0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Contribution |

Use of an Automated, Load-Distributing Band Chest Compression Device for Out-of-Hospital Cardiac Arrest Resuscitation FREE

Marcus Eng Hock Ong, MD, MPH; Joseph P. Ornato, MD; David P. Edwards, MBA, EMT-P; Harinder S. Dhindsa, MD, MPH; Al M. Best, PhD; Caesar S. Ines, MD, MS; Scott Hickey, MD; Bryan Clark, DO; Dean C. Williams, MD; Robert G. Powell, MD; Jerry L. Overton, MPA; Mary Ann Peberdy, MD
[+] Author Affiliations

Author Affiliations: Departments of Epidemiology and Community Health (Dr Ong) and Biostatistics (Dr Best), Virginia Commonwealth University, and Department of Emergency Medicine (Drs Ong, Dhindsa, Ines, and Hickey), Department of Internal Medicine, Division of Cardiology (Dr Peberdy), and Department of Emergency Medicine and the Virginia Commonwealth University Reanimation, Engineering, and Shock Center (Drs Ornato and Peberdy), Virginia Commonwealth University Health System; The Richmond Ambulance Authority (Messrs Edwards and Overton); Department of Emergency Medicine, Chippenham & Johnston-Willis Hospital (Dr Clark); Department of Emergency Medicine, Richmond Community Hospital (Dr Williams); and Department of Emergency Medicine, St Mary's Hospital (Dr Powell), Richmond.

More Author Information
JAMA. 2006;295(22):2629-2637. doi:10.1001/jama.295.22.2629.
Text Size: A A A
Published online

Context Only 1% to 8% of adults with out-of-hospital cardiac arrest survive to hospital discharge.

Objective To compare resuscitation outcomes before and after an urban emergency medical services (EMS) system switched from manual cardiopulmonary resuscitation (CPR) to load-distributing band (LDB) CPR.

Design, Setting, and Patients A phased, observational cohort evaluation with intention-to-treat analysis of 783 adults with out-of-hospital, nontraumatic cardiac arrest. A total of 499 patients were included in the manual CPR phase (January 1, 2001, to March 31, 2003) and 284 patients in the LDB-CPR phase (December 20, 2003, to March 31, 2005); of these patients, the LDB device was applied in 210 patients.

Intervention Urban EMS system change from manual CPR to LDB-CPR.

Main Outcome Measures Return of spontaneous circulation (ROSC), with secondary outcome measures of survival to hospital admission and hospital discharge, and neurological outcome at discharge.

Results Patients in the manual CPR and LDB-CPR phases were comparable except for a faster response time interval (mean difference, 26 seconds) and more EMS-witnessed arrests (18.7% vs 12.6%) with LDB. Rates for ROSC and survival were increased with LDB-CPR compared with manual CPR (for ROSC, 34.5%; 95% confidence interval [CI], 29.2%-40.3% vs 20.2%; 95% CI, 16.9%-24.0%; adjusted odds ratio [OR], 1.94; 95% CI, 1.38-2.72; for survival to hospital admission, 20.9%; 95% CI, 16.6%-26.1% vs 11.1%; 95% CI, 8.6%-14.2%; adjusted OR, 1.88; 95% CI, 1.23-2.86; and for survival to hospital discharge, 9.7%; 95% CI, 6.7%-13.8% vs 2.9%; 95% CI, 1.7%-4.8%; adjusted OR, 2.27; 95% CI, 1.11-4.77). In secondary analysis of the 210 patients in whom the LDB device was applied, 38 patients (18.1%) survived to hospital admission (95% CI, 13.4%-23.9%) and 12 patients (5.7%) survived to hospital discharge (95% CI, 3.0%-9.3%). Among patients in the manual CPR and LDB-CPR groups who survived to hospital discharge, there was no significant difference between groups in Cerebral Performance Category (P = .36) or Overall Performance Category (P = .40). The number needed to treat for the adjusted outcome survival to discharge was 15 (95% CI, 9-33).

Conclusion Compared with resuscitation using manual CPR, a resuscitation strategy using LDB-CPR on EMS ambulances is associated with improved survival to hospital discharge in adults with out-of-hospital nontraumatic cardiac arrest.

