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Derivation and validation of the CREST model for very early prediction of circulatory etiology death in patients without ST-segment-elevation myocardial infarction after cardiac arrest

Bascom, Karen E. ; Dziodzio, John ; Vasaiwala, Samip ; Mooney, Michael ; Patel, Nainesh ; McPherson, John ; McMullan, Paul ; Unger, Barbara ; Nielsen, Niklas LU and Friberg, Hans LU , et al. (2018) In Circulation 137(3). p.273-282
Abstract

BACKGROUND: No practical tool quantitates the risk of circulatory-etiology death (CED) immediately after successful cardiopulmonary resuscitation in patients without ST-segment-elevation myocardial infarction. We developed and validated a prediction model to rapidly determine that risk and facilitate triage to individualized treatment pathways. METHODS: With the use of INTCAR (International Cardiac Arrest Registry), an 87-question data set representing 44 centers in the United States and Europe, patients were classified as having had CED or a combined end point of neurological-etiology death or survival. Demographics and clinical factors were modeled in a derivation cohort, and backward stepwise logistic regression was used to identify... (More)

BACKGROUND: No practical tool quantitates the risk of circulatory-etiology death (CED) immediately after successful cardiopulmonary resuscitation in patients without ST-segment-elevation myocardial infarction. We developed and validated a prediction model to rapidly determine that risk and facilitate triage to individualized treatment pathways. METHODS: With the use of INTCAR (International Cardiac Arrest Registry), an 87-question data set representing 44 centers in the United States and Europe, patients were classified as having had CED or a combined end point of neurological-etiology death or survival. Demographics and clinical factors were modeled in a derivation cohort, and backward stepwise logistic regression was used to identify factors independently associated with CED. We demonstrated model performance using area under the curve and the Hosmer-Lemeshow test in the derivation and validation cohorts, and assigned a simplified point-scoring system. RESULTS: Among 638 patients in the derivation cohort, 121 (18.9%) had CED. The final model included preexisting coronary artery disease (odds ratio [OR], 2.86; confidence interval [CI], 1.83-4.49; P≤0.001), nonshockable rhythm (OR, 1.75; CI, 1.10-2.77; P=0.017), initial ejection fraction<30% (OR, 2.11; CI, 1.32-3.37; P=0.002), shock at presentation (OR, 2.27; CI, 1.42-3.62; P<0.001), and ischemic time >25 minutes (OR, 1.42; CI, 0.90-2.23; P=0.13). The derivation model area under the curve was 0.73, and Hosmer-Lemeshow test P=0.47. Outcomes were similar in the 318-patient validation cohort (area under the curve 0.68, Hosmer-Lemeshow test P=0.41). When assigned a point for each associated factor in the derivation model, the average predicted versus observed probability of CED with a CREST score (coronary artery disease, initial heart rhythm, low ejection fraction, shock at the time of admission, and ischemic time >25 minutes) of 0 to 5 was: 7.1% versus 10.2%, 9.5% versus 11%, 22.5% versus 19.6%, 32.4% versus 29.6%, 38.5% versus 30%, and 55.7% versus 50%. CONCLUSIONS: The CREST model stratified patients immediately after resuscitation according to risk of a circulatory-etiology death. The tool may allow for estimation of circulatory risk and improve the triage of survivors of cardiac arrest without ST-segment-elevation myocardial infarction at the point of care.

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keywords
Cardiomyopathies, Cardiopulmonary resuscitation, Forecasting, Heart arrest, Prognosis, Shock
in
Circulation
volume
137
issue
3
pages
273 - 282
publisher
Lippincott Williams and Wilkins
external identifiers
  • pmid:29074504
  • scopus:85047931506
ISSN
0009-7322
DOI
10.1161/CIRCULATIONAHA.116.024332
language
English
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yes
id
046fee7b-0b96-45c6-b744-9e615a016c90
date added to LUP
2019-06-29 22:54:32
date last changed
2020-07-08 04:58:12
@article{046fee7b-0b96-45c6-b744-9e615a016c90,
  abstract     = {<p>BACKGROUND: No practical tool quantitates the risk of circulatory-etiology death (CED) immediately after successful cardiopulmonary resuscitation in patients without ST-segment-elevation myocardial infarction. We developed and validated a prediction model to rapidly determine that risk and facilitate triage to individualized treatment pathways. METHODS: With the use of INTCAR (International Cardiac Arrest Registry), an 87-question data set representing 44 centers in the United States and Europe, patients were classified as having had CED or a combined end point of neurological-etiology death or survival. Demographics and clinical factors were modeled in a derivation cohort, and backward stepwise logistic regression was used to identify factors independently associated with CED. We demonstrated model performance using area under the curve and the Hosmer-Lemeshow test in the derivation and validation cohorts, and assigned a simplified point-scoring system. RESULTS: Among 638 patients in the derivation cohort, 121 (18.9%) had CED. The final model included preexisting coronary artery disease (odds ratio [OR], 2.86; confidence interval [CI], 1.83-4.49; P≤0.001), nonshockable rhythm (OR, 1.75; CI, 1.10-2.77; P=0.017), initial ejection fraction&lt;30% (OR, 2.11; CI, 1.32-3.37; P=0.002), shock at presentation (OR, 2.27; CI, 1.42-3.62; P&lt;0.001), and ischemic time &gt;25 minutes (OR, 1.42; CI, 0.90-2.23; P=0.13). The derivation model area under the curve was 0.73, and Hosmer-Lemeshow test P=0.47. Outcomes were similar in the 318-patient validation cohort (area under the curve 0.68, Hosmer-Lemeshow test P=0.41). When assigned a point for each associated factor in the derivation model, the average predicted versus observed probability of CED with a CREST score (coronary artery disease, initial heart rhythm, low ejection fraction, shock at the time of admission, and ischemic time &gt;25 minutes) of 0 to 5 was: 7.1% versus 10.2%, 9.5% versus 11%, 22.5% versus 19.6%, 32.4% versus 29.6%, 38.5% versus 30%, and 55.7% versus 50%. CONCLUSIONS: The CREST model stratified patients immediately after resuscitation according to risk of a circulatory-etiology death. The tool may allow for estimation of circulatory risk and improve the triage of survivors of cardiac arrest without ST-segment-elevation myocardial infarction at the point of care.</p>},
  author       = {Bascom, Karen E. and Dziodzio, John and Vasaiwala, Samip and Mooney, Michael and Patel, Nainesh and McPherson, John and McMullan, Paul and Unger, Barbara and Nielsen, Niklas and Friberg, Hans and Riker, Richard R. and Kern, Karl B. and Duarte, Christine W. and Seder, David B.},
  issn         = {0009-7322},
  language     = {eng},
  month        = {01},
  number       = {3},
  pages        = {273--282},
  publisher    = {Lippincott Williams and Wilkins},
  series       = {Circulation},
  title        = {Derivation and validation of the CREST model for very early prediction of circulatory etiology death in patients without ST-segment-elevation myocardial infarction after cardiac arrest},
  url          = {http://dx.doi.org/10.1161/CIRCULATIONAHA.116.024332},
  doi          = {10.1161/CIRCULATIONAHA.116.024332},
  volume       = {137},
  year         = {2018},
}