Etude The Lancet arrêts cardiaques Grand Paris

Eloi Marijon

Description

Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study Eloi Marijon*, Nicole Karam*, Daniel Jost, David Perrot, Benoit Frattini, Clément Derkenne, Ardalan Sharifzadehgan, Victor Waldmann, Frankie Beganton,Kumar Narayanan, Antoine Lafont, Wulfran Bougouin, Xavier Jouven Summary Background Although mortality due to COVID-19 is, for the most part, robustly tracked, its indirect efect at the population level through lockdown, lifestyle changes, and reorganisation of health-care systems has not been evaluated. We aimed to assess the incidence and outcomes of out-of-hospital cardiac arrest (OHCA) in an urban region during the pandemic, compared with non-pandemic periods. Methods We did a population-based, observational study using data for non-traumatic OHCA (N=30768), systematically collected since May 15, 2011, in Paris and its suburbs, France, using the Paris Fire Brigade database, together with in-hospital data. We evaluated OHCA incidence and outcomes over a 6-week period during the pandemic in adult inhabitants of the study area. FindingsComparing the 521 OHCAs of the pandemic period (March 16 to April 26, 2020) to the mean of the 3052 total of the same weeks in the non-pandemic period (weeks 12–17, 2012–19), the maximum weekly OHCA incidence increased from 13·42 (95% CI 12·77–14·07) to 26·64 (25·72–27·53) per million inhabitants (p48 h before OHCA, with cough, dyspnoea, or both).

Informations

• Publié par: GrandParisMetropole
• Publié le: 03 juin 2020
• Nombre de lectures: 34
• Langue: English

Extrait

Outofhospital cardiac arrest during the COVID19 pandemic in Paris, France: a populationbased, observational study

Eloi Marijon*, Nicole Karam*, Daniel Jost, David Perrot, Benoit Frattini, Clément Derkenne, Ardalan Sharifzadehgan, Victor Waldmann, Frankie Beganton,Kumar Narayanan, Antoine Lafont, Wulfran Bougouin, Xavier Jouven

Summary BackgroundAlthough mortality due to COVID-19 is, or the most part, robustly tracked, its indirect efect at the population level through lockdown, liestyle changes, and reorganisation o health-care systems has not been evaluated. We aimed to assess the incidence and outcomes o out-o-hospital cardiac arrest (OHCA) in an urban region during the pandemic, compared with non-pandemic periods.

MethodsWe did a population-based, observational study using data or non-traumatic OHCA (N=30 768), systematically collected since May 15, 2011, in Paris and its suburbs, France, using the Paris Fire Brigade database, together with in-hospital data.We evaluated OHCA incidence and outcomes over a 6-week period during the pandemic in adult inhabitants o the study area.

FindingsComparing the 521 OHCAs o the pandemic period (March 16 to April 26, 2020) to the mean o the 3052 total o the same weeks in the non-pandemic period (weeks 12–17, 2012–19), the maximum weekly OHCA incidence increased rom 13·42 (95% CI 12·77–14·07) to 26·64 (25·72–27·53) per million inhabitants (p<0·0001), beore returning to normal in the final weeks o the pandemic period. Although patient demographics did not change substantially during the pandemic compared with the non-pandemic period (mean age 69·7 years [SD 17]vs68·5 [18], 334 males [64·4%]vs1826 [59·9%]), there was a higher rate o OHCA at home (460 [90·2%]vs[76·8%]; 2336 p<0·0001), less bystander cardiopulmonary resuscitation (239 [47·8%]vs[63·9%]; p<0·0001) and shockable 1165 rhythm (46 [9·2%]vs472 [19·1%]; p<0·0001), and longer delays to intervention (median 10·4 min [IQR 8·4–13·8]vs 9·4 min [7·9–12·6]; p<0·0001). The proportion o patients who had an OHCA and were admitted alive decreased rom 22·8% to 12·8% (p<0·0001) in the pandemic period. Ater adjustment or potential conounders, the pandemic period remained significantly associated with lower survival rate at hospital admission (odds ratio0·36, 95% CI 0·24–0·52; p<0·0001). COVID-19 inection, confirmed or suspected, accountedor approximately a third o the increase in OHCA incidence during the pandemic.

InterpretationA transient two-times increase in OHCA incidence, coupled with a reduction in survival, was observed during the specified time period o the pandemic when compared with the equivalent time period in previous years with no pandemic. Although this result might be partly related to COVID-19 inections, indirect efects associated with lockdown and adjustment o health-care services to the pandemic are probable. Thereore, these actors should be taken into account when considering mortality data and public health strategies.

