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Deb S, Drennan IR, Turner L, Cheskes S. Association of coronary angiography with ST-elevation and no ST-elevation in patients with refractory ventricular fibrillation - A substudy of the DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE-VF randomized control trial). Resuscitation 2024; 198:110163. [PMID: 38447909 DOI: 10.1016/j.resuscitation.2024.110163] [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] [Received: 12/19/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Refractory ventricular fibrillation or pulseless ventricular tachycardia (rVF/pVT) during out-of-hospital cardiac arrest (OHCA) is associated with poor survival. Double sequential defibrillation (DSED) and vector change (VC) improved survival for rVF/pVT in the DOSE-VF RCT. However, the role of angiography and percutaneous coronary intervention (angiography/PCI) during the trial is unknown. OBJECTIVES To determine the incidence of ST-elevation (STE) and no ST-elevation (NO-STE) on post-arrest ECG and the use of angiography/PCI in patients with rVF/pVT during the DOSE-VF RCT. METHOD Adults (≥18-years) with rVF/pVT OHCA randomized in the DOSE-VF RCT who survived to hospital admission were included. The primary analysis compared the proportion of angiography in STE and NO-STE. We performed regression modelling to examine association between STE, the interaction with defibrillation strategy, and survival to discharge controlling for known covariates. RESULTS We included 151 patients, 74 (49%) with STE and 77 (51%) with NO-STE. The proportion of angiography was higher in the STE cohort than NO-STE (87.8% vs 44.2%, p < 0.001); similarly the proportion of PCI was also higher (75.7% vs 9.1%, p < 0.001). Survival to discharge was similar between STE and NO-STE (63.5% vs 51.9%, p = 0.15). Use of angiography/PCI did not differ between defibrillation strategies. Decreased age (OR 0.95, 95% CI 0.92-0.98; p = 0.001) and angiography (OR 9.33, 95% CI 3.60-26.94; p < 0.001) were predictors of survival; however, STE was not. CONCLUSION We found high rates of angiography/PCI in patients with STE compared to NO-STE, however similar rates of survival. Angiography was an independent predictor of survival. Improved rates of survival employing DSED and VC were independent of angiography/PCI.
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Affiliation(s)
- Saswata Deb
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Sunnybrook Research Institute, Toronto, Canada.
| | - Ian R Drennan
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Sunnybrook Research Institute, Toronto, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Sunnybrook Centre for Prehospital Medicine, Toronto, Canada.
| | - Linda Turner
- Sunnybrook Centre for Prehospital Medicine, Toronto, Canada.
| | - Sheldon Cheskes
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Sunnybrook Centre for Prehospital Medicine, Toronto, Canada.
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Darabi F, Tan NS, Allan KS, Lin S, Angaran P, Dorian P. ICD Implantation Rates in Cardiac Arrest Survivors in Canada. CJC Open 2024; 6:699-707. [PMID: 38846442 PMCID: PMC11150952 DOI: 10.1016/j.cjco.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/12/2023] [Indexed: 06/09/2024] Open
Abstract
Background Patients resuscitated from out-of-hospital cardiac arrest (OHCA) are at high risk of recurrence, posing a substantial burden on healthcare systems. Despite the established benefit of implantable cardioverter defibrillator (ICD) therapy in many such patients, and recommendations by guidelines, few studies have described the proportion of OHCA patients who receive guideline-concordant care. Methods The Canadian Institute for Health Information Discharge Abstract Database dataset was used to identify OHCA patients admitted to hospitals across Canada, excluding Quebec. We analyzed all patients without a probable ischemic or bradycardia etiology of cardiac arrest, who survived to discharge, to estimate the ICD implantation rates in patients who were potentially eligible to have an ICD. Results Between 2013 and 2017, a total of 10,435 OHCA patients who were admitted to the hospital were captured in the database; 4486 (43%) survived to hospital discharge, and 2580 survivors (57.5%) were potentially eligible to receive an ICD. Among these potentially eligible patients, 757 (29.3%) received an ICD during their index admission or within 30 days after discharge from the hospital. The ICD implantation rate during index admission increased from 13.8% in 2013 to 19.6% in 2017 (P-value for time trend < 0.05). The rate of ICD implantations in potentially eligible patients was higher in urban than in rural settings (19.5% vs 11.1%) and in teaching vs community hospitals (34.7% vs 9.8%). Conclusions Although ICD implantation rates show an increasing trend among patients with OHCA who are likely eligible for secondary prevention, significant underutilization of ICDs persists in these patients.
