufficiency, autoimmune disease, steroid use within 1 year prior to cardiac arrest, and were treated in a tertiary medical center. In contrast, lower percentages of patients in the steroid group had coronary artery disease (CAD) chronic kidney disease (CKD), a low frequency of shockable rhythm, and required only a smaller dose of epinephrine. After matching with the PS, there were 5,445 patients in the steroid and nonsteroid groups, respectively. Supplemental Table 5 (Supplemental Digital Content 5, http://links.lww.com/CCM/E71) and Supplemental Table 6 (Supplemental Digital Content 6, http://links.lww.com/CCM/E72) shows demographic and clinical characteristics of the patients with and without steroid use prior to cardiac arrest, respectively. After PS matching, no difference existed between the steroid and nonsteroid groups in the patients with and without steroid use prior to cardiac arrest, respectively. Baseline characteristic of unmatched patients in each steroid group were listed in Supplemental Table 7 (Supplemental Digital Content 7, http://links.lww.com/CCM/E73).

Among all the samples (total patients, patients with and without prior steroid use before cardiac arrest), steroid use during hospitalization benefitted the following endpoints: survival to discharge and 1-year survival in both unmatched and matched cohorts (Table 2). With 100 bootstrap replications, the optimism-corrected area under the ROC curve ranged from 0.77 to 0.80 for models with either steroid use or steroid dose as a predictor, showing the models have good performance. The adjusted 1-year survival curves shown in Figure 2 showed significant difference between the two groups in total matched patients (adjusted hazard ratio, 0.73; 95% CI, 0.70–0.76; p < 0.0001). We next investigated whether the steroid use during hospitalization may have interacted with individual clinical characteristics to affect the survival to discharge. As shown in Supplemental Figure 1 (Supplemental Digital Content 8, http://links.lww.com/CCM/E74), steroid use during hospitalization was associated with better survival to discharge, regardless of age, gender, underlying diseases (diabetes, COPD, asthma), shockable rhythm, and steroid use within 1 year prior to cardiac arrest.

Figure 2.

The 1-yr survival curves of the groups. There is a significant difference between these groups (p < 0.0001).

The outcomes of patients in each quartile with consecutive increases in steroid dose are listed in Table 3. The demographic and clinical characteristics of each quartile of the total patients, patients with and without steroid use prior to cardiac arrest are shown in Supplemental Table 8 (Supplemental Digital Content 9, http://links.lww.com/CCM/E75), Supplemental Table 9 (Supplemental Digital Content 10, http://links.lww.com/CCM/E76), and Supplemental Table 10 (Supplemental Digital Content 11, http://links.lww.com/CCM/E77). Supplemental Table 11 (Supplemental Digital Content 12, http://links.lww.com/CCM/E78) demonstrates the duration of hospitalization in each steroid strata. The duration of hospitalization and prednisolone dose equivalent of each quartile were listed in Supplemental Table 12 (Supplemental Digital Content 13, http://links.lww.com/CCM/E79). In all the samples, patients in the first (the lowest dose) and second quartiles benefited from steroids in terms of survival to discharge and 1-year survival. However, these benefits began to disappear in the third quartile and reversed in the fourth quartile (the highest dose). Therefore, we created a ROC curve of the third quartile which suggested a steroid dose of 50 mg/d as the optimal cut-off value (Supplemental Figure 2, Supplemental Digital Content 14, http://links.lww.com/CCM/E80). Thus the steroid group was divided into a low steroid group (≤ 50 mg/d) and a high steroid group (> 50 mg/d). Supplemental Table 13 (Supplemental Digital Content 15, http://links.lww.com/CCM/E81) shows that the low steroid group was associated with lower mortality when compared with the nonsteroid group, and the high steroid group was associated with worse outcomes. The estimations of model internal validity in assessing survival to discharge in matched cohorts are shown in Supplemental Table 14 (Supplemental Digital Content 16, http://links.lww.com/CCM/E82).

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