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Brain damage can be prevented in cardiac patients with cooling therapy

In recognition that prompt cooling therapy can reduce the chance of brain damage in patients suffering from cardiac arrest, the City of New York has taken the important step of requiring ambulances to only take cardiac patient's to hospitals that offer this therapy. This new policy will become effective on January 1, 2009.

New York is joining several other cities including Seattle, Boston and Miami in requiring transport to hospitals with cooling systems.  Studies have shown that if a patient's body temperature can be cooled to 8 degrees Fahrenheit below normal, brain damage can be reduced or minimized following cardiac arrest.  Studies on the effectiveness of this type of therapy have been published in the New England Journal of Medicine and have been endorsed by the American Heart Association. 

Hopefully more hospitals will acquire the necessary equipment and expertise in this area. 

You can read more on cooling therapy following cardiac arrest by clicking here.

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Elizabeth Adams, MPH

I am responding to a recent article on Feedblitz on the use of therapeutic hypothermia to prevent brain injury after cardiac arrest. I am a research analyst with the Veterans Administration Technology Assessment Program (VATAP). Our program evaluated this subject matter earlier this year. A report is available on our website at: http://www.va.gov/vatap/pubs/finalreportHypothermiaaftercardiacarrest9-08.pdf

The report addresses the evaluation of, and implementation issues related to, this technology from the perspective of a national health system. I hope it explains why this technology has not been implemented widely or quickly and why enthusiasm for this technology should be tempered. I would like to address two statements in your newsletter.

“Studies have shown that if a patient's body temperature can be cooled to 8 degrees Fahrenheit below normal, brain damage can be reduced or minimized following cardiac arrest.”

This is unclear. Systematic literature reviews by a number of organizations with expertise in health technology assessment (HTA) cited the existing evidence as insufficient to show that therapeutic hypothermia after resuscitation from cardiac arrest improves survival or lowers the risk for permanent functional impairment. Reasons given were: heterogeneity among trials; small numbers; and technical or organizational impediments to wide implementation. For now, the method appears to be promising but should be used within the framework of rigorous controlled trials to determine its clinical and cost-effectiveness.

“Studies on the effectiveness of this type of therapy have been published in the New England Journal of Medicine and have been endorsed by the American Heart Association.”

True, but presence of RCTs in the medical literature and organizational endorsements do not always translate into sufficient research evidence. As a clinical professional association, AHA is comprised of members who are rarely experts in the critique of research design. AHA relied on consensus in formulating its recommendations for management of cardiac arrest/adult life support, and its supporting literature review would be characterized as quasi-systematic at best i.e. it applied some components of a systematic review but did not provide a critical analysis of individual studies and thus was prone to bias.

HTA agencies, in contrast, do critique details and emphasize transparent, rigorous processes to systematically review the quality of the existing evidence. Their reports cited the small numbers of patients enrolled in individual trials and aggregated in meta-analyses relative to other established therapies; small numbers prevent sub-group analyses, detection of uncommon adverse events, and refinement of patient selection criteria that are needed to optimize outcomes using therapeutic hypothermia in cardiac arrest. Organizational and technical impediments to broad diffusion need to be better understood and corrected in order to promote effective use of this technology.

Therefore, HTA agencies that work on behalf of national healthcare systems and are in positions to contribute to research agendas tend to be more cautious than organizations such as the AHA or local politicians who appear to be driving this issue in a knowledge vacuum in the popular press. The New York Times did a great disservice to the public by not presenting a complete picture of the issue. We don’t have a dime to waste on costly, unproven interventions.

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