Tailoring Targeted Temperature Management in Comatose Out-of-Hospital Cardiac Arrest Survivors: A Retrospective Analysis Based on the rCAST Score Classification

<b>Background/Objectives</b>: Stratifying post-cardiac arrest survivors based on the likelihood of good neurologic outcomes can guide the decision for targeted temperature management (TTM). This study aimed to compare the impact of TTM on neurological improvement among comatose out-of-hospital cardiac arrest (OHCA) survivors stratified by the revised post-cardiac arrest syndrome for therapeutic hypothermia (rCAST) score. <b>Methods</b>: This retrospective observational cohort study was conducted from February 2018 to April 2023 at the emergency department. We calculated the rCAST score immediately after the return of spontaneous circulation in adult patients and compared neurological outcomes at discharge for TTM based on the severity classification of the rCAST score (low: ≤5.5; moderate: 6.0-14.0; high: ≥14.5). We utilized inverse probability of treatment weighting (IPTW) analysis to adjust for selection bias and potential confounding factors between the TTM and non-TTM groups. <b>Results</b>: Among 300 comatose OHCA survivors, the proportions of patients with good neurological outcomes at discharge were 60.7% (17/28), 38.9% (56/144), and 2.3% (3/128) in the low, moderate, and high-severity rCAST groups, respectively. With increasing severity of the rCAST, the absolute difference in the proportion of patients with good neurological outcomes decreased between those who underwent TTM and those who did not (68.0% vs. 0.0%; <i>p</i> = 0.023, 45.2% vs. 27.5%; <i>p</i> = 0.037, and 3.5% vs. 0.0%; <i>p</i> = 0.221, respectively). After adjusting using IPTW, TTM was associated with good neurologic outcomes in the moderate-severity group (odds ratio, 2.31; 95% confidence interval, 1.09-4.91; <i>p</i> = 0.029). <b>Conclusions</b>: This study suggests that TTM may offer specific benefits for certain groups of OHCA survivors. Further research is needed to refine risk stratification tools for improved patient selection.