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Ortega-Paz L, Mehran R, Angiolillo DJ. North American perspective on the 2023 European Society of Cardiology guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:165-172. [PMID: 38092517 DOI: 10.1093/ehjacc/zuad153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 12/08/2023] [Indexed: 02/10/2024]
Affiliation(s)
- Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NewYork, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, 655 West 8th Street, Jacksonville, FL 32209, USA
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2
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Tamis-Holland JE, Menon V, Johnson NJ, Kern KB, Lemor A, Mason PJ, Rodgers M, Serrao GW, Yannopoulos D. Cardiac Catheterization Laboratory Management of the Comatose Adult Patient With an Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e274-e295. [PMID: 38112086 DOI: 10.1161/cir.0000000000001199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Out-of-hospital cardiac arrest is a leading cause of death, accounting for ≈50% of all cardiovascular deaths. The prognosis of such individuals is poor, with <10% surviving to hospital discharge. Survival with a favorable neurologic outcome is highest among individuals who present with a witnessed shockable rhythm, received bystander cardiopulmonary resuscitation, achieve return of spontaneous circulation within 15 minutes of arrest, and have evidence of ST-segment elevation on initial ECG after return of spontaneous circulation. The cardiac catheterization laboratory plays an important role in the coordinated Chain of Survival for patients with out-of-hospital cardiac arrest. The catheterization laboratory can be used to provide diagnostic, therapeutic, and resuscitative support after sudden cardiac arrest from many different cardiac causes, but it has a unique importance in the treatment of cardiac arrest resulting from underlying coronary artery disease. Over the past few years, numerous trials have clarified the role of the cardiac catheterization laboratory in the management of resuscitated patients or those with ongoing cardiac arrest. This scientific statement provides an update on the contemporary approach to managing resuscitated patients or those with ongoing cardiac arrest.
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3
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Smith D, Kenigsberg BB. Management of Patients After Cardiac Arrest. Crit Care Clin 2024; 40:57-72. [PMID: 37973357 DOI: 10.1016/j.ccc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Cardiac arrest remains a significant cause of morbidity and mortality, although contemporary care now enables potential survival with good neurologic outcome. The core acute management goals for survivors of cardiac arrest are to provide organ support, sustain adequate hemodynamics, and evaluate the underlying cause of the cardiac arrest. In this article, the authors review the current state of knowledge and clinical intensive care unit practice recommendations for patients after cardiac arrest, particularly focusing on important areas of uncertainty, such as targeted temperature management, neuroprognostication, coronary evaluation, and hemodynamic targets.
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Affiliation(s)
- Damien Smith
- Department of Medicine, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA
| | - Benjamin B Kenigsberg
- Department of Critical Care, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA; Division of Cardiology, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA.
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4
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Rab T. DRACULA-A mnemonic for unfavorable resuscitation features in cardiac arrest patients. Catheter Cardiovasc Interv 2023; 102:917-918. [PMID: 37698379 DOI: 10.1002/ccd.30835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 08/31/2023] [Indexed: 09/13/2023]
Affiliation(s)
- Tanveer Rab
- Interventional Cardiology, Cardiac Catheterization Laboratory, Emory Decatur Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
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5
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Aldous R, Roy R, Cannata A, Abdrazak M, Mohanan S, Beckley-Hoelscher N, Stahl D, Kanyal R, Kordis P, Sunderland N, Parczewska A, Kirresh A, Nevett J, Fothergill R, Webb I, Dworakowski R, Melikian N, Kalra S, Johnson TW, Sinagra G, Rakar S, Noc M, Patel S, Auzinger G, Gruchala M, Shah AM, Byrne J, MacCarthy P, Pareek N. MIRACLE 2 Score Compared With Downtime and Current Selection Criterion for Invasive Cardiovascular Therapies After OHCA. JACC Cardiovasc Interv 2023; 16:2439-2450. [PMID: 37609699 DOI: 10.1016/j.jcin.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND The MIRACLE2 score is the only risk score that does not incorporate and can be used for selection of therapies after out-of-hospital cardiac arrest (OHCA). OBJECTIVES This study sought to compare the discrimination performance of the MIRACLE2 score, downtime, and current randomized controlled trial (RCT) recruitment criteria in predicting poor neurologic outcome after out-of-hospital cardiac arrest (OHCA). METHODS We used the EUCAR (European Cardiac Arrest Registry), a retrospective cohort from 6 centers (May 2012-September 2022). The primary outcome was poor neurologic outcome on hospital discharge (cerebral performance category 3-5). RESULTS A total of 1,259 patients (total downtime = 25 minutes; IQR: 15-36 minutes) were included in the study. Poor outcome occurred in 41.8% with downtime <30 minutes and in 79.3% for those with downtime >30 minutes. In a multivariable logistic regression analysis, MIRACLE2 had a stronger association with outcome (OR: 2.23; 95% CI: 1.98-2.51; P < 0.0001) than zero flow (OR: 1.07; 95% CI: 1.01-1.13; P = 0.013), low flow (OR: 1.04; 95% CI: 0.99-1.09; P = 0.054), and total downtime (OR: 0.99; 95% CI: 0.95-1.03; P = 0.52). MIRACLE2 had substantially superior discrimination for the primary endpoint (AUC: 0.877; 95% CI: 0.854-0.897) than zero flow (AUC: 0.610; 95% CI: 0.577-0.642), low flow (AUC: 0.725; 95% CI: 0.695-0.754), and total downtime (AUC: 0.732; 95% CI: 0.701-0.760). For those modeled for exclusion from study recruitment, the positive predictive value of MIRACLE2 ≥5 for poor outcome was significantly higher (0.92) than the CULPRIT-SHOCK (Culprit lesion only PCI Versus Multivessel PCI in Cardiogenic Shock) (0.80), EUROSHOCK (Testing the value of Novel Strategy and Its Cost Efficacy In Order to Improve the Poor Outcomes in Cardiogenic Shock) (0.74) and ECLS-SHOCK (Extra-corporeal life support in Cardiogenic shock) criteria (0.81) (P < 0.001). CONCLUSIONS The MIRACLE2 score has superior prediction of outcome after OHCA than downtime and higher discrimination of poor outcome than the current RCT recruitment criteria. The potential for the MIRACLE2 score to improve the selection of OHCA patients should be evaluated formally in future RCTs.