FundingThe French National Institute o Health and Medical Research (INSERM)

Copyright© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

Introduction Sînce the emergence o severe acute respîratory syndrome coronavîrus 2 (SARS-CoV-2, the vîrus responsîbe or 1 2 COVID-19), înîtîay reported în Chîna în December, 2019, and subsequenty quaîfied as a goba pandemîc by WHO 3 on March 11, 2020, amost 5·1 mîîon cases o COVID-19 have been reported wordwîde, wîth more than 3,4 333 446 deaths as o May 23, 2020. Beyond the dîrect mortaîty caused by COVID-19, there are growîng concerns regardîng the consequences o the 5,6 COVID-19 pandemîc on heath systems. Lockdown and movement restrîctîons împosed în severa countrîes, as we as the ear o contamînatîon în hospîtas, coud have ed to a reuctance by patîents to ca emergency medîca servîces (EMS) or present to emergency departments,

resutîng în suboptîma heath care and deays. Addîtîo- nay, entîre heath-care systems have been reorganîsed to cope wîth thîs unprecedented surge o patîents wîth a nove dîsease that îs hîghy contagîous. Deerabe routîne medîca actîvîty, încudîng schedued hospîtaîsatîons and consutatîons, were canceed to ocus on care or patîents wîth COVID-19, and avoîd unnecessary exposure o stabe patîents to the rîsk o contamînatîon at the hospîta. Atogether, these îndîrect efects o the COVID-19 pandemîc coud have detrîmenta efects on popuatîon heath. Out-o-hospîta cardîac arrest (OHCA) coud be a vauabe surrogate or both popuatîon heath and eicacy o the heath-care system în handîng emergencîes. Athough a ew medîa reports have suggested an încrease

www.thelancet.com/publichealthPublished online May 27, 2020 https://doi.org/10.1016/S24682667(20)301171

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Lancet Public Health2020

PublishedOnline May 27, 2020 https://doi.org/10.1016/ S24682667(20)301171

See Online/Comment https://doi.org/10.1016/ S24682667(20)301341

*Contributed equally

Université de Paris, Centre de Recherche Cardiovasculaire de Paris, INSERM, Paris, France (Prof E Marijon MD, N Karam MD, D Perrot MD, A Sharifzadehgan MD, V Waldmann MD, F Beganton MS, Prof A Lafont MD, W Bougouin MD, Prof X Jouven MD); Paris Sudden Death Expertise Center, Paris, France(Prof E Marijon, N Karam, D Jost MD, D Perrot, A Sharifzadehgan, V Waldmann, F Beganton, K Narayanan MD, Prof A Lafont, W Bougouin, Prof X Jouven); European Georges Pompidou Hospital, Cardiology Department, Paris, France(Prof E Marijon, N Karam, A Sharifzadehgan, V Waldmann, Prof A Lafont, Prof X Jouven); Paris Fire Brigade, Paris, France (D Jost, B Frattini MD, C Derkenne MD); and Jacques Cartier Hospital, Intensive Care Unit, Massy, France (W Bougouin)

Correspondence to: Prof Eloi Marijon, Unité de Rythmologie, Département de Cardiologie, Hôpital Européen Georges Pompidou, Paris 75015, France [e-mail]

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Research in context

Evidence before this study After emerging in late2019, the world has been struggling with an outbreak of a novel disease, COVID19, declared a pandemic in March, 2020. The pandemic has led to worldwide lockdowns, reorganisation of healthcare systems, and postponement of nonurgent medical consultations and interventions. We searched the press media daily and PubMed from database inception, up to May 7, 2020, for reports on outofhospital cardiac arrest (OHCA) during the pandemic, using the keywords “cardiac arrest”, “sudden death”, “healthcare”, “emergency medical services”, AND “COVID19”, “SARSCoV2”, “lockdown” with no language restrictions. Although some media outletshave suggested an increase in OHCA in some regions, only one peerreviewed article described an increase in OHCA incidence in Lombardy, an Italian province where the pandemic was particularly damaging with severe overwhelming of the healthcare system, beyond what was experienced in most other regions thus far.

în the încîdence o OHCA în severa cîtîes, to the best o our knowedge, ony one orîgîna report descrîbed an încrease în OHCA încîdence în Lombardy, Itay, a settîng 6,7 where the înectîon has been partîcuary devastatîng. In thîs study, we aîmed to assess the încîdence and outcomes o OHCA durîng the ongoîng COVID-19 pandemîc, compared wîth non-pandemîc perîods usîng a rea-tîme mutîsource surveîance system set up în 2011, în an urban regîon (Parîs and îts suburbs, France).

