盡管復(fù)蘇科學(xué)取得了重大進(jìn)展，但院外心臟驟停（OHCA）復(fù)蘇后出院的存活率仍然很低，只有不到10%。那么哪幾類患者復(fù)蘇后依然很難逃脫死亡？

在愛思唯爾全醫(yī)學(xué)信息平臺(tái)ClinicalKey中，近期心血管領(lǐng)域著名期刊JACC (Journal of the American College of Cardiology)上發(fā)表了一篇論文（文末“閱讀原文”可瀏覽全文），研究者對(duì)美國(guó)舊金山4年中18歲至90歲所有突發(fā)院外心臟驟停的患者（239例）進(jìn)行分析，讓我們能夠盡早識(shí)別出這些需要特殊關(guān)注的患者。

需心臟驟停復(fù)蘇的常見原因

在239例患者中，約一半被搶救至住院治療（133例，55.6%）。其中86例（64.7%）在住院期間死亡，47例（35.3%）存活至出院。VT/VF（室性心動(dòng)過速/心室纖顫）是最常見的表現(xiàn)節(jié)律，在55例（41.3%）心臟驟停（SCA）復(fù)蘇的患者中有此發(fā)現(xiàn)，在SCA幸存者中更常見（78.7%，20.9%）。

所有SCA復(fù)蘇患者中，最常見的停搏原因是：

• 急性冠狀動(dòng)脈疾?。毙怨跔顒?dòng)脈綜合征伴或不伴ST段抬高：39.8%）

• ?神經(jīng)系統(tǒng)疾?。ㄖ酗L(fēng)、顱內(nèi)出血或癲癇：18%）

• 慢性冠狀動(dòng)脈疾?。ㄒ阎跔顒?dòng)脈疾病，無(wú)其他明確原因：16.5%）

在復(fù)蘇后SCA中，69.1%（133例中的92例）發(fā)現(xiàn)了心律失常性停搏原因。存活者心律失常的發(fā)生率明顯高于非存活者（92%，57%；p<0.001）。

排除戶外或急診室死亡（SCD后病例）或非突發(fā)性死亡的OHCA，包括了復(fù)蘇至住院的SCA。

SCA復(fù)蘇的原因在回顧綜合醫(yī)院記錄后確定：心律失常（紅色）、心臟/非心律失常（藍(lán)色）或非心臟（綠色）原因。

這些患者容易存活

年齡小的患者更易存活。SCA存活者的平均年齡比SCA非存活者年輕10.3歲以上（95%CI: 4.5-16歲；p<0.001）。

在多變量分析中，VT/VF節(jié)律、心律失常原因是SCA復(fù)蘇后存活至出院的具統(tǒng)計(jì)學(xué)意義的預(yù)測(cè)因子。因?yàn)槟壳暗膹?fù)蘇方法和自動(dòng)體外除顫器被設(shè)計(jì)為針對(duì)該病因，從而增加了心律失常原因造成停搏的幸存者數(shù)量，他們往往更容易獲得治療。

這些患者容易“再入鬼門關(guān)”

值得注意的是，近1/5的神經(jīng)系統(tǒng)疾病導(dǎo)致的SCA普遍是致命的（28%的SCA非存活者vs. 0%的SCA存活者；p<0.001）。盡管進(jìn)行了初步復(fù)蘇，但仍有100%的住院死亡率。

大部分（20/24，83.3%）的神經(jīng)系統(tǒng)引發(fā)的SCA是出血性中風(fēng)，所有這些中風(fēng)患者都在停搏發(fā)生時(shí)服用抗凝或抗血小板藥物。這類藥物的試驗(yàn)可能遺漏了以O(shè)HCAs或SCD表現(xiàn)的顱內(nèi)出血，因此這些藥物的相關(guān)風(fēng)險(xiǎn)可能被低估。