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Affiliation(s)
- Robert Aldous
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Roman Roy
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Antonio Cannata
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Muhamad Abdrazak
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Shamika Mohanan
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | - Daniel Stahl
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Ritesh Kanyal
- School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Peter Kordis
- Centre for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
| | - Nicholas Sunderland
- Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | | | - Ali Kirresh
- Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Joanne Nevett
- London Ambulance Service NHS Trust, London, United Kingdom
| | | | - Ian Webb
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Rafal Dworakowski
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Narbeh Melikian
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Sundeep Kalra
- Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Thomas W Johnson
- Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | | | - Serena Rakar
- Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Marko Noc
- Centre for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
| | - Sameer Patel
- Faculty of Life Science and Medicine, King's College London, London, United Kingdom
| | - Georg Auzinger
- Faculty of Life Science and Medicine, King's College London, London, United Kingdom
| | - Marcin Gruchala
- Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Ajay M Shah
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Jonathan Byrne
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Philip MacCarthy
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Nilesh Pareek
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom.
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6
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Bhat AG, Verghese D, Harsha Patlolla S, Truesdell AG, Batchelor WB, Henry TD, Cubeddu RJ, Budoff M, Bui Q, Matthew Belford P, X Zhao D, Vallabhajosyula S. In-Hospital cardiac arrest complicating ST-elevation myocardial Infarction: Temporal trends and outcomes based on management strategy. Resuscitation 2023; 186:109747. [PMID: 36822461 DOI: 10.1016/j.resuscitation.2023.109747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND There are limited data on the relationship of ST-segment-elevation myocardial infarction (STEMI) management strategy and in-hospital cardiac arrest (IHCA). AIMS To investigate the trends and outcomes of IHCA in STEMI by management strategy. METHODS Adult with STEMI complicated by IHCA from the National Inpatient Sample (2000-2017) were stratified into early percutaneous coronary intervention (PCI) (day 0 of hospitalization), delayed PCI (PCI ≥ day 1), or medical management (no PCI). Coronary artery bypass surgery was excluded. Outcomes of interest included in-hospital mortality, adverse events, length of stay, and hospitalization costs. RESULTS Of 3,967,711 STEMI admissions, IHCA was noted in 102,424 (2.6%) with an increase in incidence during this study period. Medically managed STEMI had higher rates of IHCA (3.6% vs 2.0% vs 1.3%, p < 0.001) compared to early and delayed PCI, respectively. Revascularization was associated with lower rates of IHCA (early PCI: adjusted odds ratio [aOR] 0.44 [95% confidence interval (CI) 0.43-0.44], p < 0.001; delayed PCI aOR 0.33 [95% CI 0.32-0.33], p < 0.001) compared to medical management. Non-revascularized patients had higher rates of non-shockable rhythms (62% vs 35% and 42.6%), but lower rates of multiorgan damage (44% vs 52.7% and 55.6%), cardiogenic shock (28% vs 65% and 57.4%) compared to early and delayed PCI, respectively (all p < 0.001). In-hospital mortality was lower with early PCI (49%, aOR 0.18, 95% CI 0.17-0.18), and delayed PCI (50.9%, aOR 0.18, 95% CI 0.17-0.19) (p < 0.001) compared to medical management (82.5%). CONCLUSION Early PCI in STEMI impacts the natural history of IHCA including timing and type of IHCA.
