Influence of Cooling duration on Efficacy in Cardiac Arrest Patients (ICECAP): study protocol for a multicenter, randomized, adaptive allocation clinical trial to identify the optimal duration of induced hypothermia for neuroprotection in comatose, adult survivors of after out-of-hospital cardiac arrest.
William J MeurerFlorian SchmitzbergerSharon YeattsViswanathan RamakrishnanBenjamin AbellaTom AufderheideWilliam BarsanJustin BenoitScott BerryJoy BlackNia BozemanKristine BroglioJeremy BrownKimberly BrownNoelle CarlozziAngela CaveneySung-Min ChoHangyul Chung-EsakiRobert ClevengerRobin ConwitRichelle CooperValentina CrudoMohamud DayaDeneil HarneyCindy HsuNicholas J JohnsonImad KhanShaveta KhoslaPeyton KlineAnna KratzPeter KudenchukRoger J LewisChaitra MadiyalSara MeyerJarrod MosierMarwan MouammarMatthew NethBrian O'NeilJames PaxtonSofia PerezSarah PermanCemal SozenerMickie SpeersAimee SpiteriValerie StevensonKavita SunthankarJoseph TonnaScott YoungquistRomergryko GeocadinRobert SilbergleitPublished in: Research square (2024)
Background Cardiac arrest is a common and devastating emergency of both the heart and brain. More than 380,000 patients suffer out-of-hospital cardiac arrest annually in the United States. Induced cooling of comatose patients markedly improved neurological and functional outcomes in pivotal randomized clinical trials, but the optimal duration of therapeutic hypothermia has not yet been established. Methods This study is a multi-center randomized, response-adaptive, duration (dose) finding, comparative effectiveness clinical trial with blinded outcome assessment. We investigate two populations of adult comatose survivors of cardiac arrest to ascertain the shortest duration of cooling that provides the maximum treatment effect. The design is based on a statistical model of response as defined by the primary endpoint, a weighted 90-day mRS (modified Rankin Scale, a measure of neurologic disability), across the treatment arms. Subjects will initially be equally randomized between 12, 24, and 48 hours of therapeutic cooling. After the first 200 subjects have been randomized, additional treatment arms between 12 and 48 hours will be opened and patients will be allocated, within each initial cardiac rhythm type (shockable or non-shockable), by response adaptive randomization. As the trial continues, shorter and longer duration arms may be opened. A maximum sample size of 1800 subjects is proposed. Secondary objectives are to characterize: the overall safety and adverse events associated with duration of cooling, the effect on neuropsychological outcomes, and the effect on patient reported quality of life measures. Discussion In-vitro and in-vivo studies have shown the neuroprotective effects of therapeutic hypothermia for cardiac arrest. We hypothesize that longer durations of cooling may improve either the proportion of patients that attain a good neurological recovery or may result in better recovery among the proportion already categorized as having a good outcome. If the treatment effect of cooling is increasing across duration, for at least some set of durations, then this provides evidence of the efficacy of cooling itself versus normothermia, even in the absence of a normothermia control arm, confirming previous RCTs for OHCA survivors of shockable rhythms and provides the first prospective controlled evidence of efficacy in those without initial shockable rhythms. Trial registration ClinicalTrials.gov (NCT04217551, 2019-12-30).
Keyphrases
- cardiac arrest
- cardiopulmonary resuscitation
- end stage renal disease
- clinical trial
- chronic kidney disease
- ejection fraction
- double blind
- newly diagnosed
- open label
- phase iii
- peritoneal dialysis
- emergency department
- prognostic factors
- patient reported
- heart failure
- type diabetes
- magnetic resonance
- magnetic resonance imaging
- cross sectional
- left ventricular
- study protocol
- skeletal muscle
- randomized controlled trial
- computed tomography
- functional connectivity
- brain injury
- adipose tissue
- placebo controlled
- metabolic syndrome
- combination therapy
- blood pressure
- blood brain barrier
- network analysis
- resting state
- childhood cancer