Vol 29, No 6 (2022)
Letter to the Editor
Published online: 2022-10-27

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Mild therapeutic hypothermia or targeted temperature management for cardiac arrest survivors?

Jacek Kubica1, Robert Gajda2, Klaudiusz Nadolny3
Pubmed: 36342034
Cardiol J 2022;29(6):1053-1054.

Abstract

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clinicAL CARDIOLOGY

Letter to the Editor

Cardiology Journal

2022, Vol. 29, No. 6, 1053–1054

DOI: 10.5603/CJ.a2022.0098

Copyright © 2022 Via Medica

ISSN 1897–5593

eISSN 1898–018X

Mild therapeutic hypothermia or targeted temperature management for cardiac arrest survivors?

Jacek Kubica1Robert Gajda2Klaudiusz Nadolny3
1Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Torun, Poland
2Gajda-Med Medical Center in Pultusk, Poland
3Faculty of Medicine, Katowice School of Technology, Katowice, Poland

Address for correspondence: Prof. Jacek Kubica, Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, ul. M. Skłodowskiej-Curie 9, 85–094 Bydgoszcz, Poland, e-mail: jkubica@cm.umk.pl

Received: 21.08.2022 Accepted: 29.09.2022 Early publication date: 27.10.2022

This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

Out-of-hospital cardiac arrest (OHCA) is burdened with a high risk of death [1–5]. Following the results of the The Targeted Temperature Management Trial (TTM trial) — a randomized study published by Nielsen et al. [6] suggesting equivalent results of targeted temperature management (TTM) at 33°C and 36°C in comatose patients after OHCA, current guidelines recommend TTM in this subset of patients [7]. TTM covers a wider body’s core temperature range (between 32°C and 36°C) than mild therapeutic hypothermia (MTH) (between 32°C and 34°C) [8–10]. However, while favorable clinical outcome of MTH was proven in several clinical studies [11–13], the impact of TTM remains less clear. A favorable effect of MTH on survival and neurological outcome was confirmed in a meta-analysis of data pooled from randomized and non-randomized studies [14]. Recently, Sob­czyk et al. [15] published another report showing benefits of MTH in cardiac arrest survivors in the early phase of myocardial infarction. Taking into account the results of studies on MTH, it should be noted that the methodology of the TTM study — the largest available randomized trial — is questionable [6, 10]. The limitations were related to the non-uniform methodology of cooling (intravascular cooling was used in only 24% of patients) and the heterogeneity of the trial population (40% of patients with myocardial infarction). Moreover, a substantial proportion of patients in the MTH arm did not reach the target temperature, and the duration of hypothermia induction was unacceptably long (a mean of 8 h) [6]. These important shortcomings of the TTM study could have negatively affected the results, with a survival rate and neurological outcome being much worse than observed in MTH arms and similar to control arms of MTH studies [6, 11–15]. Nevertheless, European Society of Cardiolo­gy recommendations are based on results of the TTM study [6, 7]. Of note, also registries accepting the MTH’s methodological diversity are burdened with a serious risk of result misinterpretations [16]. These observations strongly suggest the need for a new multicenter, methodologically uniform trial, free from the hoaxes of the TTM study. Acute coronary syndrome is the most common cause of OHCA [17]. In this context, when planning a new trial, the routine use of cangrelor in patients undergoing MTH should be considered due to the diminished antiplatelet effect of oral P2Y12 inhibitors [18–22].

