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Temporal changes in clinical practice and mortality in aneurysmal subarachnoid hemorrhage following the 2012 AHA/ASA
John H Kanter1,2, Akshay I Kelshiker3, Pablo Martinez-Camblor4,5
1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Insights
The 2012 AHA/ASA guidelines for aneurysmal subarachnoid hemorrhage (aSAH) were associated with decreased ICU mortality and increased antiseizure medication (ASM) use. These improvements were most significant in high-severity aSAH patients.
Area of Science:
- Neuroscience
- Critical Care Medicine
- Public Health
Background:
- Aneurysmal subarachnoid hemorrhage (aSAH) is a critical condition with high mortality and morbidity.
- The 2012 AHA/ASA guidelines aimed to standardize aSAH management, focusing on monitoring, vasospasm prevention, blood pressure control, early repair, and selective antiseizure medication (ASM) use.
- The real-world impact of these guidelines on ICU patient outcomes is not fully understood.
Purpose of the Study:
- To evaluate the impact of the 2012 AHA/ASA guidelines on patient outcomes in the intensive care unit (ICU).
- To assess changes in mortality, ASM use, seizure occurrence, and length of stay (LOS) following guideline implementation.
Main Methods:
- A retrospective cohort study utilized de-identified electronic health records from MIMIC-III and MIMIC-IV databases (2001-2019).
- Patients were divided into pre-guideline (2001-2011) and post-guideline (2012-2019) periods.
- Logistic and quantile regression analyses were performed, with sensitivity analyses stratified by severity scores (GCS, Hunt and Hess, mFG).
Main Results:
- A total of 516 patients were analyzed (279 pre-guideline, 237 post-guideline).
- ASM use significantly increased from 63.3% to 92.0% post-guideline.
- Mortality was significantly lower in the post-guideline cohort at 1, 6, and 12 months (fully saturated models). Mortality reductions were most pronounced in patients with low GCS, high Hunt and Hess, and high mFG scores.
Conclusions:
- Implementation of the 2012 AHA/ASA guidelines coincided with a significant decrease in ICU mortality and a substantial increase in ASM use.
- While temporal, these associations suggest guideline-driven practice changes, though not exclusively attributable to the guidelines.
- High-severity aSAH patients experienced the most significant mortality reduction, highlighting them as a priority for future research.
Background/Objective:
Aneurysmal subarachnoid hemorrhage (aSAH) carries high morbidity and mortality. The 2012 AHA/ASA aSAH management guidelines introduced recommendations for standardized monitoring, vasospasm prevention with nimodipine, blood pressure control, early aneurysm repair, and selective use of antiseizure medication (ASM) in the immediate post-hemorrhagic period. The overall impact of the guideline period on patient outcomes in real-world ICU practice remains incompletely characterized.
Methods:
We conducted a retrospective cohort study of adults admitted to the ICU with aSAH between 2001 and 2019 using MIMIC-III and MIMIC-IV, linked de-identified electronic health record databases from a single academic center. Patients were grouped into Period 1 (pre-guideline, 2001-2011) and Period 2 (post-guideline, 2012-2019). Outcomes included mortality at 1, 6, and 12 months; ASM use; seizure occurrence; and ICU/hospital length of stay (LOS). Logistic regression was used for binary outcomes and quantile regression for median LOS, with unadjusted, demographic-adjusted, and fully saturated models. Sensitivity analyses stratified by Glasgow Coma Scale (GCS), Hunt and Hess (HH), and modified Fisher grade (mFG) were performed.
Results:
A total of 516 patients (279 pre-guideline; 237 post-guideline) were included. ASM use increased from 63.3% to 92.0% post-guideline. In fully saturated models, mortality was significantly lower in the post-guideline cohort at 1 month (OR 0.17, 95% CI 0.04-0.67), 6 months (OR 0.17, 95% CI 0.05-0.64), and 1 year (OR 0.16, 95% CI 0.04-0.61). Seizure occurrence was numerically higher in Period 2 in unadjusted analyses but this difference was not significant in the saturated model. LOS effects were mixed. The largest mortality reductions occurred in patients with low GCS, high HH, and high mFG scores.
Conclusions:
In the period following publication of the 2012 AHA/ASA aSAH guidelines, ICU mortality decreased significantly and ASM use increased substantially at a single academic center. These temporal associations are consistent with guideline-driven practice change, but cannot be attributed exclusively to guideline implementation given the observational pre-post design and the many concurrent advances in neurocritical care. The mortality reduction was most pronounced in patients with high-severity aSAH. These findings highlight the value of systematic outcomes monitoring following major guideline updates and identify high-severity aSAH as a priority population for future prospective evaluation.
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