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Neurologic Critical Care

Arterial Blood Pressure and Neurologic Outcome


After Resuscitation From Cardiac Arrest*
J. Hope Kilgannon, MD1; Brian W. Roberts, MD1; Alan E. Jones, MD2; Neil Mittal, MD1;
Evan Cohen, MD1; Jessica Mitchell, MD1,3; Michael E. Chansky, MD1; Stephen Trzeciak, MD, MPH1,3

Objectives: Guidelines for postcardiac arrest care recommend effect at time-weighted average mean arterial pressure value of
blood pressure optimization as one component of neuroprotec- 70 mm Hg. This threshold (mean arterial pressure > 70 mm Hg)
tion. Although some retrospective clinical studies suggest that had the strongest association with good neurologic outcome
postresuscitation hypotension may be harmful, and laboratory (odds ratio, 4.11; 95% CI, 1.3412.66; p = 0.014). A sustained
studies suggest that a postresuscitation hypertensive surge may intrinsic hypertensive surge was relatively uncommon and was
be protective, empirical data are few. In this study, we prospec- not associated with neurologic outcome.
tively measured blood pressure over time during the postresusci- Conclusions: We found that time-weighted average mean arte-
tation period and tested its association with neurologic outcome. rial pressure was associated with good neurologic outcome at a
Design: Single center, prospective observational study from 2009 threshold of mean arterial pressure greater than 70 mm Hg. (Crit
to 2012. Care Med 2014; 42:20832091)
Patients: Inclusion criteria were age 18 years old or older, pre- Key Words: brain injury; cardiopulmonary resuscitation; ischemia-
arrest independent functional status, resuscitation from cardiac reperfusion injury; return of spontaneous circulation
arrest, and comatose immediately after resuscitation.
Measurements and Main Results: Our research protocol mea-
sured blood pressure noninvasively every 15 minutes for the first

T
he postcardiac arrest syndrome is a state of severe,
6 hours after resuscitation. We calculated the 0- to 6-hour time-
global ischemia/reperfusion injury with potentially
weighted average mean arterial pressure and used multivariable
devastating consequences (1, 2). The mortality associ-
logistic regression to test the association between increasing
ated with this condition is extremely high, and among those
time-weighted average mean arterial pressures and good neu-
that survive, many are left with permanent, disabling neuro-
rologic outcome, defined as Cerebral Performance Category 1
logic injury. The discovery that controlling body temperature
or 2 at hospital discharge. Among 151 patients, 44 (29%) expe-
after return of spontaneous circulation (ROSC) may improve
rienced good neurologic outcome. The association between
neurologic function (35) provides hope that additional
blood pressure and outcome appears to have a threshold
postresuscitation interventions may be found to reduce the
degree of brain injury and further improve clinical outcomes.
*See also p. 2145. Patients with postcardiac arrest syndrome experience ongo-
1
Department of Emergency Medicine, Cooper University Hospital, ing oxidant damage (6, 7), profound systemic inflammation
Camden, NJ.
(810), myocardial stunning (11, 12), and adrenal axis suppres-
2
Department of Emergency Medicine, The University of Mississippi Medi-
cal Center, Jackson, MS. sion (13, 14), which commonly result in major hemodynamic
3
Division of Critical Care Medicine, Department of Medicine, Cooper Uni- instability (1518). Given that the injured brain commonly has
versity Hospital, Camden, NJ. dysfunctional autoregulation of the cerebral blood flow, including
Supplemental digital content is available for this article. Direct URL cita- brain injury secondary to cardiac arrest (19, 20), it is possible that
tions appear in the printed text and are provided in the HTML and PDF
versions of this article on the journals website (http://journals.lww.com/
post-ROSC blood pressure alterations may be a factor in ongo-
ccmjournal). ing cerebral injury and eventual neurologic outcome. With dis-
Dr. Kilgannons work was supported by a Career Development Grant from ruption of normal cerebrovascular autoregulation, cerebral blood
the Emergency Medicine Foundation. The remaining authors have dis- flow may become directly related to cerebral perfusion pressure
closed that they do not have any potential conflicts of interest.
(20), which is dependent on mean arterial pressure (MAP).
For information regarding this article, E-mail: kilgannon-hope@cooper-
health.edu Although some retrospective clinical studies suggest that
Copyright 2014 by the Society of Critical Care Medicine and Lippincott postresuscitation hypotension is associated with lower sur-
Williams & Wilkins vival (1618, 21), and laboratory studies suggest that induc-
DOI: 10.1097/CCM.0000000000000406 ing a postresuscitation hypertensive surge may confer