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Affiliation(s)
- Farzad Darabi
- Division of Cardiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nigel S. Tan
- Division of Cardiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Katherine S. Allan
- Division of Cardiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Steve Lin
- Division of Cardiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul Angaran
- Division of Cardiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul Dorian
- Division of Cardiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Abdulmajeed F, Hamandi M, Malaiyandi D, Shutter L. Neurocritical Care in the General Intensive Care Unit. Crit Care Clin 2023; 39:153-169. [DOI: 10.1016/j.ccc.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Utilization of Non-Gated Chest Computed Tomography Scans in Predicting Acute Coronary Occlusion in Out-of-Hospital Cardiac Arrest. Curr Probl Cardiol 2022; 47:101276. [PMID: 35667497 DOI: 10.1016/j.cpcardiol.2022.101276] [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: 05/26/2022] [Accepted: 05/30/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Coronary artery disease is thought to be responsible for up to 60-80% of out-of-hospital cardiac arrests. The utility of Computed Tomography (CT) chest when it comes to identifying acute coronary occlusion in patients following an arrest has not been studied. We aim to we evaluate whether myocardial perfusion on a contrast-enhanced chest CT performed for a non-cardiac cause can predict culprit coronary occlusion as the cause of cardiac arrest, and if the absence of a perfusion defect can exclude an ischemic etiology. METHODS A retrospective cohort of 53 consecutive patients presenting with VT or VF arrest and successful resuscitation who had contrast chest CT before angiography. CT scans were reviewed for myocardial perfusion defects by a cardiologist and radiologist blinded to angiogram findings. CT results were then compared with angiograms. RESULTS On coronary angiography, 22(42%) of the patients presenting with out-of-hospital arrest had critical stenosis. Sensitivity and specificity of perfusion defect on CT in identifying critical stenosis on catheterization was 0.45, 95% CI [0.24, 0.68] and 0.77, 95% CI [59%, 90%], respectively. The positive likelihood ratio being 2.01 (0.91,4.46) and the negative likelihood ratio being 0.70 (0.46,1.08). The diagnostic accuracy was 64.2%. CONCLUSIONS Our study did not show much utility for the use of myocardial perfusion defect on an incidental pre-angiography contrast chest CT to predict acute thrombotic occlusion in out-of-hospital cardiac arrest patients. However, this shouldn't discourage further studies evaluating the utility of contrast-enhanced CT-images in predicting acute coronary occlusion.
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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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Coronary angiography in patients after cardiac arrest without ST-elevation myocardial infarction : A retrospective cohort analysis. Wien Klin Wochenschr 2021; 133:762-769. [PMID: 34191110 PMCID: PMC8373755 DOI: 10.1007/s00508-021-01899-8] [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] [Received: 11/04/2020] [Accepted: 05/23/2021] [Indexed: 11/29/2022]
Abstract
Background Coronary artery disease (CAD) is the most common cause of sudden cardiac arrest (SCA). Although coronary angiography (CAG) should be performed also in the absence of ST-elevation (STE) after sustained return of spontaneous circulation (ROSC), this recommendation is not well implemented in daily routine. Methods A retrospective database analysis was conducted in a tertiary care center between January 2005 and December 2014. We included all SCA patients aged ≥ 18 years with presumed cardiac cause and sustained ROSC in the absence of STE at hospital admission. The rate and timing of CAG were defined as the primary endpoints. As secondary endpoints, the reasons pro and contra CAG were analyzed. Furthermore, we observed if the signs and symptoms used for decision making occurred more often in patients with treatable CAD. Results We included 645 (53.6%) of the 1203 screened patients, CAG was performed in 343 (53.2%) patients with a diagnosis of occlusive CAD in 214 (62.4%) patients. Of these, 151 (71.0%) patients had occlusive CAD treated with coronary intervention, thrombus aspiration, or coronary artery bypass grafting. In an adjusted binomial logistic regression analysis, age ≥ 70 years, female sex, non-shockable rhythms, and cardiomyopathy were associated with withholding of CAG. In patients diagnosed and treated with occlusive CAD, initially shockable rhythms, previously diagnosed CAD, hypertension, and smoking were found more often. Conclusion Although selection bias is unavoidable due to the retrospective design of this study, a high proportion of the examined patients had occlusive CAD. The criteria used for patient selection may be suboptimal.
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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Garcheva V, Akin M, Adel J, Sanchez Martinez C, Bauersachs J, Schäfer A. High rate of critical coronary stenosis in comatose patients with Non-ST-elevation out-of-hospital cardiac arrest (NSTE-OHCA) undergoing therapeutic hypothermia-Experience from the HAnnover COoling REgistry (HACORE). PLoS One 2021; 16:e0251178. [PMID: 33945587 PMCID: PMC8096113 DOI: 10.1371/journal.pone.0251178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/22/2021] [Indexed: 11/30/2022] Open
Abstract
Background Myocardial infarction is the most frequent cause for out-of-hospital cardiac arrest (OHCA) in adults. Patients with ST-segment elevations (STE) following return of spontaneous circulation (ROSC) are regularly admitted to the catheterisation laboratory for urgent coronary angiography. Whether patients without obvious STE (NSTE) should receive coronary angiography as part of a standardised diagnostic work-up following OHCA is still debated. Methods We analysed a cohort of 517 subsequent OHCA patients admitted at our institution who received a standardised diagnostic work-up including coronary angiography and therapeutic hypothermia. Patients were 63±14 years old, 76% were male. Overall, 180 (35%) had ST-elevation in the post-ROSC ECG, 317 (61%) had shockable rhythm (ventricular fibrillation or tachycardia) at first ECG. ROSC was achieved after 26±21 minutes. Results Critical coronary stenosis requiring PCI was present in 83% of shockable and 87% of non-shockable STE-OHCA and in 48% of shockable and 22% of non-shockable NSTE-OHCA patients. In-hospital survival was 61% in shockable and 55% in non-shockable STE-OHCA and 60% in shockable and 28% in non-shockable NSTE-OHCA. Conclusion Standardised admission diagnostics in OHCA patients undergoing therapeutic hypothermia with a strict admission protocol incorporating ECG and coronary catheterisation shows a high rate of relevant coronary stenosis in STE-OHCA irrespective of the initial rhythm and in NSTE-OHCA with initial shockable rhythm. Based on the unfavourable outcome and low PCI rate observed in NSTE-OHCA patients with a primary non-shockable ECG rhythm it might be reasonable to restrict routine early coronary angiography to patients with primary shockable rhythms and/or ST-segment elevations after ROSC.
