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Int J Fire Sci Eng > Volume 36(3); 2022 > Article
Choi and Roh: Analysis of Factors Related to Return of Spontaneous Circulation in Patients with Out-of-Hospital Cardiac Arrest in Korea: Using Data from the 2019 Acute Cardiac Arrest Survey

Abstract

This study aimed to analyze the characteristics of out-of-hospital acute cardiac arrest patients collected from the Korea Centers for Disease Control and Prevention to identify the current status and provide basic data to increase the recovery rate of out-hospital acute cardiac arrest patients. As a result of the study, the number of acute cardiac arrest patients in Korea in 2019 was 30,279, of whom 1,505 (64.4%) were men and 10,774 (35.6%) were women. Of the total patients, 1,056 (51.7%) showed good neurological outcomes when paramedics performed defibrillation at the pre-hospital stage (p = 0.001). In the initial review of electrocardiographic rhythm performed by paramedics, 1,025 patients (52.8%) showed ventricular fibrillation and pulseless ventricular tachycardia, which indicated good neurological outcomes (p = 0.001).

1. Introduction

Sudden cardiac arrest refers to a sudden arrest of the blood circulation due to loss of heart function caused by myocardial infarction, trauma, and intoxication, and if not corrected within 10 minutes, irreversible damage proceeds even if spontaneous circulation is recovered[1]. The number of patients who experience sudden cardiac arrest in Korea is increasing each year to 61.6 per 100,000 population, with 25,909 in 2010, 30,771 in 2015, and 31,652 in 2020; the survival rate of cardiac arrest patients in Korea is lower than that of patients in developed countries[2,3]. The low survival rate of patients with sudden cardiac arrest in Korea is attributed to the delayed performance of cardiopulmonary resuscitation (CPR) and defibrillation during the pre-hospital phase[4].
To increase the resuscitation potential of patients with cardiac arrest, the American Heart Association proposed the following six stages of Out-of-Hospital Chain of Survival (Figure 1): recognition of cardiac arrest and activation of the emergency response system, early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions, rapid defibrillation, advanced resuscitation by emergency medical services and other healthcare providers, post-cardiac arrest care, and recovery (including additional treatment, observation, rehabilitation, and psychological support)[5] (fig 1). Among these, the main factors affecting the survival rate of patients who experienced out-of-hospital sudden cardiac arrest are the presence of bystander CPR, the implementation of rapid defibrillation, and the arrival time and treatment of paramedics[6-8].
In order to increase the bystander CPR rate, efforts have been made to spread awareness on the necessity of CPR to the public through campaigns such as Kids Save Lives and World Restart a Heart of the European Resuscitation Council and CPR awareness week of the ASA, and CPR training[9,10]. Korea also implements CPR training in various methods to increase the resuscitation rate of sudden cardiac arrest patients; with these efforts, the overall implementation rate of CPR is increasing every year, but the survival rate remains lower than that in developed countries[11,12]. Some studies have reported increasing disparities between regions[13]. Therefore, this study aimed to analyze the characteristics of emergency medical services by administrative district using the raw data of patients who experienced out-of-hospital sudden cardiac arrest collected from the Korea Disegase Control and Prevention Agency (KDCA) and provide the fundamental data for establishing a system to improve the recovery rate of out-of-hospital sudden cardiac arrest patients.

2. Method

2.1 Study design

This study used the raw data of patients who experienced sudden cardiac arrest in 2019 collected from the KDCA (approval no. 117088), and the characteristics of out-of-hospital sudden cardiac arrest patients were analyzed by administrative district. The administrative districts comprised one metropolitan city (Seoul), one special self-governing province (Jeju), one special self-governing city (Sejong), six megalopolises (Busan, Incheon, Daegu, Daejeon, Gwangju, and Ulsan), and eight provinces (Gyeonggi, Gangwon, Chungbuk, Chungnam, Jeonbuk, Jeonnam, Gyeongbuk, and Gyeongnam); the special self-governing city (Sejong) was excluded from the analysis of the factors of emergency medical services due to the small number of variables. To identify the association between defibrillation and initial electrocardiogram (ECG) rhythm interpretation performed by paramedics at the pre-hospital phase and good neurological outcomes, neurological outcomes was classified as good neurological outcomes (good cerebral performance category [CPC] score of 1-2) and poor neurological outcomes (poor CPC score of 3-5) (Table 1).