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Kilgannon et al

neuroprotection (22, 23), there remains a paucity of data on


the relationship between post-ROSC blood pressure and
neurologic outcome. The 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation (CPR) and
Emergency Cardiovascular Care recommend post-ROSC
goal-directed hemodynamic support including blood pressure
optimization with IV fluids and vasopressors to achieve a tar-
get MAP greater than or equal to 65 mm Hg (24). However,
the relationship between post-ROSC MAP and neurologic
outcome remains incompletely understood. Specifically, it is
unclear if there is an association between MAP and neuro-
logic outcome, and if they are associated, it is unknown if it
is a threshold effect at a specific low MAP value versus a linear
relationship in which hypertension is protective.
In this prospective observational study of adult patients Figure 1. Patient screening and inclusion flow diagram.
resuscitated from cardiac arrest, our objectives were to measure
blood pressure over time in the immediate postresuscitation PostCardiac Arrest Care
period and to test the association between postresuscitation Our institution uses state-of-the-art postresuscitation care for
blood pressure and neurologic outcome at hospital discharge. postcardiac arrest patients and a previously published standard
We hypothesized that higher post-ROSC blood pressures operating procedure, by our group, including all of the following
would be independently associated with good neurologic elements recommended for regional cardiac arrest centers: 1)
outcome. immediate evaluation for percutaneous coronary intervention
(if needed); 2) immediate evaluation for therapeutic hypother-
METHODS mia; 3) evaluation and management by an in-house critical care
physician; and 4) evidence-based timing and methods of neuro-
Setting logic prognostication (26, 27). Our institution uses a standard-
This was a prospective observational study conducted at a ized order set for treatment with therapeutic hypothermia, using
single urban academic medical center, Cooper University Hos- a surface cooling system (Arctic Sun, Medivance, Louisville, CO),
pital in Camden, New Jersey. Subjects were enrolled in the and our clinicians have demonstrated proficiency in achieving
emergency department (ED) and ICU from 2009 to 2012. The and maintaining target temperature (3334C) in 96% of cases,
institutional review board approved this study with a waiver of within a median time of 4.4 hours from ROSC (28). The deci-
written informed consent. sion on whether or not to initiate therapeutic hypothermia was
made by the treating physicians and was not part of the study
Participants protocol. In general, our clinicians use therapeutic hypothermia
We enrolled in- and out-of-hospital adult postcardiac arrest for out-of-hospital cardiac arrest due to ventricular fibrillation
patients who were comatose immediately after ROSC. The (VF) and pulseless ventricular tachycardia (VT) (i.e., level 1
inclusion criteria were 1) age 18 years old or older; 2) indepen- recommendation in the current guidelines) (24), and its use in
dent functional status prior to cardiac arrest; 3) cardiac arrest, other patients (e.g., nonshockable initial rhythm or in-hospital
defined as a documented absence of pulse and CPR initiated; cardiac arrest) is at the discretion of the treating physician.
4) ROSC; and 5) inability to follow commands immediately
after ROSC. We excluded patients with cardiac arrest related to Data Collection
trauma. We also excluded patients if, for any reason, post-ROSC We collected basic demographics as well as the data and out-
blood pressure recordings were not captured per protocol (see come variables consistent with the Utstein style for reporting
detail described below). Figure 1 displays our screening process. cardiac arrest research, including the post-ROSC variables rec-
ommended for postresuscitation research (29, 30). For measur-
Patient Identification ing the exposure of interest (arterial blood pressure over time),
We used the following methodology previously described for our research protocol cycled a noninvasive blood pressure cuff
real-time, prospective identification of postcardiac arrest every 15 minutes for the first 6 hours after ROSC and recorded
patients (25). This included a 24-hour per day, 7-day per week all blood pressure measurements. We entered the data into a
paging system activated in one of two ways: 1) a hospital-wide dedicated Access database (Microsoft Corporation, Redmond,
code blue activation anytime a cardiac arrest occurred in the WA) and exported to StatPlus:mac version 2009 (AnalystSoft,
hospital; 2) ED unit secretaries were trained to activate a page Alexandria, VA) for analysis.
when an out-of-hospital cardiac arrest arrived in the ED (or
a cardiac arrest occurred in the ED). An investigator received Outcome Measures
the page and responded to the cardiac arrest event to begin The primary outcome was good neurologic function at hos-
data capture. pital discharge, defined as a Cerebral Performance Category

