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LINC study: LINC - A multicenter randomized trial comparing a mechanical CPR algorithm using LUCAS vs. manual CPR in out-of-hospital cardiac arrest patients

Sudden Cardiac Death and Resuscitation

Presenter abstract
Discussant report
All the Scientific resources on ESC Congress 365


By Sten Rubertsson
Other authors: Prof. Johan Herlitz, Sweden; Dr. Erik Lindgren, Sweden; Dr.Phd Rolf Karlsten,Sweden
When performing manual chest compressions disruption due to fatigue resulting in incorrect compression rate and depth as well as pauses for defibrillation might be major factors contributing to the still poor outcome after out-of-hospital cardiac arrest (CA). We hypothesized that a concept with mechanical chest compressions using the LUCAS device and defibrillation during ongoing chest compressions (L-CPR) would improve 4 hr survival as compared to manual cardiopulmonary resuscitation (M-CPR) in out-of-hospital CA. 

In 6 European sites, January 2008 to August 2012, 2589 patients with out-of-hospital CA were randomized to be treated either with L-CPR (n=1300) or with M-CPR according to guidelines (n=1289). CA patients treated with defibrillation prior to arrival of the ambulance crew or crew witnessed CA successfully treated with the first defibrillation were excluded. Surviving patients were followed for 6 months and evaluated for neurological outcome using the Cerebral Category Performance Scale (CPC) with CPC 1-2 classified as good outcome.

There was no difference in background variables between the groups. In the Intention to Treat population (n=2589), 4 hr survival frequency was 307 patients (23.6%) with L-CPR and 305 (23.7%) with M-CPR (risk difference -0.05%, 95% C.I. -3.32 – 3.23, p=1.00). Survival with good neurological outcome was 108 (8.3%) vs 100 (7.8%) (p=0.61) at hospital discharge, 105 (8.1%) vs 94 (7.3%) (p=0.46) at one month and 110 (8.5%) vs 98 (7.6%) (p=0.43) at 6 months after CA in the L-CPR and M-CPR group respectively. Surviving patients with CPC1-2 in the L-CPR and M-CPR group was 92% vs 86% at hospital discharge, 94% vs 88% at one month and 99% vs 94% at 6 months after CA.

There was no difference in short or long-term survival up to 6 months between patients treated with the LUCAS concept as compared to manual CPR. There was good neurological outcome in the vast majority of survivors in both groups.

Discussant Report

Patrick Goldstein
Dr Rubertsson and co authors from Upsala Sweden, present the results of the LINC study. LINC is a multicenter randomized trial comparing a mechanical CPR algorithm using an automatized chest compression device (LUCAS) versus manual chest compression and CPR according to guidelines in out of hospital cardiac arrest patients (OHCA).
2589 patients were randomized in intention to treat in 6 European sites over a 4 and an half years period. ¨Primary endpoint was 4 hour survival and secondary endpoints were restoration of spontaneous circulation, arrival to the emergency room (ER) with spontaneous palpable pulse and survival to hospital discharge with severe neurological impairment and at 1 and 6 months.
The results presented by Dr Rubertsson are neutral. There was no difference in short or long term survival up to 6 months between patients treated by mechanical chest compressions as compared to manual CPR.
May be the results of this important trial could be considered as really positive for many points not considered as endpoints.
LINC is a success if we consider a trial in the field of pre-hospital medicine
2589 patients randomized over more than 4 years must be considered as  a very important contribution to clinical research in the prehospital setting. The community of physician engaged in pre-hospital medicine must be grateful to Dr Rubertsson and co-authors.
There was good neurological outcomes in both groups (8.5 % ; 7.6 %) at 6 months.
What are the reasons for such good results? Undoubtedly the performance of the emergency medical crew with a low flow under 10 minutes.
On the other hand only 6.7% of patients were defibrillated before arrival of the emergency medical crew and nearly 50% were in asystole.The chain of survival is still the key to success (1) and we must focus on the importance of the first step (BLS) and the implementation of nationwide public access to defibrillation as the most important way to improve of prognosis of OHCA (2).
The implementation of intensive post resuscitation care (3) must be considered as the last but essential fifth link of the chain of survival.
The LUCAS device was used in the LINC study for patients resuscitated and transferred to the ICU. This technique can also be proposed to patients in cardiac arrest without any sign of spontaneous circulation in two particular conditions. Implementation of non heart beating donors strategies and patients proposed for ECMO (hypothermia, intoxications) with no flow less than 5 minutes (4). The device is easy to use in routine emergency practice to facilitate access to extracorporeal life support (5).
The mechanical chest compressions could also in routine pre-hospital resuscitation be associated with other devices, such as the impedance threshold valve but without any conclusive results (6).

1 - Ornato : Circulation, 1991, 83 : 1832-47
2 - Kitamura T. : Circulation, 2012, 11 : 2834-45
3 - Tagami : Circulation, 2012, 126 : 589-592
4 - French guidelines for CA. AFAR, 2009, 28 : 182-6
5 - Am. J. Emerg. Med., 2011, 11 : 1169-72
6 - Aufderheide. N. Engl. J. Med., 2011 , 365 : 798-306 




LINC study: LINC - A multicenter randomized trial comparing a mechanical CPR algorithm using LUCAS vs. manual CPR in out-of-hospital cardiac arrest patients

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.