In-Hospital Cardiac Arrest Common, Survival Poor, in COVID-19

Fran Lowry

October 13, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Cardiac arrest is common in critically ill patients with COVID-19, and is associated with poor survival, particularly among older patients, two recent studies suggest.

In the first report, from William Beaumont Hospital, Royal Oak, Michigan, 60 of 1309 (4.6%) patients hospitalized with COVID-19 had an in-hospital cardiac arrest. Of these, 54 had documented cardiopulmonary resuscitation (CPR). None survived to discharge.

"These outcomes warrant further investigation into the risks and benefits of performing prolonged CPR in this subset of patients, especially because the resuscitation process generates aerosols that may place healthcare personnel at a higher risk of contracting the virus," the authors conclude in a Research Letter published in JAMA Internal Medicine.

In the second report, 701 of 5019 (14.0%) critically ill COVID-19 patients had in-hospital cardiac arrest. Of these, 400 received CPR and 48 patients (12%) survived to discharge, although 20 of these patients had moderate to severe neurologic dysfunction.

That Study of the Treatment and Outcomes in Critically Ill Patients With Covid-19 (STOP-COVID) was published online September 30 in BMJ.

"Cardiac arrest is associated with poor survival even when cardiopulmonary resuscitation is given, particularly in patients aged 80 or older, and in those who require prolonged CPR," first author Salim S. Hayek, MD, University of Michigan, Ann Arbor, told theheart.org | Medscape Cardiology.

"Because of this, it's important to initiate discussion on goals of care with patients and family early on. We also need to set up protocols for cardiopulmonary resuscitation that include providing a sufficient amount of PPE and protection during CPR for providers," he said.

Finally, Hayek added, "we need to be aware of the importance of intervening in COVID-19 early to prevent patients from becoming that sick, because the best way to treat cardiac arrest is to prevent it. Now that we have a lot of new therapies and have more experience with treating COVID, we hope that we may not have to deal with such a large number of very sick patients."

Nonshockable Rhythm Most Common in COVID-19

Before the pandemic, 25% of patients who had in-hospital cardiac arrest survived to discharge, and the initial rhythm was nonshockable in 81% of cases, corresponding author Corey Mayer, DO, MBA, and colleagues from William Beaumont Hospital, write.

In their study, however, the initial rhythm was nonshockable in 52 patients (96.3%), with 44 patients (81.5%) having pulseless electrical activity and eight (14.8%) having asystole.

CPR resulted in return of spontaneous circulation (ROSC) in 29 patients (53.7%), and the median time to achieve this was 8 minutes (interquartile range [IQR], 4 - 10 minutes). Fifteen of the patients who reached ROSC had their code status changed to do not resuscitate (DNR), and 14 recoded, received additional CPR, and died.

The median age was 61.5 years, and most patients were Black. The majority had obesity, hypertension, or diabetes, and at the time of cardiac arrest, 43 patients (79%) were receiving mechanical ventilation, 18 (33%) were receiving kidney replacement therapy, and 25 (46.3%) were receiving vasopressor support.

The median time from admission to cardiac arrest was 8 days (IQR, 4 - 12 days), and the overall median duration of CPR was 10 minutes (IQR, 7 - 20 minutes). The mortality rate following CPR was 100%.

Mayer and colleagues note that the transmission of COVID-19 to healthcare providers has been documented, and that this transmission may be further compounded by the limited supply of PPE nationwide.

"Further studies in this area would be beneficial, and potentially aid in informing CPR guidelines for this patient population," they write.

Some COVID-19 Patients Survive After CPR

In separate report, the multicenter STOP-COVID study, that comprised data from 68 centers across the United States, showed similar findings with regard to age and comorbidity status, with older and sicker patients experiencing in-hospital cardiac arrest to a greater extent than younger patients with fewer comorbidities.

The study also showed that being Black and being in a center with a smaller number of ICU beds were associated with a higher risk for in-hospital cardiac arrest. Coronary artery disease and congestive heart failure were not associated with in-hospital cardiac arrest.

Among the 701 patients who experienced in-hospital cardiac arrest, 400 (57.1%) received CPR. The 301 patients who did not had a DNR code at the time of their cardiac arrest.

Younger patients were more likely to get CPR: 75.0% of patients younger than 45 years received CPR, compared with 39.5% of patients 80 years and older.

Patients who received CPR were also less likely to be receiving invasive mechanical ventilation.

As in the smaller study by the Beaumont Hospital researchers, the most common initial cardiac rhythms at the time of CPR were pulseless electrical activity, in 199 patients (49.8%), and asystole, in 95 patients (23.8%).

