Effects of COVID-19 pandemic on out-of-hospital cardiac arrests: A systematic review

Abstract

Introduction: In addition to the directly attributed mortality, COVID-19 is also likely to increase mortality indirectly. In this systematic review, we investigate the direct and indirect effects of COVID-19 on out-of-hospital cardiac arrests.

Methods: We searched PubMed, BioMedCentral, Embase and the Cochrane Central Register of Controlled Trials for studies comparing out-of-hospital cardiac arrests occurring during the pandemic and a non-pandemic period. Risk of bias was assessed with the ROBINS-I tool. The primary endpoint was return of spontaneous circulation. Secondary endpoints were bystander-initiated cardiopulmonary resuscitation, survival to hospital discharge, and survival with favourable neurological outcome.

Results: We identified six studies. In two studies, rates of return of spontaneous circulation and survival to hospital discharge decreased significantly during the pandemic. Especially in Europe, bystander-witnessed cases, bystander-initiated cardiopulmonary resuscitation and resuscitation attempted by emergency medical services were reduced during the pandemic. Also, ambulance response times were significantly delayed across all studies and patients presenting with non-shockable rhythms increased in two studies. In 2020, 3.9-5.9% of tested patients were SARS-CoV-2 positive and 4.8-26% had suggestive symptoms (fever and cough or dyspnoea).

Conclusions: Out-of-hospital cardiac arrests had worse short-term outcomes during the pandemic than a non-pandemic period suggesting direct effects of COVID-19 infection and indirect effects from lockdown and disruption of healthcare systems. Patients at high risk of deterioration should be identified outside the hospital to promptly initiate treatment and reduce fatalities. Study registration PROSPERO CRD42020195794.

Keywords: COVID-19; Cardiopulmonary resuscitation; Out-of-hospital cardiac arrest.

Fig. 1

Selection of included studies.

Fig. 2

Forest plot for return of spontaneous circulation (A) and survival to hospital discharge (B). M–H = Mantel–Haenszel, CI = confidence interval.

Fig. 3

Forest plot for rates of bystander-witnessed out-of-hospital cardiac arrests (A) and bystander-initiated cardiopulmonary resuscitation (B) with subgroup analysis by continent. M–H = Mantel–Haenszel, CI = confidence interval.

Fig. 4

Forest plot of the response times of emergency medical services (A) and proportion of patients with out-of-hospital cardiac arrest where resuscitation was attempted by emergency medical services (B). SD = standard deviation, IV = inverse variance, M–H = Mantel–Haenszel, CI = confidence interval.