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Affiliation(s)
- Vera Garcheva
- Department of Cardiology and Angiology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Muharrem Akin
- Department of Cardiology and Angiology, Medizinische Hochschule Hannover, Hannover, Germany
| | - John Adel
- Department of Cardiology and Angiology, Medizinische Hochschule Hannover, Hannover, Germany
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Medizinische Hochschule Hannover, Hannover, Germany
- * E-mail:
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 280] [Impact Index Per Article: 93.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Song H, Kim HJ, Park KN, Kim SH, Kim WY, Lee BK, Cho IS, Lee JH, Youn CS. Which Out-of-Hospital Cardiac Arrest Patients without ST-Segment Elevation Benefit from Early Coronary Angiography? Results from the Korean Hypothermia Network Prospective Registry. J Clin Med 2021; 10:jcm10030439. [PMID: 33498728 PMCID: PMC7865270 DOI: 10.3390/jcm10030439] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/11/2021] [Accepted: 01/20/2021] [Indexed: 11/16/2022] Open
Abstract
The effect of early coronary angiography (CAG) in out-of-hospital cardiac arrest (OHCA) patients without ST-elevation (STE) is still controversial. It is not known which subgroups of patients without STE are the most likely to benefit. The objective of this study was to evaluate the association between emergency CAG and neurologic outcomes and identify subgroups with improved outcomes when emergency CAG was performed. This prospective, multicenter, observational cohort study was based on data from the Korean Hypothermia Network prospective registry (KORHN-PRO) 1.0. Adult OHCA patients who were treated with targeted temperature management (TTM) without any obvious extracardiac cause were included. Patients were dichotomized into early CAG (≤24 h) and no early CAG (>24 h or not performed) groups. High-risk patients were defined as having the Global Registry of Acute Coronary Events (GRACE) score > 140, time from collapse to return of spontaneous circulation (ROSC) > 30 min, lactate level > 7.0 mmol/L, arterial pH < 7.2, cardiac enzyme elevation and ST deviation. The primary outcome was good neurologic outcome at 6 months after OHCA. Of the 1373 patients from the KORHN-PRO 1.0 database, 678 patients met the inclusion criteria. The early CAG group showed better neurologic outcomes at 6 months after cardiac arrest (CA) (adjusted odds ratio: 2.21 (1.27-3.87), p = 0.005). This was maintained even after propensity score matching (adjusted odds ratio: 2.23 (1.39-3.58), p < 0.001). In the subgroup analysis, high-risk patients showed a greater benefit from early CAG. In contrast, no significant association was found in low-risk patients. Early CAG was associated with good neurologic outcome at 6 months after CA and should be considered in high-risk patients.
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Affiliation(s)
- Hwan Song
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.S.); (H.J.K.); (K.N.P.)
| | - Hyo Joon Kim
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.S.); (H.J.K.); (K.N.P.)
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.S.); (H.J.K.); (K.N.P.)
| | - Soo Hyun Kim
- Department of Emergency Medicine, Eunpyeong St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, Korea;
| | - Won Young Kim
- Asan Medical Center, Department of Emergency Medicine, Ulsan University College of Medicine, Seoul 05505, Korea;
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju 61469, Korea;
| | - In Soo Cho
- Department of Emergency Medicine, Hanil General Hospital, Korea Electric Power Medical Corporation, Seoul 01450, Korea;
| | - Jae Hoon Lee
- Department of Emergency Medicine, Dong-A University College of Medicine, Busan 49201, Korea;
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.S.); (H.J.K.); (K.N.P.)