2.1.1 Data analysis

For the collected data, frequency analysis of the means and standard deviations, minimum values, and maximum values was performed using SPSS software 20.0 (SPSS Inc., USA). A chi-square test was performed to verify the difference in the characteristics of emergency medical services by administrative district, and a p-value of less than 0.05 was considered significant.

3. Study Results

3.1 General characteristics

The patients’ general characteristics by gender distribution are shown in Table 2. Of the total patients, 19,505 (64.4%) were men and only 10,774 (35.6%) were women. By age group, 709 (2.3%) of the patients were aged < 20 years, 2,034 (6.7%) were aged 20-39 years, 6,867 (22.7%) were aged 40-59 years, 12,013 (39.7%) were aged 60-79 years, and 8,648 (28.6%) were aged > 80 years. The distributions of patients by administrative district were as follows: 4,604 (15.2%) in one metropolitan city (Seoul), 12 (0.1%) in one special self-governing city (Sejong), 622 (2.1%) in one special self-governing province (Jeju) 7,061 (23.3%) in six megalopolises (Busan, Incheon, Daegu, Daejeon, Gwangju, and Ulsan), and 17,980 (59.4%) in eight provinces (Gyeonggi, Gangwon, Chungbuk, Chungnam, Jeonbuk, Gyeongbuk, and Gyeongnam). The insurance types were as follows: 24,485 (80.9%) had national health insurance, 1,201 (4.0%) had car insurance, 97 (0.3%) had occupational health and safety insurance, 2,594 (8.6%) had medical benefit type 1, 224 (0.7%) had medical benefit type 2, 3 (0.0%) had general insurance, 52 (0.2%) had other types of insurance, and 1,623 (5.4%) had unknown insurance. With regard to past history, 9,208 (30.4%) patients had hypertension, 5,939 (19.6%) had diabetes mellitus, 4,701 (15.5%) had heart disease, 1,542 (5.1%) had renal disease, 1,835 (6.1%) had respiratory disease, 2,413 (8.0%) had stroke, and 992 (3.3%) had hyperlipidemia.

3.2 Causes of out-of-hospital sudden cardiac arrest

The causes of cardiac arrest were disease in 23,132 patients (76.4%) and non-disease in 6,975 (23.0%), indicating that majority of the patients experienced sudden cardiac arrest due to a disease (Table 3). The places of occurrence were public places in 5,544 (18.3%) patients, non-public places in 17,120 (56.5%) patients, other places in 1,065 (3.5%) patients, and unknown places in 6,550 (21.6%) patients, with non-public places being the most common place of occurrence. For pre-hospital CPR, CPR was performed in 28,234 (93.2%) patients, CPR was not performed in 404 (1.3%) patients, and the CPR status was unknown in 11,641 (5.4%). As for pre-hospital defibrillation, it was implemented in 3,960 (13.1%) patients, it was not implemented in 1,613 (5.3%) patients, and the defibrillation status was unknown in 24,706 (81.6%). In terms of pre-hospital return of spontaneous circulation, 2,470 (8.2%) patients showed recovery, while 27,809 (91.8%) patients showed non-recovery. As for the presence of witnessed cardiac arrest, cardiac arrest in 13,710 (45.3%) patients was witnessed, cardiac arrest in 13,710 (45.3%) patients was not witnessed, and the status in 2,630 (8.7%) patients was unknown. As for the presence of bystander CPR, it was performed in 6,694 (22.1%) patients, it was not performed in 2,128 (7.0%) patients, it was not applicable in 3,222 (10.6%) patients, and the status was unknown in 18,235 (60.2%) patients.

