Intensive Care Med (2007) 33:1628–1632

DOI 10.1007/s00134-007-0633-z BRIEF REPORT

Min-Shan Tsai
Chien-Hua Huang
Postresuscitation accelerated idioventricular
Hung-Ren Chen rhythm: a potential prognostic factor
Cheng-Chun Hsieh
Wei-Tien Chang for out-of-hospital cardiac arrest survivors
Chiung-Yuan Hsu
Matthew Huei-Ming Ma
Shyr-Chyr Chen
Wen-Jone Chen

Received: 17 October 2006
Accepted: 26 March 2007
Published online: 25 April 2007
© Springer-Verlag 2007
M.-S. Tsai · C.-H. Huang · H.-R. Chen ·
C.-C. Hsieh · W.-T. Chang · C.-Y. Hsu ·
M. H.-M. Ma · S.-C. Chen · W.-J. Chen (u)
National Taiwan University Hospital and
College of Medicine, Department of
Emergency Medicine,
No. 7 Chung-Shan S. Road, 100 Taipei,
Taiwan
e-mail: jone@ha.mc.ntu.edu.tw
Tel.: +886-2-23562831
Fax: +886-2-23223150
C.-H. Huang · W.-T. Chang · M. H.-M. Ma ·
W.-J. Chen
National Taiwan University Hospital and
College of Medicine, Division of
Cardiology, Department of Internal
Medicine,
No. 7 Chung-Shan S. Road, 100 Taipei,
Taiwan
Abstract Objective: Data are lacking
on the relationship between postresus-
citation ECG and outcome in out-of-
hospital cardiac arrest (OHCA). We
examined the prognostic information
that postresuscitation ECG rhythm
can provide for predicting outcome
in OHCA survivors. Methods: The
retrospective observational study
enrolled 56 successfully resuscitated
nontraumatic adult OHCA patients.
Postresuscitation 12-lead ECGs of
the enrolled patients were interpreted
independently by two cardiologists.
We compared baseline clinical char-
acteristics, CPR process, and outcome
in the 8 patients with postresuscitation
accelerated idioventricular rhythm
(AIVR, n = 8) and the 48 without
AIVR. Results: The AIVR group
had a higher proportion of patients
with coronary artery disease (50%
vs. 15%), initial ventricular tachycar-
dia/fibrillation rhythm (50% vs. 8%),
and cardiac origin of OHCA (75%
vs. 23%). AIVR patients had longer
total CPR duration (32 vs. 18 min)
and higher dose of epinephrine use
(10 vs. 3 mg). Postresuscitation AIVR
was associated with an increased
incidence of repeated CPR within
1 h after return of spontaneous cir-
culation (38% vs. 4%), and lower
7-day survival rate (0% vs. 50%).
Conclusions: AIVR on postresusci-
tation ECG offers a prognostic factor
related to a higher repeated CPR rate
within 1 h after return of spontaneous
circulation and a lower 7-day survival
rates in successfully resuscitated
OHCA victims.
Keywords Accelerated idioven-
tricular rhythm · Postresuscitation
electrocardiogram · Out-of-hospital
cardiac arrest

Introduction
Many pre- and in-hospital factors including witnessed col-
lapse, collapse-to-resuscitation interval, cardiac index, and
neurological findings are associated with survival in pa-
tients with out-of-hospital cardiac arrest (OHCA) [1–6].
QRS duration on admission and discharge electrocardiog-
raphy (ECG) are reported to predict in-hospital and long-
term outcome in resuscitated patients [3]. However, the
prognostic implication of postresuscitation ECG rhythm is
unclear and information is limited. The objective of this
study was to determine the prognostic value of postresus-
citation ECG rhythm to predict outcomes for OHCA sur-
vivors.
Methods
This retrospective observational study was approved
by the Institutional Review Board and enrolled OHCA
survivors from the Emergency Department of the National
Taiwan University Hospital between February and Decem-
ber 2005. Eligible patients included nontraumatic adult
(> 18 years old) OHCA survivors. Exclusion criterion was
the absence of analyzable postresuscitation 12-lead ECG.
The university hospital is a tertiary-referred center hospi-
tal with about 100,000 emergency department visits per
year [1, 7]. The emergency medical service configuration
is a fire-based, single-tiered, basic-life-support and defib-
rillation system described in our previous studies [8, 9].
 1629