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Neurologic Critical Care

(CPC) 1 or 2, which is the most commonly used outcome mea- [PEA]), and 3) prearrest comorbidities (i.e., Charlson comor-
sure in clinical trials of postcardiac arrest interventions (31). bidities index) (24, 3739).
The CPC is a validated five-point scale of neurologic disability Sample Size Calculation. To ensure adequate power to test
(1: good cerebral performance, 2: moderate cerebral disabil- these four covariates in a multivariate model, we estimated
ity, 3: severe cerebral disability, 4: coma/vegetative state, and 5: the necessary sample size, based on the following assump-
death) (29, 32, 33). Patients with a CPC of 1 or 2 had sufficient tions: 1) a predicted survival with good neurologic function
cerebral function at discharge to live independently. rate of 28% (40); and 2) an estimated event (survival with
good neurologic function) per covariate ratio of 10:1 neces-
Data Analysis sary for multivariate modeling (41, 42). In order to accrue
We began our analysis with descriptive statistics. We described the necessary 40 survivors with good neurologic function,
continuous data as mean values and SD or median values and we estimated that a minimum of 143 total subjects would be
interquartile range (IQR), based on distribution of data, and necessary.
displayed categorical data as counts and proportions.
Quantifying the Exposure. For each postcardiac arrest
RESULTS
patient, we calculated the time-weighted average mean arte-
One hundred fifty-one patients met all inclusion and no exclu-
rial pressure (TWA-MAP) for the first 6 hours after ROSC. We
sion criteria and were enrolled. Table 1 displays baseline char-
calculated the TWA-MAP for each patient in a manner consis-
acteristics. The mean (SD) age of subjects was 63 ( 16) years.
tent with previously published methods of calculating expo- Sixty-four (42%) were women. The majority of the subjects in
sures over time in epidemiological research (3436). For each
the cohort had an in-hospital arrest, and most had an initial
patient, we multiplied the length of time that the patient spent
recorded rhythm of PEA or asystole. Eighty-six of the subjects
at a specific MAP value by that MAP value, added all these val-
(57%) required a continuous infusion of vasopressor agents in
ues together, and then divided by the total length of postresus-
the first 6 hours after ROSC.
citation observation time. Thus, we used the equation:
Therapeutic hypothermia was used in 16 of 23 patients
(70%) with out-of-hospital arrest, and 52 of 151 of all patients
[(MAPa Time a) (34%). In the treated population, target temperature was
+ (MAPb Time b) achieved in 46 of 52 patients (88%), with a median (IQR) time
to target temperature of 3.9 hours (2.84.9 hr). Good neuro-
+ (MAPz Time z)] logic outcome occurred in 26% of those treated versus 31% of
TWA-MAP =
( T ime a + Time b + Time z ) patients not treated with therapeutic hypothermia (p = 0.578,
using Fisher exact test). The majority of those treated with
For example, if a patient had the following exposures therapeutic hypothermia (42 of 54 [78%]) had PEA/asystole
MAP 70 mm Hg for 30 minutes, MAP 72 mm Hg for 15 min- as initial rhythm.
utes, MAP 74 mm Hg for 60 minutes, MAP 77 mm Hg for 45 The mean (SD) TWA-MAP for the entire cohort was 79 ( 17).
minutes, MAP 80 mm Hg for 60 minutes, MAP 82 mm Hg for Figure 2 displays the distribution of TWA-MAP values and
45 minutes, MAP 85 mm Hg for 60 minutes, and MAP 87 mm shows that sustained low arterial pressure, for example, TWA-
Hg for 45 minutes, the TWA-MAP for the 6-hour postresus- MAP less than or equal to 70 mm Hg, was relatively common
citation period would be: (2,100 mm Hg min + 1,080 mm (25% of patients), whereas an intrinsic sustained hypertensive
Hg min + 4,440 mm Hg min + 3,465 mm Hg min + surge, for example, TWA-MAP greater than 100 mm Hg, was
4,800 mm Hg min + 3,690 mm Hg min + 5,100 mm Hg relatively uncommon (< 10% of patients).
min + 3,915 mm Hg min)/360 min = 79 mm Hg. Thus, this Twenty-nine percent (44 of 151) of all patients were found
value, 79 mmHg, would be the time-weighted average value for to have the primary outcome of good neurologic function at
the MAP over the duration of the 6-hour period. hospital discharge. Fourteen (32%) of those who met the pri-
We calculated odds ratios (ORs) using multivariate logistic mary outcome had initial rhythm of VF/VT. Twenty-nine per-
regression to determine if the TWA-MAP was independently cent (14 of 49) of those with an initial rhythm of VT/VF had
associated with neurologic function at hospital discharge. To a good neurologic outcome and likewise 29% (30 of 102) of
test if the TWA-MAP had a linear association with neurologic those with an initial rhythm of PEA/asystole had a good neu-
outcome, we entered TWA-MAP into the model as a continu- rologic outcome.
ous variable. To test if the association was a threshold effect The mean (SD) TWA-MAP among patients with good neu-
at a specific arterial blood pressure, we performed additional rologic fnction and poor neurologic function at hospital dis-
multivariate logistic regression analyses, each with TWA-MAP charge was 83 ( 13) and 77 ( 18), respectively (p = 0.042).
at different binary cutoffs (5 mm Hg increments from MAP > Figure 3 displays the good neurologic function at hospital dis-
65 mm Hg to MAP > 90 mm Hg). We selected the following charge in relation to the TWA-MAP value for the first 6 hours
candidate variables for the regression models on the grounds after ROSC.
that they were previously demonstrated to predict outcome in Table 2 displays the results of the multivariate logistic regres-
postcardiac arrest patients: 1) age (decile), 2) initial cardiac sion model with TWA-MAP as a continuous independent vari-
rhythm (i.e., VF/VT vs asystole or pulseless electrical activity able and good neurologic function at hospital discharge as the