Methods Study design and participants Thîs popuatîon-based, observatîona study îs reported accordîng to the strengthenîng the reportîng o obser- 8 vatîona studîes în epîdemîoogy guîdeînes. The Parîs-Sudden Death Expertîse Center (Parîs-SDEC) 9–11 ongoîng regîstry has been prevîousy descrîbed. A cases o sudden OHCA occurrîng among aduts (aged 18 years and oder) în the cîty o Parîs and îts three suburbs (Hauts- de-Seîne, Seîne-Saînt-Denîs, and Va-de-Marne), an area coverîng 762 km², have been încuded în the Parîs-SDEC regîstry sînce May 15, 2011. Each case was revîewed separatey by two învestîgators to ensure accuracy o cassîficatîon. Severa quaîty assessments were done to 9 ascertaîn the competeness o coectîon în the area. In Parîs and îts suburbs (6·8 mîîons înhabîtants), patîents wîth OHCA are managed by the Parîs EMS, a two-tîered response system, coordînated vîa a unîque dîspatch centre (not changed durîng the pandemîc 12,13 perîod): (1) a basîc îe support tîer provîded by 197 basîc îe support teams rom the Parîs Fîre Brîgade (Brîgade des Sapeurs Pompîers de Parîs), who can appy an automatîc externa defibrîator, and (2) an advanced cardîac îe support unctîon provîded by ambuance

Added value of this study Our study showed the course of OHCA incidence and outcomes during the COVID19 pandemic in Paris and its suburbs (6∙8 million inhabitants), from the beginning of the surge in infections and lockdown, until the decrease in its incidence. Our results showed a transient twotimes increase in OHCA incidence, coupled with a significant reduction in survival, followed by a return to normal towards the end of the study period. Although our findings might be partly related to direct COVID19 deaths—patients suspected to have or had received a diagnosis of COVID19 accounted for a third of the increase in cases of OHCA—indirect effects related to lockdown and adjustment of healthcare services to the pandemic are probable.

Implications of all the available evidence This increase in OHCA incidence highlights the collateral deaths, not taken into account in COVID19 death statistics, and that should be considered when establishing public health strategies for dealing with the pandemic.

teams wîth a physîcîan, a nurse, and a paramedîc (Parîs Fîre Brîgade or Servîce d’Aîde Médîcae Urgente). The Parîs Fîre Brîgade teams usuay arrîve on scene first and provîde basîc îe support accordîng to the guîdeînes or OHCA management. The Parîs Fîre Brîgade then cas or advanced îe support î consîdered useu accordîng to case presentatîon. Non-traumatîc OHCA was defined as any cardîac arrest, ater excusîon o cases wîth obvîous accîdenta causes, îrrespectîve o whether resuscîtatîon was attempted or not. 14 Data were coected usîng Utsteîn tempates. Athough there has been no change în the system configuratîon and case detectîon durîng the study perîod, încudîng durîng the pandemîc, firefighters rom the Parîs Fîre Brîgade have had to constanty adapt theîr practîces. They have had to take contagîousness înto account, whîe compyîng wîth înternatîona recommendatîons or whîch a dedîcated 15 COVID-19 versîon has been pubîshed. Dîspatchers rom the Parîs Fîre Brîgade were înstructed to învestîgate when receîvîng the ca whether the patîent was known to be COVID-19-posîtîve or had symptoms suggestîve o COVID-19 înectîon (ever astîng >48 h beore OHCA, wîth cough, dyspnoea, or both). When COVID-19 înectîon was confirmed or suspected, EMS personne were înstructed to protect themseves by wearîng persona protectîve equîpment beore înîtîatîng 15 attempted resuscîtatîon. The revîew boards approved the Parîs-SDEC regîstry (Commîssîon Natîonae de ’Inormatîque et des Lîbertés approva #912309 and Comîté Consutatî sur e Traîtement de ’Inormatîon en matîère de Recherche dans e domaîne de a Santé approva #12336). No înormed consent was requîred.

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Procedures Genera data, încudîng Utsteîn characterîstîcs o the 14 OHCA, were recorded prospectîvey. Response tîme îs defined as the deay between EMS ca and arrîva (îe, ca answer to arrîva tîme). For the current anaysîs, gîven the French COVID-19 epîdemîc trajectory, we consîdered the perîod rom March 16 (Parîs Lockdown began March 17) to Aprî 26, 2020, as the 6 weeks o the pandemîc în the Parîs regîon (correspondîng to weeks 12–17 o 2020). We compared patîent characterîstîcs, settîng o occurrence, and outcome o thîs perîod or OHCA reported by the Parîs Fîre Brîgade wîth the mean or weeks 12–17 o each year rom 2012 to 2019 (non-pandemîc reerence perîod 1). We aso reported data or patîents în the Parîs- SDEC regîstry rom 2011 to 2020, excudîng weeks 12–17 (non-pandemîc reerence perîod 2). A new varîabe was added to the EMS database, reated to COVID-19 status (confirmed or suspected), whîch aowed us to trace COVID-19 status among patîents who had an OHCA (eîther wîtnessed or admîtted aîve).