"Typically, nonshockable rhythm is due to noncardiac causes, respiratory failure, clots, so this suggests cardiovascular injury is not the primary cause of death in these patients," Hayek said. "More likely it is related more to the impact of COVID on the lungs and possibly clotting, since respiratory failure and the propensity to have lung clots are common causes of these types of nonshockable rhythms."

Additionally, 33 patients (8.3%) had ventricular tachycardia and 15 patients (3.8%) had ventricular fibrillation.

Pulseless electrical activity was more common in patients who survived to discharge than in those who died, but the distribution of other rhythms was similar between survivors and nonsurvivors.

Epinephrine was the most common treatment during CPR, used in 324 patients (81.0%), followed by defibrillation, in 74 patients (18.5%).

The median duration of CPR was 10 minutes (IQR, 5 - 18 minutes), and younger patients received CPR for a longer duration than older patients. For patients younger than 45 years, CPR was given for a median of 13 minutes (IQR, 7 - 20 minutes), and in patients 80 years and older, the median duration was 7 minutes (IQR, 4 - 14 minutes).

Overall, 135 of the 400 patients (33.8%) who received CPR achieved ROSC, but only 48 patients (12.0%) survived to hospital discharge. The likelihood of survival to hospital discharge decreased with age, ranging from 21.2% in patients younger than 45 years to 2.9% in patients 80 years and older.

Among the 48 patients who survived to hospital discharge, 28 (58.3%) had normal or mildly impaired neurologic status, with a cerebral performance category score of 1 or 2, and 20 (41.7%) had moderate to severe neurologic dysfunction (cerebral performance category score of 3 or 4).

CPR in Half of Patients 'Alarming'

"The fact that half of patients received CPR was surprising to me," Hayek said. "I believe out of all the findings in this study, this is one of the most alarming."

He believes that some hospitals, especially at the peak of the pandemic, may have advised patients and families to opt for DNR orders.

"I was surprised that so few in this study received CPR," he said. "This is likely due to the fact that a lot of hospitals pre-emptively approached family members and discussed goals of care, and again, most people experiencing cardiac arrest were significantly older and sicker. Also concerns about hospital strain, issues regarding PPE — its availability or lack of availability — would have limited the ability to get CPR," he added.

"Unfortunately, our study is not designed to answer these questions, but these are certainly things to think about," he said.

Hayek said he does not agree that COVID-19 patients should get a DNR order automatically.

"In our population, where 700 patients had a cardiac arrest and 400 got CPR, we had a survival rate of about 12%. That overall survival rate is actually very similar to that in non-COVID critical illness. So we have to be very cautious in saying that it's not worth doing CPR.

"I think we should move away from that conclusion, which is prompted by these smaller studies," he added. "With small sample sizes you can reach these scary conclusions, when in reality if you look at the problem in a large cohort, that is not the case. We have to move away from these impressions because this may impact care dramatically."

Another interesting finding is that admission to a hospital with fewer ICU beds was strongly associated with a greater risk for in-hospital cardiac arrest.

"This suggests that hospital resources, staffing, expertise, strain, or other factors that were not captured in our database could have had a major impact on outcomes. Assessing hospital strain is very challenging, but the finding gives us something else to think about as we search for the best way to treat critically ill patients with COVID-19. We need to focus on preventing cardiac arrest with adequate management, have discussions around goals of care, and ensure a safe environment for CPR if it needs to happen," Hayek said.

Discuss CPR Early

In an Invited Commentary published in JAMA Internal Medicine, J. Randal Curtis, MD, MPH, professor of medicine, University of Washington, Seattle, writes that CPR for in-hospital cardiac arrest in COVID-19 patients represents unique challenges, including delays in starting CPR because of isolation procedures and the increased risk for viral transmission among healthcare workers.

Curtis agrees that having a conversation up front about goals of care with the patient and the family is essential.

"Survival after in-hospital cardiac arrest in a patient with severe COVID pneumonia is very, very poor," Curtis told theheart.org | Medscape Cardiology. "We can't say it's zero, and in fact, the paper from the STOP-COVID investigators shows that it's not zero, but it's still very, very low, particularly if people are older or have chronic underlying illnesses, and we just need to take that into account.

"It doesn't mean we should never do CPR, but it does mean that we need to talk to patients and families about it," Curtis added. "Also, most of the survivors do not survive with a good neurologic outcome, and that is important to keep in mind. So have a discussion with the patient and family up front."

Mayer and colleagues, Hayek, and Curtis report no relevant financial relationships.

JAMA Intern Med. Published online September 28, 2020. Abstract, Editorial

BMJ 2020; Published online September 30, 2020. Abstract

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