Table 1 Comparison of baseline AIVR (n = 8) Non-AIVR (n = 48) p

clinical characteristics between
the AIVR and non-AIVR groups Sex: M/F 7/1 (88%/12%) 25/23 (52%/48%) 0.120
(CK-MB creatine kinase Age (years) 76.7 (60.1–85.9) 78.3 (64.9–83.9) 0.972
isoenzyme MB, IQR Diabetes mellitus 2 (25%) 15 (31%) 1.000
interquartile range) Hypertension 2 (25%) 24 (50%) 0.426
Coronary artery disease 4 (50%) 7 (15%) 0.024
Arrhythmia 1 (13%) 6 (13%) 1.000
Chronic obstructive 1 (13%) 5 (10%) 0.577
pulmonary disease
End-stage renal disease 0 (0%) 3 (6%) 1.000
Cerebral vascular disease 2 (25%) 10 (21%) 0.639
Malignancy 0 (0%) 8 (17%) 0.577
Arterial blood gas, median (IQR)
PH 7.11 (6.94 to 7.23) 7.08 (6.96 to 7.22) 0.977
PaCO2 (mmHg) 44 (28.5 to 89.4) 67.7 (50.5 to 82.3) 0.209
HCO3 (mEq/l) 13.9 (7.8 to 20.3) 21.6 (14.7 to 25.1) 0.051
Base excess (mEq/l) –11.5( - 7.7 to 18.1) –9.1( –2.4 to 16.3) 0.253
Lactate (mmol/l) 7.63 (5.92 to 9.34) 8.08 (6.29 to 9.83) 0.865
White blood cell count 9,150 11,805 0.071
(µl−1 ) (7,850 to 11,180) (9,030 to 14,560)
Hemoglobin (g/dl) 11.4 (6.4 to 15.6) 11.2 (8.6 to 13.1) 0.935
C-reactive protein (mg/dl) 0.77 (0.31 to 1.91) 1.18 (0.28 to 4.45) 0.854
Myoglobin (U/l) 183.5 (139 to 488) 109 (78 to 224) 0.062
CK-MB (U/l) 44.95 (23.3 to 54) 31.5 (21.1 to 42.9) 0.114
Troponin-I (ng/ml) 0.41 (0.17 to 1.07) 0.05 (0 to 0.12) 0.387
Blood urea nitrogen (mg/dl) 22.5 (16.9 to 63.3) 24.6 (16.7 to 39.9) 0.905
Serum creatinine level (mg/dl) 1.55 (1.2 to 1.9) 1.4 (1.0 to 2.1) 0.802
Serum sodium level (mmol/l) 141 (137 to 149) 139 (134 to 146) 0.256
Serum potassium level (mmol/l) 5.1 (4.1 to 6.6) 5.4 (4.1 to 6.4) 0.980

OHCA patients received cardiopulmonary resusci-

tation (CPR) according to the guidelines established
by the American Heart Association in 2000. Data on
resuscitation were collected according to the Utstein style.
Causes of OHCA were classified as cardiac or noncardiac.
To determine the causes of cardiac arrests in OHCA
survivors we performed repeated laboratory examin-
ations and 12-lead ECG, and additional selective exami-
nations such as computed tomography scans, transthoracic
echocardiography, abdominal ultrasound, and coronary
angiography. The cause of cardiac arrest was determined
by the physician-in-charge and was reviewed by the study
physicians. The controversy was settled after discussion
among the physicians [10]. Return of spontaneous cir-
culation (ROSC) was defined as a palpable pulse with
measurable blood pressure. None of the enrolled patients
received therapeutic hypothermia during resuscitation or
after ROSC.
There were 177 OHCA patients during the study
period. Of the 137 nontraumatic adult OHCA patients
ROSC was achieved in 65. Excluding four without 12-lead
ECG (due to ROSC duration that was too short) and
five without analyzable 12-lead ECG (due to inadequate
quality), a total of 56 OHCA survivors was included in the
study (Fig. 1; 32 men, 24 women; age 73.4 ± 14.7 years).
Cardiac origin accounted for one-third OHCA causes
Fig. 1 Flow chart of the enrolled patients. AIVR Accelerated (n = 17, 30%) and asystole was the most common first
idioventricular rhythm; ECG electrocardiography; OHCA out-of- monitored rhythm (n = 36, 64%). Fifty-five patients (98%)
hospital cardiac arrest; ROSC return of spontaneous circulation had sustained ROSC, 54 patients (96%) with postresusci-
1630