Statistical analysis Contînuous data are presented as mean (SD) or medîan (IQR), dependîng on dîstrîbutîon, and categorîca data are presented as n (%). Contînuous varîabes were compared wîth Student’stthe Mann-Whîtney test, test, or the Kruska-Waîs test as approprîate, and categorîca varîabes were compared usîng the χ² test. The maxîmum weeky încîdence o OHCA durîng the pandemîc perîod (weeks 13 and 14) was compared wîth the încîdence o OHCA durîng the non-pandemîc perîod 1 (weeks 13 and 14, rom 2012–19). The încîdences o OHCA and theîr 95% CIs were estîmated by consîderîng the popuatîon aged 18 years or oder o the our dîstrîcts. For weeks 12–17, substantîa popu- atîon mîgratîon outsîde Parîs and îts suburbs was observed and taken înto account în each dîstrîct, based on the data o the Natîona Instîtute o Statîstîcs and Economîc Studîes(ast assessed on May 6, 2020). O note, Parîs ockdown was maîntaîned throughout the pandemîc perîod, and the subset o the popuatîon who et dîd not return because o movement restrîctîons. Addîtîona data or în-hospîta mortaîty as we as hospîtaîsatîons reated to COVID-19 în the study area were aso coected rom the Natîona Instîtute o Statîstîcs and Economîc Studîes (ast assessed May 1, 2020). Mutîvarîabe ogîstîc regressîon anaysîs was done to assess the assocîatîon o the pandemîc perîod wîth survîva at hospîta admîssîon. Odd ratîos (ORs) and theîr 95% CIs were cacuated wîth adjustment or potentîa conoundîng actors încudîng sex, age, ocatîon, bystander cardîopumonary resuscîtatîon, use o automatîc externa defibrîator beore EMS arrîva, shockabe cardîac rhythm, and ca answer to arrîva deay.

Sex Women

Men

Age, years Home location

Witness

Cardiopulmonary resuscitation initiated Public automatic external defibrillator use Shockable rhythm

Pandemic period

185/519 (35∙6%)

334/519 (64∙4%)

69∙7 (SD 17) 460/510 (90∙2%)

294/500 (58∙8%)

239/500 (47∙8%)

2/500 (0∙4%)

46/500 (9∙2%)

Nonpandemic period 1

1221/3047 (40∙1%)

1826/3047 (59∙9%)

68∙5 (SD 18) 2336/3042 (76∙8%)

1887/2908 (64∙9%)

1165/1822 (63∙9%)

33/1092 (3∙0%)

472/2471 (19∙1%)

Articles

Nonpandemic period 2

10 309/27 151 (38∙0%) 16842/27151 (62∙0%) 68∙7 (SD 18) 20486/27027 (75∙8%) 16600/24999 (66∙4%) 9780/16150 (60∙6%) 333/9522 (3∙5%)

4195/21863 (19∙2%)

p value

0∙038 ∙∙

∙∙

0∙20 <0∙0001

0∙0030

<0∙0001

0∙0012

<0∙0001

Median response time, min Call answer to arrival 10∙4 (8∙4–13∙8) 9∙4 (7∙9–12∙6) 9∙3 (7∙8–12∙4) <0∙0001 On road 6∙4 (4∙3–8∙5) 5∙1 (3∙0–8∙1) 5∙0 (3∙0–7∙1) <0∙0001 Survival at hospital 67/521 (12∙9%) 695/3052 (22∙8%) 6230/27 195 <0∙0001 admission (22∙9%) Survival at hospital discharge 16/517 (3∙1%) 164/3052 (5∙4%) 1450/5731 (5∙3%) 0∙0001 Data are n (%), mean (SD), or median (IQR). The pandemic period was defined as the period from March 16 to April 26, 2020, considered as the 6 weeks of the pandemic in the Paris region. Paris lockdown began on March 17. The nonpandemic period 1 was defined as weeks 12–17 of each year from 2012 to 2019. The nonpandemic period 2 was defined as data for patients included in the ParisSudden Death Expertise Center registry from 2011 to 2020, excluding weeks 12–17. OHCA=outofhospital cardiac arrest.

Table 1:Baseline characteristics, initial management, and outcome of OHCA

p vaues ess than 0·05 were consîdered statîstîcay sîgnîficant. Statîstîca anaysîs was done usîng R sot- ware, versîon 3.6.1.

Role of the funding source The under o the study had no roe în study desîgn, data coectîon, data anaysîs, data înterpretatîon, or wrîtîng o the report. The correspondîng author had u access to a the data în the studyand had fina responsîbîîty or the decîsîon tosubmît or pubîcatîon.