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Kilgannon et al

TABLE 1. Baseline Characteristics of All Subjects


All Subjects Subjects With Subjects With
Patient Characteristics (n = 151) TWA-MAP 70a (n = 36) TWA-MAP > 70a (n = 115)

Age, yr (SD) 63 ( 16) 66 ( 13) 62 ( 17)


Female gender, n (%) 64 (42) 14 (39) 50 (43)
Preexisting comorbidities, n (%)
Diabetes 55 (36) 14 (39) 41 (36)
Known coronary artery disease 34 (23) 9 (25) 25 (22)
Hypertension 79 (52) 23 (64) 56 (47)
Malignancy 30 (20) 10 (28) 20 (17)
Renal insufficiency 32 (21) 12 (33) 20 (17)
Pulmonary disease 32 (32) 6 (17) 26 (23)
Congestive heart failure 29 (19) 7 (19) 22 (19)
Charlson comorbidity score (39), 2 (14) 3 (15) 2 (04)
median (interquartile range)
Arrest location, n (%)
Out-of-hospital/emergency department 41 (27) 11 (31) 30 (26)
ICU 74 (49) 19 (53) 55 (48)
Floor/monitored bed 19 (13) 5 (14) 14 (12)
Floor/unmonitored bed 2 (1) 0 2 (2)
Other 15 (10) 1 (3) 14 (12)
Initial arrest rhythm, n (%)
Pulseless electrical activity/asystole 119 (79) 32 (89) 87 (76)
Ventricular fibrillation/ventricular 32 (21) 4 (11) 28 (24)
tachycardia
Estimated downtime > 10 min, n (%) 50 (33) 13 (38) 37 (33)
TWA-MAP = time-weighted average mean arterial pressure.
a
Measured in mm Hg.