3.3 Characteristics of emergency medical services by administrative district

Table 4 shows the factors correlated with sudden cardiac arrest by administrative district. The pre-hospital return rate of spontaneous circulation showed significant differences of 1,349 (4.5%) in eight provinces (Gyeonggi, Gangwon, Chungbuk, Chungnam, Jeonbuk, Jeonnam, Gyeongbuk, and Gyeongnam), 686 (2.3%) in six megalopolises (Busan, Incheon, Daegu, Daejeon, Gwangju, and Ulsan), 47 (0.2%) in one special self-governing province (Jeju), and 388 (1.3%) in one metropolitan city (Seoul) (p = 0.001). Meanwhile, bystander CPR showed significant differences of 3,569 (40.5%) in the provinces, 1,552 (17.6%) in the metropolitan city, 1,470 (16.7%) in the megalopolises, and 102 (1.2%) in the special self-governing province. The incidence of sudden cardiac arrest was relatively high in non-public places among all administrative districts, showing a significant difference (p = 0.018). Moreover, the number of cases of witnessed sudden cardiac arrest were 2,257 (8.2%) in the metropolitan city, 242 (0.9%) in the special self-governing province, 3,240 (11.7%) in the megalopolises, and 8,197 (29.6%) in the provinces, showing a significant difference (p = 0.006). When the types of pre-hospital cardiac arrest rhythm was examined, asystole was noted in 2,139 (10.3%) patients from the metropolitan city, 221 (1.1%) patients from the special self-governing province, 3,196 (15.4%) patients from the megalopolises, and 7,798 (37.6%) patients from the provinces, indicating that asystole was the most common ECG rhythm observed in cardiac arrest patients in all studied districts (p = 0.001). The pre-hospital defibrillation implementation showed significant differences of 678 (12.2%) in the metropolitan city, 70 (1.3%) in the special self-governing province, 1,033 (18.5%) in the megalopolises, and 2,179 (39.1%) in the provinces (p = 0.001). According to the neurological outcomes (CPC) results, the metropolitan city had 176 (8.5%) patients with a CPC score of 1, 110 (5.3%) with a CPC score of 2, 92 (4.4%) with a CPC score of 3, and 85 (4.1%) with a CPC score of 4; the special self-governing province had 25 (1.2%) patients with a CPC score of 1, 14 (0.7%) with a CPC score of 2, and 3 (0.1%) with a CPC score of 3; the megalopolises had 223 (10.8%) patients with a CPC score of 1, 158 (7.6%) with a CPC score of 2, 86 (4.2%) with a CPC score of 3, and 123 (5.9%) with a CPC score of 4; and the provinces had 403 (19.5%) patients with a CPC score of 1, 212 (10.3%) patients with a CPC score of 2, 177 (8.6%) with a CPC score 3, and 181 (8.8%) with a CPC score of 4.

3.4 Association between initial ECG rhythm and defibrillation by paramedics and neurological outcomes

After analyzing the association between the type of pre-hospital initial ECG rhythm and defibrillation and neurological outcomes, results showed that 1,056 (51.7%) patients had good neurological outcomes when defibrillated by paramedics at the pre-hospital phase (p = 0.001). In addition, 1,025 (52.8%) patients showed good neurological outcomes when the initial ECG rhythm indicated ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) rhythms (shockable rhythm) (p = 0.001) (Table 5).