Table 2 The comparison of AIVR (n = 8) Non-AIVR (n = 48) p

resuscitation events between the
AIVR and non-AIVR groups OHCA of cardiac origin 6 (75%) 11 (23%) 0.007
(AED automated external First monitored rhythm
defibrillator, CPR Asystole 3 (38%) 33 (69%) 0.118
cardiopulmonary resuscitation, Pulseless electrical activity 1 (13%) 11 (23%) 0.672
OHCA out-of-hospital cardiac Ventricular tachycardia/fibrillation 4 (50%) 4 (8%) 0.010
arrest) Prehospital events
Witnessed collapse 6 (75%) 29 (60%) 0.649
Prehospital intubation 2 (25%) 16 (33%) 1.000
Prehospital CPR duration, median (min; IQR) 9 (2 to 13) 5 (2 to 15.5) 0.818
AED defibrillation 3 (38%) 5 (10%) 0.078
In-hospital events
In-hospital CPR duration, median (min; IQR) 22.5 (7 to 37) 11.5 (7 to 16.5) 0.025
Vasopressin use 1 (13%) 7 (15%) 1.000
Total epinephrine dose, median (mg; IQR) 10 (6 to 14) 3 (2 to 5) 0.000
In-hospital defibrillation, median (no. IQR) 1.5 (0 to 3) 0 (0 to 1) 0.091
Return of spontaneous circulation
Total CPR duration, median (min; IQR) 32 (20 to 42) 18 (12 to 26) 0.029
Systolic blood pressure, median (mmHg; IQR) 118 (74 to 132) 121 (87 to 149.5) 0.412
Diastolic blood pressure, median (mmHg; IQR) 67.5 (55 to 91) 59 (49 to 76) 0.542

tation shock defined as the need for vasopressor therapy Results

to maintain systolic blood pressure over 90 mmHg, 24
patients (43%) survived more than 7 days, and 14 (25%) The AIVR group comprised a higher proportion of
patients survived to hospital discharge. There were 27 patients with coronary artery disease (CAD; 50% vs.
patients with sinus rhythm, 12 with atria fibrillation/flutter, 15%, p = 0.024; Table 1). and during resuscitation the
8 with accelerated idioventricular rhythm (AIVR), 5 with had a higher proportion of cardiac origins of OHCA
multifocal atrial rhythm, and 4 with junctional rhythm. causes (75% vs. 23%, p = 0.007) and initial ventricular
In survivors 12-lead ECG was routinely obtained tachycardia/fibrillation (50% vs. 8%, p = 0.01). AIVR
within minutes after ROSC and interpreted independently patients also had longer in-hospital CPR duration (22.5
by two cardiologists. AIVR was defined as a ventricular vs. 11.5 min, p = 0.025), longer total CPR duration (32
ectopic rhythm with more than three consecutive beats vs. 18 min, p = 0.029), and higher total epinephrine dose
and a rate between 50 and 120 bpm [11, 12]. Sustained (10 vs. 3 mg, p < 0.0001; Table 2). Fewer patients with
ROSC was deemed to have occurred when chest compres-
sions were not required for 20 min. Repeated CPR was
considered when chest compression was needed within
1 h after the first ROSC. One-day survival was defined
as patients surviving more than 1 day after ROSC, and
the 3-day and 7-day survival had similar definitions. The
hospital discharge was defined as patients’ survival up to
discharge, including to home or a nursing home.
Patients were divided into two groups: those with
AIVR (n = 8, including those whose postresuscitation
12-lead ECG showed AIVR) and those without (n = 48).
Baseline clinical characteristics of the two groups are
presented in Table 1. The groups were compared with
SPSS software (release 10.0; SPSS, Chicago, Ill., USA).
Median and quartiles are used to describe numeric
variables. The Mann-Whitney U test was used for the
comparison of groups and χ2 test was for comparison
of proportions. Survival curves were determined by the
Kaplan-Meier method and compared by the log-rank test.
A p-value less than 0.05 was regarded as statistically Fig. 2 Survival curves in those with and those without accelerated
significant. idioventricular rhythm (AIVR)

