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Gasparetto, Nicola (2017) Arresto cardiaco e cure post arresto cardiaco in ambito cardiologico. [Ph.D. thesis]

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Abstract (english)

INTRODUCTION: Cardiac arrest (CA) is a dramatic clinical event due to an absence of mechanical myocardial contraction. Without an emergency intervention it is characterized by high mortality and morbidity. High quality cardiopulmonary resuscitation (CPR) and early defibrillation are the only factors able to reduce neurological damage. The following phases of advanced resuscitation may include different strategies to improve neurological recovery but they are less important than the early phases.
AIM OF THE STUDY: the aim of this PhD was to examine, from an epidemiological point of view, the impact of CA, the organization of out-of-hospital care, the implementation of post CA care and, consequently, the survival rate of post CA patients in Italy and in Veneto region. One of the most important aims was to determine early parameters related with good neurological outcome in post CA patients. In addition to this we investigate the utility and feasibility of mechanical chest compression devices. Furthermore, in resuscitated patients, the effect of temperature changes on coronary flow velocity by transthoracic echocardiography was investigated.
METHODS: the first part of the research (epidemiological) was based on the revision of scientific studies published in PubMed. The survey of therapeutic hypothermia in Intensive Care Units and in Emergency Services was based on a questionnaire/telephonic interview. The second part (clinical research) was based on database analysis of CA patients admitted in Intensive Cardiac Care Units in University Hospital of Padua (for early neurological predictors and coronary blood flow velocity) and in the regional Hospital of Treviso (for mechanical chest compression devices).
RESULTS: epidemiological analysis has shown persistent high mortality rate of CA. Italy, compared with the other European countries, has low rate of CPR before emergency medical service arrival. In Italian ambulances and Intensive Care Units the implementation of post CA care is low compared to the other European countries. Our analyses have shown the possibility to determine neurological outcome only after 24 hours from the index event. NSE values more than 45.1 µg/L or NSE values less than 45.1 µg/L in a patient older than 78 years old are index of unfavourable neurological outcome (respectively p<0.0001 and p=0.009). A good neurological outcome, was associated with NSE value at 24 hours less than 45.1 µg/L in a patient younger than 78 years old with S-100B value at 24 hours <0.31 µg/L (p=0.025). During therapeutic hypothermia at 32°C coronary blood flow velocity showed significant reduction, proportional to rate-pressure product reduction (p=0.0001) with a potential in reducing ischemia-reperfusion damage. Finally the use of mechanical chest compression devices is feasible during cardiac arrest, by allowing the transport of cardiac arrest patients with the possibility to perform emergent coronary angioplasty or ECMO implantation.
CONCLUSION: high quality CPR and early defibrillation are able to improve survival in out-of-hospital CA patients. For this reason it is crucial to spread the resuscitation culture from an institutional level. To increase the prognosis of these patients it is also important to integrate high quality CPR with early defibrillation and advance post CA care. Our data demonstrate the possibility to determine neurological outcome after 24 hours only with biochemical values and the beneficial effect of temperature reduction for myocardial ischemic-reperfusion damage.

Abstract (italian)

