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Heart Rate Variability Discriminates Outcomes After Pediatric Cardiac Arrest
Duncan B Mackie1, Craig M Smith1,2, L Nelson Sanchez-Pinto1,2
1Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
Insights
Lower heart rate variability (HRV) in the first 12 hours after pediatric cardiac arrest indicates a higher risk of death and poor neurologic outcomes. This finding suggests HRV can aid in prognostication for critically ill children.
Area of Science:
- Pediatric critical care medicine
- Cardiovascular physiology
- Neurology
Background:
- Cardiac arrest in children is associated with significant mortality and long-term neurologic deficits.
- Accurate prognostication is crucial for guiding treatment decisions and resource allocation in pediatric intensive care units (PICUs).
- Heart rate variability (HRV) reflects autonomic nervous system function and has shown potential as a prognostic marker in various critical illnesses.
Purpose of the Study:
- To evaluate the effectiveness of heart rate variability (HRV) in predicting mortality and functional neurologic outcomes in pediatric patients following cardiac arrest.
- To determine if HRV measurements within the initial 12 hours of PICU admission can discriminate between survivors and non-survivors, and between good and poor neurologic recovery.
Main Methods:
- A retrospective review of physiologic and clinical data was conducted in a 46-bed PICU.
- Seventy-five pediatric patients (older than 28 days and younger than 18 years) admitted after cardiac arrest between 2013 and 2019 were included.
- Median integer HRV (mHRVi) was calculated from the first 12 hours of PICU admission and analyzed for its association with mortality and neurologic outcomes (Pediatric Cerebral Performance Category scores).
Main Results:
- The 1-week in-hospital mortality rate was 23% (17 patients).
- Lower mHRVi in the first 12 hours was significantly associated with 1-week mortality (p < 0.01) and poor neurologic outcomes (odds ratio 0.26; p = 0.01).
- The 12-hour mHRVi demonstrated moderate discrimination for mortality (area under the ROC curve: 0.74) and remained significant after multivariable adjustment.
Conclusions:
- Reduced mHRVi within the first 12 hours post-cardiac arrest in children is a significant predictor of both 1-week mortality and adverse neurologic outcomes.
- mHRVi shows potential as an adjunctive tool in multimodal prognostication frameworks for pediatric cardiac arrest survivors.
- Further validation in larger, diverse patient cohorts is necessary to establish clinical utility.
Objective:
To assess the performance of heart rate variability (HRV) in discriminating death and functional neurologic outcomes in children post-cardiac arrest.
Design:
Single-center retrospective review of physiologic and clinical data.
Setting:
Forty-six-bed PICU.
Patients:
Children older than 28 days and 18 years old or younger admitted to the PICU after in-hospital or out-of-hospital cardiac arrest between 2013 and 2019.
Interventions:
None.
Measurements And Main Results:
The primary outcome was all cause in-hospital mortality within 1 week of arrest. Secondary outcomes included functional neurologic status at hospital discharge by Pediatric Cerebral Performance Category (PCPC) scores, and the presence of poor prognostic findings on transcranial Doppler and/or electroencephalography within 72 hours of ICU admission. Seventy-five patients were included, with a 1-week in-hospital mortality rate of 23% (17 patients). Median integer HRV (mHRVi) in the first 12 hours of PICU admission was significantly lower in patients who experienced 1-week in-hospital mortality ( p < 0.01). The 12-hour mHRVi had an area under the receiver operating characteristic of 0.74 (95% CI, 0.61-0.86) with an area under the precision recall curves of 0.42 for discriminating 1-week in-hospital mortality, and remained statistically significant after adjusting for age, location of arrest, illness severity by Pediatric Risk of Mortality III scoring, and a patients maximum vasoactive-inotropic score ( p = 0.034). There was also a significant association seen between lower 12-hour mHRVi and poor neurologic outcomes by PCPC scoring (odds ratio 0.26 [95% CI, 0.076-0.72]; p = 0.01).
Conclusions:
Lower mHRVi over the first 12 hours of PICU admission after cardiac arrest demonstrated moderate discrimination for 1-week in-hospital mortality and poor neurologic outcomes. These findings suggest that mHRVi may serve as a helpful adjunct within multimodal prognostication frameworks, though further validation in larger, diverse cohorts is required before clinical application.
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