所以可以預(yù)見，既往中風(fēng)史與生存率降低相關(guān)。

雖然沒有藥物治療與生存率增加相關(guān)，但鈣通道阻滯劑與生存率降低獨(dú)立相關(guān)。

先前的研究表明，二氫吡啶鈣通道阻滯劑硝苯地平與OHCA的風(fēng)險(xiǎn)增加有關(guān)。這可能是由于其快速降壓或冠狀動(dòng)脈盜血后交感神經(jīng)張力增加所致。然而，這一發(fā)現(xiàn)可能不適用于其他鈣通道阻滯劑。

研究還發(fā)現(xiàn)，有一半使用選擇性5-羥色胺再攝取抑制劑（SSRIs）的SCA患者有顱內(nèi)出血。盡管這一發(fā)現(xiàn)可能是偶然的，但它也與SSRIs與血小板功能障礙和出血性中風(fēng)風(fēng)險(xiǎn)增加相關(guān)的報(bào)道一致，尤其是在那些服用抗凝劑或抗血小板藥物的患者之中。

總結(jié)

在心臟驟停復(fù)蘇后，年齡小、VT/VF節(jié)律、心律失常原因造成心臟驟停的患者相對(duì)更易存活。

而神經(jīng)系統(tǒng)疾病引發(fā)停搏、有既往中風(fēng)史、使用鈣通道阻滯劑與SSRIs的患者需要特別關(guān)注，避免在住院期間依然出現(xiàn)死亡結(jié)局。

參考文獻(xiàn)

[1].?Sasson C, Rogers MAM, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest. Circ Cardiovasc Qual Outcomes 2010;3: 63–81.?

[2].?Chugh SS, Jui J, Gunson K, et al. Current burden of sudden cardiac death: Multiple source surveil- lance versus retrospective death certificate-based review in a large U.S. community. J Am Coll Car- diol 2004;44:1268–75.?

[3].?Nichol G, Rumsfeld J, Eigel B, et al. Essential features of designating out-of-hospital cardiac arrest as a reportable event. Circulation 2008;117: 2299–308.?

[4].?Narayan SM, Wang PJ, Daubert JP. New con- cepts in sudden cardiac arrest to address an intractable epidemic. J Am Coll Cardiol 2019;73: 70–88.?

[5].?McNally B, Stokes A, Crouch A, Kellermann AL. CARES: Cardiac Arrest Registry to Enhance Sur- vival. Ann Emerg Med 2009;54:674–83.e2.

[6].?Hayashi M, Shimizu W, Albert CM. The spectrum of epidemiology underlying sudden cardiac death. Circ Res 2015;116:1887–906.?

[7].?Rohde LE, Chatterjee NA, Vaduganathan M, et al. Sacubitril/valsartan and sudden cardiac death according to implantable cardioverter- defibrillator use and heart failure cause. J Am Coll Cardiol HF 2020;8:844–55.?

[8].?Chatterjee NA, Moorthy MV, Pester J, et al. Sudden death in patients with coronary heart disease without severe systolic dysfunction. JAMA Cardiol 2018;3:591–600.?

[9].?Tseng ZH, Olgin JE, Vittinghoff E, et al. Pro- spective countywide surveillance and autopsy characterization of sudden cardiac death. Circula- tion 2018;137:2689–700.?

[10].?World Health Organization. Sudden cardiac death: report of a WHO scientific group. World Health Organization technical report series 726. 1985 1985. Available at: https://apps.who.int/iris/ bitstream/handle/10665/39554/WHO_TRS_726. pdf. Accessed March 18, 2020.?

[11].?Barnard J, Meng X-L. Applications of multiple imputation in medical studies: from AIDS to NHANES. Stat Methods Med Res 1999;8:17–36.?

[12].?Fischer M, Fischer NJ, Schüttler J. One-year survival after out-of-hospital cardiac arrest in Bonn city: outcome report according to the “Utstein style.” Resuscitation 1997;33:233–43.?

[13].?Pijls RWM, Nelemans PJ, Rahel BM, Gorgels APM. Circumstances and causes of sudden

circulatory arrests in the Dutch province of Lim- burg and the involvement of citizen rescuers. Neth Heart J 2018;26:41–8.?

[14].?Kuisma M, Alasp?? A. Out-of-hospital cardiac arrests of noncardiac origin: epidemiology and outcome. Eur Heart J 1997;18:1122–8.?

