The First Dubai Cardiac Arrest Symposium: A Focus on Improving Outcomes in Resuscitation

On February 22, 2014, ZOLL Medical Corporation, in cooperation with the Emirates Cardiac Society, hosted the first Dubai Cardiac Arrest Symposium to increase awareness of the global burden of sudden cardiac arrest (SCA), reinforce the chain of survival, and improve patient care and outcomes in resuscitation.   

A scientific panel of international experts in cardiology and cardiopulmonary resuscitation (CPR) addressed an audience of 225 cardiologists, emergency physicians, anesthesiologists, resuscitation officers, nurses, and directors from across the Gulf Region. Alawi Alsheikh-Ali, MD, MSc, FACC, president of the Emirates Cardiac Society and consultant cardiologist and cardiac electrophysiologist at the Heart and Vascular Institute of Sheikh Khalifa Medical City in Abu Dhabi, United Arab Emirates, moderated the day-long event. CME accreditation was made available.

Incidence, survival rates, neurologically intact survival, and other statistics on cardiac arrest in the Gulf Region are hard to come by. In his remarks, Dr. Alsheikh-Ali pointed to an English language literature search he conducted on the epidemiology of SCA. In one recently published systematic review he found that included 67 studies, none was from Africa or the Middle East. As a still developing region, the Middle East and North Africa are at an earlier stage than Europe and other more developed countries in the epidemiologic transition, which takes place as societies mature. This was reflected in a slide showing that deaths from cardiovascular disease (CVD) as a percentage of all deaths have decreased in the developed world over the last 20 years, while in the Middle East and North Africa, deaths from CVD have increased by 11% over the same period.  

Based on this and other CVD data, as well as the results from the DISCOVERY2 study conducted by the Emirates Cardiac Society, Dr. Alsheikh-Ali suspects that the epidemiology of cardiac arrest in the Gulf is different than that found in North America and Europe. In the DISCOVERY2 study, people shopping in malls were asked to self-report conventional CVD risk factors. Among participants, 70% reported hypertension, 20% hypercholesterolemia, and 15% diabetes. “The striking part is not the significant burden,” said Dr. Alsheikh-Ali. “The striking part is that the median age of these people was 37. This is your typical 37-year-old walking in a mall in Dubai. So 10, 15, 20 years from now, they’re very likely to have cardiovascular disease, which is a major trigger for cardiac arrest.” 

It is already clear that heart attack patients are younger in the Gulf. Citing data from the Gulf RACE and GRACE registries, Dr. Alsheikh-Ali said that 47% of acute coronary syndrome (ACS) patients are under 55 — approximately 10 years younger than their Western counterparts. In addition, he pointed out that ACS patients in this region tend to present later, predisposing them to a higher risk of cardiac arrest. 

A recent MEDLINE search conducted by Dr. Alsheikh-Ali turned up just three studies that provided insight into cardiac arrest in the Gulf Region. One of these papers focused on out-of-hospital cardiac arrest in Riyadh, Saudi Arabia, over a seven-year period. Nine percent of patients in this 1999 study received pre-hospital CPR, 14% were in ventricular fibrillation upon arrival at the emergency department, and only 12% were transported to the hospital via ambulance. According to Dr. Alsheikh-Ali, the vast majority of ACS patients in the Gulf are brought to the hospital by family members, even when ambulance service is available. He believes that this may in part be due to a lack of trust in the system based on how fast an ambulance typically arrives. As he pointed out, this means that “the opportunity for pre-hospital ambulance care is totally absent in 80% of ACS patients.” Despite this, survival-to-hospital discharge in this study mirrored survival rates seen across the globe: 5% for adults and 7% for children. 

To get a better handle on the incidence of SCA in the six Arab countries that constitute the Gulf Cooperation Council, Dr. Alsheikh-Ali used what he referred to as back-of-the-envelope calculations. Based on a population of 50 million people, he assumed that incidence of out-of-hospital cardiac arrest is the same as that from the systematic review referred to earlier that included 67 studies, 55 cases per 100,000 person years. Using these numbers, he said there would be a total of 26,000 out-of-hospital cardiac arrests in these six countries each year. “If you assume 7% survival, you will have 1,800 survivors of out-of-hospital cardiac arrest every year in the Gulf.” He went on to say, “And what if there is public access to AEDs in the region? If you assume that AEDs increase the odds of survival by 1.75, which is from a study recently published in the Journal of American College of Cardiology, 1,370 people would probably be saved annually if AEDs were widely available.” 