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Affiliation(s)
- Anusha G Bhat
- Division of Cardiovascular Medicine, Department of Medicine, University of Maryland, Baltimore, MD, USA
| | - Dhiran Verghese
- Division of Cardiovascular Medicine, Department of Medicine, Naples Heart Institute, Naples, FL, USA
| | | | - Alexander G Truesdell
- Virginia Heart, Falls Church, VA, USA; Inova Heart and Vascular Institute, Falls Church, VA, USA
| | | | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, USA
| | - Robert J Cubeddu
- Division of Cardiovascular Medicine, Department of Medicine, Naples Heart Institute, Naples, FL, USA
| | - Matthew Budoff
- Division of Cardiovascular Medicine, Department of Medicine, Harbor UCLA Medical Center, Torrance, CA, USA
| | - Quang Bui
- Division of Cardiovascular Medicine, Department of Medicine, Harbor UCLA Medical Center, Torrance, CA, USA
| | - Peter Matthew Belford
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - David X Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
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7
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Gottula AL, Shaw CR, Gorder KL, Lane BH, Latessa J, Qi M, Koshoffer A, Al-Araji R, Young W, Bonomo J, Langabeer JR, Yannopoulos D, Henry TD, Hsu CH, Benoit JL. Eligibility of out-of-hospital cardiac arrest patients for extracorporeal cardiopulmonary resuscitation in the United States: A geographic information system model. Resuscitation 2022; 180:111-120. [PMID: 36183812 DOI: 10.1016/j.resuscitation.2022.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/10/2022] [Accepted: 09/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recent evidence suggest that extracorporeal cardiopulmonary resuscitation (ECPR) may improve survival rates for nontraumatic out-of-hospital cardiac arrest (OHCA). Eligibility criteria for ECPR are often based on patient age, clinical variables, and facility capabilities. Expanding access to ECPR across the U.S. requires a better understanding of how these factors interact with transport time to ECPR centers. METHODS We constructed a Geographic Information System (GIS) model to estimate the number of ECPR candidates in the U.S. We utilized a Resuscitation Outcome Consortium (ROC) database to model time-dependent rates of ECPR eligibility and the Cardiac Arrest Registry to Enhance Survival (CARES) registry to determine the total number of OHCA patients who meet pre-specified ECPR criteria within designated transportation times. The combined model was used to estimate the total number of ECPR candidates. RESULTS There were 588,203 OHCA patients in the CARES registry from 2013 to 2020. After applying clinical eligibility criteria, 22,104 (3.76%) OHCA patients were deemed eligible for ECPR. The rate of ROSC increased with longer resuscitation time, which resulted in fewer ECPR candidates. The proportion of OHCA patients eligible for ECPR increased with older age cutoffs. Only 1.68% (9,889/588,203) of OHCA patients in the U.S. were eligible for ECPR based on a 45-minute transportation time to an ECMO-ready center model. CONCLUSIONS Less than 2% of OHCA patients are eligible for ECPR in the U.S. GIS models can identify the impact of clinical criteria, transportation time, and hospital capabilities on ECPR eligibility to inform future implementation strategies.
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Affiliation(s)
- Adam L Gottula
- Department of Emergency Medicine, University of Michigan, United States; Department of Anesthesiology, University of Michigan, United States; Max Harry Weil Institute for Critical Care Research and Innovation, United States.
| | - Christopher R Shaw
- Department of Medicine Division of Pulmonary and Critical Care, Oregon Health and Science University, United States
| | - Kari L Gorder
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, United States.
| | - Bennett H Lane
- Department of Emergency Medicine, University of Cincinnati, United States.
| | - Jennifer Latessa
- Department of Planning, The University of Cincinnati, United States.
| | - Man Qi
- Department of Geography and Geographic Information System, The University of Cincinnati, United States.
| | - Amy Koshoffer
- University of Cincinnati Libraries, The University of Cincinnati, United States.
| | - Rabab Al-Araji
- Department of Emergency Medicine, Emory University, United States; The Cardiac Arrest Registry to Enhance Survival, United States.
| | - Wesley Young
- College of Medicine, The University of Cincinnati, United States
| | - Jordan Bonomo
- Department of Emergency Medicine, University of Cincinnati, United States; Department of Neurosurgery, University of Cincinnati, United States.
| | - James R Langabeer
- Department of Emergency, Medicine McGovern School of Medicine, The University of Texas Health Center, United States; UT School of Public Health, The University of Texas Health Center, United States; School of Biomedical Informatics, The University of Texas Health Center, United States.
| | | | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, United States.
| | - Cindy H Hsu
- Department of Emergency Medicine, University of Michigan, United States; Max Harry Weil Institute for Critical Care Research and Innovation, United States; Department of Surgery, University of Michigan, United States.
| | - Justin L Benoit
- Department of Emergency Medicine, University of Cincinnati, United States.
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8
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Rashid M, Kinnaird T, Ludman P, Keeble TR, Mamas M, Curzen N. Variation in practice for out-of-hospital cardiac arrest treated with percutaneous coronary intervention in England and Wales. Catheter Cardiovasc Interv 2022; 100:306-316. [PMID: 35766046 DOI: 10.1002/ccd.30316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/05/2022] [Accepted: 06/04/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES We assessed the association between total center volume, operator volume, and out-of-hospital cardiac arrest (OHCA) percutaneous coronary intervention (PCI) volume. BACKGROUND Variations between OHCA PCI volume, hospital total PCI, and primary PCI volume are not well studied and are unlikely to be clinically justifiable. METHODS Patients undergoing PCI for the acute coronary syndrome (ACS) between January 1, 2014, and March 31, 2019, in England and Wales were grouped as OHCA PCI and non-OHCA PCI. Spearman's correlation was used to determine the degree of correlation between each hospital PCI volume and OHCA PCI volume. RESULTS Out of 250,088 PCI procedures undertaken for ACS, 12,016 (4.8%) were performed for OHCA, and 238,072 (95.2%) were non-OHCA PCI procedures. The OHCA PCI group were younger [mean age (SD) 63.2 (12.3) and 65.6 (12.5, p < 0.001)], less likely to be female (20.2% vs. 26.9%, p < 0.001) or Black, Asian, and Minority Ethnicity (11.5% vs. 14.8%, p < 0.001) compared to the non-OHCA PCI group. Although there was a degree of correlation between total PCI and OHCA PCI, there was wide variation for both ACS cohort (Spearman correlation R2 = 0.50) and total PCI volume (Spearman correlation R2 = 0.60). Furthermore, the correlation between primary PCI volume and OHCA PCI within centers was weak (R2 = 0.10). Similarly, wide variations between operator PCI volume and OHCA PCI volume were observed. CONCLUSION These national data demonstrate wide variation in the practice of OHCA PCI both between centers and individuals. These variations are not expected according to clinical factors and require further investigation.
