Association Between Serum Ionized Calcium Levels and Neurological Outcomes in Patients with Out-of-Hospital Cardiac Arrest

Abstract

Despite advances in post-cardiac arrest care, mortality and poor neurological outcomes remain common after out-of-hospital cardiac arrest (OHCA). Calcium imbalance is characteristic of post-cardiac arrest syndrome, but its prognostic role is unclear. We retrospectively analyzed 421 OHCA patients treated with targeted temperature management (TTM) (2011-2023). pH-adjusted ionized calcium levels were measured at 0, 12, 24, 48, and 72 h after return of spontaneous circulation (ROSC). Associations with 30-day neurological outcomes and mortality were assessed using multivariable logistic regression with two-stage maximum likelihood estimation. Higher baseline-adjusted ionized calcium levels were significantly associated with better neurological outcomes (Cerebral Performance Category 1-2) and lower 30-day mortality, regardless of calcium infusion or clinical covariates. Each 0.01-unit increase corresponded to 17% lower odds of unfavorable neurological outcome (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.76-0.90) and 10% lower mortality (OR, 0.90; 95% CI, 0.84-0.96). Incorporating longitudinal calcium measurements improved predictive accuracy, raising the area under the curve for neurological outcomes from 0.843 to 0.919. Early post-ROSC ionized calcium levels were independently associated with neurological outcomes and mortality in patients with OHCA treated with TTM. Serial ionized calcium monitoring may serve as a prognostic marker, warranting prospective evaluation of therapeutic implications.