Amplitude spectrum area as an indicator of effective return of spontaneous circulation in prehospital resuscitation—experience from a single regional center in Romania

Analysis of electrocardiography (ECG) signals recorded during cardiopulmonary resuscitation showed that it could be effectively used to predict successful defibrillation. The amplitude spectrum area (AMSA) was not affected by chest compression and showed potential as a monitoring parameter for defibrillators. This retrospective observational study aimed to evaluate AMSA values during out-of-hospital cardiac arrest (OHCA) due to ventricular fibrillation (VF) and to identify the optimal AMSA value indicating a higher chance of return of spontaneous circulation (ROSC) maintained until Emergency Department (ED) admission. Additionally, we examined factors influencing AMSA and ROSC in our emergency medical services (EMS) system. To achieve these, we analyzed the AMSA values of each patient with OHCA and VF using ECGs recorded before each manual defibrillation. Patient data were collected from the EMS database, prospectively gathered from 01 July 2014, to 30 April 2015. The cohort of 46 patients was divided into two groups: Group 1, admitted to the ED with ROSC (n = 25), and Group 2, who died at the scene (n = 21). Successful defibrillation resulted in ROSC for 21 patients (45.65%). Statistically significant higher AMSA values (p < 0.0029) were observed in Group 1 (30.77 ± 13.20 mV-Hz) compared to Group 2 (23.21 ± 10.73 mV-Hz). AMSA values of 27.6 mV-Hz were associated with a specificity of 73.33% for ROSC after manual defibrillation. In Group 1, 64% of patients had a shorter time to start advanced life support (ALS) of less than 5 minutes (p = 0.0798). Additionally, a significantly lower dose of adrenaline was observed in Group 1 (p < 0.0001). Fewer defibrillation attempts were required in Group 1 compared to Group 2 (p = 0.0872). In conclusion, a delay in the initiation of ALS (>5 minutes) and delayed manual defibrillation attempts are associated with lower AMSA values and reduced defibrillation efficiency.

Amplitude spectrum area (AMSA); Ventricular fibrillation (VF); Defibrillation; Out-of-hospital cardiac arrest (OHCA); Return of spontaneous circulation (ROSC)

[1] Yan S, Gan Y, Jiang N, Wang R, Chen Y, Luo Z, et al. The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: a systematic review and meta-analysis. Critical Care. 2020; 24: 61.

[2] Gräsner JT, Herlitz J, Tjelmeland IBM, Wnent J, Masterson S, Lilja G, et al. European resuscitation council guidelines 2021: epidemiology of cardiac arrest in Europe. Resuscitation. 2021; 161: 61–79.

[3] Rea TD, Pearce RM, Raghunathan TE, Lemaitre RN, Sotoodehnia N, Jouven X, et al. Incidence of out-of-hospital cardiac arrest. The American Journal of Cardiology. 2004; 93: 1455–1460.

[4] Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, et al. European resuscitation council guidelines 2021: adult advanced life support. Resuscitation. 2021; 161: 115–151.

[5] Yamaguchi H, Weil MH, Tang W, Kamohara T, Jin X, Bisera J. Myocardial dysfunction after electrical defibrillation. Resuscitation. 2002; 54: 289–296.

[6] Li Y, Tang W. Optimizing the timing of defibrillation: the role of ventricular fibrillation waveform analysis during cardiopulmonary resuscitation. Critical Care Clinics. 2012; 28: 199–210.

[7] Gentile FR, Wik L, Isasi I, Baldi E, Aramendi E, Steen-Hansen JE, et al. Amplitude spectral area of ventricular fibrillation and defibrillation success at low energy in out-of-hospital cardiac arrest. Internal and Emergency Medicine. 2023; 18: 2397–2405.

[8] Aiello SR, Mendelson JB, Baetiong A, Radhakrishnan J, Gazmuri RJ. Targeted delivery of electrical shocks and epinephrine, guided by ventricular fibrillation amplitude spectral area, reduces electrical and adrenergic myocardial burden, improving survival in swine. Journal of the American Heart Association. 2021; 10: e023956.

[9] Aiello S, Perez M, Cogan C, Baetiong A, Miller SA, Radhakrishnan J, et al. Real-time ventricular fibrillation amplitude-spectral area analysis to guide timing of shock delivery improves defibrillation efficacy during cardiopulmonary resuscitation in swine. Journal of the American Heart Association. 2017; 6: e006749.

[10] Young C, Bisera J, Gehman S, Snyder D, Tang W, Weil MH. Amplitude spectrum area: measuring the probability of successful defibrillation as applied to human data. Critical Care Medicine. 2004; 32: S356–S358.

[11] Marn-Pernat A, Weil MH, Tang W, Pernat A, Bisera J. Optimizing timing of ventricular defibrillation. Critical Care Medicine. 2001; 29: 2360–2365.