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Affiliation(s)
- Muhammad Rashid
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK.,Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke on Trent, UK
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Peter Ludman
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, Edgbaston, Birmingham, UK
| | - Thomas R Keeble
- Essex Cardiothoracic Centre, MSE, Basildon, UK.,MTRC, Anglia Ruskin School of Medicine, Chelmsford, UK
| | - Mamas Mamas
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK.,Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke on Trent, UK
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, Southampton, UK.,Department of Cardiology, University Hospital NHS Trust, Southampton, UK
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9
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Wa MELK, Silva KD, Pareek N, Perera D. Coronary Revascularization and Out-of-hospital Cardiac Arrest: Past, Present and Future. Heart Int 2021; 15:94-102. [PMID: 36277833 PMCID: PMC9524604 DOI: 10.17925/hi.2021.15.2.94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/24/2021] [Indexed: 03/07/2024] Open
Abstract
Cardiologists and the cardiac catheter laboratory have key roles to play in the management of patients after out-of-hospital cardiac arrest (OHCA). Although immediate catheter laboratory activation is the standard of care in cardiogenic shock and ST elevation myocardial infarction, the majority of patients will present without these features and with an uncertain diagnosis. Even in the latter, early assessment and invasive management may be beneficial, but this is counterbalanced by significant resource utilization, potential to cause harm and the possibility that any diagnostic or therapeutic gains are offset by a poor neurological outcome. Past consensus on the management of the OHCA patient without ST elevation or cardiogenic shock is being challenged by emerging results from new trials in this field. Further randomized trials are ongoing, and are expected to deliver robust data from over 4,000 patients, allowing us to further refine the optimal management strategy in this challenging cohort. This article describes the benefits and pitfalls of a strategy of immediate coronary angiography in these patients, examines the recently published COACT and TOMAHAWK trials in detail, and describes a framework with which to approach the patient after resuscitated OHCA, based on the available evidence to date.
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Affiliation(s)
- Matthew E Li Kam Wa
- Cardiovascular Division, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College London, London, UK
| | - Kalpa De Silva
- Cardiovascular Division, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College London, London, UK
| | - Nilesh Pareek
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College London, London, UK
- King’s College Hospital, King’s College Hospital NHS Foundation Trust, London, UK
| | - Divaka Perera
- Cardiovascular Division, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College London, London, UK
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10
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Yeo JW, Ng ZHC, Goh AXC, Gao JF, Liu N, Lam SWS, Chia YW, Perkins GD, Ong MEH, Ho AFW. Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 11:e023806. [PMID: 34927456 PMCID: PMC9075197 DOI: 10.1161/jaha.121.023806] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background The role of cardiac arrest centers (CACs) in out‐of‐hospital cardiac arrest care systems is continuously evolving. Interpretation of existing literature is limited by heterogeneity in CAC characteristics and types of patients transported to CACs. This study assesses the impact of CACs on survival in out‐of‐hospital cardiac arrest according to varying definitions of CAC and prespecified subgroups. Methods and Results Electronic databases were searched from inception to March 9, 2021 for relevant studies. Centers were considered CACs if self‐declared by study authors and capable of relevant interventions. Main outcomes were survival and neurologically favorable survival at hospital discharge or 30 days. Meta‐analyses were performed for adjusted odds ratio (aOR) and crude odds ratios. Thirty‐six studies were analyzed. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR, 1.85 [95% CI, 1.52–2.26]), even when including high‐volume centers (aOR, 1.50 [95% CI, 1.18–1.91]) or including improved‐care centers (aOR, 2.13 [95% CI, 1.75–2.59]) as CACs. Survival significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59–2.32]), even when including high‐volume centers (aOR, 1.74 [95% CI, 1.38–2.18]) or when including improved‐care centers (aOR, 1.97 [95% CI, 1.71–2.26]) as CACs. The treatment effect was more pronounced among patients with shockable rhythm (P=0.006) and without prehospital return of spontaneous circulation (P=0.005). Conclusions were robust to sensitivity analyses, with no publication bias detected. Conclusions Care at CACs was associated with improved survival and neurological outcomes for patients with nontraumatic out‐of‐hospital cardiac arrest regardless of varying CAC definitions. Patients with shockable rhythms and those without prehospital return of spontaneous circulation benefited more from CACs. Evidence for bypassing hospitals or interhospital transfer remains inconclusive.