4. Discussion

Sudden cardiac arrest refers to a condition in which the mechanical activity of the heart ceases, and no signs of circulation are detected[15]. The implementation of initial bystander CPR and early defibrillation in out-of-hospital sudden cardiac arrest patients is a major factor that may increase the survival rate in this group[6,7]. In Korea, although the rate of CPR implementation is increasing due to the expansion of CPR training for the general public to improve the resuscitation rate of patients who experience sudden cardiac arrest, the implementation rate of CPR by the general public remains low compared with the rates of 34.8% in Japan, 27%-56% in the United States, 77% in Sweden, and 40.3% in Norway, and with the global average of 32%[12]. This study also showed that the implementation rate of CPR by the general public was only 22.1%, which was lower compared with that in other countries. In particular, bystander CPR and the use of a rapid automated external defibrillator (AED) are important to increase the survival rate of patients who experienced out-of-hospital sudden cardiac arrest; the survival rate of patients increases by more than six times when AED by the general public are performed together[16-19]. In the initial rhythm of cardiac arrest patients, VF and pulseless VT were found to have a higher 24-hour survival rate and survival discharge rate than those with asystole and pulseless electrical activity (PEA)[20]. Moreover, patients with VF and pulseless VT in the initial stages of cardiac arrest had five times higher neurological prognoses than those with asystole and PEA. Globally, improvement of the return of spontaneous circulation and good neurological outcomes (cerebral performance category scale, CPC) in out-of-hospital sudden cardiac arrest patients are recognized as important public health issues[12]. The CPC scale is divided into 5 categories, with CPC 1 defined as normal, CPC 2 as mild or moderate disability, CPC 3 as severe disability, CPC 4 as coma or vegetative state, and CPC 5 as brain death or death[14]. According to the results of overseas studies, good neurological outcomes (corresponding to CPC 1 and 2 scores and the return to daily life after cardiac arrest) was observed in 12% of cardiac arrest patients in Norway, 6.9% in the United States, and 6.0% in Japan, while the results of domestic studies were relatively low (0.66%-1.6%)[20-22]. As a measure to improve the neurological outcomes of patients who experienced out-of-hospital sudden cardiac arrest, the neurological outcomes was good when pre-hospital defibrillation was performed by the general public or paramedics[23]. This study also reported good neurological outcomes (CPC score of 1-2) when the paramedics performed defibrillation at the pre-hospital phase. Therefore, it is necessary to continuously educate and recommend the use of AED to the general public and emergency medical practitioners to increase the neurological outcomes of patients who experienced out-of-hospital sudden cardiac arrest. In order to strengthen the capabilities of paramedics and efficiently operate the emergency medical system, Korea has been operating a Smart Advanced Life Support pilot project since 2015 and 119 Special Emergency Medical Services Team (hereinafter referred to as Special Emergency Medical Services Team) since 2019. Paramedics are performing professional cardiac resuscitation, including the administration of epinephrine and amiodarone, under direct medical guidance from an emergency physician at the site for cardiac arrest patients. The implementation of professional cardiac resuscitation in the field increased the survival rates of severe and sudden cardiac arrest patients; when the outcome was compared between before and after implementing professional cardiac resuscitation, the survival discharge rates have improved, and discharge with good neurological outcomes has been reported[24]. Some studies have reported that the economic status of communities, presence of teaching hospitals, size of beds, and number of emergency medical institutions per million population are the factors affecting the survival rate of out-of-hospital patients who experienced sudden cardiac arrest[25]. Such differences in survival rates by region are attributed to the fact that the more urbanized regions have higher implementation rate of bystander CPR and have greater access to high-level emergency medical institutions such as regional emergency medical centers and local emergency medical centers; therefore, the out-of-hospital survival chain is operating appropriately[26]. In this study, a significant difference was observed in the administrative district when the factors and characteristics of out-of-hospital sudden cardiac arrest were analyzed by administrative district, including one metropolitan city, six megalopolises, and eight provinces. In the future, it may be necessary to establish measures to reduce the regional disparities so that appropriate treatment of patients with sudden cardiac arrest can be provided at the government level.

