Left-sided valvular heart disease and survival in out-of-hospital cardiac arrest: a nationwide registry-based study

Abstract

Survival in left-sided valvular heart disease (VHD; aortic stenosis [AS], aortic regurgitation [AR], mitral stenosis [MS], mitral regurgitation [MR]) in out-of-hospital cardiac arrest (OHCA) is unknown. We studied all cases of OHCA in the Swedish Registry for Cardiopulmonary Resuscitation. All degrees of VHD, diagnosed prior to OHCA, were included. Association between VHD and survival was studied using logistic regression, gradient boosting and Cox regression. We studied time to cardiac arrest, comorbidities, survival, and cerebral performance category (CPC) score. We included 55,615 patients; 1948 with AS (3,5%), 384 AR (0,7%), 17 MS (0,03%), and 704 with MR (1,3%). Patients with MS were not described due to low case number. Time from VHD diagnosis to cardiac arrest was 3.7 years in AS, 4.5 years in AR and 4.1 years in MR. ROSC occurred in 28% with AS, 33% with AR, 36% with MR and 35% without VHD. Survival at 30 days was 5.2%, 10.4%, 9.2%, 11.4% in AS, AR, MR and without VHD, respectively. There were no survivors in people with AS presenting with asystole or PEA. CPC scores did not differ in those with VHD compared with no VHD. Odds ratio (OR) for MR and AR showed no difference in survival, while AS displayed OR 0.58 (95% CI 0.46-0.72), vs no VHD. AS is associated with halved survival in OHCA, while AR and MR do not affect survival. Survivors with AS have neurological outcomes comparable to patients without VHD.

Figure 1

Cox adjusted survival curves from valvular diagnosis to cardiac arrest and coexisting and intervening conditions at valvular diagnosis. (A) Cox-adjusted survival curves for time from VHD to cardiac arrest. (B–D) Prior (i.e., to VHD diagnosis) and intervening (i.e., after VHD diagnosis) coexisting conditions. AS = aortic stenosis; AR = aortic regurgitation; MR = mitral regurgitation. Previous conditions is defined as comorbidities present prior to hospitalization for valvular disease. Intervening conditions refer to conditions developed after hospitalization for valvular disease, prior to cardiac arrest.

Figure 2

Rates of ROSC, hospitalization and 30 days survival in relation to aortic stenosis status. Crude rates of ROSC, hospitalization and 30-days survival in patients with AS and those with no VHD.

Figure 3

Kaplan Meier curves for survival from cardiac arrest. Kaplan–Meier curves describing short- and long-term survival stratified by (a) VHD status and (b) age-group in patients with AS. Note that y-axes are truncated.

Figure 4

Cerebral performance category score. Distribution of CPC score in relation to (A) VHD status and (B) age-group in patients with AS. Odds ratios are adjusted for age and sex.

Figure 5

A–D Adjusted probability of survival overall and in subgroups. AS = Aortic stenosis. AR = Aortic regurgitation. MR = Mitral regurgitation. Logistic regression for 30-days survival in the (A) overall cohort and subgroups (B–D). Models in (B–D) were adjusted for age, sex, initial rhythm, location, and no-flow time.