Sex differences in management and outcomes after out-of-hospital cardiac arrest with angiographically confirmed obstructive coronary artery disease

Abstract

Background

Previous studies have reported sex-based disparities in care, often disadvantaging women. Large registry analyses are limited by incomplete characterization of out-of-hospital cardiac arrest OHCA aetiology and coronary angiography (CAG) findings. We aimed to evaluate sex differences in management and outcomes among patients with angiographically confirmed obstructive coronary artery disease (CAD) following OHCA.

Methods

We performed a post hoc analysis of consecutive adult OHCA patients with angiographically confirmed obstructive CAD admitted between 2012 and 2023 using a prospective OHCA registry. Obstructive CAD was defined as ≥70% coronary stenosis identified by coronary angiography and considered the most likely cause of OHCA. The primary outcome of this analysis was 30-day survival. The secondary outcome was favourable neurological outcome at hospital discharge. Multivariable logistic regression was used to assess the independent association between sex and 30-day survival.

Results

Among 1219 OHCA admissions, 634 (52%) patients had angiographically confirmed CAD, and 580 (91.5%) were included in the final analysis (median age 61 years, 15.3% women). ST-segment elevation myocardial infarction was the predominant aetiology in both groups (64% in women vs. 59.9% in men). Men more frequently had a history of CAD and prior myocardial infarction. No significant sex-related differences were observed in PCI utilization, procedural success, targeted temperature management, or extracorporeal cardiopulmonary resuscitation use. Thirty-day survival was 66.2% in women and 61.5% in men (log-rank p = 0.33), while favourable neurological outcome (Cerebral Performance Category 1–2) occurred in 55.1% and 53.8%, respectively (p = 0.82). Men more frequently exhibited multivessel CAD, whereas women more often had identifiable culprit lesions. In multivariable analysis, sex was not significantly associated with 30-day survival (adjusted OR 0.75, 95% CI 0.39–1.41, p = 0.37).

Conclusions

In this cohort of patients with angiographically confirmed obstructive CAD following OHCA, no statistically significant sex-related differences were observed in management, procedural success, 30-day survival, or neurological outcomes. Men exhibited more extensive CAD.

Introduction

Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death in Europe.¹ Most studies demonstrate that women admitted for OHCA to a cardiac center have a different cause of arrest, different treatment strategies and outcome compared with men.2, 3, 4, 5, 6

One of the most pronounced sex-related differences concerns arrest aetiology. Women more frequently experience OHCA due to non-cardiac causes, whereas men more often have a primary cardiac aetiology, predominantly coronary artery disease (CAD) including acute myocardial infarction (AMI).3, 6 These etiological differences are closely linked to presenting cardiac rhythm: women are less likely to present with shockable rhythms and more commonly have pulseless electrical activity or asystole, while men more often present with ventricular fibrillation.2, 3, 4, 5, 6 Because initial rhythm is one of the strongest predictors of survival after OHCA, these upstream differences substantially influence downstream treatment decisions and outcomes.

CAD represents the most common cardiac cause of OHCA.2, 3, 5 However, data specifically addressing sex differences among patients with CAD-related OHCA (CAD-OHCA) remain limited and inconsistent. Although contemporary guidelines7, 8 recommend identical diagnostic and therapeutic strategies for women and men with CAD and cardiac arrest, several large national registry and administrative database studies have suggested persistent sex-based disparities in care that appear to disadvantage women.2, 3, 4, 5, 9, 10 In these studies, women were less likely to undergo coronary angiography (CAG), percutaneous coronary intervention (PCI), or coronary artery bypass grafting, and less likely to receive other evidence-based therapies, with higher unadjusted or adjusted in-hospital mortality compared with men.9, 10, 11

Interpretation of these findings is challenging because most large-scale studies rely on administrative coding and lack detailed clinical characterization. They often cannot reliably confirm the aetiology of cardiac arrest, distinguish CAD from alternative causes, or provide granular data on coronary anatomy, culprit lesions, procedural success, or post–cardiac arrest care.2, 3, 4, 5