- Correspondence: ; Tel.: +82-2-2258-1988; Fax: +82-2-2258-1997
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Kim DK, Cho YS, Kim J, Lee BK, Lee DH, Jung E, Moon JM, Chun BJ. Is two-dimensional echocardiography better than electrocardiography for predicting patient outcomes after cardiac arrest? Acute Crit Care 2020; 36:37-45. [PMID: 33342200 PMCID: PMC7940108 DOI: 10.4266/acc.2020.00773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/04/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Coronary artery stenosis increases hospital mortality and leads to poor neurological recovery in cardiac arrest (CA) patients. However, electrocardiography (ECG) cannot fully predict the presence of coronary artery stenosis in CA patients. Hence, we aimed to determine whether regional wall motion abnormality (RWMA), as observed by two-dimensional echocardiography (2DE), predicted patient survival outcomes with greater accuracy than did ST segment elevation (STE) on ECG in CA patients who underwent coronary angiography (CAG) after return of spontaneous circulation. METHODS This was a retrospective observational study of adult patients with CA of presumed cardiac etiology who underwent CAG at a single tertiary care hospital. We investigated whether RWMA observed on 2DE predicted patient outcomes more accurately than did STE observed on ECG. The primary outcome was incidence of hospital mortality. The secondary outcomes were Glasgow-Pittsburgh Cerebral Performance Category scores measured 6 months after discharge and significant coronary artery stenosis on CAG. RESULTS Among the 145 patients, 36 (24.8%) experienced in-hospital death. In multivariable analysis of survival outcomes, only total arrest time (P=0.011) and STE (P=0.035) were significant. The odds ratio (OR) and 95% confidence interval (CI), which were obtained by adjusting the total arrest time for survival outcomes, were significant only for STE (OR, 0.40; 95% CI, 0.17-0.94). The presence of RWMA was not a significant factor. CONCLUSIONS While STE predicted survival outcomes in adult CA patients, RWMA did not. The decision to perform CAG after CA should include ECG under existing guidelines. The use of RWMA has limited benefits in treatment of this population.
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Affiliation(s)
- Dong Ki Kim
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yong Soo Cho
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Joochan Kim
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Eujene Jung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Jeong Mi Moon
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Byeong Jo Chun
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
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12
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Yang MC, Meng-Jun W, Xiao-Yan X, Peng KL, Peng YG, Wang RR. Coronary angiography or not after cardiac arrest without ST segment elevation: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e22197. [PMID: 33031262 PMCID: PMC7544299 DOI: 10.1097/md.0000000000022197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE This meta-analysis aimed to review the available evidence and evaluate the necessity of immediate coronary angiography (CAG) to obtain positive outcomes for out-of-hospital cardiac arrest (OHCA) patients without ST segment elevation. DATA SOURCES Web of Science, PubMed, Embase, Chinese National Knowledge Infrastructure, Wanfang, and SinoMed databases. STUDY SELECTION We included observational and case-control studies of outcomes among individuals without ST segment elevation experiencing OHCA who had immediate, delayed, or no CAG. DATA EXTRACTION We extracted study details, as well as patient characteristics and outcomes. DATA SYNTHESIS Six studies (n = 2665) investigating mortality until discharge demonstrated a significant increase in survival benefit with early CAG (odds ratio [OR] = 1.78; 95%CI = 1.51-2.11; I = 81%; P < .0001). Seven studies (n = 2909) showed a significant preservation of neurological functions with early CAG at discharge (OR = 1.66; 95%CI = 1.37-2.02; P < .00001). Four studies (n = 1357) investigating survival outcomes with middle-term follow-up revealed no significant benefit with early CAG (OR = 1.21; 95%CI = 0.93-1.57; I = 66%; P = .15). CONCLUSIONS Our meta-analysis demonstrates that there may be significant benefits in performing immediate CAG on patients who experience OHCA without ST segment elevation.
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Affiliation(s)
- Meng-Chang Yang
- Department of Anesthesiology, West China Hospital, Sichuan University
- Department of Anesthesiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital
| | - Wu Meng-Jun
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's and Children's Central Hospital, Chengdu, Sichuan, P.R. China
| | - Xu Xiao-Yan
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's and Children's Central Hospital, Chengdu, Sichuan, P.R. China
| | | | - Yong G. Peng
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Ru-Rong Wang
- Department of Anesthesiology, West China Hospital, Sichuan University
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13
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Carr C, Hardy J, Scharf B, Levy M. Emergency Clinician Experiences Using a Standardized Communication Tool for Cardiac Arrest. Cureus 2020; 12:e9759. [PMID: 32944473 PMCID: PMC7489792 DOI: 10.7759/cureus.9759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction Sudden cardiac arrest remains a common and critical disease burden. As post-cardiac arrest care grows in complexity, communication between pre-hospital providers, emergency department personnel, and hospital consultants is increasingly important. Methods This study evaluated the use of a standard handoff tool between pre-hospital personnel and hospital staff, including emergency medical services (EMS), emergency department nurses, physicians, and cardiologists. Personnel were surveyed regarding attitudes surrounding the important aspects of cardiac arrest care, challenges faced, and preference of handoff mechanism. Results Most of the survey respondents (58, 76%) found that the initial rhythm was the most important factor in post-cardiac arrest care, followed by the presence of bystander cardiopulmonary resuscitation (CPR; 55, 72%) and the presence of ST-elevation on initial electrocardiogram (46, 61%). Both emergency physicians (7, 63%), as well as cardiologists (3, 100%), preferred to have this tool performed over radio prior to arrival in the emergency department. Conclusion The importance given to various post-cardiac arrest factors varied amongst specialty and clinical background; however, all agreed on common features such as the initial rhythm, electrocardiogram (ECG) morphology, and the presence or absence of bystander CPR. Additionally, the timing and structure of how this information is delivered were further elucidated. This data will guide future handoff methods between specialties managing patients after cardiac arrest.