Approximately 400 to 460 000 individuals die every year from out-of-hospital cardiac arrest (OHCA),1 representing approximately one third of all cardiovascular deaths2 in the United States. Only 1% to 8% of individuals with OHCA survive to hospital discharge.36 Patients who have ventricular fibrillation for less than 3 to 4 minutes (the electrical phase of cardiac arrest)7 fare relatively well if rescuers arrive quickly and provide prompt defibrillation.811

However, once ventricular fibrillation has been present longer, the myocardium becomes depleted of adenosine triphosphate and defibrillation usually results in conversion to asystole or a pulseless electrical rhythm.7 Several studies suggest that a brief period of cardiopulmonary resuscitation (CPR) before defibrillation can increase intracellular adenosine triphosphate levels and improve survival.1214

Attaining a coronary perfusion pressure of more than 15 mm Hg is one of the best predictors of return of spontaneous circulation (ROSC) in animals1521 and humans.22,23 Manual chest compression provides only approximately one third of the normal blood supply to the brain and 10% to 20% of the normal blood flow to the heart.24 The use of a load-distributing band (LDB) device for chest compressions has been shown to achieve intrathoracic pressures higher than achievable safely during manual chest compression. The device improves coronary and systemic perfusion pressures and flows compared with those that can be achieved with manual CPR in animal models and in a small number of terminally ill patients.15,25 In addition, in 1 study,26 an LDB device was associated with improved ROSC compared with manual chest compression when used by paramedic fire captains in a large, urban emergency medical services (EMS) system.

The goal of our study was to compare survival outcomes in patients with OHCA treated before and after the LDB device was used on urban EMS ambulances.

Corresponding Author: Joseph P. Ornato, MD, Department of Emergency Medicine, Virginia Commonwealth University Medical Center, 1250 E Marshall St, 2nd Floor, Richmond, VA 23298-0401 (ornato@aol.com).

Author Contributions: Dr Ong had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Ong, Ornato, Dhindsa, Peberdy.

Acquisition of data: Ong, Edwards, Ines, Hickey, Clark, Williams, Powell, Overton.

Analysis and interpretation of data: Ong, Best.

Drafting of the manuscript: Ong, Ornato, Best.

Critical revision of the manuscript for important intellectual content: Ong, Edwards, Dhindsa, Best, Ines, Hickey, Clark, Williams, Powell, Overton, Peberdy.

Statistical analysis: Ong, Best.

Administrative, technical, or material support: Ong, Edwards, Dhindsa, Ines, Hickey, Clark, Williams, Powell, Overton.

Study supervision: Ornato, Peberdy.

Financial Disclosures: Dr Ornato is a Science Advisor to ZOLL Circulation (Sunnyvale, Calif), the manufacturer of the Autopulse device used in the study. Dr Ornato reported receiving reimbursement for travel expenses to Science Advisory board meetings approximately twice yearly and a small honorarium amounting to less than $2000 per year. He reported no other financial benefits (stock, stock options) from this relationship. Because of this relationship, Dr Ornato did not have access to data acquisition, entry, or analysis during this study. No other authors reported financial disclosures.

Funding/Support: This study was not a sponsored project. The 3 LDB devices used during the evaluation phase were provided free by ZOLL Circulation. Eight additional devices were loaned to the EMS system by the manufacturer for 12 months when ambulance deployment occurred to provide feedback to the manufacturer on the device’s design/durability on ambulances. The EMS system subsequently purchased all of the devices along with 7 additional units.

Acknowledgment: We are grateful for the voluntary contributions of Thomas Franck, MD, MPH, Department of Epidemiology and Community Health, Virginia Commonwealth University; Andrew J. Anderson, Department of Emergency Medicine, Richmond Community Hospital; Patti Aldridge, RN, Department of Emergency Medicine, Retreat Hospital; and Lorie Liptak, Chris Schaeffer, Richard Pertgen, and Derek Andresen, all from the Richmond Ambulance Authority.