Table 3 Comparison of
outcomes between the AIVR and
non-AIVR groups (CPR Sustained ROSC
cardiopulmonary resuscitation; Repeated CPR within 1 h
ROSC return of spontaneous 1-day survival
circulation) 3-day survival
7-day survival
Hospital discharge
postresuscitation sinus rhythm suffered repeated CPR (0%
vs. 17%, p = 0.031). Patients with postresuscitation AIVR
had increased incidence of repeated CPR (38% vs. 4%,
p = 0.017) and lower 7-day survival rate (0% vs. 50%,
p = 0.007; Table 3). No patient was discharged alive in the
AIVR group (0% vs. 29%, p = 0.083). The comparison
of survival curves between these two groups is shown in
Fig. 2.
Discussion
This study found that postresuscitation AIVR is associated
with a higher repeated CPR rate and a lower 7-day survival
rate in successfully resuscitated OHCA victims. AIVR is
usually considered as a benign rhythm [11–13]. It can be
seen in any kind of heart disease [11, 13] and even in pa-
tients without apparent heart disease [11]. In those receiv-
ing thrombolytic therapy for myocardial infarct AIVR is
regarded as a sign of successful reperfusion without satis-
factory sensitivity [14, 15]. In our study, however, postre-
suscitation AIVR was associated with worse outcome. No
patient with postresuscitation AIVR in the study survived
hospital discharge.
Cardiac arrest patients with initial pulseless idioven-
tricular rhythm or asystole usually have less chance of
gaining ROSC and thus have a higher mortality rate [2].
Concerning postresuscitation ECG Spaulding et al. [16]
reported that ECG was poor in predicting acute coronary-
artery occlusion in OHCA survivors. Immediate coronary
angiography could help accurate diagnosis and improve
survival in selected patients. In contrast, increased QRS
duration after resuscitation is reported to be associated
with increased long-term mortality and implantable
cardioverter-defibrillator shocks in ventricular fibrillation
OHCA survivors [3]. In addition, idioventricular rhythm or
AIVR was considered as a frequent terminal electrocardio-
graphic change in human hearts [17]. To our knowledge,
no published study has addressed the correlation between
postresuscitation AIVR and outcomes in cardiac arrests.
Although it has been previously considered as a benign
arrhythmia, AIVR was associated in our study with poor
prognosis. Our findings suggest a different viewpoint
about AIVR for postresuscitation victims.
The reason why AIVR patients had poorer out-
come may be attributed to their longer CPR duration.
1631
AIVR (n = 8) Non-AIVR (n = 48) p
7 (88%) 48 (100%) 0.143
3 (38%) 2 (4%) 0.017
3 (38%) 30 (63%) 0.173
2 (25%) 27 (56%) 0.104
0 (0%) 24 (50%) 0.007
0 (0%) 14 (29%) 0.083
Longer CPR duration may result in more myocardial
injury. It is reasonable to hypothesize that longer CPR
duration is associated with increased myocardial in-
jury and damage to supraventricular pacemakers. The
dysfunction of supraventricular pacemakers therefore
may lead into a takeover of the ventricular pace-
maker, which accelerates with increased automaticity
under the effect of epinephrine during resuscitation. How-
ever, it was difficult in our study to determine whether
AIVR is due to the prolonged CPR duration itself or pre-
existing heart diseases (which resulted in prolonged CPR).
In addition to prolonged CPR, higher epinephrine dose in
the AIVR group may be another reason for poor prognosis.
Epinephrine has been proven to significantly increase the
severity of postresuscitation myocardial dysfunction and
decrease survival duration in resuscitated rodents [18].
Another interesting finding is that the OHCA in the
AIVR group was more often of cardiac origin, which was
previously associated with better outcomes than those with
noncardiac origin [19]. In the setting of acute myocardial
infarct AIVR has not been found to be associated with
an increase incidence of ventricular fibrillation [20].
However, in our study the AIVR group had higher per-
centages of patients with CAD and initial ventricular
tachycardia/fibrillation rhythm. These findings suggest
that supraventricular pacemakers are more likely to be
damaged in OHCA patients with underlying CAD. More
extensive studies are necessary to clarify this finding.
There are several limitations in our study. First, the
exclusion of patients having too short a ROSC duration to
undergo a 12-lead ECG, and who are at higher risk of poor
outcome restricts our results to patients with longer ROSC
duration. Secondly, the cause of cardiac arrest was mostly
determined clinically rather than pathologically [16].
Finally, the patient number is small, and larger-scale
studies are needed to establish the relationships between
the postresuscitation ECG rhythm and outcomes in OHCA
survivors.
Based on the finding of the present study we conclude
that postresuscitation AIVR is prognostic factor related to
a higher repeated CPR rate within 1 h after ROSC and
a lower 7-day survival rate in initially successfully resusci-
tated OHCA victims. However, since the number of pa-
tients included is small, further studies are necessary to
determine the relationships between the ECG rhythm and
outcomes in OHCA survivors.
1632
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