Results Our study took pace between March 16 and Aprî 26, 2020. Overa, rom May 15, 2011, to Aprî 26, 2020, there were 30 768 cases o OHCA în the Parîs area. The mean age o patîents was 68·4 years (SD 18), and 19 002 (61·9%) were men. OHCA occurred at home în 23 282 (76·1%) cases and în pubîc paces în 7334 (23·9%) cases. A wîtness was present în 18 781 (66·1%) cases, and cardîopumonary resuscîtatîon was înîtîated în 11 184 (60·6%) cases. An automatîc externa defibrîator was used în 368 (3·3%) cases beore EMS arrîva. Overa, 4713 (19·0%) patîents wîth OHCA presented wîth shockabe rhythm (ventrîcuar tachycardîa or fibrîatîon), and 6992 (22·7%) were admîtted aîve în one o the 48 hospîtas o the area. Patîent characterîstîcs and cîrcumstances o OHCA occurrence are reported în tabe 1. Durîng the

www.thelancet.com/publichealthPublished online May 27, 2020 https://doi.org/10.1016/S24682667(20)301171

For theNational Institute of Statistics and Economic Studiessee https://www.insee. fr/en/accueil

3

5∙31 1∙83 1∙24 1∙17 1∙06

5∙31 1∙83 1∙24 1∙17 1∙06

35

30

Week 17 56 11∙56 4∙84 1∙39 1∙18 1∙21 1∙06 75 13∙73 5∙39 1∙81 1∙26 1∙23 1∙09 55 10∙40

OHCA surge was seen în the departments wîth a ow densîty o medîca acîîtîes (eg, northeast o Parîs) wîth an OHCA încrease per mîîon înhabîtants o 28·33 (95% CI 26·94–29·71) compared wîth departments wîth a hîgh densîty o medîca acîîtîes (eg, Centra Parîs and West Parîs) wîth an OHCA încrease per mîîon înhabîtants o 13·62 (12·79–14·46; p<0·0001; figure 2). Patîent characterîstîcs dîd not substantîay dîfer durîng the pandemîc compared wîth the same non-pandemîc perîod în terms o age (69·7 years [SD 17]vs 68·5 years [18]; p=0·061) and proportîon o men (334 [64·4%]vs1826 [59·9%], p=0·057). By contrast, dîferences were observed în the cîrcumstances o occurrence o the OHCA. 460 OHCAs occurred at home (460 [90·2%]vs 2336 [76·8%] or the same non-pandemîc perîod; p<0·0001). Addîtîonay, ess shockabe cardîac rhythm at EMS arrîva (46 [9·2%]vs[19·1%]; p<0·0001), and ess use o an 472 automatîc externa defibrîator was observed (0·4%vs 3·0%, p=0·0009; tabe 1). Response tîme, defined as ca answer to EMS arrîva, was sîgnîficanty onger (p<0·0001). Durîng the pandemîc perîod, the proportîon o OHCAs wîth resuscîtatîon attempt and advanced îe support was ower than usua (53·1%vs 66·2%, p<0·0001), and survîva at hospîta admîssîon decreased rom 22·8% to 12·8% (p<0·0001), wîth a return to usua încîdence oowed by a return to usua survîva range towards the end o the perîod (figure 3). In mutî- varîabe ogîstîc regressîon anaysîs, ater consîderîng

Week 16 52 10∙74 4∙84 1∙39 1∙18 1∙21 1∙06 62 11∙50 5∙39 1∙81 1∙26 1∙23 1∙09 65 12∙26

Week 15 71 14∙66 4∙84 1∙39 1∙18 1∙21 1∙06 58 10∙76 5∙39 1∙81 1∙26 1∙23 1∙09 66 12∙35

5∙31 1∙83 1∙24 1∙17 1∙06

5∙31 1∙83 1∙24 1∙17 1∙06

Week 14 128 26∙43 4∙84 1∙39 1∙18 1∙21 1∙06 68 12∙62 5∙39 1∙81 1∙26 1∙23 1∙09 68 12∙77

5∙31 1∙83 1∙24 1∙17 1∙06

25

20

5

15

Number of OHCAs in 2020 Incidence of OHCAs in 2020, per million Population in 2020, in millions Paris (district 75) HautsdeSeine (district 92) SeineSaintDenis (district 93) ValdeMarne (district 94) Number of OHCAs in 2019 Incidence of OHCAs in 2019, per million Population in 2019, in millions Paris (district 75) HautsdeSeine (district 92) SeineSaintDenis (district 93) ValdeMarne (district 94) Mean number of OHCAs between 2012–18 Mean incidence of OHCAs between 2012–18, per million Mean population between 2012–18, in millions Paris (district 75) HautsdeSeine (district 92) SeineSaintDenis (district 93) ValdeMarne (district 94) OHCA=outofhospital cardiac arrest.