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Affiliation(s)
- Casey Carr
- Department of Emergency Medicine, University of Florida - Shands, Gainesville, USA
| | - Joshua Hardy
- School of Medicine, Georgetown University, District of Columbia, USA
| | - Becca Scharf
- Department of Fire and Rescue Services, Howard County Department of Fire and Rescue Services, Marriottsville, USA
| | - Matthew Levy
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.,Office of the Medical Director, Howard County Department of Fire and Rescue Services, Marriottsville, USA
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14
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Spoormans EM, Lemkes JS, Janssens GN, van der Hoeven NW, Bonnes JL, van Royen N. The role of coronary angiography in out-of-hospital cardiac arrest patients in the absence of ST-segment elevation: A literature review. Neth Heart J 2020; 28:108-114. [PMID: 32780340 PMCID: PMC7419423 DOI: 10.1007/s12471-020-01460-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) is a major cause of death. Although the aetiology of cardiac arrest can be diverse, the most common cause is ischaemic heart disease. Coronary angiography and percutaneous coronary intervention, if indicated, has been associated with improved long-term survival for patients with initial shockable rhythm. However, in patients without ST-segment elevation on the post-resuscitation electrocardiogram, the optimal timing of performing this invasive procedure is uncertain. One important challenge that clinicians face is to appropriately select patients that will benefit from immediate coronary angiography, yet avoid unnecessary delay of intensive care support and targeted temperature management. Observational studies have reported contradictory results and until recently, randomised trials were lacking. The Coronary Angiography after Cardiac Arrest without ST-segment elevation (COACT) was the first randomised trial that provided comparative information between coronary angiography treatment strategies. This literature review will provide the current knowledge and gaps in the literature regarding optimal care for patients successfully resuscitated from OHCA in the absence of ST-segment elevation and will primarily focus on the role and timing of coronary angiography in this high-risk patient population.
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Affiliation(s)
- E M Spoormans
- Department of Cardiology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - J S Lemkes
- Department of Cardiology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands.
| | - G N Janssens
- Department of Cardiology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - N W van der Hoeven
- Department of Cardiology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - J L Bonnes
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - N van Royen
- Department of Cardiology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
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15
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Jentzer JC, Herrmann J, Prasad A, Barsness GW, Bell MR. Utility and Challenges of an Early Invasive Strategy in Patients Resuscitated From Out-of-Hospital Cardiac Arrest. JACC Cardiovasc Interv 2020; 12:697-708. [PMID: 31000007 DOI: 10.1016/j.jcin.2019.01.245] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/09/2019] [Accepted: 01/15/2019] [Indexed: 12/16/2022]
Abstract
Out-of-hospital cardiac arrest (OHCA) is frequently triggered by acute myocardial ischemia. Coronary angiography is an important component of post-resuscitation care for patients with OHCA without an evident noncardiac cause, to identify underlying coronary artery disease and allow revascularization. Most patients undergoing coronary angiography after OHCA have obstructive coronary artery disease, and nearly one-half of patients have acute coronary occlusion. Early coronary angiography and percutaneous coronary intervention after OHCA have been associated with improved survival in observational studies, but these studies demonstrate selection bias, and randomized trials are lacking. Selection of patients for coronary angiography after OHCA can be challenging, particularly in comatose patients whose outcomes are driven primarily by anoxic brain injury. As for other patients with acute coronary syndromes, patients with ST-segment elevation after OHCA have a high probability of acute coronary occlusion warranting emergent coronary angiography. Patients with cardiogenic shock after OHCA are a high-risk population also requiring emergent coronary angiography. Among patients in stable condition after OHCA without ST-segment elevation, other clinical predictors can be used to identify those needing early coronary angiography to identify obstructive coronary artery disease. Despite the challenges with early neurological prognostication in comatose patients with OHCA, those with multiple objective markers of poor prognosis appear less likely to benefit from revascularization, and early coronary angiography may be reasonably deferred in appropriately selected patients meeting these criteria. The authors propose an algorithm to guide patient selection for coronary angiography after OHCA that combines clinical predictors of acute coronary occlusion and early clinical predictors of severe brain injury.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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16