We hypothesize that prior studies might be biased by inclusion of substantial proportions of women with non-obstructive coronary arteries or misclassified arrest aetiologies, which may not represent confirmed obstructive CAD-related OHCA and are associated with distinct mechanisms, management and outcomes.2, 4, 5

Therefore, the aim of this study was to investigate the association of sex with outcomes, resuscitation characteristics, and in-hospital management in a well-defined cohort of patients with angiographically-confirmed obstructive CAD-related OHCA, admitted to a cardiac arrest center, with detailed characterization of coronary anatomy, PCI performance, post–cardiac arrest care, and neurological outcomes.

Methods

Study setting

The pre-hospital cardiopulmonary resuscitation system and its results in the city of Prague, Czech Republic have been described previously.¹² General University Hospital is a tertiary cardiac arrest center that accepts the full spectrum of OHCA patients referred by EMS, including those transported with ongoing CPR without sustained return of spontaneous circulation (ROSC). In cases of presumed cardiac cause (initial VF or significant ST changes on post-ROSC ECG), most patients are directly admitted to the catheterization laboratory available 24 h a day, 7 days a week. Patients with presumed non-cardiovascular cause are referred from emergency medical service (EMS) directly to an intensive care unit (ICU). In all patients, a detailed examination of the cardiac arrest causes including invasive assessment, immediate biochemical evaluation, echocardiogram, and whole-body computed tomography if feasible and clinically indicated, is performed.

Study design and data collection

This is a post hoc analysis using the prospective registry including all adult patients (≥18 years) that were admitted to the tertiary cardiac arrest center of the General University Hospital in Prague (Czech Republic) from January 2012 to December 2023. The Prague OHCA registry is a single-center registry offering a detailed description of the prehospital and hospital treatment characteristics of OHCA and their outcomes. Data on cardiac arrest characteristics were prospectively collected after hospital admission. The treating physician entered all relevant prehospital and in-hospital data, including patient characteristics and treatment details, into predefined standardized worksheets based on information obtained from emergency medical service records, hospital documentation, and outpatient databases. OHCA data were collected according to Utstein recommendations.¹³ All OHCA patients admitted to the hospital were treated according to the ERC and ESC guidelines valid at the time.

A strategy of performing an emergent CAG was encouraged in patients with a presumed cardiac cause. Immediate PCI was performed as per the decision of the interventional cardiologist, where the general strategy was PCI of a culprit lesion considered to be the cause of cardiac arrest. After the procedure, patients were admitted to the intensive care unit for standardized supportive treatment. All angiography analyses were performed at the Catheterization Laboratory of the Cardiology Department of the General University Hospital, Prague, Czech Republic. Flow in obstructed arteries was assessed with the Thrombolysis in Myocardial Infarction (TIMI) classification.¹⁴

Outcomes

The primary outcome of this analysis was 30-day survival. The secondary outcome was favourable neurological outcome at hospital discharge (defined as a Cerebral Performance Category (CPC) score of 1–2, CPC 3–5 was considered a poor neurological outcome).¹⁵

Data regarding specific cardiac arrest cause were recorded in all patients and subsequently classified into categories. Referral to the catheterisation laboratory was based on a presumed cardiac cause; this category is broader than obstructive CAD and also encompasses non-ischaemic cardiac conditions (e.g., cardiomyopathy, primary arrhythmia, and decompensated heart failure). For the present analysis we included only patients in whom obstructive CAD was confirmed angiographically and adjudicated as the most likely cause of arrest; non-ischaemic cardiac causes were not included. Obstructive CAD was defined by CAG findings of at least one ≥70% stenosis in a major epicardial vessel, significant left main stem disease with >50% stenosis or coronary occlusion (TIMI 0 or 1 flow). Coronary culprit lesion was defined as a lesion considered to be the cause of cardiac arrest based on CAG and electrocardiogram findings. Chronic total occlusion was defined as a completely occluded coronary artery (TIMI 0 flow) with an estimated duration of at least 3 months and established collaterals. A successful PCI was defined as a decrease in minimum stenosis diameter to <50% and TIMI flow grade 3 on the coronary angiogram.¹⁴