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Affiliation(s)
- Jun Wei Yeo
- Yong Loo Lin School of Medicine National University of Singapore Singapore
| | - Zi Hui Celeste Ng
- Yong Loo Lin School of Medicine National University of Singapore Singapore
| | | | | | - Nan Liu
- Centre for Quantitative Medicine Duke-NUS Medical SchoolNational University of Singapore Singapore
| | - Shao Wei Sean Lam
- Health Services Research Centre SingHealth Duke-NUS Academic Medical Centre Singapore
| | - Yew Woon Chia
- Department of Cardiology Tan Tock Seng Hospital Singapore
| | - Gavin D Perkins
- Warwick Medical School University of Warwick Coventry United Kingdom
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine Singapore General Hospital Singapore.,Health Services & Systems Research Duke-NUS Medical School Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine Singapore General Hospital Singapore.,Pre-Hospital and Emergency Research Centre Health Services and Systems Research Duke-NUS Medical School Singapore
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11
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Jacobs AK, Ali MJ, Best PJ, Bieniarz MC, Bufalino VJ, French WJ, Henry TD, Hollowell L, Jauch EC, Kurz MC, Levy M, Patel P, Spier T, Stone RH, Tataris KL, Thomas RJ, Zègre-Hemsey JK. Systems of Care for ST-Segment-Elevation Myocardial Infarction: A Policy Statement From the American Heart Association. Circulation 2021; 144:e310-e327. [PMID: 34641735 DOI: 10.1161/cir.0000000000001025] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The introduction of Mission: Lifeline significantly increased timely access to percutaneous coronary intervention for patients with ST-segment-elevation myocardial infarction (STEMI). In the years since, morbidity and mortality rates have declined, and research has led to significant developments that have broadened our concept of the STEMI system of care. However, significant barriers and opportunities remain. From community education to 9-1-1 activation and emergency medical services triage and from emergency department and interfacility transfer protocols to postacute care, each critical juncture presents unique challenges for the optimal care of patients with STEMI. This policy statement sets forth recommendations for how the ideal STEMI system of care should be designed and implemented to ensure that patients with STEMI receive the best evidence-based care at each stage in their illness.
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Atreya AR, Patlolla SH, Devireddy CM, Jaber WA, Rab ST, Nicholson WJ, Douglas JS, King SB, Vallabhajosyula S. Geographic variation and temporal trends in management and outcomes of cardiac arrest complicating acute myocardial infarction in the United States. Resuscitation 2021; 170:339-348. [PMID: 34767902 DOI: 10.1016/j.resuscitation.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/21/2021] [Accepted: 11/01/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Limited studies have evaluated regional disparities in the care of acute myocardial infarction (AMI) patients with cardiac arrest (CA). This study sought to evaluate 18-year national trends, resource utilization, and geographical variation in outcomes in AMI-CA admissions. METHODS AND RESULTS Using the National Inpatient Sample (2000-2017), we identified adults with AMI and concomitant CA admitted to the United States census regions of Northeast, Midwest, South, and West. Clinical outcomes of interest included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), hospitalization costs and length of stay. Of 9,680,257 admissions for AMI, 494,083 (5.1%) had concomitant CA. The West (6.0%) had higher prevalence compared to the Northeast (4.4%), Midwest (5.0%), and South (5.1%), p < 0.001. Admissions in the West had higher rates of STEMI, cardiogenic shock, multiorgan failure, mechanical ventilation, and hemodialysis. Northeast admissions had lower use of coronary angiography (52.0% vs. 67.9% vs. 60.9% vs. 61.5%), PCI (38.7% vs. 51.9% vs. 44.8% vs. 46.7%), and MCS (18.4% vs. 21.8% vs. 18.1%, vs. 20.0%) compared to the Midwest, West and South (all p < 0.001). Compared with the Northeast, adjusted in-hospital mortality was higher in the Midwest (odds ratio [OR] 1.06 [95% confidence interval {CI} 1.03-1.08]), South (OR 1.11 [95% CI 1.09-1.13]) and highest in the West (OR 1.16 [95% CI 1.13-1.18]), all p < 0.001. Temporal trends showed a decline in in-hospital mortality except in the West, which showed a slight increase. CONCLUSIONS There remain significant regional disparities in the management and outcomes of AMI-CA.
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Affiliation(s)
- Auras R Atreya
- Institute of Cardiac Sciences and Research, AIG Hospitals, Hyderabad, India
| | - Sri Harsha Patlolla
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Chandan M Devireddy
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Wissam A Jaber
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - S Tanveer Rab
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - William J Nicholson
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - John S Douglas
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Spencer B King
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States; Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, United States.
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Yildiz M, Wade SR, Henry TD. STEMI care 2021: Addressing the knowledge gaps. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 11:100044. [PMID: 34664037 PMCID: PMC8515361 DOI: 10.1016/j.ahjo.2021.100044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/27/2022]
Abstract
Tremendous progress has been made in the treatment of ST-segment elevation myocardial infarction (STEMI), the most severe and time-sensitive acute coronary syndrome. Primary percutaneous coronary intervention (PCI) is the preferred method of reperfusion, which has stimulated the development of regional STEMI systems of care with standardized protocols designed to optimize care. However, challenges remain for patients with cardiogenic shock, out-of-hospital cardiac arrest, an expected delay to reperfusion (>120 min), in-hospital STEMI, and more recently, those with Covid-19 infection. Ultimately, the goal is to provide timely reperfusion with primary PCI coupled with the optimal antiplatelet and anticoagulant therapies. We review the challenges and provide insights into the remaining knowledge gaps for contemporary STEMI care.