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Matsuda J, Kato S, Yano H, Nitta G, Kono T, Ikenouchi T, Murata K, Kanoh M, Inamura Y, Takamiya T, Negi K, Sato A, Yamato T, Inaba O, Morita H, Matsumura Y, Nitta J, Yonetsu T. The Sequential Organ Failure Assessment (SOFA) score predicts mortality and neurological outcome in patients with post-cardiac arrest syndrome. J Cardiol 2020; 76:295-302. [PMID: 32305260 DOI: 10.1016/j.jjcc.2020.03.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/26/2020] [Accepted: 03/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients experiencing out-of-hospital cardiac arrest (OHCA) and subsequent post-cardiac arrest syndrome are often compromised by multi-organ failure. The Sequential Organ Failure Assessment (SOFA) score has been used to predict clinical outcome of patients requiring intensive care for multi-organ failure. Thus, the assessment of SOFA score is recommended as a criterion for sepsis. Although post-cardiac arrest patients frequently develop sepsis-like status in ICU, there are limited reports evaluating the SOFA score in post-cardiac arrest patients. We investigated the predictive value of the SOFA score in survival and neurological outcomes in patients with post-cardiac arrest syndrome. METHODS A total of 231 cardiovascular arrest patients achieving return of spontaneous circulation (ROSC) were finally extracted from the institutional consecutive database comprised of 1218 OHCA patients transferred to the institution between January 2015 and July 2018. The SOFA score was calculated on admission and after 48h. Predictors of survival and neurological outcome defined as having cerebral-performance-category (CPC) 1 or 2 at 30 days were determined. RESULTS SOFA score was lower in survived patients (5.0 vs 10.0, p<0.001) and those with favorable neurological outcome (5.0 vs 8.0, p<0.001) as compared with the counterparts. The SOFA score on admission was an independent predictor of survival (OR 0.68, 95% confidence interval [CI] 0.59-0.78; p<0.001) and favorable neurological performance (OR 0.79; 95% CI 0.69-0.90; p<0.001) at 30 days. Furthermore, a change in SOFA score (48-0h) was predictive of favorable 30-day neurological outcome (OR 0.71, 95% CI 0.60-0.85; p<0.001). CONCLUSIONS Evaluation of the SOFA score in the ICU is useful to predict survival and neurological outcome in post-cardiac arrest patients.
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Affiliation(s)
- Junji Matsuda
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan; Department of Cardiovascular Surgery, Japanese Red Cross Saitama Hospital, Saitama, Japan.
| | - Shunichi Kato
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Hirotaka Yano
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Giichi Nitta
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Toshikazu Kono
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Takashi Ikenouchi
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Kazuya Murata
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Miki Kanoh
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Yukihiro Inamura
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Tomomasa Takamiya
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Ken Negi
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Akira Sato
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Tsunehiro Yamato
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Osamu Inaba
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Hideki Morita
- Department of Cardiovascular Surgery, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Yutaka Matsumura
- Department of Cardiology, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Junichi Nitta
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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17
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Sonnier M, Rittenberger JC. State-of-the-art considerations in post-arrest care. J Am Coll Emerg Physicians Open 2020; 1:107-116. [PMID: 33000021 PMCID: PMC7493544 DOI: 10.1002/emp2.12022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 11/10/2022] Open
Abstract
Cardiac arrest has a high rate of morbidity and mortality. Several advances in post-cardiac arrest management can improve outcome, but are time-dependent, placing the emergency physician in a critical role to both recognize the need for and initiate therapy. We present a novel perspective of both the workup and therapeutic interventions geared toward the emergency physician during the first few hours of care. We describe how the immediate care of a post-cardiac arrest patient is resource intensive and requires simultaneous evaluation for the underlying cause and intensive management to prevent further end organ damage, particularly of the central nervous system. The goal of the initial focused assessment is to rapidly determine if any reversible causes of cardiac arrest are present and to intervene when possible. Interventions performed in this acute period are aimed at preventing additional brain injury through optimizing hemodynamics, providing ventilatory support, and by using therapeutic hypothermia when indicated. After the initial phase of care, disposition is guided by available resources and the clinician's judgment. Transfer to a specialized cardiac arrest center is prudent in centers that do not have significant support or experience in the care of these patients.