[15].?Ro YS, Shin SD, Song KJ, et al. A comparison of outcomes of out-of-hospital cardiac arrest with noncardiac etiology between emergency de- partments with low- and high-resuscitation case volume. Resuscitation 2012;83:855–61.?

[16].?Hinkle LE, Thaler HT. Clinical classification of cardiac deaths. Circulation 1982;65:457–64.?

[17].?Perkins GD, Jacobs IG, Nadkarni VM, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resusci- tation Registry templates for out-of-hospital car- diac arrest. Circulation 2015;132:1286–300.?

[18].?Pasupula DK, Bhat A, Siddappa MSK, et al. Impact of change in 2010 American Heart Asso- ciation cardiopulmonary resuscitation guidelines on survival after out-of-hospital cardiac arrest in the United States. Circ Arrhythm Electrophysiol 2020;13:e007843.?

[19].?Ashar FN, Mitchell RN, Albert CM, et al. A comprehensive evaluation of the genetic archi- tecture of sudden cardiac arrest. Eur Heart J 2018; 39:3961–9.?

[20].?Galea S, Blaney S, Nandi A, et al. Explaining racial disparities in incidence of and survival from out-of-hospital cardiac arrest. Am J Epidemiol 2007;166:534–43.

[21].?Becker LB, Han BH, Meyer PM, et al. Racial differences in the incidence of cardiac arrest and subsequent survival. N Engl J Med 1993;329: 600–6.?

[22].?Nichol G, Thomas E, Callaway CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 2008;300:1423–31.?

[23].?Myat A, Song K-J, Rea T. Out-of-hospital car- diac arrest: current concepts. Lancet 2018;391: 970–9.?

[24].?Lombardi G, Gallagher EJ, Paul. Outcome of out-of-hospital cardiac arrest in New York City: the Pre-Hospital Arrest Survival Evaluation (PHASE) study. JAMA 1994;271:678–83.?

[25].?Eid SM, Abougergi MS, Albaeni A, Chandra- Strobos N. Survival, expenditure and disposition in patients following out-of-hospital cardiac arrest: 1995–2013. Resuscitation 2017;113:13–20.?

[26].?Tseng ZH, Hayward RM, Clark NM, et al. Sudden death in patients with cardiac implantable electronic devices. JAMA Intern Med 2015;175: 1342–50.

[27].?Siegel ER, Salazar JW, Tseng ZH. The weak LINQ—continuous rhythm monitoring during sudden death. JAMA Intern Med 2020;180: 1380–1.?

[28].?Kim AS, Moffatt E, Ursell PC, Devinsky O, Olgin J, Tseng ZH. Sudden neurologic death masquerading as out-of-hospital sudden cardiac death. Neurology 2016;87:1669–73.?

[29].?Lopes RD, Heizer G, Aronson R, et al. Antith- rombotic therapy after acute coronary syndrome or PCI in atrial fibrillation. N Engl J Med 2019;380: 1509–24.?

[30].?Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST- segment elevation. N Engl J Med 2001;345: 494–502.?

[31].?Eroglu TE, Mohr GH, Blom MT, et al. Differ- ential effects on out-of-hospital cardiac arrest of dihydropyridines: real-world data from population-based cohorts across two European countries. Eur Heart J Cardiovasc Pharmacother 2020;6:347–55.?

[32].?Hackam DG, Mrkobrada M. Selective sero- tonin reuptake inhibitors and brain hemor- rhage: a meta-analysis. Neurology 2012;79: 1862–5.?

[33].?Renoux C, Vahey S, Dell’Aniello S, Boivin J- F. Association of selective serotonin reuptake inhibitors with the risk for spontaneous intra- cranial hemorrhage. JAMA Neurol 2017;74: 173–80.?

[34].?Chugh SS, Reinier K, Balaji S, et al. Population- based analysis of sudden death in children: the Oregon sudden unexpected death study. Heart Rhythm 2009;6:1618–22.?

[35].?Wilson PWF, d’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor cate- gories. Circulation 1998;97:1837–47.?