[12] Benini S, Ivanovic MD, Savardi M, Krsic J, Hadžievski L, Baronio F. ECG waveform dataset for predicting defibrillation outcome in out-of-hospital cardiac arrested patients. Data in Brief. 2021; 34: 106635.

[13] Ristagno G, Mauri T, Cesana G, Li Y, Finzi A, Fumagalli F, et al. Amplitude spectrum area to guide defibrillation. Circulation. 2015; 131: 478–487.

[14] Zuo F, Ding Y, Dai C, Wei L, Gong Y, Wang J, et al. Estimating the amplitude spectrum area of ventricular fibrillation during cardiopulmonary resuscitation using only ECG waveform. Annals of Translational Medicine. 2021; 9: 619.

[15] Ristagno G, Li Y, Fumagalli F, Finzi A, Quan W. Amplitude spectrum area to guide resuscitation-a retrospective analysis during out-of-hospital cardiopulmonary resuscitation in 609 patients with ventricular fibrillation cardiac arrest. Resuscitation. 2013; 84: 697–703.

[16] Indik JH, Conover Z, McGovern M, Silver AE, Spaite DW, Bobrow BJ, et al. Association of amplitude spectral area of the ventricular fibrillation waveform with survival of out-of-hospital ventricular fibrillation cardiac arrest. Journal of the American College of Cardiology. 2014; 64: 1362–1369.

[17] Nakagawa Y, Sato Y, Kojima T, Wakabayashi T, Morita S, Amino M. et al. Electrical defibrillation outcome prediction by waveform analysis of ventricular fibrillation in cardiac arrest out of hospital patients. The Tokai Journal of Experimental and Clinical Medicine. 2012; 37: 1–5.

[18] Ruggeri L, Fumagalli F, Bernasconi F, Semeraro F, Meessen JMTA, Blanda A, et al. Amplitude spectrum area of ventricular fibrillation to guide defibrillation: a small open-label, pseudo-randomized controlled multicenter trial. EBioMedicine. 2023; 90: 104544.

[19] Lazzarin T, Tonon CR , Martins D , Fávero EL, Baumgratz TD, Leal Pereira FW, Pinheiro VR, et al. Post-cardiac arrest: mechanisms, management, and future perspectives. Journal of Clinical Medicine. 2023; 12: 259.

[20] Neurauter A, Eftestøl T, Kramer-Johansen J, Abella BS, Wenzel V, Lindner KH, et al. Improving countershock success prediction during cardiopulmonary resuscitation using ventricular fibrillation features from higher ECG frequency bands. Resuscitation. 2008; 79: 453–459.

[21] Ruiz de Gauna S, Ruiz J, Irusta U, Aramendi E, Eftestøl T, Kramer-Johansen J. A method to remove CPR artefacts from human ECG using only the recorded ECG. Resuscitation. 2008; 76: 271–278.

[22] Gong Y, Gao P, Wei L, Dai C, Zhang L, Li Y. An enhanced adaptive filtering method for suppressing cardiopulmonary resuscitation artifact. IEEE Transactions on Biomedical Engineering. 2017; 64: 471–478.

[23] Krasteva V, Didon JP, Ménétré S, Jekova I. Deep learning strategy for sliding ECG analysis during cardiopulmonary resuscitation: influence of the hands-off time on accuracy. Sensors. 2023; 23: 4500.

[24] Gentile FR, Wik L, Aramendi E, Baldi E, Isasi I, Steen-Hansen JE, et al. aMplitude spectral area of ventricular fibrillation and amiOdarone Study in patients with out-of-hospital cArdIaC arrest. The MOSAIC study. Frontiers in Cardiovascular Medicine. 2023; 10: 1179815.

[25] Borgstedt L, Schaller SJ, Goudkamp D, Fuest K, Ulm B, Jungwirth B, et al. Successful treatment of out-of- hospital cardiac arrest is still based on quick activation of the chain of survival. Frontiers in Public Health. 2023; 11: 1126503.

[26] Semeraro F, Greif R, Böttiger BW, Burkart R, Cimpoesu D, Georgiou M, et al. European resuscitation council guidelines 2021: systems saving lives. Resuscitation. 2021; 161: 80–97.

[27] Kontos MC, Scirica BM, Chen AY, Thomas L, Anderson ML, Diercks DB, et al. Cardiac arrest and clinical characteristics, treatments and outcomes among patients hospitalized with ST-elevation myocardial infarction in contemporary practice: a report from the National Cardiovascular Data Registry. American Heart Journal. 2015; 169: 515–522.

[28] Laurent I, Monchi M, Chiche JD, Joly LM, Spaulding C, Bourgeois B, et al. Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. Journal of the American College of Cardiology. 2002; 40: 2110–2116.

[29] Vallabhajosyula S, Verghese D, Henry TD, Katz JN, Nicholson WJ, Jaber WA, et al. Contemporary management of concomitant cardiac arrest and cardiogenic shock complicating myocardial infarction. Mayo Clinic Proceedings. 2022; 97: 2333–2354.