Zheng ZJ, Croft JB, Giles WH, Mensah GA. Sudden cardiac death in the United States, 1989 to 1998.  Circulation. 2001;104:2158-2163
PubMed   |  Link to Article
Becker LB, Smith DW, Rhodes KV. Incidence of cardiac arrest: a neglected factor in evaluating survival rates.  Ann Emerg Med. 1993;22:86-91
PubMed   |  Link to Article
Eisenberg MS, Horwood BT, Cummins RO, Reynolds-Haertle R, Hearne TR. Cardiac arrest and resuscitation: a tale of 29 cities.  Ann Emerg Med. 1990;19:179-186
PubMed   |  Link to Article
Ornato JP, McBurnie MA, Nichol G.  et al.  The Public Access Defibrillation (PAD) trial: study design and rationale.  Resuscitation. 2003;56:135-147
PubMed   |  Link to Article
Lombardi G, Gallagher J, Gennis P. Outcome of out-of-hospital cardiac arrest in New York City: the Pre-Hospital Arrest Survival Evaluation (PHASE) study.  JAMA. 1994;271:678-683
PubMed   |  Link to Article
Becker LB, Ostrander MP, Barrett J, Kondos GT. Outcome of CPR in a large metropolitan area: where are the survivors?  Ann Emerg Med. 1991;20:355-361
PubMed   |  Link to Article
Weisfeldt ML, Becker LB. Resuscitation after cardiac arrest: a 3-phase time-sensitive model.  JAMA. 2002;288:3035-3038
PubMed   |  Link to Article
White RD, Hankins DG, Bugliosi TF. Seven years' experience with early defibrillation by police and paramedics in an emergency medical services system.  Resuscitation. 1998;39:145-151
PubMed   |  Link to Article
Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos.  N Engl J Med. 2000;343:1206-1209
PubMed   |  Link to Article
Caffrey SL, Willoughby PJ, Pepe PE, Becker LB. Public use of automated external defibrillators.  N Engl J Med. 2002;347:1242-1247
PubMed   |  Link to Article
Hallstrom AP, Ornato JP, Weisfeldt M.  et al.  Public-access defibrillation and survival after out-of-hospital cardiac arrest.  N Engl J Med. 2004;351:637-646
PubMed   |  Link to Article
Cobb LA, Fahrenbruch CE, Walsh TR.  et al.  Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation.  JAMA. 1999;281:1182-1188
PubMed   |  Link to Article
Eftestol T, Wik L, Sunde K, Steen PA. Effects of cardiopulmonary resuscitation on predictors of ventricular fibrillation defibrillation success during out-of-hospital cardiac arrest.  Circulation. 2004;110:10-15
PubMed   |  Link to Article
Wik L, Hansen TB, Fylling F.  et al.  Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial.  JAMA. 2003;289:1389-1395
PubMed   |  Link to Article
Halperin HR, Guerci AD, Chandra N.  et al.  Vest inflation without simultaneous ventilation during cardiac arrest in dogs: improved survival from prolonged cardiopulmonary resuscitation.  Circulation. 1986;74:1407-1415
PubMed   |  Link to Article
Ralston SH, Voorhees WD, Babbs CF. Intrapulmonary epinephrine during prolonged cardiopulmonary resuscitation: improved regional blood flow and resuscitation in dogs.  Ann Emerg Med. 1984;13:79-86
PubMed   |  Link to Article
Michael JR, Guerci AD, Koehler RC.  et al.  Mechanisms by which epinephrine augments cerebral and myocardial perfusion during cardiopulmonary resuscitation in dogs.  Circulation. 1984;69:822-835
PubMed   |  Link to Article
Kern KB, Ewy GA, Voorhees WD, Babbs CF, Tacker WA. Myocardial perfusion pressure: a predictor of 24-hour survival during prolonged cardiac arrest in dogs.  Resuscitation. 1988;16:241-250
PubMed   |  Link to Article
Sanders AB, Ewy GA, Taft TV. Prognostic and therapeutic importance of the aortic diastolic pressure in resuscitation from cardiac arrest.  Crit Care Med. 1984;12:871-873
PubMed   |  Link to Article
Sanders AB, Ogle M, Ewy GA. Coronary perfusion pressure during cardiopulmonary resuscitation.  Am J Emerg Med. 1985;3:11-14
PubMed   |  Link to Article
Wolfe JA, Maier GW, Newton JR Jr.  et al.  Physiologic determinants of coronary blood flow during external cardiac massage.  J Thorac Cardiovasc Surg. 1988;95:523-532
PubMed
Paradis NA, Martin GB, Rivers EP.  et al.  Coronary perfusion pressure and the return of spontaneous circulation in human cardiopulmonary resuscitation.  JAMA. 1990;263:1106-1113
PubMed   |  Link to Article
McDonald JL. Coronary perfusion pressure during CPR in human beings [abstract].  Ann Emerg Med. 1983;12:144
Link to Article
Kern KB. Coronary perfusion pressure during cardio-pulmonary resuscitation.  Baillieres Clin Anaesthesiol. 2000;14:591-609
Halperin H, Paradis N, Ornato J. Improved hemodynamics with a novel chest compression device during a porcine model of cardiac arrest [abstract].  Circulation. 2002;106:(19 suppl 2)  538
Casner M, Andersen D, Isaacs SM. The impact of a new CPR assist device on rate of return of spontaneous circulation in out-of-hospital cardiac arrest.  Prehosp Emerg Care. 2005;9:61-67
PubMed   |  Link to Article
Jacobs I, Nadkarni V, Bahr J.  et al.  Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries.  Resuscitation. 2004;63:233-249
PubMed   |  Link to Article
Jacobs I, Nadkarni V, Bahr J.  et al.  Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries.  Circulation. 2004;110:3385-3397
PubMed   |  Link to Article
Cummins RO, Chamberlain DA, Abramson NS.  et al.  Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style.  Circulation. 1991;84:960-975
PubMed   |  Link to Article
Cummins RO, Chamberlain DA, Abramson NS.  et al.  Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style.  Ann Emerg Med. 1991;20:861-874
PubMed   |  Link to Article
The Brain Resuscitation Clinical Trial II Study Group.  A randomized clinical trial of calcium entry blocker administration to comatose survivors of cardiac arrest: design, methods, and patient characteristics.  Control Clin Trials. 1991;12:525-545
PubMed   |  Link to Article
Halperin HR, Tsitlik JE, Gelfand M.  et al.  A preliminary study of cardiopulmonary resuscitation by circumferential compression of the chest with use of a pneumatic vest.  N Engl J Med. 1993;329:762-768
PubMed   |  Link to Article
Timerman S, Cardoso LF, Ramires JA, Halperin H. Improved hemodynamic performance with a novel chest compression device during treatment of in-hospital cardiac arrest.  Resuscitation. 2004;61:273-280
PubMed   |  Link to Article
Wik L, Kramer-Johansen J, Myklebust H.  et al.  Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest.  JAMA. 2005;293:299-304
PubMed   |  Link to Article
Abella BS, Alvarado JP, Myklebust H.  et al.  Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest.  JAMA. 2005;293:305-310
PubMed   |  Link to Article
Abella BS, Sandbo N, Vassilatos P.  et al.  Chest compression rates during cardiopulmonary resuscitation are suboptimal: a prospective study during in-hospital cardiac arrest.  Circulation. 2005;111:428-434
PubMed   |  Link to Article