INTRODUZIONE: l’arresto cardiaco (AC) è una condizione clinica drammatica, caratterizzata dall’improvvisa assenza di attività meccanica del cuore. E’ gravata da un’elevatissima mortalità e morbidità se non si interviene prontamente. Per poter garantire al paziente le maggiori possibilità di superare l’evento senza reliquati neurologici è fondamentale un’immediata rianimazione cardiopolmonare (RCP) di base di alta qualità seguita da una precoce defibrillazione. Le successive fasi di rianimazione avanzata comprendono diverse strategie che anch’esse possano aumentare la probabilità di recupero neurologico del paziente ma di secondaria importanza rispetto alle fasi iniziali.
SCOPO DELLO STUDIO: nella prima parte del dottorato di ricerca lo scopo è stato quello di indagare epidemiologicamente l’impatto dell’AC, l’organizzazione delle cure nel territorio, la diffusione delle cure post AC e conseguentemente la sopravvivenza globale in Italia e in Veneto. A seguire si sono voluti ricercare gli elementi precoci correlati ad un esito neurologico favorevole, indagare la fattibilità e l’utilità di utilizzo dei massaggiatori meccanici e infine valutare la risposta del miocardio alla riduzione della temperatura durante l’ipotermia terapeutica post arresto cardiaco.
METODI: la prima parte della ricerca (parte epidemiologica) è stata basata su una revisione della letteratura ricercando tutti gli studi epidemiologici con i dati di sopravvivenza italiani e i principali europei. In merito alla survey dell’ipotermia terapeutica nelle Terapie Intensive e nei Sistemi di Emergenza ed Urgenza, invece, la raccolta dati è avvenuta mediante un questionario. La seconda parte della ricerca (parte di ricerca clinica) sono stati analizzati i dati dei pazienti ricoverati in UCIC di Padova (per l’analisi sui predittori di outcome neurologico e la variazione della velocità del flusso coronarico) e di Treviso (per l’analisi sull’utilizzo dei massaggiatori meccanici).
RISULTATI: l’analisi epidemiologica ha messo in luce come l’AC sia ancora un evento clinico ad elevato impatto sociale e con percentuali di mortalità ancora molto elevate. A differenza degli altri paesi europei l’Italia si colloca come fanalino di coda in particolare quando si analizza la percentuale di RCP da parte di astanti e la diffusione dei sistemi di accesso pubblico alla defibrillazione. Anche nell’ambito della implementazione delle cure post AC nelle ambulanze e nelle nostre Terapie Intensive il dato italiano è ancora i più bassi a livello europeo. L’analisi dei predittori di outcome neurologico ci ha permesso di descriverne alcuni precoci che già dopo 24 ore dall’evento danno preziose informazioni. All’analisi multivariata è emerso come valori di enolasi neurono-specifica (NSE) >45.1 µg/L o NSE <45.1 µg/L ma con età >78 anni erano indici di outcome neurologico sfavorevole (rispettivamente p<0.001 e p=0.009). Un buon recupero neurologico era invece correlato a valori di NSE <45.1 µg/L in paziente con età <78 anni e valori di S-100B <0.31 µg/L (p=0.025).
L’analisi dei dati raccolti ci ha permesso inoltre di capire come durante riduzione della temperatura a 32°C nei pazienti post AC, la velocità del flusso coronarico, determinato con tecnica Doppler, mostrava una significativa riduzione, proporzionalmente alla riduzione del doppio prodotto, evidenza di una riduzione del consumo di ossigeno miocardico, potenziale meccanismo capace di ridurre il danno da ischemia-riperfusione.
Infine l’utilizzo dei massaggiatori meccanici per facilitare la RCP può permettere il trasporto del paziente durante AC con la possibilità di poter eseguire l’angioplastica o posizionare un sistema di assistenza tipo ECMO.
CONCLUSIONI: la diffusione della cultura della RCP e dei sistemi di accesso pubblico alla defibrillazione permettono di migliorare notevolmente le possibilità di sopravvivenza dei pazienti colpiti da AC nel territorio. Molti sono i progressi possibili in Italia che dovrebbero partire a livello istituzionale. E’ molto importante, inoltre, attuare delle ottime cure post AC che si integrino perfettamente con quanto già attuato nel territorio e con ciò che è possibile attuare a livello ospedaliero (es. posizionamento di massaggiatore meccanico per angioplastica primaria o posizionamento di ECMO). L’integrazione di una buona cultura della defibrillazione, i sistemi di accesso pubblico alla defibrillazione, l’ACLS e le cure post arresto cardiaco rappresenta la catena essenziale per migliorare la prognosi dei pazienti colpiti.

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EPrint type:Ph.D. thesis
Tutor:Cacciavillani, Luisa
Ph.D. course:Ciclo 28 > Scuole 28 > SCIENZE MEDICHE, CLINICHE E SPERIMENTALI > SCIENZE CARDIOVASCOLARI
Data di deposito della tesi:29 January 2017
Anno di Pubblicazione:29 January 2017
Key Words:Arresto cardiaco / Cardiac arrest Cure post arresto cardiaco / Post resuscitato care Controllo della temperatura target / Target temperature management Massaggiatori meccanici / Meccanica chest compressione devices
Settori scientifico-disciplinari MIUR:Area 06 - Scienze mediche > MED/11 Malattie dell'apparato cardiovascolare
Struttura di riferimento:Dipartimenti > Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari
Codice ID:10032
Depositato il:03 Nov 2017 10:37
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