Authors: Tsai MS, Chuang PY, et al. Postarrest steroid use may improve outcomes of cardiac arrest survivors. CCM. 2019 Feb;47(2):167-175.
Reviewed by: Sara Stern-Nezer, MD, MPH; and Kyle Hobbs, MD
Read the article.*
*You will need to log in to US National Library of Medicine National Institutes of Health to read this article.
Even in the era of TTM, a large number of post-cardiac arrest patients have poor outcomes, in part owing to the ongoing secondary brain injury that occurs after ROSC. In these reviews, we consider additional targets to improve outcomes for survivors of cardiac arrest (CA). Increased MAP may have benefit to improve cerebral blood flow in tissue that lacks normal autoregulation and steroids may provide benefit to the sepsis-like inflammatory picture and relative adrenal insufficiency that develop after CA. The study below suggests that thinking beyond targeted temperature management after CA is necessary to continue improvement in patient outcomes.
Human and animal research demonstrates survival and outcome benefits from corticosteroids in the post-arrest period, but these studies are conflicting. This paper describes a nationwide retrospective cohort study of >99% of the entire Taiwanese population investigating possible benefits of corticosteroids after out-of-hospital cardiac arrest by utilizing the Taiwan health insurance administrative database.
Study authors identified 19,229 post-arrest patients, excluding children, trauma patients, patients who received steroids during CPR, or patients who received a prolonged or high-dose course of steroids during or after hospitalization. Primary outcome was survival at discharge and secondary outcome 1-year survival.
Impact of steroid use and dose on survival was assessed by Cox proportional hazard model. Patients who received steroids were more likely to have COPD/asthma, adrenal insufficiency, autoimmune disease, steroid use prior to CA and to be at a tertiary center; they were less likely to have CAD and CKD. In all patients, steroid use improved survival to discharge and 1-year survival (p<0.0001 for both), and this was true regardless of age, gender, comorbidities, shockable rhythm and steroid use prior to arrest. It also held true when analysis was dichotomized into patients with and without steroid use prior to CA. Furthermore, a dose-response benefit was seen; patients in the lowest two quartiles (0.53-27.59mg/d prednisolone equivalent dose) benefited, but those in the third quartile (27.63-58.18mg/d) showed no benefit, and those in the highest quartile (58.33-1250mg/d) had worse outcomes compared to the no steroid group.
Cortisol levels in humans after CA have been shown to be lower than other patients with stress conditions, with relative adrenal insufficiency possibly worsening hemodynamic instability and inflammatory responses after CA.
Earlier studies have demonstrated improved outcomes when stress-dose hydrocortisone was given during post-arrest shock and this retrospective, nationwide cohort study builds on prior literature. The results suggest that use of corticosteroids after CA has a survival benefit at discharge and at one-year; however, the retrospective nature of the study makes it difficult to generalize, as patients given steroids after CA may be fundamentally different than those who are not.
However, even when the authors did a separate analysis for patients previously on steroids vs. those who were not, the survival benefits were statistically significant.
Future RCTs should focus on elucidating the true survival and outcomes benefits of steroids after cardiac arrest, as well as optimal dosing of steroids.