Concise Critical Appraisal: Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest

The principal goals of in-hospital cardiac arrest (IHCA) management include early recognition, basic and advanced life support, and post-cardiac arrest care. Only 25% of patients with IHCA survive to hospital discharge.¹ In October’s Concise Critical Appraisal, Daniel Sloniewsky reviewed the association between epinephrine dosing interval and outcome in pediatric IHCA.² Today’s Concise Critical Appraisal examines the utility of vasopressin and methylprednisolone for adult patients with ICHA.
 
Although several trials have examined ICHA, only two trials in the past decade have examined the use of vasopressin and glucocorticoids for IHCA.^3,4 Both trials found improved survival and favorable neurologic outcome with a vasopressin-epinephrine-methylprednisolone combination. Because of a lack of additional supporting evidence, neither the American nor European international guidelines have recommended this combination for IHCA. Recently, Andersen et al attempted to validate the results of these trials.⁵ The objective of the Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest (VAM-IHCA) trial was to determine whether the drug combination can improve return of spontaneous circulation (ROSC), mortality, and neurologic outcome.
 
In this recently published multicenter, randomized, double-blinded and placebo-controlled study, the authors analyzed collected data for adult patients with ICHA. Excluded patients were younger than 18 years, pregnant, had the cardiac arrest outside the hospital, had a do-not-resuscitate order, or required invasive mechanical circulatory support at the time of cardiac arrest. The primary outcome was ROSC for at least 20 minutes; secondary outcomes were survival and favorable neurologic outcome at 30 days.
 
A total of 501 patients were included, 237 in the vasopressin and methylprednisolone (VAM) group, and 264 in the placebo group. There was a statistically significantly increase in ROSC in the VAM group compared to placebo (42% vs. 33%, P = 0.03). There was no significant difference in the secondary outcomes of survival and favorable neurologic outcome at 30 days. A major limitation of the trial was the differences in post-cardiac arrest care that may have influenced the statistical significance of the secondary outcomes, including the use of glucocorticoids and extracorporeal membrane oxygenation.
 
While the improvement in ROSC for at least 20 minutes using VAM in patients with ICHA is notable, the lack of improved survival or neurologic recovery remains a major drawback. Further studies and increased awareness are needed to help curtail the morbidity and mortality of patients with IHCA.
 
References:

1. Andersen LW, Holmberg MJ, Berg KM, Donnino MW, Granfeldt A. In-hospital cardiac arrest: a review. JAMA. 2019 Mar 26;321(12):1200-1210. https://pubmed.ncbi.nlm.nih.gov/30912843/
2. Sloniewsky DE. Society of Critical Care Medicine. Concise Critical Appraisal. Epinephrine dosing intervals on outcomes from pediatric in-hospital cardiac arrest. October 14, 2021. Accessed January 14, 2021. https://www.sccm.org/Blog/October-2021/Concise-Critical-Appraisal-Epinephrine-Dosing-Int.
3. Mentzelopoulos SD, Zakynthinos SG, Tzoufi M, et al. Vasopressin, epinephrine, and corticosteroids for in-hospital cardiac arrest. Arch Intern Med. 2009 Jan 12;169(1):15-24. https://pubmed.ncbi.nlm.nih.gov/19139319/
4. Mentzelopoulos SD, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA. 2013 Jul 17; 310(3):270-279. https://pubmed.ncbi.nlm.nih.gov/23860985/
5. Andersen LW, Isbye D, Kjargaard J, et al. Effect of vasopressin and methylprednisolone vs placebo on return of spontaneous circulation in patients with in-hospital cardiac arrest: a randomized clinical trial. JAMA. 2021 Oct 26;326(16):1586-1594. https://pubmed.ncbi.nlm.nih.gov/34587236/