Regional Intensity of Outpatient Cardiovascular Testing and Cardiac-Origin Out-of-Hospital Cardiac Arrest　― A 10-Year Nationwide Ecological Study Using the All-Japan Utstein Registry ―

Q: What are the key findings of this study?

Higher prefecture-level outpatient 12-lead ECG testing intensity was significantly associated with a lower standardized incidence ratio of cardiac-origin out-of-hospital cardiac arrest (RR 0.95).

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Cardiac-origin out-of-hospital cardiac arrest (CO-OHCA) (n=248633). Intervention: Regional intensity of outpatient 12-lead ECG testing vs. Lower regional testing intensity. Primary outcome: Age- and sex-standardized incidence ratio (SIR) of CO-OHCA (RR 0.95, 95% CI 0.93-0.98, p=<0.001).

Q: What does this research mean for the field?

Higher regional intensity of outpatient 12-lead ECG testing is significantly associated with a lower standardized incidence of cardiac-origin out-of-hospital cardiac arrest. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To determine whether regional intensity of outpatient cardiovascular diagnostic testing is associated with the incidence of cardiac-origin out-of-hospital cardiac arrest (CO-OHCA) among adults aged 40–74 years in Japan.

Hiroki Sato; Naohiko Takahashi; Naohiro Yonemoto; Tetsuya Matoba; Yoshio Tahara; for the Japanese Circulation Society Resuscitation Science Study (JCS-ReSS) Group

doi:10.1253/circrep.cr-26-0152

June 25, 2026Circulation ReportsOpen Access

Regional Intensity of Outpatient Cardiovascular Testing and Cardiac-Origin Out-of-Hospital Cardiac Arrest　― A 10-Year Nationwide Ecological Study Using the All-Japan Utstein Registry ―

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Key result

Higher outpatient ECG testing intensity linked to ~5% lower incidence of cardiac-origin OHCA.

RR 0.95
95% CI 0.93-0.98
P<0.001
n=248,633

Figures

Why the study?

Variations in the incidence of cardiac-origin out-of-hospital cardiac arrest may reflect differences in cardiovascular care, but the association with regional outpatient cardiovascular diagnostic testing intensity was unknown.

Is the regional intensity of outpatient cardiovascular diagnostic testing associated with the incidence of cardiac-origin out-of-hospital cardiac arrest in adults aged 40-74 years?

Key Points

To determine whether regional intensity of outpatient cardiovascular diagnostic testing is associated with the incidence of cardiac-origin out-of-hospital cardiac arrest (CO-OHCA) among adults aged 40–74 years in Japan.
Conducted a 10-year nationwide ecological study (2014–2023) across 47 prefectures analyzing 248,633 presumed CO-OHCA cases from the All-Japan Utstein Registry and testing data from the National Database Open Data.
Quantified prefecture-level outpatient testing intensity as observed-to-expected (O/E) ratios for 12-lead electrocardiography (ECG), Holter ECG, transthoracic echocardiography (TTE), and BNP/NT-proBNP.
Evaluated age- and sex-standardized incidence ratios (SIRs) of CO-OHCA using multivariable models adjusted for calendar year and prefecture-level cardiometabolic risk factor prevalences (diabetes, dyslipidemia, hypertension, and obesity).
Higher 12-lead ECG testing intensity was significantly associated with lower CO-OHCA SIR after full adjustment for calendar year and individual cardiometabolic risks (RR 0.95 per 0.1-unit increase in O/E ratio; 95% CI 0.93–0.98; P<0.001).
Higher obesity prevalence was significantly associated with higher CO-OHCA SIR (RR 1.35 per 10-percentage-point increase; 95% CI 1.16–1.57; P<0.001), whereas diabetes, dyslipidemia, and hypertension showed no significant associations.

Study Design

Type

Observational (n=248,633)

Multicenter

Yes

Structured PICO

Is the regional intensity of outpatient cardiovascular diagnostic testing associated with the incidence of cardiac-origin out-of-hospital cardiac arrest in adults aged 40-74 years?

P

Population

248,633 adults aged 40-74 years with out-of-hospital cardiac arrest of presumed cardiac origin across 47 prefectures in Japan, analyzed over a 10-year period.

E

Exposure

Intensity of outpatient 12-lead electrocardiography (ECG) testing (quantified as observed/expected ratio)

O

Outcome

Age- and sex-standardized incidence ratio (SIR) of cardiac-origin out-of-hospital cardiac arrest (CO-OHCA)hard clinical

Main Result

Relative Risk: 0.95 (95% CI 0.93–0.98)

p-value: p=<0.001

Higher regional intensity of outpatient 12-lead ECG testing is associated with a lower incidence of cardiac-origin out-of-hospital cardiac arrest, suggesting it may serve as a useful indicator of regional cardiovascular care quality.

