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Current evidence of survival benefit between chest-compression only versus standard cardiopulmonary resuscitation in out-of-hospital cardiac arrest

Updated systematic review and meta-analysis of randomized controlled trials with trial sequential analysis

Aktuelle Evidenz für einen Überlebensvorteil zwischen reiner Brustkompression und kardiopulmonaler Standardreanimation bei außerklinischem Herzstillstand

Aktualisierte systematische Übersicht und Metaanalyse randomisierter kontrollierter Studien mit TSA (Trial Sequential Analysis)

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Abstract

Background

Evidence to support a better cardiopulmonary resuscitation method between standard vs. continuous chest compression (STD-CPR vs. CCC-CPR) is lacking.

Materials and methods

Our systematic review followed PRISMA guidelines. We searched PubMed, ScienceDirect, EBSCOhost, and ProQuest database from 1985 to 26 September 2019 restricted to randomized controlled trial, human study, and English articles. Quality assessment of between-study heterogeneity and a trial sequential analysis (TSA) were conducted. We estimated overall significance with 80% power and adjusted Z values thresholds using O’Brien–Fleming α‑spending function. Required information size with 21% relative risk using the estimation between-group incidences provided from the median rate across trials was determined. Inconclusive TSA result will lead to size estimation of future RCT. Quality of evidence was analyzed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) Handbook and TSA.

Results

Based on three trials in OHCA with dispatcher-guided and bystander-initiated CPR, our meta-analysis favors CCC-CPR for survival to hospital discharge, compared to STD-CPR (RR [Risk Ratio] = 1.21[1.01–1.46], 95% CI, p = 0.68, I2 = 0). However, current meta-analyses with 3031 patients appeared to be inconclusive. There is a significant risk of type 1 error and therefore, results are potentially false positive. It is estimated that a minimal of 4331 patients needed to deem a conclusive result and a total of 5894 patients with similar risk profile required to stabilize statistic results in future trials. Quality of evidence is downgraded to moderate due to serious imprecision based on TSA.

Conclusion

Based on these analyses, evidence is inadequate to conclude the superiority of one CPR method over the other. Further trials with larger numbers of patients are needed to deem a conclusive and stable meta-analysis.

Zusammenfassung

Hintergrund

Nach wie vor fehlt die Evidenz für eine überlegene Reanimationsmethode: kardiopulmonoale Standardreanimation (STD-CPR) vs. kontinuierliche Thoraxkompression (CCC-CPR).

Materialien und Methoden

Unsere systematische Überprüfung folgte den PRISMA-Richtlinien. Wir durchsuchten die Datenbanken PubMed, ScienceDirect, EBSCOhost und ProQuest von 1985 bis zum 26. September 2019, beschränkt auf randomisierte kontrollierte Studien, Humanstudien und englischsprachige Veröffentlichungen. Es wurden eine Qualitätsbewertung der studienübergreifenden Heterogenität und eine TSA (Trial Sequential Analysis) durchgeführt. Wir schätzten die Gesamtsignifikanz auf eine 80%ige Power und passten die Z‑Schwellenwerte mithilfe der O’Brien-Fleming-α-Ausgabefunktion an. Der erforderliche Informationsumfang mit einem relativen Risiko von 21% wurde anhand der Schätzung der Inzidenz zwischen den Gruppen anhand der Medianrate über die Studien hinweg ermittelt. Ein nicht eindeutiges TSA-Ergebnis führt zu einer Größenschätzung der zukünftigen RCT. Die Qualität der Evidenz wurde anhand des GRADE(Grading of Recommendations Assessment, Development and Evaluation)-Handbuchs und der TSA analysiert.

Ergebnisse

Auf der Grundlage von 3 OHCA-Studien mit Dispatcher-geführter und Bystander-initiierter CPR favorisiert unsere Metaanalyse die CCC-CPR für das Überleben bis zur Aufnahme ins Krankenhaus im Vergleich zur STD-CPR (RR = 1,21[1,01‑1,46], 95%-KI, p = 0,68, I2 = 0). Die aktuellen Metaanalysen mit 3031 Patienten schienen jedoch nicht aussagekräftig zu sein. Es besteht ein erhebliches Risiko für einen Typ-1-Fehler und damit für potenziell falsch-positive Ergebnisse. Es wird geschätzt, dass mindestens 4331 Patienten benötigt werden, um ein abschließendes Ergebnis zu erhalten, und insgesamt 5894 Patienten mit ähnlichem Risikoprofil, um die statistischen Befunde in zukünftigen Studien zu bestätigen. Die Qualität der Evidenz wird aufgrund der erheblichen Ungenauigkeit auf der Basis der TSA auf mäßig herabgestuft.

Schlussfolgerung

Auf der Grundlage der vorgestellten Analysen reicht die Evidenz nicht aus, um die Überlegenheit einer CPR-Methode gegenüber der anderen nachzuweisen. Für eine aussagekräftige und zuverlässige Metaanalyse sind weitere Studien mit mehr Patienten erforderlich.

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Authors and Affiliations

  1. School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia

    I. Ivan, F. Budiman, R. Ruby, I. P. Wendi & D. A. Ridjab

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Correspondence to D. A. Ridjab.

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I. Ivan, F. Budiman, R. Ruby, I. P. Wendi and D. A. Ridjab declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

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Ivan, I., Budiman, F., Ruby, R. et al. Current evidence of survival benefit between chest-compression only versus standard cardiopulmonary resuscitation in out-of-hospital cardiac arrest. Herz 46 (Suppl 2), 198–208 (2021). https://doi.org/10.1007/s00059-020-04982-4

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