5. Conclusion

This study aimed to contribute to the establishment of a system to increase the rate of return of spontaneous circulation in patients who experienced sudden cardiac arrest by analyzing its impact on the return of spontaneous circulation in the studies population. The implementation of out-of-hospital defibrillation by paramedics resulted in an excellent neurological outcomes. In addition, the implementation rate of emergency medical services differed according to the characteristics and factors of patients who experienced sudden cardiac arrest by administrative district. Therefore, appropriate measures will be required to reduce the disparity in the implementation rate of emergency medical services by the administrative district.

Notes

Author contributions

Conceptualization, C.-H.J. and R.-S.G.; methodology, C.-H.J. and R.-S.G.; validation, R.-S.G.; formal analysis, R.-S.G and CHJ; investigation, C.-H.J and R.-S.G.; resources, R.-S.G.; data curation, C.-H.J.; writing—original draft preparation, C.-H.J. and R.-S.G.; writing—review and editing, C.-H.J. and R.-S.G.; visualization, C.-H.J.; supervision, R.-S.G.; project administration, R.-S.G. All authors have read and agreed to the published version of the manuscript.

Conflicts of interest

The authors declare that they have no conflict of interest.

Figure 1
2020 American heart association’s out-of-hospital Chain of survival guidelines.
kifse-9c7f755af1.jpg
Table 1
Cerebral Performance Category Scale Scores[14]
CPC 1 Good cerebral performance: conscious, alert, able to work, and might have mild neurologic or psychologic deficit
CPC 2 Moderate cerebral disability: conscious, have sufficient cerebral function to perform independent activities of daily life, and able to work in sheltered environment
CPC 3 Severe cerebral disability: conscious, dependent on others for daily support because of impaired brain function, may be ambulatory but have severe memory disturbances or dementia, or paralyzed
CPC 4 Coma or vegetative state: any degree of coma without the presence of all criteria of brain death; unawareness, even if the patient appears awake (vegetative state), he or she has no interaction with the environment; may have spontaneous eye opening and sleep/awake cycles; and cerebral unresponsiveness
CPC 5 Brain death: apnea, areflexia, EEG silence, etc.

CPC: Cerebral Performance Category

Table 2
Patients’ General Characteristics (n = 30,279)
Variables N(%)
Gender Male 19,505 (64.4)
Female 10,774 (35.6)
Age < 20 709 (2.3)
20-39 2,034 (6.7)
40-59 6,867 (22.7)
60-79 12,013 (39.7)
> 80 8,648 (28.6)
Administrative District Metropolitan city (Seoul) 4,604 (15.2)
Special self-governing city (Sejong) 12 (0.1)
Special self-governing province (Jeju) 622 (2.1)
Megalopolis 7,061 (23.3)
Province (Do) 17,980 (59.4)
Insurance Type National health insurance 24,485 (80.9)
Car insurance 1,201 (4.0)
Occupational health and safety insurance 97 (0.3)
Medical benefit type 1 2,594 (8.6)
Medical benefit type 2 224 (0.7)
General insurance 3 (0.0)
Others 52 (0.2)
Unknown 1,623 (5.4)
Hypertension Yes 9,208 (30.4)
No 2,293 (7.6)
Unknown 18,778 (62.0)
Diabetes Mellitus Yes 5,939 (19.6)
No 2,544 (8.4)
Unknown 21,796 (72.0)
Heart Disease Yes 4,701 (15.5)
No 2,498 (8.2)
Unknown 23,080 (76.2)
Renal Disease Yes 1,542 (5.1)
No 2,544 (8.4)
Unknown 26,193 (86.5)
Respiratory Disease Yes 1,835 (6.1)
No 2,526 (8.3)
Unknown 25,918 (85.6)
Stroke Yes 2,413 (8.0)
No 2,532 (8.4)
Unknown 25,334 (83.7)
Hyperlipidemia Yes 992 (3.3)
No 2,511 (8.3)
Unknown 26,776 (88.4)

* Megalopolises: Busan, Incheon, Daegu, Daejeon, Gwangju, Ulsan. Do; Gyeonggi, Gangwon, Chungbuk, Chungnam, Jeonbuk, Jeonnam, Gyeongbuk, Gyeongnam

