Tailored strategy for managing post-cardiac-arrest patients using an early stratification tool: a French university hospital experience

Abstract

To the Editor,

For patients who remain comatose after cardiac arrest and return of spontaneous circulation (ROSC), the benefits and indications of sedatives and hypothermia remain unclear. The latest guidelines recommend continuous core-temperature monitoring and active fever (>37.7 °C) prevention for at least 72 h [1], with no adjustments according to the severity of hypoxic-ischemic brain injury (HIBI) at ICU admission. Short-acting sedatives and opioids are also recommended, but the optimal depth and duration of sedation is unknown. Conceivably, patients with limited HIBI may be unlikely to require hypothermia or prolonged sedation [2], two treatments that prolong the ICU stay. Tools designed for early HIBI assessment are available but rarely used [3]. One such tool is the modified Cardiac Arrest Hospital Prognosis (mCAHP) score [4, 5], whose accuracy has been validated in an external study [3].

Since January 2024, we routinely determine the mCAHP score immediately at ICU admission. Among patients admitted after cardiac arrest in a shockable rhythm, we compared those admitted during the 14 months before vs. the 14 months after this protocol change. All patients received controlled normothermia using the Medi-Therm III device (Gaymarc, NYC, NY). During the before period, all patients were given continuous sedation targeting a Richmond Agitation Sedation Scale (RASS) score of −4. During the after period, this sedation strategy was applied only in those patients whose mCAHP score was ≥ 80, indicating moderate-to-severe HIBI. The other patients had their sedation stopped early (Figure 1). Data collection was prospective, as part of a different study (NCT05606809).

Continuous data were described as mean ± SD or median [inter-quartile range], depending on distribution, and categorical data as number (percentage). Continuous variables were compared by applying Student’s t test, the Mann–Whitney U test, or the Kruskal-Wallis test, as appropriate, and categorical variables using the Chi2 test or Fisher’s test, as appropriate. P values < 0.05 were considered significant. Given the exploratory nature of the study, no adjustment for multiple testing was performed.

We included 36 patients during the before period and 34 during the after period (eFigure 1). Three patients in the after period were managed with hypothermia at 33° due to suspected severe HIBI (mCAHP = 81, 102 and 116). We found no significant differences between the two groups regarding patient and cardiac-arrest characteristics, resuscitation modalities, proportion of patients with a presumed cardiac cause, mechanical ventilation duration, ICU length of stay, ICU survival, or favorable outcome on day 90 defined as a modified Rankin scale score of 0 to 3 (eTable 1).

When we compared the patients in the after period whose mCAHP score was < 80 vs. ≥80, we found that the latter were older (P = 0.03), had a longer low-flow duration (P < 0.001), required more epinephrine (P < 0.001), had longer ICU stays (P = 0.04) and lower ICU survival (P = 0.04), and less often had a favorable day-90 outcome (40% vs. 90%, P = 0.006) (eTable 2).

We then retrospectively computed the mCAHP scores in the patients included during the before period. When we compared the patients in the two periods within the population with mCAHP scores < 80, we found that patients in the before period required higher epinephrine doses (P = 0.03) and had lower ICU survival (74% vs. 90%, P = 0.02) (eTable 3). When we performed the same comparisons within the population with mCAHP scores ≥ 80, the only significant difference was lower ICU survival in the before period (22% vs. 50%, P = 0.02) (eTable 4).

Thus, in our small cohort of prospectively enrolled patients, tailoring the management based on HIBI severity as assessed using the mCAHP score did not significantly change the outcomes of patients after cardiac arrest in a shockable rhythm.

Among patients with mild HIBI assessed at ICU admission, a majority of patients required less than 24 h of mechanical ventilation. Such patients probably do not require neuroprotective interventions and can be transferred early, for instance to an ST-elevation myocardial infarction cardiology ward. In contrast, patients with a shockable rhythm and mCAHP ≥ 80 or with a non-shockable rhythm may benefit from intensified care.

The mCAHP was designed for out-of-hospital cardiac arrest (OHCA) but has been validated for in-hospital cardiac arrest. Other tools for HIBI assessment after cardiac arrest include rCAST and MIRACLE2. Further research on clinical assessment scores and on biomarkers available at the bedside such as glial fibrillary acidic protein and ubiquitin carboxy-terminal hydrolase L1 (NCT06387225) are urgently needed. An ongoing study is identifying predictors of early awakening of patients with OHCA of presumed cardiac cause (NCT05895838).

Of note, a Hawthorne-like effect in the after period, i.e., shortly after the change in the treatment protocol, may have resulted in better patient outcomes. Also, that we found no significant differences between the two periods in the overall population, and few significant differences in the populations with mCAHP < 80 and ≥ 80, may be ascribable to insufficient statistical power.

In conclusion, HIBI evaluation using the mCAHP score immediately after ICU admission is feasible and may allow the identification of patients unlikely to require neuroprotective interventions.

Fig. 1

Temperature management and sedation protocol during the two periodsDuring the second period, patients with cardiac arrest in shockable rhythm received different treatment strategies according to whether the modified Cardiac Arrest Hospital Prognosis (mCAHP) score was < 80 or ≥ 80

Full size image

The dataset will be available upon reasonable request to the corresponding author.

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Authors and Affiliations

1. Medecine Intensive Reanimation, Motion- Interactions-Performance Laboratory (MIP), Nantes University Hospital, Nantes, 4334, UR, France

   Clotilde Bachollet & Jean-Baptiste Lascarrou

2. Medecine Intensive Reanimation, Cochin University Hospital, AP-HP, Paris, France

   Alain Cariou

3. Biochemistry Laboratory, Nantes University Hospital, Nantes, France

   Hélène Caillon

4. Medecine Intensive Reanimation, Nantes University Hospital, Nantes, France

   Emmanuel Canet

5. Médecine Intensive Réanimation, CHU de Nantes, 30 Boulevard Jean Monnet, Nantes Cedex 9, 44093, France

   Jean-Baptiste Lascarrou

Authors

1. Clotilde BacholletView author publications

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2. Alain CariouView author publications

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3. Hélène CaillonView author publications

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4. Emmanuel CanetView author publications

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5. Jean-Baptiste LascarrouView author publications

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Contributions

Conceptualization CB, JBL; Data curation JBL; Formal analysis JBL; Funding acquisition NA;Investigation CB, AC, HC, EC, JBL; Methodology JBL; Project administration JBL;Resources JBL; Software JBL; Supervision CB, JBL Validation; JBL VisualizationJBL; Roles/Writing - original draft JBL; Writing - review & editing CB, AC, HC, EC, JBL.

Corresponding author

Correspondence to Jean-Baptiste Lascarrou.

Ethics approval and consent to participate

Information was provided to the relatives of each patient. In cases where relatives were unavailable, emergency inclusion was permitted by French law. In the latter case, patients were informed of their participation in the study when they regained their decision-making capacity, and their consent was requested. If they refused, their data was deleted. This study was approved by the appropriate ethics committee (2022-A01811-42; CPP-IDFI 251022).

Competing interests

JBL has received speaker fees from BD and Masimo. Prof. Cariou is member of the scientific committee of ORIXHA. None of the other authors has any potential conflicts of interest to declare. 

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Bachollet, C., Cariou, A., Caillon, H. et al. Tailored strategy for managing post-cardiac-arrest patients using an early stratification tool: a French university hospital experience. Crit Care 29, 429 (2025). https://doi.org/10.1186/s13054-025-05667-2

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• Received: 08 September 2025

• Accepted: 13 September 2025

• Published: 09 October 2025

• DOI: https://doi.org/10.1186/s13054-025-05667-2

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