Limitations

Ecological study design precludes establishing causality or individual-level relationships.
Potential residual confounding by unmeasured regional factors such as healthcare accessibility and socioeconomic conditions.
Cardiometabolic risk prevalences from health checkups may not fully reflect underlying risk burden due to incomplete participation.
Absence of kidney-related adjustment (eGFR) in the primary models.
Testing intensity was defined using all-age prefecture-level O/E ratios rather than being restricted to adults aged 40-74 years.
Outpatient diagnostic test counts did not include 12-lead ECGs performed as part of health checkups or screening programs.
Presumed cardiac origin classification does not confirm the underlying cause and may include non-cardiac medical causes.
Causal interpretation is not possible

Implication

Regional diagnostic testing intensity may correlate with CO-OHCA rates; leaves open causality and need for prospective confirmation.

Abstract

Background: Cardiac-origin out-of-hospital cardiac arrest (CO-OHCA) remains a public health challenge, and variations in its incidence may reflect differences in cardiovascular care. We investigated whether the intensity of regional outpatient cardiovascular diagnostic testing was associated with the CO-OHCA incidence among adults aged 40–74 years in Japan. Methods and Results: This prefecture-level ecological study (2014–2023) used the All-Japan Utstein Registry and National Database Open Data. The outcome was the age- and sex-standardized incidence ratio (SIR) of CO-OHCA. The intensity of outpatient 12-lead electrocardiography (ECG) testing was quantified as an observed/expected ratio. Among 248,633 patients, higher 12-lead ECG testing intensity was significantly associated with lower SIR after adjusting for calendar year and cardiometabolic risk factors (rate ratio [RR] 0.95 per 0.1-unit increase; 95% confidence interval [CI] 0.93–0.98; P<0.001). Conversely, higher obesity prevalence was associated with higher SIR (RR 1.35 per 10-percentage-point increase; 95% CI 1.16–1.57; P<0.001). No significant associations were seen for transthoracic echocardiography and B-type natriuretic peptide/N-terminal pro B-type natriuretic peptide testing. Conclusions: In this nationwide ecological study, higher prefecture-level 12-lead ECG testing intensity was associated with lower CO-OHCA SIR among adults aged 40–74 years. Although causal interpretation is not possible, 12-lead ECG testing intensity may represent a prefecture-level indicator of regional outpatient cardiovascular care and offer a useful perspective for understanding geographic variations in CO-OHCA burden.

Discussion

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Cite This Study

Sato et al. (2026) conducted an observational in Cardiac-origin out-of-hospital cardiac arrest (CO-OHCA) (n=248,633). Regional intensity of outpatient 12-lead ECG testing vs. Lower regional testing intensity was evaluated on Age- and sex-standardized incidence ratio (SIR) of CO-OHCA (RR 0.95, 95% CI 0.93-0.98, p=<0.001). Higher prefecture-level outpatient 12-lead ECG testing intensity was significantly associated with a lower standardized incidence ratio of cardiac-origin out-of-hospital cardiac arrest (RR 0.95).

synapsesocial.com/papers/6a3f6b81aea7db3c19540a85 https://doi.org/10.1253/circrep.cr-26-0152

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Regional Intensity of Outpatient Cardiovascular Testing and Cardiac-Origin Out-of-Hospital Cardiac Arrest　― A 10-Year Nationwide Ecological Study Using the All-Japan Utstein Registry ―

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Regional Intensity of Outpatient Cardiovascular Testing and Cardiac-Origin Out-of-Hospital Cardiac Arrest　― A 10-Year Nationwide Ecological Study Using the All-Japan Utstein Registry ―

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Keep reading

Keep reading

Regional Intensity of Outpatient Cardiovascular Testing and Cardiac-Origin Out-of-Hospital Cardiac Arrest ― A 10-Year Nationwide Ecological Study Using the All-Japan Utstein Registry ―

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Regional Intensity of Outpatient Cardiovascular Testing and Cardiac-Origin Out-of-Hospital Cardiac Arrest ― A 10-Year Nationwide Ecological Study Using the All-Japan Utstein Registry ―

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Keep reading

Keep reading

Regional Intensity of Outpatient Cardiovascular Testing and Cardiac-Origin Out-of-Hospital Cardiac Arrest　― A 10-Year Nationwide Ecological Study Using the All-Japan Utstein Registry ―

Regional Intensity of Outpatient Cardiovascular Testing and Cardiac-Origin Out-of-Hospital Cardiac Arrest　― A 10-Year Nationwide Ecological Study Using the All-Japan Utstein Registry ―