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Key Words
- CCL, cardiac catheterization laboratory
- CS, cardiogenic shock
- Cangrelor
- Cardiogenic shock
- Covid-19
- Covid-19, coronavirus disease 2019
- DAPT, dual antiplatelet therapy
- EMS, emergency medical service
- MCS, mechanical circulatory support
- OHCA, out-of-hospital cardiac arrest
- Out-of-hospital cardiac arrest
- PCI, percutaneous coronary intervention
- Regional systems
- SARS-CoV-2, severe acute respiratory syndrome coronavirus-2
- ST-segment elevation myocardial infarction
- STEMI, ST-segment elevation myocardial infarction
- TH, therapeutic hypothermia
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Affiliation(s)
- Mehmet Yildiz
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, United States of America
| | - Spencer R. Wade
- Department of Internal Medicine at The Christ Hospital, Cincinnati, OH, United States of America
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, United States of America,Corresponding author at: The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital Health Network, 2123 Auburn Avenue Suite 424, Cincinnati, OH 45219, United States of America
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14
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van Diepen S, Henry TD. Risk stratifying patients with out-of-hospital cardiac arrest: The case for dynamic predictions models. Catheter Cardiovasc Interv 2021; 97:235-236. [PMID: 33587800 DOI: 10.1002/ccd.29476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 01/10/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Edmonton, Alberta
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital Health Network, Cincinnati, Ohio
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15
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Vedamurthy D, Singh S, Subedi K, Garratt KN, Wimmer NJ. Outcomes With Early Cardiac Catheterization in Out of Hospital Cardiac Arrest Survivors and Utility of a Prognostic Scoring System. Cureus 2021; 13:e16775. [PMID: 34345571 PMCID: PMC8325397 DOI: 10.7759/cureus.16775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2021] [Indexed: 01/23/2023] Open
Abstract
Objectives A retrospective study in patients presenting out of hospital cardiac arrest (OHCA) to assess the impact of early cardiac catheterization on survival and cerebral performance category (CPC) on discharge. Background The role of early coronary angiography in OHCA patients remains controversial. The cardiac arrest hospital prognosis (CAHP) scoring system has not been validated in the US population. Methods Inclusion criteria were OHCA patients with a sustained return of spontaneous circulation (ROSC), presumed cardiac cause of arrest, and elements to calculate CAHP score. We compared in-hospital mortality rates and final inpatient CPC in patients who underwent early cardiac catheterization to those with delayed or no cardiac catheterization. We assessed the performance of the CAHP score in the entire OHCA population using receiver-operator curve (ROC) analysis. Results A hundred and fifty-eight patients were included, of which 39 underwent early cardiac catheterization. The mortality rate of the early catheterization group was lower than the delayed or no catheterization group (41% vs 61.3%, p=0.02); the Early cardiac catheterization group had more favorable final hospital CPC scores overall (53.8% vs 24.3%, p<0.001). However, when risk-adjusted, there was no benefit in early catheterization for mortality or CPC level in any of the CAHP score subgroups. CAHP scores showed good discrimination with c-statistics of 0.85 for mortality and 0.90 for the CPC category. Conclusion Early use of cardiac catheterization in OHCA patients with sustained ROSC was not associated with lower mortality rates or higher rates of favorable neurologic recovery when adjusted for baseline risk factors in each of the different CAHP score-based sub-groups. This was despite a higher proportion of patients with STEMI in the early catheterization group. We demonstrated a good fit between observed outcomes and outcomes predicted by the CAHP scoring system.
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Affiliation(s)
| | - Shilpa Singh
- Internal Medicine, Christiana Care Health System, Newark, USA
| | - Keshab Subedi
- Biostatistics, Christiana Care Health System, Newark, USA
| | | | - Neil J Wimmer
- Cardiology, Christiana Care Health System, Newark, USA
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16
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Angelini P, Muthupillai R, Lopez A, Cheong B, Uribe C, Hernandez E, Coulter S, Perin E, Molossi S, Gentile F, Flamm S, Lorenz G, D'Ascenzi F, Tobis J, Sarnari R, Corno A, Furgerson J, Chiribiri A, Villa ADM, Orzan F, Brugada P, Jefferies J, Aubry P, Towbin J, Thiene G, Tomanek R. Young athletes: Preventing sudden death by adopting a modern screening approach? A critical review and the opening of a debate. IJC HEART & VASCULATURE 2021; 34:100790. [PMID: 34124338 PMCID: PMC8175289 DOI: 10.1016/j.ijcha.2021.100790] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/07/2021] [Accepted: 04/23/2021] [Indexed: 10/29/2022]
Abstract
Preventing sudden cardiac death (SCD) in athletes is a primary duty of sports cardiologists. Current recommendations for detecting high-risk cardiovascular conditions (hr-CVCs) are history and physical examination (H&P)-based. We discuss the effectiveness of H&P-based screening versus more-modern and accurate methods. In this position paper, we review current authoritative statements and suggest a novel alternative: screening MRI (s-MRI), supported by evidence from a preliminary population-based study (completed in 2018), and a prospective, controlled study in military recruits (in development). We present: 1. Literature-Based Comparisons (for diagnosing hr-CVCs): Two recent studies using traditional methods to identify hr-CVCs in >3,000 young athletes are compared with our s-MRI-based study of 5,169 adolescents. 2. Critical Review of Previous Results: The reported incidence of SCD in athletes is presently based on retrospective, observational, and incomplete studies. H&P's screening value seems minimal for structural heart disease, versus echocardiography (which improves diagnosis for high-risk cardiomyopathies) and s-MRI (which also identifies high-risk coronary artery anomalies). Electrocardiography is valuable in screening for potentially high-risk electrophysiological anomalies. 3. Proposed Project : We propose a prospective, controlled study (2 comparable large cohorts: one historical, one prospective) to compare: (1) diagnostic accuracy and resulting mortality-prevention performance of traditional screening methods versus questionnaire/electrocardiography/s-MRI, during 2-month periods of intense, structured exercise (in military recruits, in advanced state of preparation); (2) global costs and cost/efficiency between these two methods. This study should contribute significantly toward a comprehensive understanding of the incidence and causes of exercise-related mortality (including establishing a definition of hr-CVCs) while aiming to reduce mortality.