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Affiliation(s)
| | - Jon C. Rittenberger
- Guthrie Robert Packer HospitalSayrePennsylvania
- Geisinger Commonwealth Medical CollegeScrantonPennsylvania
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18
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Rosenberg RD, Guo CC, Chatterjee S, Schreyer KE, Bashir R, O'Murchu B, Aggarwal V, DeAngelis M, Edmundowicz D, O'Neill BP. The prognostic value of initial serum lactate for survival in postcardiac arrest patients undergoing cardiac catheterization. Catheter Cardiovasc Interv 2020; 97:228-234. [DOI: 10.1002/ccd.28836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/07/2020] [Accepted: 02/25/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Russell D. Rosenberg
- Division of Cardiology, Department of Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
| | - Chen‐Yu C. Guo
- Division of Cardiology, Department of Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
| | - Saurav Chatterjee
- Department of Cardiology, Saint Francis Hospital, Teaching Affiliate University of Connecticut School of Medicine Hartford USA
| | - Kraftin E. Schreyer
- Department of Emergency Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
| | - Riyaz Bashir
- Division of Cardiology, Department of Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
| | - Brian O'Murchu
- Division of Cardiology, Department of Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
| | - Vikas Aggarwal
- Division Cardiology, Department of Medicine University of Michigan School of Medicine Ann Arbor USA
| | - Michael DeAngelis
- Department of Emergency Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
| | - Daniel Edmundowicz
- Division of Cardiology, Department of Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
| | - Brian P. O'Neill
- Division of Cardiology, Department of Medicine Lewis Katz School of Medicine at Temple University Philadelphia USA
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19
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Coronary angiographic findings after cardiac arrest in relation to ECG and comorbidity. Resuscitation 2020; 146:213-219. [DOI: 10.1016/j.resuscitation.2019.09.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 08/15/2019] [Accepted: 09/16/2019] [Indexed: 11/22/2022]
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20
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Akin M, Sieweke JT, Zauner F, Garcheva V, Tongers J, Napp LC, Friedrich L, Treptau J, Bahntje MU, Flierl U, Sedding DG, Bauersachs J, Schäfer A. Mortality in Patients With Out-of-Hospital Cardiac Arrest Undergoing a Standardized Protocol Including Therapeutic Hypothermia and Routine Coronary Angiography: Experience From the HACORE Registry. JACC Cardiovasc Interv 2019; 11:1811-1820. [PMID: 30236353 DOI: 10.1016/j.jcin.2018.06.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 06/07/2018] [Accepted: 06/13/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES This study sought to analyze the impact of mandatory therapeutic hypothermia and cardiac catheterization in the absence of overt noncardiac cause of arrest as part of the Hannover Cardiac Resuscitation Algorithm before intensive care admission. BACKGROUND Despite advanced therapies, out-of-hospital cardiac arrest (OHCA) is still associated with high mortality rates. Recently, the TTM (Target Temperature Management 33°C Versus 36°C After Out-of-Hospital Cardiac Arrest)-trial caused severe uncertainty about the efficacy of and need for therapeutic hypothermia. Furthermore, the role of early coronary angiography in OHCA survivors without ST-segment elevation remains undetermined. METHODS In the HACORE (HAnnover Cooling REgistry) we investigated 233 consecutive patients (median age 64 [interquartile range: 53 to 74] years) with OHCA admitted to our institution between January 2011 and December 2015 who were treated according to the algorithm. RESULTS A total of 73% had ventricular fibrillation as primary rhythm. Return of spontaneous circulation was achieved after 20 (interquartile range: 10 to 30) min. Immediate percutaneous coronary angiography was performed in 96% and coronary angioplasty in 59% of all cases. ST-segment elevation was present in 47%. Critical coronary stenosis requiring percutaneous coronary intervention was present in 67% of patients with and 52% of patients without ST-segment elevation. Overall 30-day intrahospital mortality in this real-world registry was 37%. Patients in our local registry who matched the inclusion/exclusion criteria of the TTM-trial (n = 145) had a markedly lower 30-day mortality (27%) compared with the published trial (44%). CONCLUSIONS Standardized treatment of patients with OHCA following a strict protocol incorporating computed tomography, cardiac catheterization and revascularization, liberal use of active hemodynamic support in presence of shock, and mandatory therapeutic hypothermia results in mortality rates lower than previously reported.
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Affiliation(s)
- Muharrem Akin
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Jan-Thorben Sieweke
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Florian Zauner
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Vera Garcheva
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Jörn Tongers
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - L Christian Napp
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lars Friedrich
- Department of Anaesthesiology, Hannover Medical School, Hannover, Germany
| | - Jens Treptau
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Max-Udo Bahntje
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Ulrike Flierl
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Daniel G Sedding
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Johann Bauersachs
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Andreas Schäfer
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.
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21
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Lipe D, Giwa A, Caputo ND, Gupta N, Addison J, Cournoyer A. Do Out-of-Hospital Cardiac Arrest Patients Have Increased Chances of Survival When Transported to a Cardiac Resuscitation Center? J Am Heart Assoc 2019; 7:e011079. [PMID: 30482128 PMCID: PMC6405559 DOI: 10.1161/jaha.118.011079] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Patients suffering from an out‐of‐hospital cardiac arrest are often transported to the closest hospital. Although it has been suggested that these patients be transported to cardiac resuscitation centers, few jurisdictions have acted on this recommendation. To better evaluate the evidence on this subject, a systematic review and meta‐analysis of the currently available literature evaluating the association between the destination hospital's capability (cardiac resuscitation center or not) and resuscitation outcomes for adult patients suffering from an out‐of‐hospital cardiac arrest was performed. Methods and Results PubMed, EMBASE, and the Cochrane Library databases were first searched using a specifically designed search strategy. Both original randomized controlled trials and observational studies were considered for inclusion. Cardiac resuscitation centers were defined as having on‐site percutaneous coronary intervention and targeted temperature management capability at all times. The primary outcome measure was survival. Twelve nonrandomized observational studies were retained in this review. A total of 61 240 patients were included in the 10 studies that could be included in the meta‐analysis regarding the survival outcome. Being transported to a cardiac resuscitation center was associated with an increase in survival (odds ratio=1.95 [95% confidence interval 1.47‐2.59], P<0.001). Conclusions Adult patients suffering from an out‐of‐hospital cardiac arrest transported to cardiac resuscitation centers have better outcomes than their counterparts. When possible, it is reasonable to transport these patients directly to cardiac resuscitation centers (class IIa, level of evidence B, nonrandomized). Clinical Trial Registration URL: http://www.crd.york.ac.uk/PROSPERO/. Unique identifier: CRD42018086608.