Statistical analysis

Numeric variables are expressed as medians with interquartile ranges, and categorical variables as counts with percentages. Mann Whitney U test was used for numeric variables, while categorical variables were compared using the χ² or Barnard’s test as appropriate. Survival was analysed with Kaplan-Meier and the log-rank test. Neurological outcome (CPC) was analysed using the χ² test. Multivariable logistic regression assessed the association of sex with 30-day survival, adjusting for established prognostic factors (age, initial rhythm, location of arrest, and total CPR duration), with results expressed as odds ratios (ORs) for death by day 30. Covariates for the multivariable model were pre-specified as established prognostic factors of survival after OHCA; covariates were not selected on the basis of univariable baseline differences. P < 0.05 was considered significant. Analyses were performed using R software, version 4.2.3.¹⁶

Results

Patients flow

Between January 2012 and December 2023, 1219 adult patients with OHCA were admitted to our institution. Of these, 893 patients (73.3%) underwent coronary angiography to confirm or exclude obstructive coronary artery disease. Obstructive CAD was identified as the primary aetiology in 634 patients, based on either coronary angiography or autopsy findings. After excluding patients in whom the diagnosis of obstructive CAD was based on autopsy without coronary angiography (n = 32) and those with unknown 30-day outcome (n = 22), the final study population consisted of 580 patients (Fig. 1). The cohort included 491 men (84.7%) and 89 women (15.3%).

Fig. 1.

Flowchart of the study population.

Baseline and resuscitation characteristics

Baseline characteristics are shown in Table 1. Women were slightly older (median 63 vs. 61 years). Men more frequently had known CAD (30.9% vs. 17.9%, p = 0.01) and prior myocardial infarction (23.0% vs. 10.1%, p = 0.006). Arrest location differed significantly between sexes, with women more often experiencing cardiac arrest in EMS/outpatient facilities (25.8% vs. 11.0%).

Table 1.

Baseline demographics and resuscitation characteristics.

	Overall (n = 580)	Men (n = 491)	Women (n = 89)	P value
Age, median (IQR), years	61 (52–68)	61 (53–67)	63 (52–72)	0.05
Medical history
Hypertension	323 (55.6%)	268 (54.5%)	55 (61.7%)	0.21
Diabetes	129 (22.2%)	113 (23.0%)	16 (17.9%)	0.21
Cigarette smoking	175 (30.1%)	153 (31.1%)	22 (24.7%)	0.22
CAD	168 (28.9%)	152 (30.9%)	16 (17.9%)	0.01
History of MI	122 (21%)	113 (23.0%)	9 (10.1%)	0.006
History of PCI	92 (15.8%)	82 (16.7%)	10 (11.2%)	0.19
History of CABG	49 (8.4%)	45 (9.1%)	4 (4.4%)	0.14
Dyslipidemia	189 (32.5%)	158 (32.1%)	31 (34.8%)	0.62
Atrial fibrillation	51 (8.7%)	43 (8.7%)	8 (8.9%)	0.94
Chronic heart failure	54 (9.3%)	47 (9.5%)	7 (7.8%)	0.61
Chronic kidney disease	52 (8.9%)	43 (8.7%)	9 (10.1%)	0.68
Location of cardiac arrest
Home	178 (30.6%)	152 (30.9%)	26 (29.2%)	<0.001
Public	325 (56%)	285 (58.0%)	40 (44.9%)
EMS/outpatient facility	77 (13.2%)	54 (11.0%)	23 (25.8%)
Rhythm at admission
VF	479 (82.5%)	407 (82.8%)	72 (80.8%)	0.89
PEA	52 (8.9%)	43 (8.7%)	9 (10.1%)
Asystole	49 (8.4%)	41 (8.3%)	8 (8.9%)
Witnessed arrest	531 (91.5%)	451 (91.8%)	80 (89.8%)	0.54
Bystander CPR	540 (93.1%)	458 (93.2%)	82 (92.1%)	0.70
Intermittent ROSC	114 (19.6%)	98 (19.9%)	16 (17.9%)	0.67
Adrenaline (mg), median (IQR)	1 (0–4)	1 (0–4)	0 (0–3)	0.18
Number of defibrillations prehospitally, median (IQR)	2 (1–4)	2 (1–4)	2 (1–4)	0.20
Mechanical CPR	220 (37.9%)	192 (39.1%)	28 (31.4%)	0.17
Total time of CPR, median (IQR) min	23 (12–47)	23.5 (12–50)	20 (10–42)	0.25