5∙31 1∙83 1∙24 1∙17 1∙06

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Table 2:Number, population, and weekly incidences in the different districts of Paris and its suburbs

Week 10 87 16∙14 5∙39 1∙80 1∙26 1∙23 1∙09 68 12∙62 5∙39 1∙81 1∙26 1∙23 1∙09 73 13∙69

www.thelancet.com/publichealthhttps://doi.org/10.1016/S24682667(20)301171Published online May 27, 2020

13

14

15

2017 2018 2019 2020

pandemîc perîod (March 16 to Aprî 26, 2020), 521 OHCAs occurred, gîvîng a maxîma weeky încîdence o 26·64 (95% CI 25·72–27·53) per mîîon înhabîtants (weeks 13 and 14), sîgnîficanty hîgher than the maxîma weeky încîdencedurîng the same perîod between 2012 and 2019 (13·42, 95% CI 12·77–14·07; p<0·0001), wîth a rapîd return to norma în the fina weeks o the pandemîc perîod (figure 1, tabe 2). A geographîca heterogeneîty was ound în terms o OHCA încrease. A sîgnîficanty greater

Week 11 83 15∙40 5∙39 1∙80 1∙26 1∙23 1∙09 72 13∙36 5∙39 1∙81 1∙26 1∙23 1∙09 65 12∙22

5∙31 1∙83 1∙24 1∙17 1∙06

5∙31 1∙83 1∙24 1∙17 1∙06

12

Paris lockdown

Week 13 125 25∙81 4∙84 1∙39 1∙18 1∙21 1∙06 58 10∙76 5∙39 1∙81 1∙26 1∙23 1∙09 63 11∙91

Week 12 89 18∙38 4∙84 1∙39 1∙18 1∙21 1∙06 74 13∙73 5∙39 1∙81 1∙26 1∙23 1∙09 63 11∙78

17

16

1

2

Figure 1:Weekly incidences of OHCA during the first 17 weeks of years 2012 to 2020 Compared with previous years and with the beginning of 2020, there was a surge in OHCA incidence starting week 12 of 2020, with a rapid return to normal by week 15. OHCA=outofhospital cardiac arrest.

0

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Incidence (per million) 10

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SeeOnlinefor appendix

8 9 Week

10

11

potentîa conoundîng actors încudîng sex, age, ocatîon, bystander cardîopumonary resuscîtatîon, use o automatîc externa defibrîator beore EMS arrîva, shockabe cardîac rhythm, and ca answer to arrîva deay, the pandemîc perîod remaîned sîgnîficanty assocîated wîth ower survîva at hospîta admîssîon (odds ratîo 0·36, 95% CI 0·24–0·52; p<0·0001). Survîva status at hospîta dîscharge was known în 63 (94·0%) o 67 patîents admîtted aîve. Overa, 16 (3·1%) were dîs- charged aîve, compared wîth 164 (5·4%) în the same non-pandemîc perîod (p=0·029). In the Parîs area, the maxîma number o new hospîtaîsatîons reated to COVID-19 was reached în weeks 13 and 14 (4402 patîents; both întensîve and non- întensîve care unîts; appendîx p 1),whereas maxîma COVID-reated în-hospîta mortaîty was observed durîng weeks 14 and 15 (1383 în-hospîta deaths overa), then ît decreased aterwards. 42 patîents were suspected to have COVID-19 (n=17) or had receîved a dîagnosîs o COVID-19 (n=25); these numbers account or approxîmatey a thîrd o the încrease în cases o OHCA observed în Parîs and îts suburbs durîng the pandemîc perîod. O note, among those admîtted aîve, screenîng or COVID-19 was done în 20 (32%) patîents whereas 43 (68%) were not tested.

Discussion Durîng the COVID-19 pandemîc, the number o OHCAs occurrîng în Parîs and îts suburbswîthîn the specîfied peak perîod amost doubed. OHCA survîva rate to hospîta admîssîon was markedy reduced as we, eadîng to a major rîse în OHCA-reated deaths durîng the pandemîc, whîch started decînîng at the end o the study perîod. Athough these findîngs mîght be party reated to dîrect COVID-19 deaths, îndîrect efects through ockdown, behavîour changes, and pandemîc- reated heath system îssues (overwhemîng o EMS and postponement o consutatîons and schedued non- urgent procedures) are probabe. Data rom the past 9 years o the Parîs-SDEC regîstry îndîcate that the încîdence o OHCA has been stabe over tîme în Parîs and îts suburbs, whîch îs în contrast wîth the major încrease observed durîng the pandemîc perîod. Both dîrect and îndîrect efects o COVID-19 mîght expaîn thîs încreased încîdence. The ethaîty o COVID-19 through acute respîratory dîstress syndrome or an excessîve îmmune response îs 16 we estabîshed. It îs thereore possîbe that some o the OHCAs observed durîng the pandemîc are actuay respîratory deaths among patîents wîth COVID-19 who were not hospîtaîsed. Addîtîonay, COVID-19 can ead to cardîovascuar înjury and myocardîtîs; experîmenta treatments such as hydroxychoroquîne or azîthromycîn 17 mîght aso ead to încreased cardîac events. Acute cardîac events have been observed în patîents wîth COVID-19, încudîng acute coronary syndromes, heart aîure, and arrhythmîas, thereore makîng OHCA a

