Elsevier

Resuscitation

Volume 81, Issue 11, November 2010, Pages 1479-1487
Resuscitation

Clinical paper
Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies,☆☆

https://doi.org/10.1016/j.resuscitation.2010.08.006Get rights and content

Abstract

Aim

The aim of this investigation was to estimate and contrast the global incidence and outcome of out-of-hospital cardiac arrest (OHCA) to provide a better understanding of the variability in risk and survival of OHCA.

Methods

We conducted a review of published English-language articles about incidence of OHCA, available through MEDLINE and EmBase. For studies including adult patients and both adult and paediatric patients, we used Utstein data reporting guidelines to calculate, summarize and compare incidences per 100,000 person-years of attended OHCAs, treated OHCAs, treated OHCAs with a cardiac cause, treated OHCA with ventricular fibrillation (VF), and survival-to-hospital discharge rates following OHCA.

Results

Sixty-seven studies from Europe, North America, Asia or Australia met inclusion criteria. The weighted incidence estimate was significantly higher in studies including adults than in those including adults and paediatrics for treated OHCAs (62.3 vs 34.7; P < 0.001); and for treated OHCAs with a cardiac cause (54.6 vs 40.8; P = 0.004). Neither survival to discharge rates nor VF survival to discharge rates differed statistically significant among studies. The incidence of treated OHCAs was higher in North America (54.6) than in Europe (35.0), Asia (28.3), and Australia (44.0) (P < 0.001). In Asia, the percentage of VF and survival to discharge rates were lower (11% and 2%, respectively) than those in Europe (35% and 9%, respectively), North America (28% and 6%, respectively), or Australia (40% and 11%, respectively) (P < 0.001, P < 0.001).

Conclusions

OHCA incidence and outcome varies greatly around the globe. A better understanding of the variability is fundamental to improving OHCA prevention and resuscitation.

Introduction

Survival rates from out-of-hospital cardiac arrest (OHCA) vary greatly among studies and regions. Interestingly, Becker et al. observed a direct relationship between the incidence of OHCA and survival rates.1 However, it is also possible that the variability in incidence and survival rates is simply related to differences in definitions of OHCA.

In order for these studies to be comparable, they need to use the same definitions of the numerator (cardiac arrest) and denominator (population at risk during a specific period of time). The definition of incidence is the number of new cases per unit of person-time at risk. However, the definition of an OHCA could be all patients who die outside of a hospital, only patients who die suddenly, only those attended by emergency medical services (EMS) personnel, only those for whom resuscitation efforts were attempted, only those with a presumed cardiac cause (i.e., no evidence of a non-cardiac cause), only those with witnessed arrests, or only those with witnessed ventricular fibrillation (VF). In addition, the denominator may include all people in a region, only adults, or only children. Also, the best approach to estimating incidence depends on the intent of the investigation and certainly could vary depending on whether the focus was epidemiology (risk factors) versus health services (resuscitation).

The goal of this review is to better understand the global and continental burden and variability of OHCA. The investigation provides the underpinnings for understanding the potential for public health benefit with improvements in OHCA prevention and resuscitation.

Section snippets

Literature search

On 18 December 2009, we (investigators) conducted a MEDLINE and EmBase search for “out-of-hospital,” or “pre hospital,” and “heart arrest,” “cardiopulmonary resuscitation,” or “sudden cardiac death,” limited to publications in English and in humans (Fig. 1). Additional keywords “vital statistics,” “incidence,” “epidemiology,” or “Utstein” resulted in 1391 articles for review. An additional 185 articles were reviewed from the original 2726, based on the search terms “Middle East,” “Asia,” “South

Results

We found 30 studies performed in Europe, 24 in North America, 7 in Asia and 6 in Australia. Table 1 shows the incidences and survival rates presented per area.

Discussion

In the present systematic overview of 67 studies and 178,440 OHCAs in a source population of over a 100 million people, we found substantially different incidences among the studies, with 10-fold variability in incidences of OHCA. The global average incidence was 55 adult OHCAs of presumed cardiac cause per 100,000 person-years. Of all OHCAs, 27% had VF as the initial rhythm. The average survival following adult OHCA was 7%. We did not find a relation between OHCA incidence rates and survival.

Conclusions

There is a 10-fold global variation in reported OHCA incidences and outcome. This may reflect differences in methodology, in EMS systems, in case definitions, as well as true differences in risk and treatment. Uniform reporting practices with precise case definitions and clearly stated inclusion and exclusion criteria allow a more accurate and consistent estimate of the incidence of OHCA. To achieve this uniformity, researchers who report their experience on out-of-hospital cardiac arrest need

Conflict of interest statement

No conflict of interest declared.

Funding sources

None.

Acknowledgement

We thank Dr Mickey Eisenberg for his valuable analytical contribution (University of Washington, Seattle, WA).

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    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.08.006.

    ☆☆

    This review includes information on resuscitation questions developed through the C2010 Consensus on Science and Treatment Recommendations process, managed by the International Liaison Committee on Resuscitation (http://www.americanheart.org/ILCOR). The questions were developed by ILCOR Task Forces, using strict conflict of interest guidelines. In general, each question was assigned to two experts to complete a detailed structured review of the literature, and complete a detailed worksheet. Worksheets are discussed at ILCOR meetings to reach consensus and will be published in 2010 as the Consensus on Science and Treatment Recommendations (CoSTR). The conclusions published in the final CoSTR consensus document may differ from the conclusions of in this review because the CoSTR consensus will reflect input from other worksheet authors and discussants at the conference, and will take into consideration implementation and feasibility issues as well as new relevant research.

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