Abbreviations: CABG: coronary artery bypass grafting, CAD: coronary artery disease, CPR: cardiopulmonary resuscitation, ECPR: extracorporeal cardiopulmonary resuscitation, EMS: Emergency Medical Services, IQR: interquartile range, MI: myocardial infarction, PCI: percutaneous coronary intervention, PEA: pulseless electrical activity, ROSC: return of spontaneous circulation, VF: ventricular fibrillation.

The distribution of initial rhythm did not differ between sexes. Ventricular fibrillation was the predominant presenting rhythm in both men and women (82.8% vs. 80.8%). Rates of witnessed arrest, bystander CPR, prehospital defibrillations, adrenaline administration, total CPR time and mechanical CPR were comparable between sexes.

Hospitalization, CAG and PCI characteristics

Hospitalization characteristics are summarized in Table 2. ST-segment elevation myocardial infarction was the leading cause in both sexes (59.9% men vs. 64.0% women). Post-ROSC ECG findings were similar between groups.

Table 2.

Hospitalization characteristics and procedures.

	Men (n = 491)	Women (n = 89)	P value
TTM used	389 (79.2%)	66 (74.1%)	0.28
ECMO used	94 (19.1%)	13 (14.6%)	0.31
Cause of cardiac arrest
– STEMI	294 (59.9%)	57 (64.0%)	0.26
– NSTEMI	101 (20.5%)	21 (23.6%)
– Obstructive CAD	96 (19.6%)	11 (12.4%)
Post-ROSC ECG
– ST elevation	294 (59.8%)	56 (62.9%)	0.86
– LBBB/RBBB	55 (11.2%)	9 (10.1%)
– No ST-elevation	142 (28.9%)	24 (26.9%)
Coronary angiography	491(100%)	89 (100%)
Significant coronary disease ≥70%	491 (100%)	89 (100%)
– Single-vessel disease	163 (33.1%)	43 (48.3%)	0.02
– Two-vessel disease	124 (25.3%)	18 (20.0%)
– Three-vessel disease	204 (41.5%)	28 (31.4%)
Culprit lesion identified	366 (74.5%)	78 (87.6%)	0.007
Chronic total occlusion	166 (33.8%)	21 (23.5%)	0.06
Immediate PCI	376 (76.5%)	76 (85.3%)	0.07
– One-vessel PCI	328 (66.8%)	68 (76.4%)	0.95
– Two-vessel PCI	43 (8.7%)	8 (8.9%)
– Three-vessel PCI	4 (0.8%)	0 (0%)
– Thrombus aspiration	131 (34.8%)	23 (30.3%)	0.87
– Balloon angioplasty only	45 (11.9%)	6 (7.9%)	0.46
– Stent implantation	310 (82.4%)	68 (76.4%)	0.13
TIMI flow after procedure
– TIMI 0	27 (7.2%)	3 (3.9%)	0.51
– TIMI 1	11 (2.9%)	3 (3.9%)
– TIMI 2	20 (5.3%)	2 (2.6%)
– TIMI 3	318 (84.6%)	68 (89.5%)

Abbreviations: CAD: coronary artery disease, ECG: electrocardiogram, ECMO: extracorporeal membrane oxygenation, LBBB: left bundle branch block, NSTEMI: non-ST elevation myocardial infarction, PCI: percutaneous coronary intervention, RBBB: right bundle branch block, ROSC: return of spontaneous circulation, STEMI: ST-elevation myocardial infarction, TIMI: thrombolysis in mycocardial infarction flow grades, TTM: targeted temperature management.