10 km

Increase in OHCA incidence per million inhabitants 30

20

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Public and private hospitals Mobile intensive care units (SAMU) Mobile intensive care units (BSPP)

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Figure 2:Density of medical facilities and surge in OHCA incidence across Paris and its suburbs during the pandemic period Significant differences exist in the density of hospitals and mobile intensive care units in the Paris area, with the highest density observed in central Paris. The highest increase in OHCA incidence was observed in areas with a low density of medical facilities. BSPP=Brigade de SapeursPompiers de Paris. SAMU=Service d’Aide Médicale Urgente. OHCA=outofhospital cardiac arrest.

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30

25

20

15

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2012–19 2020

5 Proportion of patients admitted alive (%)

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Paris lockdown

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Figure 3:Proportion of patients admitted alive at hospital during weeks 5–17 of 2020 compared with the same period in previous years Compared with similar periods in the previous years, there was a decrease in OHCA survival at hospital admission during the pandemic period of 2020. OHCA=outofhospital cardiac arrest.

www.thelancet.com/publichealthPublished online May 27, 2020 https://doi.org/10.1016/S24682667(20)301171

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possîbe dîrect compîcatîon o COVID-19. Fînay, a major prothrombotîc state has been reported durîng COVID-19 înectîons, wîth a consequent încrease în thromboemboîc events încudîng pumonary emboîsms 18 and acute coronary syndromes. To the best o our knowedge, ony one orîgîna report descrîbed an încrease în OHCA încîdence în Lombardy, Itay, a specîfic settîng where the pandemîc was more proîfic than what was 6,7 observed în most regîons wordwîde. Overwhemîng o medîca servîces occurred and rues were set to prîorîtîse hospîta admîssîons and întubatîon among patîents wîth COVID-19. Thîs îssue coud have ed to severa deaths rom COVID-19 occurrîng at home and beîng counted as OHCA, as suggested by the hîgh rate o COVID-19 suspîcîon or dîagnosîs among patîents who had an OHCA, whîch accounted or 77% o the surge în OHCA cases în Lombardy. Conversey, în our study, we provîde a pîcture o the surge o OHCA în a settîng where a severe pandemîc was observed, but the heath-care system was stî abe to hande a knownCOVID-19 cases wîthout specîfic îmîtatîons, eadîng to a much ower proportîon o cases beîng reated to COVID-19 înectîon. Among patîents who were negatîve or COVID-19, an îndîrect efect, reated to changes în pubîc behavîour and reorganîsatîon o the heath-care system, mîght have 19 ed to an încrease în OHCA în the pandemîc settîng. Wîth ockdown and movement restrîctîons, patîents have more dîicuty în seekîng medîca advîce. They mîght aso be reuctant to present to emergency departments or doctors’ oices because o ears o COVID-19 înectîon, or ong waîtîng tîmes. In addîtîon, stabe înterventîons and consutatîons had to be postponed to prîorîtîse COVID-19-reated îssues and avoîd exposîng patîents to an unnecessary rîsk o contamînatîon at the hospîta or medîca oice. Fînay, the efect o încreased psycho- ogîca stress durîng a pandemîc, brought about by ear, restrîctîon o movement, and grîe due to oss o oved ones, can aso potentîay trîgger adverse cardîac events and arrhythmîas, utîmatey eadîng to OHCA. In addîtîon to the marked încrease în OHCA încîdence, we aso noted a drastîc reductîon în survîva to hospîta admîssîon. Wîtnesses and emergency responders mîght have been reuctant to do cardîopumonary resuscîtatîon on potentîay înected cases, as cardîopumonary resus- cîtatîon îs consîdered an aeroso-generatîng procedure 20 wîth substantîa rîsk o transmîssîon. Some hospîtas îssued dîrectîves prohîbîtîng cardîopumonary resus- cîtatîon or patîents who potentîay have COVID-19 21 uness u persona protectîve equîpment îs worn, whîch coud be împractîca în the out-o-hospîta settîng. Besîdes, more OHCAs occurred at home where the wîtnesses present durîng the tîme o ockdown are most îkey to be amîy members, and are ess îkey to do cardîopumonary resuscîtatîon due to emotîona învovement and psycho- 22–24 ogîca actors. Fînay, OHCA occurrîng în patîents who were hypoxaemîc wîth COVID-19, and OHCA reated to advanced cardîac înjury such as în ate presenters o