Table 3
Factors causing out-of-hospital cardiac arrest
Variables N(%)
Arrest Cause Disease 23,132 (76.4)
Non-disease 6,975 (23.0)
Unknown 172 (0.6)
Place Public 5,544 (18.3)
Non-public 17,120 (56.5)
Others 1,065 (3.5)
Unknown 6,550 (21.6)
PRE_ER_CPR Yes 28,234 (93.2)
No 404 (1.3)
Unknown 1,641 (5.4)
PRE_ER_DEFIB Yes 3,960 (13.1)
No 1,613 (5.3)
Unknown 24,706 (81.6)
PRE_ER_ROSC ROSC(+) 2,470 (8.2)
ROSC(−) 27,809 (91.8)
Witness Yes 13,939 (46.0)
No 13,710 (45.3)
Unknown 2,630 (8.7)
Bystander CPR Yes 6,694 (22.1)
No 2,128 (7.0)
Not applicable 3,222 (10.6)
Unknown 18,235 (60.2)

* CPR; cardiopulmonary resuscitation, ROSC; return of spontaneous circulation

Table 4
Characteristics of 119 EMS by Administrative Region
Variables Metropolitan City (Seoul) Special Self-Governing Province (Jeju) Megalopolis Province p
PRE_ER_ROSC ROSC(+) 388 (1.3) 47 (0.2) 686 (2.3) 1,349(4.5) 0.001
ROSC(−) 4,216 (13.9) 575 (1.9) 6,375 (21.1) 16,631(54.9)
Bystander CPR No 811 (9.2) 13 (0.1) 443 (5.0) 860(9.7) 0.001
Yes 1,552 (17.6) 102 (1.2) 1,470 (16.7) 3,569(40.5)
Place Public 475 (7.0) 22 (0.3) 452 (6.7) 954(14.1) 0.018
Non public 1,397 (20.6) 69 (1.0) 1,042 (15.3) 2,377(35.0)
Witness No 2,140 (7.7) 310 (1.1) 3,278 (11.9) 7,975(28.8) 0.006
Yes 2,257 (8.2) 242 (0.9) 3,240 (11.7) 8,197(29.6)
PRE_ER_EKG VF5 27 (2.5) 46 (0.2) 763 (3.7) 1,517(7.3) 0.001
Pulseless VT 27 (0.1) 4 (0.0) 61 (0.3) 95(0.5)
PEA 1,041 (5.0) 57 (0.3) 1,112 (5.4) 2,144(10.3)
Asystole 2,139 (10.3) 221 (1.1) 3,196 (15.4) 7,798(37.6)
PRE_ER_DEFIB No 247 (4.4) 39 (0.7) 516 (9.3) 811(14.6) 0.001
Yes 678 (12.2) 70 (1.3) 1,033 (18.5) 2,179(39.1)
CPC 1 176 (8.5) 25 (1.2) 223 (10.8) 403(19.5) 0.001
2 110 (5.3) 14 (0.7) 158 (7.6) 212(10.3)
3 92(4.4) 3 (0.1) 86 (4.2) 177(8.6)
4 85 (4.1) 0 (0.0) 123 (5.9) 181(8.8)
5 0 (0.0) 0 (0.0) 0 (0.0) 0(0.0)
Table 5
Association of Initial ECG Rhythm, Defibrillation, and Cerebral Performance Category by Paramedics
Variables Good CPC Poor CPC p
119 Defibrillation
None 241 (11.8) 498 (24.4) 0.001
Done 1,056 (51.7) 249 (12.2)
119 Initial Rhythm
Shockable 1,025 (52.8) 219 (11.3) 0.001
Non-shockable 205 (10.6) 494 (25.4)

* Shockable rhythm type: VF, pulseless VT; non-shockable rhythm type: asystole, PEA

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