Women more frequently had single-vessel disease compared with men (48.3% vs. 33.1%), three-vessel disease was more common in men (31.4% vs. 41.5%), p = 0.02. Culprit lesion identification was significantly more frequent in women than in men (87.6% vs. 74.5%) (Table 2), p = 0.007.

Immediate PCI was performed in most patients, with no significant difference between women and men (76.5% men vs. 85.3% women, p = 0.07). The extent of PCI, use of thrombus aspiration, balloon-only angioplasty, and stent implantation were comparable between groups. Final angiographic result with TIMI 3 flow was achieved in a high proportion of patients in both sexes (84.6% men vs. 89.5% women, p = 0.51) (Table 2).

Survival and neurological outcomes

Thirty-day survival was 66.2% in women and 61.5% in men, without a significant difference (log-rank p = 0.33; Fig. 2). The absolute risk difference was 4.7% (95% CI −6.4% to 14.8%) in favour of women.

Fig. 2.

Kaplan-Meier analysis of 30-day survival according to sex in the overall study population.

At hospital discharge, favourable neurological outcome (CPC 1–2) occurred in 55.1% of women and 53.8% of men (p = 0.82, Table 2). The absolute risk difference was 1.3% (95% CI −9.9% to 12.1%).

Multivariable analysis of survival

In multivariable logistic regression (Table 3), sex was not independently associated with 30-day survival (OR for men vs. women 0.75; 95% CI 0.39–1.41; p = 0.37). Ventricular fibrillation as the initial rhythm (vs. asystole) was independently associated with higher 30-day survival (OR 4.61; 95% CI 2.16–10.33; p < 0.001), whereas older age (OR 0.94 per year; 95% CI 0.92–0.96; p < 0.001) and longer duration of CPR (OR 0.94 per minute; 95% CI 0.93–0.95; p < 0.001) were associated with lower 30-day survival.

Table 3.

Multivariable logistic regression analysis of evaluated factors with 30-day survival.

Factor	OR	95% CI	p-value
Sex (men vs. women)	0.75	0.39–1.41	0.37
Age (per year increase)	0.94	0.92–0.96	<0.001
Total time CPR (per minute increase)	0.94	0.93–0.95	<0.001
Initial rhythm vs. asystole
– VF	4.61	2.16–10.33	<0.001
– PEA	0.67	0.23–1.95	0.46
Place of arrest (vs. home)
– Public	1.15	0.71–1.86	0.56
– EMS/outpatient facility	2.11	0.92–5.03	0.09

Abbreviations: CPR: cardiopulmonary resuscitation, EMS: emergency medical services, PEA: pulseless electrical activity, VF: ventricular fibrillation.

P < 0.05 was considered statistically significant.

ECPR subgroup

Among the total cohort, 107 patients (18.4%) underwent ECPR for refractory CAD-OHCA. ECPR was performed in 14.6% of women and 19.1% of men (p = 0.31). Median time from collapse to ECPR initiation was 60 min (IQR 53–70). Thirty-day survival did not differ between sexes (23.1% women vs. 28.1% men; log-rank p = 0.64; Fig. 3). There were no significant differences between the men and women undergoing ECPR in clinical characteristics, resuscitation variables, or subsequent management (Supplementary Tables 1 and 2).

Fig. 3.

Kaplan-Meier analysis of 30-day survival according to sex in the ECPR subgroup.

