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Original Research |

Warning Symptoms Are Associated With Survival From Sudden Cardiac ArrestWarning Symptoms and Sudden Cardiac Arrest

Eloi Marijon, MD, PhD*; Audrey Uy-Evanado, MD*; Florence Dumas, MD, PhD; Nicole Karam, MD, MPH; Kyndaron Reinier, MPH, PhD; Carmen Teodorescu, MD, PhD; Kumar Narayanan, MD; Karen Gunson, MD; Jonathan Jui, MD; Xavier Jouven, MD, PhD; and Sumeet S. Chugh, MD
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 22 December 2015.

* Drs. Marijon and Uy-Evanado contributed equally to this work.


From Cedars-Sinai Medical Center, Los Angeles, California; Paris Descartes University and European Georges Pompidou Hospital, Paris, France; and Oregon Health & Science University, Portland, Oregon.

Acknowledgment: The authors thank all EMS personnel (American Medical Response and Portland and Gresham fire departments), the Oregon State Medical Examiner's Office, and hospitals in the Portland metropolitan area for their assistance; and Dr. Wulfran Bougouin (Paris Sudden Death Expertise Center, Paris, France) and Prof. David S. Celermajer (Sydney Medical School, Sydney, Australia) for their critical review of the manuscript.

Grant Support: In part by the National Heart, Lung, and Blood Institute (grants R01HL105170 and R01HL122492; Dr. Chugh). Dr. Marijon was a visiting faculty scientist at the Cedars-Sinai Heart Institute funded by research grant support from the Philip Foundation, Bettencourt Schueller Foundation, French Society of Cardiology, Foundation for Medical Research, and French National Institute of Health and Medical Research.

Disclosures: Dr. Chugh reports grants from the National Heart, Lung, and Blood Institute. Dr Marijon reports grants from the Philip Foundation, Bettencourt Schueller Foundation, French Society of Cardiology, Foundation for Medical Research, Fondation Coeur et Artères, and French National Institute of Health and Medical Research outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2342.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Reproducible Research Statement:Study protocol: Available from Dr. Chugh (e-mail, sumeet.chugh@cshs.org). Statistical code and data set: Not available.

Requests for Single Reprints: Sumeet S. Chugh, MD, Cedars-Sinai Medical Center, Heart Institute, Advanced Health Sciences Pavilion, Suite A3100, 127 South Vicente Boulevard, Los Angeles, CA 90048; e-mail, sumeet.chugh@cshs.org.

Current Author Addresses: Drs. Marijon, Karam, and Jouven: Cardiology Department, European Georges Pompidou Hospital, 20-40 rue Leblanc, 75908 Paris, Cedex 15, France.

Drs. Uy-Evanado, Reinier, Teodorescu, Narayanan, and Chugh: Cedars-Sinai Medical Center, Heart Institute, Advanced Health Sciences Pavilion, Suite A3100, 127 South Vicente Boulevard, Los Angeles, CA 90048.

Dr. Dumas: Department of Emergency Medicine, Cochin Hospital, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France.

Dr. Gunson: Department of Pathology, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239.

Dr. Jui: Department of Emergency Medicine, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239.

Author Contributions: Conception and design: E. Marijon, J. Jui, S.S. Chugh.

Analysis and interpretation of the data: E. Marijon, F. Dumas, N. Karam, K. Narayanan, S.S. Chugh.

Drafting of the article: E. Marijon, N. Karam, S.S. Chugh.

Critical revision of the article for important intellectual content: E. Marijon, N. Karam, K. Reinier, K. Narayanan, J. Jui, X. Jouven, S.S. Chugh.

Final approval of the article: E. Marijon, F. Dumas, N. Karam, K. Reinier, S.S. Chugh.

Provision of study materials or patients: K. Gunson, J. Jui, S.S. Chugh.

Statistical expertise: E. Marijon, F. Dumas, N. Karam, K. Reinier, X. Jouven.

Obtaining of funding: S.S. Chugh.

Administrative, technical, or logistic support: J. Jui.

Collection and assembly of data: A. Uy-Evanado, C. Teodorescu, J. Jui, S.S. Chugh.


Ann Intern Med. 2016;164(1):23-29. doi:10.7326/M14-2342
Text Size: A A A

Background: Survival after sudden cardiac arrest (SCA) remains low, and tools for improved prediction of patients at long-term risk for SCA are lacking. Alternative short-term approaches aimed at preemptive risk stratification and prevention are needed.

Objective: To assess characteristics of symptoms in the 4 weeks before SCA and whether response to these symptoms is associated with better outcomes.

Design: Ongoing prospective population-based study.

Setting: Northwestern United States (2002 to 2012).

Patients: Residents aged 35 to 65 years with SCA.

Measurement: Assessment of symptoms in the 4 weeks preceding SCA and association with survival to hospital discharge.

Results: Of 839 patients with SCA and comprehensive assessment of symptoms (mean age, 52.6 years [SD, 8]; 75% men), 430 (51%) had warning symptoms (50% of men vs. 53% of women; P = 0.59), mainly chest pain and dyspnea. In most symptomatic patients (93%), symptoms recurred within the 24 hours preceding SCA. Only 81 patients (19%) called emergency medical services (911) to report symptoms before SCA; these persons were more likely to be patients with a history of heart disease (P < 0.001) or continuous chest pain (P < 0.001). Survival when 911 was called in response to symptoms was 32.1% (95% CI, 21.8% to 42.4%) compared with 6.0% (CI, 3.5% to 8.5%) in those who did not call (P < 0.001).

Limitation: Potential for recall and response bias, symptom assessment not available in 24% of patients, and missing data for some patients and SCA characteristics.

Conclusion: Warning symptoms frequently occur before SCA, but most are ignored. Emergent medical care was associated with survival in patients with symptoms, so new approaches are needed for short-term prevention of SCA.

Primary Funding Source: National Heart, Lung, and Blood Institute.

Figures

Grahic Jump Location
Figure 2.

Warning symptoms in patients with SCA based on period between onset of symptoms and occurrence of SCA.

Information about the timing of symptom onset was available in 267 of 299 patients with chest pain, dyspnea, or syncope or palpitations. Error bars correspond to 95% CIs. SCA = sudden cardiac arrest.

Grahic Jump Location

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Summary for Patients

Warning Symptoms May Prevent Some Cases of Sudden Cardiac Arrest

The full report is titled “Warning Symptoms Are Associated With Survival From Sudden Cardiac Arrest.” It is in the 5 January 2016 issue of Annals of Internal Medicine (volume 164, pages 23-29). The authors are E. Marijon, A. Uy-Evanado, F. Dumas, N. Karam, K. Reinier, C. Teodorescu, K. Narayanan, K. Gunson, J. Jui, X. Jouven, and S.S. Chugh.

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