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Affiliation(s)
- Paolo Angelini
- Department of Cardiology, Texas Heart Institute, Houston, TX, USA
| | - Raja Muthupillai
- Department of Radiology, University of Houston, Houston, TX, USA
| | - Alberto Lopez
- Electrophysiology Laboratory, Department of Cardiology, Texas Heart Institute, Houston, TX, USA
| | - Benjamin Cheong
- Department of Radiology, Texas Heart Institute, Houston, TX, USA
| | - Carlo Uribe
- Department of Cardiology, Texas Heart Institute, Houston, TX, USA
| | | | | | - Emerson Perin
- Department of Cardiology, Texas Heart Institute, Houston, TX, USA
| | - Silvana Molossi
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States
| | | | - Scott Flamm
- Department of Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Giovanni Lorenz
- Department of Radiology, Wilford Hall Ambulatory Center, San Antonio Military Health System, Joint Base San Antonio, San Antonio, TX, USA
| | | | - Jonathan Tobis
- Department of Cardiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Roberto Sarnari
- Department of Radiology, Northwestern University, Chicago, IL, USA
| | - Antonio Corno
- Department of Congenital Cardiac Surgery, Children's Memorial Hermann Hospital, UTHealth, Houston, TX, USA
| | - James Furgerson
- Department of Cardio-Radiology, US Air Force Lackland Hospital, San Antonio, TX, USA
| | - Amedeo Chiribiri
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom
| | - Adriana D M Villa
- Department of Radiology, St. Thomas Hospital, King's College London, United Kingdom
| | - Fulvio Orzan
- Division of Cardiology, Department of Medical Sciences, University of Turin, Italy
| | - Pedro Brugada
- Cardiovascular Division, Free University of Brussels (UZ Brussel) VUB, Brussels, Belgium
| | - John Jefferies
- The Cardiac Institute, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Pierre Aubry
- Department of Cardiology, Bichat Hospital, Paris, France
| | - Jeffrey Towbin
- Division of Adult Cardiovascular Diseases, Methodist University of Tennessee Cardiovascular Institute and Department of Preventive Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Gaetano Thiene
- Department of Pathologic Anatomy, University of Padua, Italy
| | - Robert Tomanek
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, IA, USA
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17
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Kashef MA, Lotfi AS. Evidence-Based Approach to Out-of-Hospital Cardiac Arrest. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021; 23:43. [PMID: 33994773 PMCID: PMC8107417 DOI: 10.1007/s11936-021-00924-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2021] [Indexed: 12/13/2022]
Abstract
Purpose of review Out-of-hospital cardiac arrest (OHCA) is a leading cause of death. Despite improvements in the cardiac disease management, OHCA outcomes remain poor. The purpose of this review is to provide information on the management of OHCA survivors, evidence-based treatments, and current gaps in the knowledge. Recent findings Most common cause of death from OHCA is neurological injury followed by shock and multiorgan failure. Prognostication tools are available to help with the clinical decision-making. Taking measures to improve EMS response time, encouraging bystander CPR, early defibrillation, and targeted temperature management are shown to improve survival. Early activation of cardiac catheterization lab for coronary angiography, hemodynamic assessment, and mechanical circulatory support should be considered in patients with shockable rhythm and presumed cardiac cause, those with ST elevation, ongoing ischemia, or evidence of hemodynamic and electrical instability. Randomized controlled trials are lacking in this field and benefits of interventions should be weighed against risk of pursuing a futile treatment. COVID-19 pandemic has added new challenges to the care of OHCA patients. Summary Clinical decision-making to care for OHCA patients is challenging. There is a need for trials to provide evidence-based knowledge on the care of OHCA patients. Supplementary Information The online version contains supplementary material available at 10.1007/s11936-021-00924-3.
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Affiliation(s)
| | - Amir S Lotfi
- Division of Cardiology, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199 USA
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18
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Henry TD, Tomey MI, Tamis-Holland JE, Thiele H, Rao SV, Menon V, Klein DG, Naka Y, Piña IL, Kapur NK, Dangas GD. Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e815-e829. [DOI: 10.1161/cir.0000000000000959] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cardiogenic shock (CS) remains the most common cause of mortality in patients with acute myocardial infarction. The SHOCK trial (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) demonstrated a survival benefit with early revascularization in patients with CS complicating acute myocardial infarction (AMICS) 20 years ago. After an initial improvement in mortality related to revascularization, mortality rates have plateaued. A recent Society of Coronary Angiography and Interventions classification scheme was developed to address the wide range of CS presentations. In addition, a recent scientific statement from the American Heart Association recommended the development of CS centers using standardized protocols for diagnosis and management of CS, including mechanical circulatory support devices (MCS). A number of CS programs have implemented various protocols for treating patients with AMICS, including the use of MCS, and have published promising results using such protocols. Despite this, practice patterns in the cardiac catheterization laboratory vary across health systems, and there are inconsistencies in the use or timing of MCS for AMICS. Furthermore, mortality benefit from MCS devices in AMICS has yet to be established in randomized clinical trials. In this article, we outline the best practices for the contemporary interventional management of AMICS, including coronary revascularization, the use of MCS, and special considerations such as the treatment of patients with AMICS with cardiac arrest.
