共病症對接受目標體溫管理的到院前心肺功能停止成人患者之院內死亡及出院時神經學預後的影響

Abstract

背景

全球到院前心肺功能停止的死亡率跟不良神經學預後普遍高，識別具有良好出院預後潛力的患者對於優化臨床決策和資源分配相當重要。本研究旨在探討共病症對到院前心肺功能停止預後的影響，並評估其預測潛力。

研究材料與方法

本研究為多中心的回溯性世代研究，資料採用2014年到2019年間進行的 Taiwan Network of Targeted Temperature Management for Cardiac Arrest (TIMECARD) registry，受試者為經歷非外傷所致到院前心肺功能停止後，接受目標體溫管理的成人患者。本研究發展修訂版年齡調整後查爾森共病症指數量化受試者共病症負擔，並依此分成四組。使用多變量羅吉斯迴歸分析單一共病症、修訂版年齡調整後查爾森共病症指數與院內死亡率、出院時不良神經學預後的關聯。此外，透過比較基本模型跟納入修訂版年齡調整後查爾森共病症指數模型間的ROC曲線下面積，以評估修訂版年齡調整後查爾森共病症指數的預測力增益。

結果

本研究共分析375名受試者。多變量羅吉斯迴歸分析顯示糖尿病(調整後勝算比，1.67，95%信賴區間，1.01-2.76)、心衰竭(調整後勝算比，2.85，95%信賴區間，1.36-5.95)、需透析之末期腎病(調整後勝算比，2.47，95%信賴區間，1.03-5.92)均與院內死亡顯著相關。較高的修訂版年齡調整後查爾森共病症指數與院內死亡率增加相關 [修訂版年齡調整後查爾森共病症指數 0-1組相對於修訂版年齡調整後查爾森共病症指數≥6組(調整後勝算比，4.93，95%信賴區間，1.62-14.94，趨勢P值=0.003)]。此外心衰竭(調整後勝算比，2.78， 95%信賴區間，1.01-7.64)亦與出院時不良神經學預後相關。較高的修訂版年齡調整後查爾森共病症指數和出院時不良神經學預後風險增加相關[修訂版年齡調整後查爾森共病症指數 0-1組相對於修訂版年齡調整後查爾森共病症指數≥6組(調整後勝算比，4.78，95%信賴區間，1.08-21.12，趨勢P值= 0.02)。基本模型與納入修訂版年齡調整後查爾森共病症指數的模型在院內死亡的AUC差異為0.01 (95%信賴區間，-0.004-0.03，P=0.16)，而在出院時不良神經學預後的AUC差異為0.008 (95%信賴區間，-0.004-0.02，P=0.21)，顯示加入修訂版年齡調整後查爾森共病症指數未能顯著提升預測效能。

結論

特定共病症、修訂版年齡調整後查爾森共病症指數與接受目標體溫管理的成人非外傷所致到院前心肺功能停止後患者的院內死亡率及出院時不良神經學預後相關。然而將修訂版年齡調整後查爾森共病症指數納入預測模型未能提高預測效力，有待進一步研究以闡明共病症對此族群之風險分層。

Background: Mortality and unfavorable neurological outcomes following out-of-hospital cardiac arrest (OHCA) remain high worldwide. Identifying patients with a favorable prognosis is crucial for optimizing clinical decision-making and resource allocation. This study aimed to investigate the effect of comorbidity on post-OHCA outcomes and evaluate its prognostic potential.

Methods: This multicenter retrospective cohort study enrolled adult non-traumatic OHCA patients receiving targeted temperature management (TTM) through the Taiwan Network of Targeted Temperature Management for Cardiac Arrest (TIMECARD) registry from 2014 to 2019. Patients were grouped into 4 categories based on the modified Age-adjusted Charlson Comorbidity Index (mACCI), which quantifies comorbid burden. Multivariable logistic regression was employed to evaluate the associations between individual comorbidities, as well as the mACCI, and both in-hospital mortality and unfavorable neurological outcomes at hospital discharge. The incremental prognostic value of the mACCI was assessed by comparing the area under the receiver operating characteristic curve (AUC) between the basic model and the mACCI-incorporated model.

Results: A total of 375 patients were analyzed. Multivariable logistic regression identified diabetes mellitus (adjusted odds ratio [aOR], 1.67, 95% confidence interval [CI], 1.01-2.76), heart failure (aOR, 2.85, 95% CI, 1.36-5.95) and end stage renal disease under dialysis (aOR, 2.47, 95% CI, 1.03-5.92) were consistently associated with in-hospital mortality. Additionally, a higher mACCI was linked to an increased risk of in-hospital mortality, with an aOR of 4.93 (95% CI, 1.62-14.94, P for trend=0.003) for the mACCI ≥6 group compared to the mACCI 0-1 group. Moreover, heart failure (aOR, 2.78, 95% CI, 1.01-7.64) was consistently associated with unfavorable neurological outcomes at hospital discharge. Similarly, a higher mACCI was associated with an increased risk of unfavorable neurological outcomes at hospital discharge, with an aOR of 4.78 (95% CI, 1.08-21.12, P for trend=0.020) for the mACCI ≥6 group compared to the mACCI 0-1 group. The AUC difference between the basic model and mACCI-incorporated model was 0.01 (95% CI, -0.004-0.03, P=0.16) for in-hospital mortality and 0.008 (95% CI, -0.004-0.02, P=0.21) for unfavorable neurological outcomes at hospital discharge, indicating that adding the mACCI to the prognostic mode did not significantly improve predictive performance.

Conclusion: Specific comorbidities and the mACCI were related to in-hospital mortality and unfavorable neurologic outcomes at hospital discharge in adult non-traumatic OHCA patients treated with TTM. However, the addition of the mACCI did not enhance prognostic model performance, highlighting the need for further research to elucidate the risk stratification of comorbidity in this population.