Genetics may also be playing a role in the epidemiology of cardiac arrest in the Gulf. He pointed to Brugada syndrome as a possible culprit. “We see at least one or two cases a month. For many years, when I was in other parts of the world, I saw only one.” Over the past six years, there have been seven prospective, multicenter, multinational registries related to the care of patients with cardiovascular disease across the Gulf. So there is a lot of prospective good-quality research on cardiovascular care in the Gulf, but none of them looks at out-of-hospital cardiac arrest. However, Dr. Alsheikh-Ali said that more data are currently being collected, so a better picture of cardiac arrest in the Gulf Region is forthcoming. 

In contrast to the Gulf, residents of London, where Ceri Hunter-Dunn, BM, BS practices, have a lot of trust in the ambulance service, which typically arrives within four minutes if possible with a physician and a paramedic. Trained as an emergency physician, she is a member of the physician response unit for London’s Air Ambulance as well as a clinical research fellow there. The air ambulance service operates in partnership with London’s Ambulance Service, which uses conventional ambulances. 

“I’m very passionate about cardiac arrests,” said Dr. Hunter-Dunn, who has provided care for 149 cardiac arrest patients since July 2010 in London, where overall survival from SCA is 10.9%. “Mechanical CPR has absolutely, in my mind, revolutionized the way that we manage cardiac arrests,” she explained during the symposium. “You can deploy the AutoPulse^® [Non-invasive Cardiac Support Pump] in less than 25 seconds. It gives you uninterrupted, consistent, quality compressions. But of utmost importance — and the thing that has absolutely changed the way that we do things in London — once the AutoPulse is on, you can step back and actually think about what you are doing. Your bandwidth increases tenfold.” 

Dr. Hunter-Dunn went on to say, “We can no longer solely rely on the ECG to predict whether we should be taking patients to the PPCI [primary percutaneous coronary intervention] center. It is quite possible to get an absolutely normal-appearing ECG and still have a blocked vessel that we can do something about.” She added, “So even with the best algorithmic resuscitation that you’ve ever done with maximal ALS [advanced life support], unless you actually fix the underlying problem, you will never get a return of circulation.”

Interventional cardiologist Marleen van Wely, MD, echoed Dr. Hunter-Dunn’s sentiments: “A French study found that 26% of patients who had cardiac arrest without an ST elevation had a culprit lesion that was accessible for PCI.” Dr. van Wely is on staff at the University Medical Centre St. Radboud in Nijmegen, the Netherlands, where she has a lot of experience using the AutoPulse in the cardiac cath lab. She presented two cases in detail. In one, a 58-year-old male who collapsed at home and whose ECG showed anterior STEMI went into pulseless electrical activity during transport. Return of spontaneous circulation (ROSC) was not achieved after 45 minutes of manual compressions. Mechanical resuscitation was started in the emergency room, and he was sent to the cath lab on the AutoPulse. “We did a PCI of the left main and the proximal LAD [left anterior descending], and he recovered very, very well,” said Dr. van Wely. The other patient, a 48-year-old male who collapsed at home and who was in ventricular fibrillation (VF), did not fare as well. Although he achieved ROSC, it was not persistent. He survived the placement of a stent, facilitated by the AutoPulse, and was moved to the ICU where hypothermia was induced, but because of extensive neurological damage, he died three days later.

Dr. van Wely also presented data on 18 patients who suffered out-of-hospital cardiac arrest with no sustained ROSC who were referred for AutoPulse-facilitated catheterization or PCI. Five of these patients collapsed at home, 14 received bystander BLS, and seven were in VF or VT. She said, “We tried to do a PCI in 13 of these patients and were successful in 86%. I think for STEMI [ST-elevation myocardial infarction], we should have over 95%, but these kinds of patients have complex coronary lesions, complex situations. So I think that 86% is acceptable.”