Discussion

In this angiography-confirmed cohort of patients with obstructive CAD–related OHCA, we found no evidence of clinically meaningful sex-based differences in prehospital characteristics, invasive management, procedural success, or clinical outcomes. Thirty-day survival and favourable neurological outcome at discharge were comparable between women and men, and sex was not independently associated with survival after adjustment for established prognostic factors.

These findings contrast with several large registry and administrative database studies reporting worse outcomes and lower use of invasive strategies in women after cardiac arrest.2, 3, 4, 9, 10, 11 However, most prior analyses included heterogeneous OHCA populations without systematic confirmation of arrest aetiology. In such unselected cohorts, women are more frequently represented among non-cardiac causes of arrest and non-obstructive coronary disease.2, 3, 4 These conditions are associated with lower rates of revascularization and inherently different prognoses.

A major strength of our study is the strict inclusion of patients with angiographically confirmed obstructive CAD as the primary cause of OHCA. By limiting the analysis to patients with angiographically confirmed obstructive CAD, we reduced heterogeneity related to arrest aetiology and coronary anatomy compared with previous registry studies. This may partially explain why no statistically significant sex-related differences were observed in our cohort compared with previous reports.

Prehospital characteristics

Importantly, upstream resuscitation factors were highly comparable between sexes. Rates of witnessed arrest, bystander CPR, shockable initial rhythm, defibrillation burden, and total resuscitation time did not differ significantly. In many unselected OHCA cohorts, women experience lower rates of bystander CPR and lower prevalence of shockable rhythms, both of which negatively influence survival. The absence of such differences within our admitted cohort reduces confounding by these factors in our comparisons; however, because only patients surviving to admission with confirmed obstructive CAD were included, this does not establish that prehospital characteristics was equitable at the population level.

Interestingly, women in our cohort more frequently experienced OHCA in EMS or outpatient healthcare settings. Although speculative, this observation may reflect sex-related differences in symptom recognition or healthcare-seeking behaviour prior to cardiac arrest. However, most previous OHCA studies have not specifically reported EMS-witnessed arrests by sex, and such cases are frequently excluded from analyses. Therefore, supporting evidence for this observation is currently limited. Whether this finding represents a true difference in disease trajectory or a chance observation warrants further investigation.

Coronary anatomy, PCI and ECPR treatment

Our angiographic findings offer insight into sex-related differences in underlying coronary anatomy. Women more frequently presented with single-vessel disease, whereas men more often exhibited three-vessel disease, and culprit lesion identification was significantly more common in women possibly reflecting less complex coronary disease with a more clearly defined acute thrombotic substrate in this selected population. These observations align with the broader CAD literature, which demonstrates that when women develop obstructive CAD, they often have less extensive angiographic disease than men.¹⁷ Similar patterns have been described in acute coronary syndrome (ACS) populations: women presenting with ACS more often have less extensive obstructive disease, yet their higher crude early mortality is markedly attenuated after adjustment for age, comorbidities, and angiographic severity.19, 20

Despite these anatomical differences, invasive treatment was delivered similarly in both sexes. Immediate PCI was performed in most patients, and multivessel intervention, thrombus aspiration, stent implantation, and final angiographic success (TIMI 3 flow) were all comparable, indicating no systematic differences in revascularization strategy. In-hospital management was likewise well balanced, including the use of targeted temperature management and ECPR. This supports the notion that when women with obstructive CAD-OHCA are treated within a standardized cardiac arrest pathway in a developed prehospital system linked to a specialized cardiac arrest center, there are no significant sex-based treatment differences.

Determinants of outcome

In multivariable analysis, established resuscitation variables rather than sex were independently associated with 30-day survival. Increasing age and longer resuscitation duration were associated with lower survival, whereas an initial shockable rhythm was associated with higher survival, consistent with previous reports.¹⁸ Importantly, after adjustment for these variables, sex was not independently associated with 30-day survival. This suggests that, in patients with angiographically confirmed and treated obstructive CAD, previously reported sex disparities in OHCA outcomes may reflect differences in arrest aetiology and initial rhythm distribution rather than an intrinsic biological disadvantage. However, the number of women in our cohort was modest, and larger studies are needed to confirm these findings.