dependent variable (OR, 1.02; 95% CI, 1.001.02; p = 0.086). Content 1, http://links.lww.com/CCM/A971). Table 4 reports
Table 3 displays additional multivariate logistic regression neurologic outcome as it relates to vasopressor use in the first
models with TWA-MAP at different binary thresholds. There 6 hours after ROSC.
appears to be a threshold effect at a TWA-MAP greater than
70 mm Hg. We found that a TWA-MAP greater than 70 mm
Hg was the highest blood pressure threshold that was inde- DISCUSSION
pendently associated with the outcome. That is, in starting In this prospective observational study, we tested the relation-
at a MAP of 90 mm Hg and decreasing the binary cutoff by ship between arterial blood pressure after resuscitation from
5 mm Hg increments, TWA-MAP first becomes an indepen- cardiac arrest and neurologic outcome. We sought to test this
dent predictor of outcome at a threshold greater than 70 mm relationship because the injured brain may be especially vul-
Hg. A TWA-MAP greater than 70 mm Hg also had the highest nerable to blood pressure alterations after ROSC due to a loss
OR for good neurologic function at hospital discharge among of normal cerebral autoregulation and disruption of micro-
all binary thresholds tested, OR 4.11 (95% CI, 1.3412.66, vascular perfusion (19, 20), and thus maintaining an adequate
p = 0.014). On further sensitivity analysis, TWA-MAP greater MAP (or raising the MAP) in the postresuscitation period may
than 70 mm Hg remained the MAP threshold with the stron- help ensure adequate cerebral perfusion and confer neuropro-
gest association with good neurologic outcome after adjusting tection. To date, there has been little empirical data on this
for duration of CPR or downtime longer than 10 minutes, topic in human subjects, limited only to retrospective analyses
OR 5.25 (95% CI, 1.7315.98, p = 0.003) (details of the models (1618) and one recent pilot study (43); thus, we felt that a
are displayed in the supplemental data, Supplemental Digital rigorous prospective study with dense data capture of blood

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Neurologic Critical Care

resuscitated from cardiac


arrest (40). We found that arte-
rial hypotension was common
while relatively fewer patients
had an intrinsic hypertensive
surge. On multivariate logistic
regression analyses, we found
that TWA-MAP was associated
with good neurologic out-
come. This association appears
to be driven by the strong asso-
ciation between hypotension
and poor neurologic outcome,
as opposed to an association
between intrinsic hyperten-
sion and better neurologic
outcome. In our analysis, there
was a threshold effect with a
TWA-MAP greater than 70
mm Hg having the greatest
association with good neuro-
Figure 2. Distribution of the time-weighted average mean arterial blood pressure values in the first 6 hr after logic function, and we did not
cardiac arrest.
find higher MAP thresholds
pressure recordings over time in the immediate postresuscita- (> 75, > 80, > 85 mm Hg, etc.) to be associated with favorable
tion period was needed. neurologic outcome.
We found that of the 151 patients enrolled, 29% (44 of In contrast to some prior studies, a major strength of the
151) met our primary outcome of good neurologic outcome current study is the prospective, dense data capture of blood
at hospital discharge; this is consistent with the outcomes pressure recordings over the early postresuscitation period to
in previously published large series of patients successfully allow rigorous measurement of the true exposure and using
TWA as mechanism of quanti-
fying the exposure; the unique-
ness of the results is that they
provide more granular data on
the relationship between blood
pressure and neurologic out-
come by identifying a numeric
threshold of potential harm. In
2008, the International Liaison
Committee on Resuscitation
identified that determining
the optimal target range for
MAP after cardiac arrest was a
critical knowledge gap in post
cardiac arrest care (2). This is
an important area of clinical
investigation, as sudden car-
diac arrest is a leading cause of
death and neurologic devasta-
tion among adults (4446).
Furthermore, the postcardiac
arrest syndrome is typically
Figure 3. Good neurologic function at hospital discharge in relation to the time-weighted average mean
arterial pressure (TWA-MAP) value for the first 6 hr after return of spontaneous circulation. There was a characterized with marked
statistically significant difference in the proportion of patients with good neurologic outcome between the swings in blood pressure due
TWA-MAP 70 and TWA-MAP 7180 groups, 11% versus 37% (p = 0.009 by Fisher exact test). There to fluctuating hemodynamic
was no difference between the TWA-MAP 7180 and TWA-MAP 8190 groups, 37% versus 36% (p = 1
by Fisher exact test) or between TWA-MAP 8190 and TWA-MAP > 90 groups, 36% versus 32% perturbations after reperfu-
(p = 0.804 by Fisher exact test). sion (2, 1518). Therefore, this

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Kilgannon et al

TABLE 2. Multivariate Logistic Regression Model of the Association Between Time-


Weighted Average Mean Arterial Pressure During the First 6 Hours After Return
of Spontaneous Circulation and Good Neurologic Outcome (Defined as Cerebral
Performance Category 1 or 2) at Hospital Discharge
Variable OR 95% Lower CI 95% Upper CI p

Mean arterial pressure 1.02 1.00 1.04 0.086


Age 0.93 0.75 1.15 0.490
Pulseless electrical activity/asystole initial rhythm 0.45 0.20 1.05 0.064
Charlson comorbidity index 0.88 0.62 1.25 0.474
OR = odds ratio.
Time-weighted average mean arterial pressure is entered into the model as a continuous variable.

