Use of implantable cardioverter defibrillators after out-of-hospital cardiac arrest: a prospective follow-up study

Background

Survivors of out-of-hospital cardiac arrest are at high risk of recurrent arrests, many of which could be prevented with implantable cardioverter defibrillators (ICDs). We sought to determine the ICD insertion rate among survivors of out-of-hospital cardiac arrest and to determine factors associated with ICD implantation.

Methods

The Ontario Prehospital Advanced Life Support (OPALS) study is a prospective, multiphase, before–after study assessing the effectiveness of prehospital interventions for people experiencing cardiac arrest, trauma or respiratory arrest in 19 Ontario communities. We linked OPALS data describing survivors of cardiac arrest with data from all defibrillator implantation centres in Ontario.

Results

From January 1997 to April 2002, 454 patients in the OPALS study survived to hospital discharge after experiencing an out-of-hospital cardiac arrest. The mean age was 65 (standard deviation 14) years, 122 (26.9%) were women, 398 (87.7%) had a witnessed arrest, 372 (81.9%) had an initial rhythm of ventricular tachycardia or ventricular fibrillation (VT/VF), and 76 (16.7%) had asystole or another arrhythmia. The median cerebral performance category at discharge (range 1–5, 1 = normal) was 1. Only 58 (12.8%) of the 454 patients received an ICD. Patients with an initial rhythm of VT/VF were more likely than those with an initial rhythm of asystole or another rhythm to undergo device insertion (adjusted odds ratio [OR] 9.63, 95% confidence interval [CI] 1.31–71.50). Similarly, patients with a normal cerebral performance score were more likely than those with abnormal scores to undergo ICD insertion (adjusted OR 12.52, 95% CI 1.74–92.12).

Interpretation

A minority of patients who survived cardiac arrest underwent ICD insertion. It is unclear whether this low usage rate reflects referral bias, selection bias by electrophysiologists, supply constraint or patient preference.People who survive out-of-hospital cardiac arrest have an increased risk of recurrent arrest of 18%–20% in the first year.^1,2 Three large randomized studies evaluated the use of implantable cardioverter defibrillators (ICDs) versus antiarrhythmic drugs in survivors of out-of-hospital cardiac arrest.^3,4,5 The largest of the 3 studies involved 1016 patients and found a 39% relative risk reduction in mortality in the ICD group.³ The 2 smaller studies both reported nonsignificant reductions in mortality in the ICD group.^4,5 Two recent meta-analyses showed that the use of ICDs was associated with significant and important increases in survival among cardiac arrest survivors: all-cause mortality was reduced by 23%–28% with their use for secondary prevention, and the rate of sudden cardiac death was reduced by 50% in both meta-analyses.^6,7Guidelines from several national and international societies recommend insertion of ICDs in all survivors of cardiac arrest without a reversible cause.^8,9 Despite advances in ICD insertion and technology, studies to date suggest that the utilization rate is low, at least in some settings.^10,11 Several factors, including patient preference, physician referral, availability and cost, may contribute to the underutilization of ICDs.The Ontario Prehospital Advanced Life Support Study (OPALS)^12,13 is a multiphase before–after study designed to systematically evaluate the effectiveness of various prehospital interventions for people experiencing cardiac arrest, trauma or respiratory arrest. As an extension of the OPALS study, we sought to determine the rate of ICD insertion among survivors of cardiac arrest, as well as the factors associated with ICD implantation.     

Purification and characterization of moschins,arginine-glutamate-rich proteins with translation-inhibiting activity from brown pumpkin (Cucurbita moschata) seeds

From fresh brown pumpkin seeds, two proteins with a molecular mass of 12kDa and an N-terminal sequence rich in arginine and glutamate residues were obtained. The protein designated alpha-moschin closely resembled the fruitfly programmed-cell death gene product and the protein designated beta-moschin demonstrated striking similarity to prepro 2S albumin in N-terminal sequence. alpha- and beta-moschins inhibited translation in the rabbit reticulocyte lysate system with an IC(50) of 17 microM and 300nM, respectively.     

Magnesium deficiency increases oxidative stress in rats

Magnesium deficiency has been implicated in the development of atherosclerosis and late diabetic complications, diseases often associated with increased oxidative stress. Present study was carried out to examine the effect of magnesium deficiency on oxidative stress and total radical trapping antioxidant parameter (calculated) in rats and correlate it with the development of free radical mediated diseases. Male Wistar rats were divided into two groups and pair fed for six weeks with low magnesium diet (70 mg/kg) and control diet (990 mg/kg) prepared synthetically. Deionized water was given ad libitum. Low magnesium diet caused a significant decrease in plasma and red blood cell magnesium levels. A marked increase in plasma malondialdehyde and corresponding decrease in total radical trapping antioxidant parameters (calculated) were observed in the low magnesium diet group than control group. The level of plasma glucose increased moderately in the low magnesium diet group. Hypertriglyceridemia and significantly decreased plasma HDL (high density lipoprotein)-cholesterol levels were observed in the low magnesium diet group. The results clearly demonstrate that magnesium deficiency is associated with increased oxidative stress through reduction in plasma antioxidants and increased lipid peroxidation suggesting that the increased oxidative stress may be due to increased susceptibility of body organs to free radical injury.     

Microspatial genetic differentiation for tolerance and utilization of various alcohols and acetic acid in Drosophila species from India

In five Indian localities, it was possible to collect D. melanogaster in two different types of habitats, namely ordinary domestic and alcohol rich ones. Tolerance and utilization capacity of several alcohols and of acetic acid were analyzed in a total of 10 local populations. Results on two other species (D. repleta and D. immigrans) were also available from one place. In each locality, the population from alcohol rich habitat proved to be more tolerant to all the investigated products and also to be more capable of using them as a resource. Alcohols toxicity increased with increasing carbon chain length and secondary alcohols were more toxic than primary ones. Utilization capacity of all products was relatively independent of their toxicity. Especially acetic acid, the toxicity of which was low and similar to that of ethanol, was always a fairly poor resource. From a genetic point of view, tolerance and utilization capacity appeared as two relatively independent traits. Natural selection, which is responsible for the genetic differentiation of local populations, is likely to act simultaneously on both traits. This revised version was published online in July 2006 with corrections to the Cover Date.