Impact of the COVID-19 pandemic on the epidemiology of out-of-hospital cardiac arrest: a systematic review and meta-analysis

Abstract

Background: The coronavirus disease 2019 (COVID-19) pandemic has significantly influenced epidemiology, yet its impact on out-of-hospital cardiac arrest (OHCA) remains unclear. We aimed to evaluate the impact of the pandemic on the incidence and case fatality rate (CFR) of OHCA. We also evaluated the impact on intermediate outcomes and clinical characteristics.

Methods: PubMed, EMBASE, Web of Science, Scopus, and Cochrane Library databases were searched from inception to May 3, 2021. Studies were included if they compared OHCA processes and outcomes between the pandemic and historical control time periods. Meta-analyses were performed for primary outcomes [annual incidence, mortality, and case fatality rate (CFR)], secondary outcomes [field termination of resuscitation (TOR), return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge], and clinical characteristics (shockable rhythm and etiologies). This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42021253879).

Results: The COVID-19 pandemic was associated with a 39.5% increase in pooled annual OHCA incidence (p < 0.001). Pooled CFR was increased by 2.65% (p < 0.001), with a pooled odds ratio (OR) of 1.95 for mortality [95% confidence interval (95%CI) 1.51-2.51]. There was increased field TOR (OR = 2.46, 95%CI 1.62-3.74). There were decreased ROSC (OR = 0.65, 95%CI 0.55-0.77), survival to hospital admission (OR = 0.65, 95%CI 0.48-0.89), and survival to discharge (OR = 0.52, 95%CI 0.40-0.69). There was decreased shockable rhythm (OR = 0.73, 95%CI 0.60-0.88) and increased asphyxial etiology of OHCA (OR = 1.17, 95%CI 1.02-1.33).

Conclusion: Compared to the pre-pandemic period, the COVID-19 pandemic period was significantly associated with increased OHCA incidence and worse outcomes.

Keywords: Ambulance; COVID-19; Cardiac arrest; Coronavirus; Emergency medical services; Epidemiology; OHCA; Out of hospital; Pandemic; Resuscitation; Sudden cardiac death.

Fig. 1

PRISMA-P 2020 flow diagram for study selection

Fig. 2

Forest plots of estimates from meta-analysis of proportions—A Annual OHCA incidence in Pre-COVID-19 time period. B Annual OHCA incidence in COVID-19 time period. C Case fatality rate in Pre-COVID-19 time period. D Case fatality rate in COVID-19 time period COVID-19, coronavirus disease 2019; OHCA, out-of-hospital cardiac arrest

Fig. 3

Forest plot of reported estimates for the primary outcome of mortality among patients with out-of-hospital cardiac arrest

Fig. 4

Box plots stratifying estimates for Pre-Covid-19 and COVID-19 time periods for A Annual OHCA Incidence. B Case Fatality Rate. Two-proportion z-tests were statistically significant (p < 0.001) for both outcomes, as represented by asterisks (*). COVID-19 coronavirus disease 2019, OHCA out-of-hospital cardiac arrest

Fig. 5

Forest plots of reported estimates for the secondary outcomes—a termination of resuscitation in the field. B Return of spontaneous circulation. C Survival to hospital admission. D Survival to Hospital discharge

Fig. 6

Forest plots of reported estimates for clinical characteristics of patients with out-of-hospital cardiac arrest—A Shockable rhythm. B Medical etiology. C Traumatic etiology. D Asphyxial etiology