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Observational Study
. 2023 Aug:189:109857.
doi: 10.1016/j.resuscitation.2023.109857. Epub 2023 Jun 1.

Pulseless electrical activity and asystole during in-hospital cardiac arrest: Disentangling the 'nonshockable' rhythms

Luke Andrea  1 , Ariel L Shiloh  2 , Mai Colvin  2 , Marjan Rahmanian  2 , Maneesha Bangar  2 , Anne V Grossestreuer  3 , Katherine M Berg  4 , Michelle N Gong  2 , Ari Moskowitz  2 ; American Heart Association's Get With The Guidelines®-Resuscitation Investigators
Affiliations
Observational Study

Pulseless electrical activity and asystole during in-hospital cardiac arrest: Disentangling the 'nonshockable' rhythms

Luke Andrea et al. Resuscitation. 2023 Aug.

Abstract

Background: Pulseless electrical activity (PEA) and asystole account for 81% of initial in-hospital cardiac arrest (IHCA) rhythms in the U.S.A. These "non-shockable" rhythms are often grouped together in resuscitation research and practice. We hypothesized that PEA and asystole are distinct initial IHCA rhythms with distinguishing features.

Methods: This was an observational cohort study using the prospectively collected nationwide Get With The Guidelines®-Resuscitation registry. Adult patients with an index IHCA and an initial rhythm of PEA or asystole between the years of 2006 and 2019 were included. Patients with PEA vs. asystole were compared with respect to pre-arrest characteristics, resuscitation practice, and outcomes.

Results: We identified 147,377 (64.9%) PEA and 79,720 (35.1%) asystolic IHCA. Asystole had more arrests in non-telemetry wards (20,530/147,377 [13.9%] PEA vs. 17,618/79,720 [22.1%] asystole). Asystole had 3% lower adjusted odds of ROSC (91,007 [61.8%] PEA vs. 44,957 [56.4%] asystole, aOR 0.97, 95%CI 0.96-0.97, P < 0.01); there was no statistically significant difference in survival to discharge (28,075 [19.1%] PEA vs. 14,891 [18.7%] asystole, aOR 1.00, 95%CI 1.00-1.01, P = 0.63). Duration of resuscitation for those without ROSC were shorter for asystole (29.8 [±22.5] minutes in PEA vs. 26.2 [±21.5] minutes in asystole, adjusted mean difference -3.05 95%CI -3.36--2.74, P < 0.01).

Interpretation: Patients suffering IHCA with an initial PEA rhythm had patient and resuscitation level differences from those with asystole. PEA arrests were more common in monitored settings and received longer resuscitations. Even though PEA was associated with higher rates of ROSC, there was no difference in survival to discharge.

Keywords: Cardiac arrest; Cardiac rhythm; Resuscitation.

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Conflict of interest statement

Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Figure 1:
Figure 1:
Study flow chart Final inpatient locations that were included: adult coronary care unit, adult intensive care unit, cardiac catheterization lab, delivery suite, diagnostic intervention area, emergency department, general inpatient area, operating room, post-anesthesia recovery room, telemetry unit, step down unit
Figure 2:
Figure 2:
ROSC and survival to discharge for PEA and asystole 2a: Percentage of ROSC and survival to discharge for each initial rhythm by year 2b: Adjusted odds with 95% confidence intervals of ROSC and survival to discharge each year with respect to the reference year 2006 for each initial rhythm
Figure 2:
Figure 2:
ROSC and survival to discharge for PEA and asystole 2a: Percentage of ROSC and survival to discharge for each initial rhythm by year 2b: Adjusted odds with 95% confidence intervals of ROSC and survival to discharge each year with respect to the reference year 2006 for each initial rhythm
Figure 3:
Figure 3:
Duration of resuscitation for PEA and asystole 3a: Average duration of resuscitation each year both overall and for those who did not achieve ROSC, for each initial rhythm 3b: Adjusted mean difference with 95% confidence intervals of duration of resuscitation each year with respect to the year reference year 2006 for each initial rhythm 3c: Adjusted mean difference with 95% confidence intervals of duration of resuscitation each year with respect to the year reference year 2006 for each initial rhythm in only those who did not achieve ROSC
Figure 3:
Figure 3:
Duration of resuscitation for PEA and asystole 3a: Average duration of resuscitation each year both overall and for those who did not achieve ROSC, for each initial rhythm 3b: Adjusted mean difference with 95% confidence intervals of duration of resuscitation each year with respect to the year reference year 2006 for each initial rhythm 3c: Adjusted mean difference with 95% confidence intervals of duration of resuscitation each year with respect to the year reference year 2006 for each initial rhythm in only those who did not achieve ROSC
Figure 3:
Figure 3:
Duration of resuscitation for PEA and asystole 3a: Average duration of resuscitation each year both overall and for those who did not achieve ROSC, for each initial rhythm 3b: Adjusted mean difference with 95% confidence intervals of duration of resuscitation each year with respect to the year reference year 2006 for each initial rhythm 3c: Adjusted mean difference with 95% confidence intervals of duration of resuscitation each year with respect to the year reference year 2006 for each initial rhythm in only those who did not achieve ROSC
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