Conflict of interest: None declared

References

  1. Szczerbiński S, Ratajczak J, Jasiewicz M, et al. Observational analysiS of out-of-hospital Cardiac Arrest occurRence and temporal variability patterns in subpopulation of southern POLand from 2006 to 2018: OSCAR-POL registry. Cardiol J. 2021 [Epub ahead of print], doi: 10.5603/CJ.a2021.0060, indexed in Pubmed: 34312830.
  2. Szczerbinski S, Ratajczak J, Lach P, et al. Epidemiology and chronobiology of out-of-hospital cardiac arrest in a subpopulation of southern Poland: A two-year observation. Cardiol J. 2020; 27(1): 16–24, doi: 10.5603/CJ.a2018.0025, indexed in Pubmed: 29611174.
  3. Nadolny K, Szczerbiński S, Ładny J, et al. Out-of-hospital cardiac arrest and COVID-19 pandemic. Med Res J. 2021; 6(2): 83–85, doi: 10.5603/mrj.2021.0029.
  4. Ratajczak J, Łach P, Szczerbiński S, et al. Atmospheric conditions and the occurrence of out-of-hospital cardiac arrest in Poland — preliminary analysis of poorly understood phenomena. Med Res J. 2018; 3(3): 121–126, doi: 10.5603/mrj.a2018.0019.
  5. Kubica A, Szczerbiński S, Kieszkowska M, et al. Wpływ czynników klimatycznych i chronologicznych na występowanie ostrych incydentów chorobowych. Folia Cardiologica. 2014; 9(3): 263–266.
  6. Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013; 369(23): 2197–2206, doi: 10.1056/NEJMoa1310519, indexed in Pubmed: 24237006.
  7. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018; 39(2): 119–177, doi: 10.1093/eurheartj/ehx393, indexed in Pubmed: 28886621.
  8. Umińska JM, Buszko K, Ratajczak J, et al. Comparison of temperature measurements in esophagus and urinary bladder in comatose patients after cardiac arrest undergoing mild therapeutic hypothermia. Cardiol J. 2020; 27(6): 735–741, doi: 10.5603/CJ.a2018.0115, indexed in Pubmed: 30246234.
  9. Ratajczak J, Łach P, Umińska JM, et al. Mild therapeutic hypothermia after out-of-hospital cardiac arrest: What does really matter? Cardiol J. 2021; 28(2): 293–301, doi: 10.5603/CJ.a2019.0023, indexed in Pubmed: 30799547.
  10. Kubica J, Pstrągowski K, Adamski P, et al. Mild therapeutic hypothermia for patients with acute coronary syndrome and cardiac arrest treated with percutaneous coronary intervention (UNICORN). The design and rationale for the prospective, observational, multicenter study. Med Res J. 2016; 1(1): 23–27, doi: 10.5603/mrj.2016.0004.
  11. Kozinski M, Pstragowski K, Kubica JM, et al. ACS network-based implementation of therapeutic hypothermia for the treatment of comatose out-of-hospital cardiac arrest survivors improves clinical outcomes: the first European experience. Scand J Trauma Resusc Emerg Med. 2013; 21: 22, doi: 10.1186/1757-7241-21-22, indexed in Pubmed: 23531402.
  12. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002; 346(8): 557–563, doi: 10.1056/NEJMoa003289, indexed in Pubmed: 11856794.
  13. Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002; 346(8): 549–556, doi: 10.1056/NEJMoa012689, indexed in Pubmed: 11856793.
  14. Kim YM, Yim HW, Jeong SH, et al. Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies. Resuscitation. 2012; 83(2): 188–196, doi: 10.1016/j.resuscitation.2011.07.031, indexed in Pubmed: 21835145.
  15. Sobczyk A, Streb W, Świątkowski A, et al. The prognostic impact of therapeutic hypothermia after a sudden cardiac arrest in the course of myocardial infarction. Cardiol J. 2022 [Epub ahead of print], doi: 10.5603/CJ.a2022.0077, indexed in Pubmed: 35975793.
  16. Kołtowski Ł, Średniawa B, Tycińska A, et al. Predicting survival in out-of-hospital cardiac arrest patients undergoing targeted temperature management: The Polish Hypothermia Registry Risk Score. Cardiol J. 2021; 28(1): 95–100, doi: 10.5603/CJ.a2019.0035, indexed in Pubmed: 30994183.
  17. Kubica A. Rationale of cardiopulmonary resuscitation training as an element of multilevel educational and motivational project (MEDMOTION). Disaster Emerg Med J. 2020, doi: 10.5603/demj.a2020.0017.
  18. Umińska J, Koziński M, Pstrągowski K, et al. Platelet reactivity during mild therapeutic hypothermia in patients with acute myocardial infarction treated with ticagrelor: study protocol of a single-centre study. Med Res J. 2017; 1(4): 115–119, doi: 10.5603/mrj.2016.0021.
  19. Umińska JM, Ratajczak J, Buszko K, et al. Impact of mild therapeutic hypothermia on bioavailability of ticagrelor in patients with acute myocardial infarction after out-of-hospital cardiac arrest. Cardiol J. 2020; 27(6): 780–788, doi: 10.5603/CJ.a2019.0024, indexed in Pubmed: 30799546.
  20. Niezgoda P, Barańska M, Adamski P, et al. Influence of METHoxyflurane on ANtiplatelet Effect of ticagrelor in patients with unstable angina pectoris: Rationale and a protocol of a randomized clinical METHANE-SIRIO 4 study. Cardiol J. 2022; 29(2): 324–328, doi: 10.5603/CJ.a2021.0126, indexed in Pubmed: 34642919.
  21. Tomala MT, Trąbka-Zawicki A, Machnik A, et al. Ticagrelor effectively inhibits platelet aggregation in comatose survivors of cardiac arrest undergoing primary percutaneous coronary intervention treated with mild therapeutic hypothermia. Cardiol J. 2021 [Epub ahead of print], doi: 10.5603/CJ.a2021.0064, indexed in Pubmed: 34165181.
  22. Umińska JM, Ratajczak J, Pstrągowski K, et al. The impact of mild therapeutic hypothermia on platelet reactivity in comatose survivors of cardiac arrest with acute myocardial infarction treated with ticagrelor. Cardiol J. 2022 [Epub ahead of print], doi: 10.5603/CJ.a2022.0029, indexed in Pubmed: 35514087.