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Gaisendrees C, Vollmer M, Walter SG, Djordjevic I, Eghbalzadeh K, Kaya S, Elderia A, Ivanov B, Gerfer S, Kuhn E, Sabashnikov A, Kahlert HA, Deppe AC, Kröner A, Mader N, Wahlers T. Management of out-of hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation in 2021. Expert Rev Med Devices 2021; 18:179-188. [PMID: 33538204 DOI: 10.1080/17434440.2021.1886076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Over the last decade, eCPR programs have become more and more popular, at least amongst high-volume centers. Despite its rise in popularity and promising outcome, strategies concerning pre- and post-implantation of VA-ECMO remain at least debatable. Besides, integrating the appropriate set-up, managing anticoagulation, implementing LV-venting, and predicting neurological outcome play important roles in caring for thise highly selective patient-collective. We sought to present our institutional´s techniques for establishing an eCPR program and managing patients peri- and post implantation in eCPR-runs. AREAS COVERED This manuscript covers the majority of clinical concerns and parameters for establishing an eCPR program and its recent advantages. We will describe a safe way of cannulation, setting anticoagulation goals, strategies for LV-venting and ICU-treatment. Also included, an elaboration on neurological and cardiac prognostication. EXPERT OPINION We advocate ultrasound-guided cannula placement in eCPR patients. Also, we emphasize the importance of using stiffer wires and smaller arterial cannula sizes due to the different physiological parameters of OHCA patients. After cannulation, we aim for lower flow goals, the concept of 'partial VA-ECMO,' and lower anticoagulatory targets. LV-venting with Impella should remain an individual case to case decision.
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Affiliation(s)
- Christopher Gaisendrees
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Matias Vollmer
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Sebastian G Walter
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Süreyya Kaya
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Ahmed Elderia
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Heike A Kahlert
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Antje C Deppe
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Axel Kröner
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
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Khan AJ, Jan Liao C, Kabir C, Hallak O, Samee M, Potts S, Klein LW. Etiology and Determinants of In-Hospital Survival in Patients Resuscitated After Out-of-Hospital Cardiac Arrest in an Urban Medical Center. Am J Cardiol 2020; 130:78-84. [PMID: 32674809 DOI: 10.1016/j.amjcard.2020.06.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/01/2020] [Accepted: 06/05/2020] [Indexed: 12/13/2022]
Abstract
Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality globally. The goals of this study were to describe common causes of OHCA in an urban US medical center, identify predictive factors for survival, and to assess whether neurological status upon return of spontaneous circulation might be predictive of outcomes: 124 consecutive patients aged 18 years and older with OHCA admitted at Advocate Illinois Masonic Medical Center were studied. All patients resuscitated in the field with return of spontaneous circulation then transferred to the emergency department were included. The Glasgow Coma Score (GCS) was evaluated immediately on hospital arrival. In the total group, 34% (42 of 124) were discharged alive. In patients with coronary artery disease (CAD), 51% (20 of 39) were discharged alive versus 26% (22 of 85) of non-CAD patients (p <0.01). Initial GCS ≥ 9 was highly predictive of survival: 94% (34 of 36) of patients with GCS ≥ 9 survived versus 9% (8 of 88) with GCS ≤ 8 (p <0.0001). Defibrillation in the field was predictive of survival (chi-square = 7.81, p = 0.005). In the CAD group, all 16 patients with GCS ≥ 9 on presentation to the Emergency Department survived whereas all 13 with GCS ≤ 5 died (both p <0.0001). In the non-CAD group, 18 of 20 patients with GCS ≥ 9 survived, whereas only 2 of 52 with GCS ≤ 5 survived (both p <0.0001). Multivariate analysis by logistic regression showed that the strongest predictor of survival in the non-CAD subgroup was GCS (OR 0.27, CI 0.19 to 0.55, p <0.001). In conclusion, the etiology of the OHCA, immediate neurologic status, and defibrillation in the field (suggesting presenting arrhythmia) were predictive of survival. Immediate neurological recovery (GCS ≥ 9) regardless of etiology was a strong predictor of survival to discharge. Additional predictive factors depend on the etiology of the OHCA event. These data suggest that these straightforward factors can be helpful in predicting outcome in patients resuscitated after OHCA.
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21
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Out-of-Hospital Cardiac Arrest and Acute Coronary Syndrome Hospitalizations During the COVID-19 Surge. J Am Coll Cardiol 2020; 76:1271-1273. [PMID: 32679154 PMCID: PMC7833304 DOI: 10.1016/j.jacc.2020.07.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/24/2020] [Accepted: 07/10/2020] [Indexed: 12/11/2022]
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