study addresses a clinical scenario that is relatively common surge hypothesis, a recently published pilot interventional
and represents a critical phase in the trajectory of the eventual trial of induced hypertension after cardiac arrest, which
outcome following cardiac arrest. reported that supranormal MAP did not affect cerebral tis-
The 2010 American Heart Association guidelines for sue oxygenation (43).
postcardiac arrest care recommended post-ROSC goal- Regarding blood pressure support after cardiac arrest
directed hemodynamic optimization; however, the guide- and outcome, there may be important parallels between the
lines acknowledged the lack of high-quality evidence to global cerebral ischemia/reperfusion injury of cardiac arrest
support a specific target for MAP after ROSC (24). As there and the regional ischemia/reperfusion injury of acute isch-
is proven benefit of goal-directed hemodynamic optimiza- emic stroke (AIS). In patients with AIS, it is widely accepted
tion, including MAP targets, for patients with other etiolo- that arterial hypotension is associated with worse outcomes
gies of critical illness (4749), it is also, in theory, possible because it exacerbates cerebral ischemia, and permissive
that blood pressure optimization could improve neurologic hypertension could preserve cerebral perfusion in the isch-
outcome among patients with postcardiac arrest syndrome. emic penumbra and protect the injured brain from further
However, this hypothesis has not yet been tested in a clini- insult (5263). Although ideal target blood pressure after
cal trial. In a subanalysis of our study population, we found cardiac arrest remains unknown, enough evidence exists to
that patients who were able to maintain a TWA-MAP greater compel clinicians at the bedside pay close attention to blood
than 70 mm Hg without vasopressor administration had a pressure, specifically avoiding hypotension after resuscitation
higher proportion of good neurologic outcome compared from cardiac arrest.
with patients who achieved a TWA-MAP greater than 70
with vasopressor administration, 48% versus 24%, respec- Limitations
tively (p = 0.01). We were unable to show a statistically sig- We acknowledge that our data have important limitations
nificant difference in good neurologic outcome for patients to consider. Most notably, this was an observational study.
administered vasopressors to maintain TWA-MAP greater Although many patients in the study received vasoactive agents,
than 70 mm Hg compared with patients with a TWAMAP this was not an interventional protocol with a predefined MAP
less than or equal to 70 who did not receive vasopressors, goal. Thus, we can only report associations in this study rather
24% versus 10%, respectively (Table 4). One possibility to than infer causation.
explain these findings is that the bodys intrinsic ability to By study design, we did not require invasive blood pressure
maintain adequate perfusion pressure without vasopressors monitoring nor could we control for the effects on outcome
after ROSC is a predictor of eventual good neurologic out- created by having various clinicians involved in patient care.
come and that supporting the MAP with the application of Our study does, however, reflect real clinical practice and a
vasopressor agents may not confer benefit. However, animal readily available marker of inadequate perfusion (cuff blood
models have shown evidence to the contrary, in fact report- pressure). Although our institution used a standardized order
ing that an induced hypertensive surge for cerebral blood set for therapeutic hypothermia (28), and our clinicians have
flow promotion can attenuate brain injury and improve out- previously demonstrated a median time to achieving target
come (22, 23, 50, 51). Our study design did not test a vaso- temperature that was less than 4 hours (compared with 8 hr in
pressor therapeutic approach, and we found fewer patients the Hypothermia After Cardiac Arrest trial) (5), there was likely
with sustained intrinsic hypertension than expected (12 of some degree of heterogeneity in the selection of patients for
151 had TWA-MAP > 100 mm Hg) with no clear associa- therapeutic hypothermia. As expected, the majority of cardiac
tion between TWA-MAPs greater than 90 mm Hg and good arrest cases were in-hospital, nonshockable initial rhythms
outcome, OR 1.12 (95% CI, 0.482.60, p = 0.794). We found a population where the efficacy of hypothermia is not clearly
only one clinical study that tested this induced hypertensive established (class IIb evidence)and thus the practice at our

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TABLE 3. Multivariate Logistic Regression Models of the Association Between Time-


Weighted Average of Mean Arterial Pressure at Different Binary Thresholds During
the First 6 Hr After Return of Spontaneous Circulation and Good Neurologic Function
(Defined as Cerebral Performance Category 1 or 2) at Hospital Discharge
Variable OR 95% LCI 95% UCI p

