Background: Despite advances in post-arrest management, cardiac arrest is frequently fatal and is often associated with high morbidity in survivors. Though there is evidence supporting the use of immediate coronary angiography (CA) and percutaneous coronary intervention among patients with ST elevation myocardial infarction (STEMI) complicated by cardiac arrest, the majority of patients that are successfully resuscitated from cardiac arrest do not have ST segment elevations on EKG. Among survivors of cardiac arrest without ST segment elevations on EKG, there are observational analyses that suggest benefit with early coronary angiography. Risk aversion has been previously demonstrated in patients with acute myocardial infarction complicated by cardiogenic shock in states with public reporting. Given concerns of risk aversion in high-risk patients, we utilized the Nationwide Inpatient Sample (NIS) to identify whether there was evidence of risk avoidant behavior in performing coronary angiography on patients with cardiac arrest in states that participate in public reporting.
Methods: We performed a cross-sectional analysis of all adult patients (age≥18 years) with in-hospital and out-of-hospital cardiac arrest between 2005 and 2011 in states with public reporting (New York and Massachusetts) and surrounding states without public reporting (Delaware, Connecticut, Maine, Maryland, Rhode Island and Vermont) in the NIS. Adjusted logistical regression models were used to assess the relationship between public reporting and CA with clustering by hospital. The association between public reporting and in-hospital mortality was assessed using logistical regression models adjusted for the same set of demographic and clinical characteristics. An interaction term was used to assess whether the association between public reporting and in-hospital mortality differed based on the performance of CA.
Results: We analyzed 75,080 patients with cardiac arrest between 2005 and 2011 in the selected states. There was a trend towards decreased utilization of CA in states with public reporting (adjusted OR 0.82, 95% CI 0.67-1.00, p=0.055), but significantly lower use of CA in those patients presenting with STEMI (adjusted OR 0.65, 95% CI 0.44-0.96, p=0.032). There was no association between public reporting and in-hospital mortality (adjusted OR 0.99, 95% CI 0.85-1.14, p=0.841) and no significant interaction of CA on the relationship between public reporting and in-hospital mortality (p=0.273).
Conclusion: There is a trend towards risk-avoidant behavior in the performance of CA on patients with cardiac arrest, and patients with STEMI and cardiac arrest are less likely to undergo CA in states with public reporting. Overall, there is no difference in mortality for patients with cardiac arrest in states with and without public reporting, and there was no interaction with CA.