Figures

Tables

References

Zheng ZJ, Croft JB, Giles WH, Mensah GA. Sudden cardiac death in the United States, 1989 to 1998.  Circulation. 2001;104:2158-2163
PubMed   |  Link to Article
Becker LB, Smith DW, Rhodes KV. Incidence of cardiac arrest: a neglected factor in evaluating survival rates.  Ann Emerg Med. 1993;22:86-91
PubMed   |  Link to Article
Eisenberg MS, Horwood BT, Cummins RO, Reynolds-Haertle R, Hearne TR. Cardiac arrest and resuscitation: a tale of 29 cities.  Ann Emerg Med. 1990;19:179-186
PubMed   |  Link to Article
Ornato JP, McBurnie MA, Nichol G.  et al.  The Public Access Defibrillation (PAD) trial: study design and rationale.  Resuscitation. 2003;56:135-147
PubMed   |  Link to Article
Lombardi G, Gallagher J, Gennis P. Outcome of out-of-hospital cardiac arrest in New York City: the Pre-Hospital Arrest Survival Evaluation (PHASE) study.  JAMA. 1994;271:678-683
PubMed   |  Link to Article
Becker LB, Ostrander MP, Barrett J, Kondos GT. Outcome of CPR in a large metropolitan area: where are the survivors?  Ann Emerg Med. 1991;20:355-361
PubMed   |  Link to Article
Weisfeldt ML, Becker LB. Resuscitation after cardiac arrest: a 3-phase time-sensitive model.  JAMA. 2002;288:3035-3038
PubMed   |  Link to Article
White RD, Hankins DG, Bugliosi TF. Seven years' experience with early defibrillation by police and paramedics in an emergency medical services system.  Resuscitation. 1998;39:145-151
PubMed   |  Link to Article
Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos.  N Engl J Med. 2000;343:1206-1209
PubMed   |  Link to Article
Caffrey SL, Willoughby PJ, Pepe PE, Becker LB. Public use of automated external defibrillators.  N Engl J Med. 2002;347:1242-1247
PubMed   |  Link to Article
Hallstrom AP, Ornato JP, Weisfeldt M.  et al.  Public-access defibrillation and survival after out-of-hospital cardiac arrest.  N Engl J Med. 2004;351:637-646
PubMed   |  Link to Article
Cobb LA, Fahrenbruch CE, Walsh TR.  et al.  Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation.  JAMA. 1999;281:1182-1188
PubMed   |  Link to Article
Eftestol T, Wik L, Sunde K, Steen PA. Effects of cardiopulmonary resuscitation on predictors of ventricular fibrillation defibrillation success during out-of-hospital cardiac arrest.  Circulation. 2004;110:10-15
PubMed   |  Link to Article
Wik L, Hansen TB, Fylling F.  et al.  Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial.  JAMA. 2003;289:1389-1395
PubMed   |  Link to Article
Halperin HR, Guerci AD, Chandra N.  et al.  Vest inflation without simultaneous ventilation during cardiac arrest in dogs: improved survival from prolonged cardiopulmonary resuscitation.  Circulation. 1986;74:1407-1415
PubMed   |  Link to Article
Ralston SH, Voorhees WD, Babbs CF. Intrapulmonary epinephrine during prolonged cardiopulmonary resuscitation: improved regional blood flow and resuscitation in dogs.  Ann Emerg Med. 1984;13:79-86
PubMed   |  Link to Article
Michael JR, Guerci AD, Koehler RC.  et al.  Mechanisms by which epinephrine augments cerebral and myocardial perfusion during cardiopulmonary resuscitation in dogs.  Circulation. 1984;69:822-835
PubMed   |  Link to Article
Kern KB, Ewy GA, Voorhees WD, Babbs CF, Tacker WA. Myocardial perfusion pressure: a predictor of 24-hour survival during prolonged cardiac arrest in dogs.  Resuscitation. 1988;16:241-250
PubMed   |  Link to Article