Cardiothoracic surgeon and researcher Ard Struijs, MD, PhD, gave a presentation on using hypothermia to treat SCA patients who achieve ROSC but who do not regain consciousness. Dr. Struijs is a senior intensive care physician at the Erasmus University Medical Center in Rotterdam, the Netherlands, who has used the ZOLL Intravascular Management System (IVTM^™) for more than a decade. He addressed cooling-related topics currently being studied and the current literature, including which temperature is optimal and how long patients should be cooled. He also emphasized the importance of a clear-cut, extensive hypothermia protocol, which he said can reduce mortality and improve neurological outcomes. 

Two EMS professionals, Mike Clumpner, RN, BSN, and Jim Mobley, PhD(c), MBA, addressed the symposium on understanding the keys to resuscitation and how high-quality CPR is related to survival. An associate clinical professor of critical care transport medicine and emergency management at two large universities, Professor Clumpner is also a fire captain/paramedic with the Charlotte Fire Department in Charlotte, North Carolina. Mr. Mobley, a paramedic and nurse, is the southeastern U.S. regional operations manager for Med-Trans Air Medical Corporation. The two stressed that during the first 10 to 15 minutes of resuscitation, chest compressions should be the only treatment provided, saying that if the CPR fraction is between 80-100%, “astronomical” survival-to-discharge rates can be realized. They explained why delays in chest compression are detrimental and suggested that endotracheal intubation be intentionally delayed. To improve outcomes, Clumpner and Mobley recommended that practitioners focus on the basics of resuscitation: frequent CPR training; dispatcher-aided CPR and rapid EMS response; treating patients where they lie; 20 minutes of CPR before ambulance transport; good scene management; and “pit crew” CPR. In summary, they highlighted how implementing these practices has led Charlotte, North Carolina, to attain the highest ROSC rates in the United States. In a city where approximately 1,500 pre-hospital cardiac arrests occur annually, ROSC has been achieved in 75% of witnessed pre-hospital cardiac arrests where resuscitation was attempted. Survival-to-discharge with no neurological deficit for witnessed pre-hospital cardiac arrests increased from 9% to 62.5%.

Federico Semeraro, MD, a specialty doctor in anesthesia and intensive care at Maggiore Hospital in Bologna, Italy, and a member of the Italian Resuscitation Council, talked about the success of the Viva! campaign in building awareness of CPR and the use of AEDs across Italy. The campaign was launched in February 2013 through a viral web effort that took advantage of Facebook, Twitter, and YouTube and culminated in Viva! week in October. Each month, new educational materials were rolled out, including a “Life in Your Hands” poster. Messages and videos on the subject were posted on social media sites, free apps of CPR tutorials were made available, and a cardiac arrest awareness game for children was distributed. 

During Viva! week, 200 public events were organized across the country with support from Italy’s president, the Ministry of Health, and the Ministry of Education. The Viva! website received 158,000 visitors, and the YouTube video garnered 23,000 hits. Dr. Semeraro concluded that, while it takes more than one year to see a change in ROSC rates, great progress was made in educating the public on how to improve outcomes from sudden cardiac arrest, and work is being undertaken to plan another cardiac awareness week in 2014.  

Closing the program was Christopher Solomons, who as an emergency medical dispatcher for Yorkshire Air Ambulance in England, has answered countless calls from bystanders who had witnessed someone who had collapsed in sudden cardiac arrest. He just never expected to become the one who needed emergency help. Chris’ near-death experience happened on July 24, 2010, when, during his drive to work, he began to experience chest pain. He somehow managed to make it to work, where he collapsed in front of a couple of paramedics. They immediately began CPR and hooked him up to a defibrillator and shocked him twice. Within two hours from the start of his pain, he was flown to a cath lab for a stent procedure. Since that day, he has stopped smoking and taken steps to reduce the stress in his life. He counts  early CPR, early defibrillation, and his co-workers with saving his life. He has also made it his mission to give talks, especially to young people, about the importance of learning CPR and how to use an AED.