Limitations

Several limitations should be acknowledged. Importantly, the cohort was conditioned on the performance of coronary angiography and confirmation of obstructive CAD. Selection for angiography depends on clinician judgement (e.g., an initial shockable rhythm or post-ROSC ECG changes), which may itself differ by sex; the present analysis therefore cannot evaluate potential disparities in the decision to perform angiography. Furthermore, this was a post hoc analysis of a prospective registry, and residual confounding by unmeasured variables cannot be excluded. Second, women represented a minority of the study population, which may limit statistical power to detect small sex-based differences. However, the low proportion of women reflects the epidemiology of angiographically confirmed obstructive CAD–related OHCA rather than selection bias. Third, this was a single-center study conducted in a specialized tertiary cardiac arrest center with standardized invasive protocols and high rates of coronary intervention. This limits the generalizability of our findings.

Conclusions

In this angiography-confirmed cohort of patients with obstructive CAD-related OHCA, management, procedural success and 30-day survival with favourable neurological outcome did not differ between women and men; outcome was driven by age, resuscitation duration and initial rhythm rather than sex. Women more often had single-vessel disease with a clear culprit lesion, without measurable effect on prognosis. Whether disparities arise upstream, in recognition, bystander resuscitation or selection for transport and angiography, cannot be answered by a cohort defined at the point of angiography; adequately powered multicentre studies covering the whole prehospital-to-hospital pathway, including patients who never reached the catheterisation laboratory, are the necessary next step.

CRediT authorship contribution statement

Klaudia Svitekova: Writing – original draft, Visualization, Validation, Project administration, Methodology, Investigation, Formal analysis, Data curation. Daniel Rob: Writing – original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Eliska Mockova: Writing – review & editing, Visualization, Validation, Project administration, Investigation, Data curation. Petra Kavalkova: Writing – review & editing, Visualization, Validation, Project administration, Investigation, Data curation. Jan Pudil: Writing – review & editing, Visualization, Validation, Investigation. Milan Dusik: Writing – review & editing, Visualization, Validation, Data curation. Jaromir Macoun: Writing – review & editing, Visualization, Validation, Software, Formal analysis, Data curation. Eva Svobodova: Writing – review & editing, Investigation. Jan Malik: Writing – review & editing, Investigation. Anna Valerianova: Writing – review & editing, Investigation. Silvie Trhlikova: Writing – review & editing, Investigation. Jan Spicak: Writing – review & editing, Investigation. Jan Belohlavek: Writing – review & editing, Visualization, Supervision, Methodology, Investigation.

Ethics approval and consent to participate

The register and database used for clinical research were approved by the Institutional Review Board of the General University Hospital and First Faculty of Medicine, Charles University in Prague (14/20 VFN IGP). All patients who regained normal neurologic function, or their legal representatives if they did not regain consciousness, were asked to provide their written consent with registry enrollment and data use. Consent requirements were waived for participants without known legal representatives who died or had severe neurological deficits and were unable to provide informed consent.

Funding

This study was supported by MH CZ–VFN00064165, General University Hospital in Prague and the Charles University Research program “Cooperatio – Intensive Care Medicine”.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: The corresponding author (DR) has received lecture honoraria from Abiomed. The corresponding author (JB) has received lecture honoraria from the Abiomed, Getinge, Xenios, Resuscitec, Novartis, Astra-Zeneca, Boehringer-Ingelheim. The remaining authors report no conflict of interest.

Appendix A. Supplementary material

The following are the Supplementary material to this article:

Supplementary Table 1

Baseline, resuscitation, hospitalization, and procedural characteristics of ECPR patients, stratified by sex.