Sanders AB, Ewy GA, Taft TV. Prognostic and therapeutic importance of the aortic diastolic pressure in resuscitation from cardiac arrest.  Crit Care Med. 1984;12:871-873
PubMed   |  Link to Article
Sanders AB, Ogle M, Ewy GA. Coronary perfusion pressure during cardiopulmonary resuscitation.  Am J Emerg Med. 1985;3:11-14
PubMed   |  Link to Article
Wolfe JA, Maier GW, Newton JR Jr.  et al.  Physiologic determinants of coronary blood flow during external cardiac massage.  J Thorac Cardiovasc Surg. 1988;95:523-532
PubMed
Paradis NA, Martin GB, Rivers EP.  et al.  Coronary perfusion pressure and the return of spontaneous circulation in human cardiopulmonary resuscitation.  JAMA. 1990;263:1106-1113
PubMed   |  Link to Article
McDonald JL. Coronary perfusion pressure during CPR in human beings [abstract].  Ann Emerg Med. 1983;12:144
Link to Article
Kern KB. Coronary perfusion pressure during cardio-pulmonary resuscitation.  Baillieres Clin Anaesthesiol. 2000;14:591-609
Halperin H, Paradis N, Ornato J. Improved hemodynamics with a novel chest compression device during a porcine model of cardiac arrest [abstract].  Circulation. 2002;106:(19 suppl 2)  538
Casner M, Andersen D, Isaacs SM. The impact of a new CPR assist device on rate of return of spontaneous circulation in out-of-hospital cardiac arrest.  Prehosp Emerg Care. 2005;9:61-67
PubMed   |  Link to Article
Jacobs I, Nadkarni V, Bahr J.  et al.  Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries.  Resuscitation. 2004;63:233-249
PubMed   |  Link to Article
Jacobs I, Nadkarni V, Bahr J.  et al.  Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries.  Circulation. 2004;110:3385-3397
PubMed   |  Link to Article
Cummins RO, Chamberlain DA, Abramson NS.  et al.  Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style.  Circulation. 1991;84:960-975
PubMed   |  Link to Article
Cummins RO, Chamberlain DA, Abramson NS.  et al.  Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style.  Ann Emerg Med. 1991;20:861-874
PubMed   |  Link to Article
The Brain Resuscitation Clinical Trial II Study Group.  A randomized clinical trial of calcium entry blocker administration to comatose survivors of cardiac arrest: design, methods, and patient characteristics.  Control Clin Trials. 1991;12:525-545
PubMed   |  Link to Article
Halperin HR, Tsitlik JE, Gelfand M.  et al.  A preliminary study of cardiopulmonary resuscitation by circumferential compression of the chest with use of a pneumatic vest.  N Engl J Med. 1993;329:762-768
PubMed   |  Link to Article
Timerman S, Cardoso LF, Ramires JA, Halperin H. Improved hemodynamic performance with a novel chest compression device during treatment of in-hospital cardiac arrest.  Resuscitation. 2004;61:273-280
PubMed   |  Link to Article
Wik L, Kramer-Johansen J, Myklebust H.  et al.  Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest.  JAMA. 2005;293:299-304
PubMed   |  Link to Article
Abella BS, Alvarado JP, Myklebust H.  et al.  Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest.  JAMA. 2005;293:305-310
PubMed   |  Link to Article
Abella BS, Sandbo N, Vassilatos P.  et al.  Chest compression rates during cardiopulmonary resuscitation are suboptimal: a prospective study during in-hospital cardiac arrest.  Circulation. 2005;111:428-434
PubMed   |  Link to Article
CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 105

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles