There were five RCTs and two observational studies included in this systematic review and meta-analysis (see Table 1). The total cohort consisted of 6,199 patients with a cardiac arrest (90 percent of the cohort came from one retrospective observational study conducted in Taiwan).
Explore This IssueACEP Now: Vol 40 – No 07 – July 2021
- Secondary Outcomes:
- ROSC: Four RCTs, relative risk 1.32 (95% CI, 1.16–1.50)
- ICU and hospital LOS: One RCT, no statistical difference
- Duration of vasopressor and inotropic treatment: No studies
- Hemodynamic: Two studies in supplemental material
- Safety: Three studies with no statistical differences
Table 1: Trial Characteristics
|Primary Outcome||Number of studies||Relative Risk (95% CI)|
|Good neurological outcome||4 RCTs||2.85 (95% CI, 1.39–5.84)|
|Survival to hospital discharge||4 RCTs||2.58 (95% CI, 1.36–4.91)|
|Survival of at least 1 year||1 RCT||2.34 (95% CI, 0.83–6.54)|
Evidence-Based Medicine Commentary
- Few Studies: There were only five RCTs with a total of 530 patients included in this systematic review and meta-analysis, despite cardiac arrest being a common event with high morbidity and mortality.
- High Risk of Bias: Only four of the five RCTs could be assessed for bias using the Cochrane Risk of Bias Assessment 2 Tool. Three of those four were at high risk of bias. The lack of high-quality studies weakens any conclusions that can be drawn from these data.
- Single Research Group: The vast majority of the RCT data for IHCA (92 percent) came from two trials by the same group of authors in Greece. One trial was published in 2008 and the other in 2013. This raises the issue of external validity to 2021 and other health care systems.
- VSE Protocol: The largest RCT (n=268) assessing corticosteroids for cardiac arrest was part of a VSE protocol for IHCA. The protocol included vasopressin, corticosteroids, and epinephrine rather than corticosteroids alone. This means there has not yet been an RCT that addresses corticosteroids alone for IHCA, though equipoise would be difficult to justify in many care settings. The one RCT for OHCA was from 1984 and failed to show a patient-oriented benefit for dexamethasone when given in addition to standard American Heart Association protocols.
- Replication: The RCT from Greece assessing VSE in IHCA has, to my knowledge, not been replicated. The lack of replication is a common problem in science.10
There is weak direct evidence to support the use of corticosteroids in IHCA as part of a VSE protocol and no evidence to support the use in OHCA.
ROSC is achieved, and the patient is transferred to the ICU. The patient eventually goes for an angiogram where a stent is place in his left anterior descending coronary artery. The patient makes a full recovery and is discharged home within a week. You decide to do a journal club with your EM residents to discuss the use of corticosteroids for IHCAs and consider whether your hospital should add a VSE protocol.
Thank you to Dr. Ryan Stanton, who is a community emergency physician with Central Emergency Physicians in Lexington, Kentucky, a member of the ACEP Board of Directors, and host of the ACEP Frontline Podcast.
Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.