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News Release

FOR RELEASE May 15, 2011, 8:15 a.m. MDT

FOR MORE INFORMATION, CONTACT: Keely Savoie or Brian Kell [email protected] or [email protected] ATS Office 212-315-8620 or 212-315-6442 (until May 13) Cell phones 917-860-5814 or 516-305-9251 ATS Press Room: 303-228-8473 (May 15-18) Mini-symposium time: 8:15-10:45 a.m. May 15 Location: Room 102-104-106 (Street Level), Colorado Convention Center PRESS CONFERENCE: Monday, May 15, 2011, 11:30 a.m. MDT Pneumonia Patients At Risk for In-Hospital Cardiac Arrest ATS 2011, DENVER ­ Hospital patients with pneumonia may be at risk of experiencing sudden cardiac arrest, often with few or no warning signs, according to research from the University of Chicago Medical Center under the auspices of the American Heart Association's Get with the Guidelines project. The results of the study will be presented at the American Thoracic Society's 2011 International Conference in Denver. "We found a compelling signal that some patients with pneumonia may develop cardiac arrest outside of the ICU, without apparent shock or respiratory failure," said lead investigator Gordon Carr, MD, pulmonary and critical Care fellow, at the University of Chicago Medical Center. "If this is true, then we need to improve how we assess risk in pneumonia." Dr. Carr and colleagues used a large registry of in-hospital cardiac arrest (IHCA) from the American Heart Association's Get with the Guidelines database to examine the characteristics of early cardiac arrest in patients with pre-existing pneumonia. Of 44,416 cardiopulmonary arrest events that occurred within 72 hours of hospital admission that had complete data, 5,367 (12.1 percent) occurred in patients with pre-existing pneumonia. Among those patients with pneumonia, almost 40 percent of cardiac arrests occurred outside of an intensive care unit. Furthermore, at the time of cardiac arrest, only 40 percent of patients with preexisting pneumonia were receiving mechanical ventilation, and 36.3 percent were receiving infusions of vasoactive

medications. The distribution of patients with early IHCA was similar in the ICU and in the general ward. Survival was poor for all groups with early in hospital cardiac arrest. "While our study design precluded definitive analyses of incidence or cause and effect, our main finding was that some patients with pneumonia and cardiac arrest did not appear to experience a premonitory period of overt critical illness," said Dr. Carr. "There appears to be an important group of patients with pneumonia who develop cardiac arrest without respiratory failure or shock." This is the first large study to report the characteristics of in-hospital cardiopulmonary arrest among patients with pneumonia. The finding that many of these patients are not receiving intensive care or interventions suggests that patients with pneumonia are either more vulnerable than previously thought to abrupt deterioration or that the triage methods used to determine whether a patient is in need of intensive care may be inadequate for patients with pneumonia. "Decisions about ICU admission may need to be more proactive rather than reactive," Dr. Carr noted. "If we focus our intensive care resources on patients with obvious shock and respiratory failure, we may miss opportunities to intervene on other patients who are at high risk for abrupt deterioration. "Future studies should investigate the incidence and causes of sudden, early cardiovascular collapse in patients with pneumonia and other forms of sepsis, and address ways to measure and mitigate this risk," he continued. "In the meantime, physicians need to be alert to the possibility of abrupt transitions in these patients." Finally, Dr. Carr suggested that these findings indicate a need for more research on the different phenotypes of sepsis, of which pneumonia is a major cause. "In recent years we have been lumping these patients into one big group, to facilitate research and the dissemination of care `bundles'," he said. "In clinical reality, pneumonia and sepsis may be very heterogeneous, and patients who die from these diseases may follow different trajectories. Accordingly, we may need different risk assessment and therapeutic tools for different subgroups."

### "In-Hospital Cardiac Arrest Among Patients With Coexisting Pneumonia: A Report From The American Heart Association's Get With The Guidelines - Resuscitation Program" (Session A20, Sunday, May 1, 8:15-10:45 a.m., MDT, Room 102-104-106 (Street Level), Colorado Convention Center; Abstract 22539) * Please note that numbers in this release may differ slightly from those in the abstract. Many of these investigations are ongoing; the release represents the most up-to-date data available at press time.

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Abstract 22539 In-Hospital Cardiac Arrest Among Patients With Coexisting Pneumonia: A Report From The American Heart Association's Get With The Guidelines - Resuscitation Program Type: Late-Breaking Scientific Abstract Category: 10.03 - Community Acquired Respiratory Infections (Including Epidemiology) (MTPI) Authors: G.E. Carr, D.P. Edelson, T.C. Yuen, J.F. McConville, J.P. Kress, T.L. VandenHoek, J.B. Hall; University of Chicago Medical Center, For the American Heart Association's Get With the GuidelinesResuscitation (National Registry of CPR) Investigators - Chicago/US Abstract Body Rationale: Many patients with pneumonia develop severe sepsis, septic shock, or respiratory failure. They may also be vulnerable to sudden cardiovascular collapse. However, little is known about the characteristics of inhospital cardiac arrest (IHCA) among patients with pneumonia. Using a large, multicenter registry of in-hospital resuscitation, we investigated IHCA in patients with pneumonia early in their hospital admission. Methods: We performed a retrospective analysis of adult IHCA events contained in the American Heart Association's Get With The Guidelines - Resuscitation (GWTG-R) database (formerly the National Registry of Cardiopulmonary Resuscitation (NRCPR)). We included all first pulseless events occurring among adult hospital inpatients within the first 72 hours of admission, and for which complete data were available. We assessed clinical and event characteristics for patients with pneumonia. Results: We analyzed 166,919 cardiopulmonary arrest events. 86,109 were first pulseless events among hospital inpatients and had complete data. Of these, 44,416 occurred within 72 hours of admission. Pneumonia was a preexisting condition before 5,367 (12.1%) of these early events. Among patients with pneumonia, 77.2% of IHCA events occurred in an intensive care or step-down unit, while 19.3% occurred in a general inpatient area. At the time of IHCA, 40.0% of pneumonia patients were receiving mechanical ventilation, 12.2% had a central venous catheter in place, and 36.3% were receiving continuous infusions of vasoactive medications. Among patients with pneumonia, immediate causes of IHCA included arrhythmia (65.0%), respiratory insufficiency (53.9%), and hypotension/hypoperfusion (49.8%). 83.8% of IHCA events in pneumonia patients were witnessed, and the median time from admission to IHCA was 20.7 hours (interquartile range, 8.2-41.8 hours). For patients with pneumonia, initial pulseless rhythms were: pulseless electrical activity (PEA) (45.2%), asystole (38.4%); and ventricular fibrillation or tachycardia (16.4%). 14.7% of patients with pneumonia and IHCA survived to hospital discharge. Conclusions: This is the first large study to report the characteristics of IHCA among patients with pneumonia. Approximately one in five events occurred in a general inpatient area, and many patients with IHCA and pneumonia were not receiving critical care interventions (e.g. mechanical ventilation or continuous vasoactive medications) before IHCA. Furthermore, arrhythmia was a common immediate cause of cardiac arrest and occurred more commonly than either respiratory insufficiency or hypotension. These findings may indicate that patients with pneumonia are vulnerable to abrupt deterioration. Alternatively, they may indicate that current triage practices or other processes of care are inadequate.

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