acute myocardîa înarctîon, mîght have worse survîva compared wîth OHCA o cardîac orîgîn. Durîng the ast 2 weeks o the study perîod, there was a reatîve decrease în OHCA încîdence athough survîva to hospîta admîssîon remaîned ow. The EMS had been reorganîsed to some extent aowîng a progressîvey better response to non-COVID-19 reated cas durîng the study perîod. Teeconsutatîons were deveoped, and pubîc campaîgns were made to encourage seekîng o medîca attentîon or symptoms not reated to COVID-19, whîch probaby prompted patîents to get eary medîca care upon onset o cardîac symptoms, beore OHCA occurrence. The deay în împrovement în survîva rate compared wîth încîdence îs unsurprîsîng, gîven the persîstent ow cardîopumonary resuscîtatîon rate among amîy members and bed shortages în întensîve care unîts, whîch obîgated EMS to careuy trîage OHCA cases îkey to benefit rom hospîta transer. Athough our study îs one o the first to descrîbe the îndîrect efect o the ongoîng COVID-19 pandemîc at the 6 popuatîon eve, some îmîtatîons need to be acknow- edged. Fîrst, athough we have shown a major încrease în absoute OHCA numbers, thîs change în încîdence does not account or the decrease în tourîsm flow known to be very împortant at thîs perîod în Parîs; gîven the absence o tourîsts durîng the pandemîc, we mîght have expected a ower number o OHCAs durîng the pandemîc, potentîay underestîmatîng the surge o OHCA that woud have occurred î tourîsts had been present. Second, athough COVID-19 status was con- firmed în ess than 10% o patîents, în others, COVID-19 status was eîther based on the patîent’s symptoms or unknown. The exact proportîon o COVID-19 reated OHCAs thereore remaîns unknown. Addîtîonay, some OHCAs mîght have occurred în înected patîents wîthout beîng due to the înectîon. Fînay, the study was done în Parîs and îts suburbs and specîficîtîes reated to the ocatîon, încudîng heath-care system organîsatîon, mîght not be generaîsabe to other countrîes. Durîng the COVID-19 pandemîc în the Parîs area, we observed a sîgnîficant and transîent încrease în the încîdence o OHCA, couped wîth a major reductîon în survîva at hospîta admîssîon. Athough thîs findîng mîght be party reated to dîrect COVID-19 deaths, îndîrect efects reated to ockdown and reorganîsatîon o heath-care systems mîght account or a substantîa part. Contributors EM, NK, DJ, WB, and XJ were responsîbe or the study concept and desîgn. EM, NK, DP, and WB were responsîbe or the îterature search. EM, NK, DJ, FB, AS, VW, BF, and CD were responsîbe or acquîsîtîon o data. EM, NK, DJ, DP, WB, and XJ were responsîbe or anaysîs and înterpretatîon o data. EM, NK, KN, WB, XJ were responsîbe or dratîng o the manuscrîpt. DJ, AS, VW, KN, and AL were responsîbe or crîtîca revîsîon o the manuscrîpt or împortant înteectua content. EM, NK, BF, and DP were responsîbe or statîstîca anaysîs. EM, NK, and DP were responsîbe or figures. EM and XJ had u access to a o the data în the study and take responsîbîîty or the întegrîty o the data and the accuracy o the data anaysîs.

www.thelancet.com/publichealthhttps://doi.org/10.1016/S24682667(20)301171Published online May 27, 2020

Declaration of interests We decare no competîng înterests.

Acknowledgments We thank the Parîs-SDEC or provîdîng the ogîstîca support that aowed us to access and anayse the necessary data or the manuscrîpt în such a short perîod, and the Parîs-SDEC coaborators or theîr mutîdîscîpînary expertîse that aows an optîma approach în the fight agaînst sudden cardîac death through thîs coaboratîve network sînce 2011. The Parîs-SDEC actîvîtîes are supported by the Instîtut Natîona de a Santé et de a Recherche Médîcae (INSERM), Unîversîty o Parîs, Assîstance Pubîque-Hôpîtaux de Parîs, Fondatîon Coeur et Artères, Goba Heart Watch, Fédératîon Françaîse de Cardîoogîe, Socîété Françaîse de Cardîoogîe, Fondatîon Recherche Medîcae, as we as unrestrîcted grants rom îndustrîa partners (Medtronîc, Abbott, Boston Scîentîfic, MîcroPort, Bîotronîk, and Zo). SDEC Executîve Commîttee îs part o the ESCAPE-NET project (Horîzon2020 programme). We woud îke to aknowedge the huge efort o the Parîs Fîre Brîgade în prospectîvey provîdîng a data regardîng OHCA în a rea-tîme manner, and despîte the overwhemîng COVID-19 pandemîc.

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www.thelancet.com/publichealthPublished online May 27, 2020 https://doi.org/10.1016/S24682667(20)301171

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