TWA-MAP > 65 mm Hg 4.04 1.13 14.42 0.031


Age 0.94 0.76 1.17 0.597
PEA/asystole initial rhythm 0.47 0.21 1.09 0.080
Charlson comorbidity index 0.90 0.63 1.28 0.565
Variable OR 95% LCI 95% UCI p

TWA-MAP > 70 mm Hg 4.11 1.34 12.66 0.014


Age 0.94 0.76 1.16 0.547
PEA/asystole initial rhythm 0.49 0.21 1.13 0.093
Charlson comorbidity index 0.92 0.64 1.32 0.656
Variable OR 95% LCI 95% UCI p

TWA-MAP > 75 mm Hg 1.22 0.58 2.57 0.594


Age 0.91 0.74 1.13 0.401
PEA/asystole initial rhythm 0.46 0.20 1.04 0.063
Charlson comorbidity index 0.86 0.61 1.22 0.407
Variable OR 95% LCI 95% UCI p

TWA-MAP > 80 mm Hg 1.44 0.70 2.98 0.321


Age 0.92 0.74 1.14 0.443
PEA/asystole initial rhythm 0.46 0.20 1.04 0.063
Charlson comorbidity index 0.87 0.62 1.24 0.442
Variable OR 95% LCI 95% UCI p

TWA-MAP > 85 mm Hg 1.48 0.70 3.14 0.310


Age 0.92 0.74 1.14 0.432
PEA/asystole initial rhythm 0.45 0.20 1.02 0.056
Charlson comorbidity index 0.86 0.61 1.22 0.396
Variable OR 95% LCI 95% UCI p

TWA-MAP > 90 mm Hg 1.12 0.48 2.60 0.794


Age 0.91 0.74 1.13 0.398
PEA/asystole initial rhythm 0.45 0.20 1.02 0.056
Charlson comorbidity index 0.86 0.61 1.21 0.381
OR = odds ratio, LCI = lower CI, UCI = upper CI, TWA-MAP = time-weighted average mean arterial pressure, PEA = pulseless electrical activity.
There appears to be a threshold effect at a TWA-MAP > 70 mm Hg. A TWA-MAP > 70 mm Hg is the highest blood pressure value that is independently
associated with good outcome. As the binary cutoff decreases by 5 mm Hg increments, TWA-MAP first becomes an independent predictor of outcome at 70 mm
Hg. A TWA-MAP > 70 mm Hg also has the highest odds ratio for good neurologic outcome at hospital discharge among all thresholds tested.

institution is to leave the decision on whether or not to treat 70 mm Hg for a good neurologic outcome (OR, 4.11; 95% CI,
with hypothermia up to the treating clinician. 1.3412.66), they remain significant (p = 0.014).
This study was limited to a single medical center, and thus, Lastly, although we used multivariable logistic regression
the sample size led to the wide CIs for the adjusted ORs on analyses to adjust for cardiac arrest characteristics known to
the multivariable logistic regression model (Table 3). Although predict poor outcomes, there always exists the potential of
the CIs are wide for the threshold cutoff of MAP greater than unmeasured confounders with an observational design.

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Kilgannon et al

TABLE 4. Good Neurologic Outcome Stratified by Time-Weighted Average Mean Arterial


Pressure (mm Hg) and Vasopressor Use
TWA-MAP > 70 TWA-MAP > 70 TWA-MAP < 70 TWA-MAP < 70

No Vasopressors Vasopressors No Vasopressors Vasopressors

n = 54 n = 59 n = 10 n = 28

Good neurologic outcome (%) 26 (48) 14 (24) 1 (10) 3 (11)


TWA-Cumulative Vasopressor Index, 0 4 (35) 0 6 (312)
median (interquartile range)
TWA-MAP = time-weighted average mean arterial pressure.
Column 2 versus column 3, 48% versus 24% (p = 0.010 by Fisher exact test).
Column 3 versus column 4, 24% versus 10% (p = 0.442 by Fisher exact test).
Column 3 versus column 5, 24% versus 11% (p = 0.247 by Fisher exact test).

CONCLUSIONS 10. Gando S, Kameue T, Nanzaki S, et al: Platelet activation with massive
formation of thromboxane A2 during and after cardiopulmonary resus-
In this prospective study of postcardiac arrest patients citation. Intensive Care Med 1997; 23:7176
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