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Affiliation(s)
- Demis Lipe
- 1 Department of Emergency Medicine MD Anderson Cancer Center Houston TX
| | - Al Giwa
- 2 Icahn School of Medicine at Mount Sinai New York NY.,3 Department of Emergency Medicine Mount Sinai Hospital New York NY
| | - Nicholas D Caputo
- 4 Department of Emergency Medicine Lincoln Medical Center New York NY
| | - Nachiketa Gupta
- 2 Icahn School of Medicine at Mount Sinai New York NY.,3 Department of Emergency Medicine Mount Sinai Hospital New York NY
| | | | - Alexis Cournoyer
- 6 Université de Montréal Montréal Québec Canada.,7 Department of Emergency Medicine Hôpital du Sacré-Cœur de Montréal Montréal Québec Canada.,8 Institut de Cardiologie de Montréal Montréal Québec Canada
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22
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Kim KH, Park JH, Ro YS, Shin SD, Song KJ, Hong KJ, Jeong J, Lee KW, Hong WP. Association Between Post-Resuscitation Coronary Angiography With and Without Intervention and Neurological Outcomes After Out-of-Hospital Cardiac Arrest. PREHOSP EMERG CARE 2019; 24:485-493. [DOI: 10.1080/10903127.2019.1668989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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23
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Harhash AA, Huang JJ, Howe CL, Hsu CH, Kern KB. Coronary angiography and percutaneous coronary intervention in cardiac arrest survivors with non-shockable rhythms and no STEMI: A systematic review. Resuscitation 2019; 143:106-113. [DOI: 10.1016/j.resuscitation.2019.08.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 08/08/2019] [Accepted: 08/15/2019] [Indexed: 12/20/2022]
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24
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Reardon PM, Hickey M, English SW, Hibbert B, Simard T, Hendin A, Yadav K. Optimizing the Early Resuscitation After Out-of-Hospital Cardiac Arrest. J Intensive Care Med 2019; 35:1556-1563. [PMID: 31512559 DOI: 10.1177/0885066619873318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Resuscitation after out-of-hospital cardiac arrest can be one of the most challenging scenarios in acute-care medicine. The devastating effects of postcardiac arrest syndrome carry a substantial morbidity and mortality that persist long after return of spontaneous circulation. Management of these patients requires the clinician to simultaneously address multiple emergent priorities including the resuscitation of the patient and the efficient diagnosis and management of the underlying etiology. This review provides a concise evidence-based overview of the core concepts involved in the early postcardiac arrest resuscitation. It will highlight the components of an effective management strategy including addressing hemodynamic, oxygenation, and ventilation goals as well as carefully considering cardiac catheterization and targeted temperature management. An organized approach is paramount to providing effective care to patients in this vulnerable time period.
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Affiliation(s)
- Peter M Reardon
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Hickey
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Shane W English
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, 6363University of Ottawa, Ottawa Ontario Canada
| | - Benjamin Hibbert
- Division of Cardiology, 27339University of Ottawa Heart Institute, Ottawa, Ontario, Canada.,Department of Cellular and Molecular Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Trevor Simard
- Division of Cardiology, 27339University of Ottawa Heart Institute, Ottawa, Ontario, Canada.,Department of Cellular and Molecular Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Ariel Hendin
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
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Direct or subacute coronary angiography in out-of-hospital cardiac arrest (DISCO)—An initial pilot-study of a randomized clinical trial. Resuscitation 2019; 139:253-261. [DOI: 10.1016/j.resuscitation.2019.04.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/08/2019] [Accepted: 04/15/2019] [Indexed: 02/08/2023]
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26
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Najarro G, Briggs K. Acute Myocardial Infarction, Cardiac Arrest, and Cardiac Shock in the Cardiac Care Unit. PHYSICIAN ASSISTANT CLINICS 2019. [DOI: 10.1016/j.cpha.2018.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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27
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Yannopoulos D, Bartos JA, Aufderheide TP, Callaway CW, Deo R, Garcia S, Halperin HR, Kern KB, Kudenchuk PJ, Neumar RW, Raveendran G. The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e530-e552. [DOI: 10.1161/cir.0000000000000630] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Coronary artery disease is prevalent in different causes of out-of-hospital cardiac arrest (OHCA), especially in individuals presenting with shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). The purpose of this report is to review the known prevalence and potential importance of coronary artery disease in patients with OHCA and to describe the emerging paradigm of treatment with advanced perfusion/reperfusion techniques and their potential benefits on the basis of available evidence. Although randomized clinical trials are planned or ongoing, current scientific evidence rests principally on observational case series with their potential confounding selection bias. Among patients resuscitated from VF/pVT OHCA with ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 70% to 85%. More than 90% of these patients have had successful percutaneous coronary intervention. Conversely, among patients resuscitated from VF/pVT OHCA without ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 25% to 50%. For these patients, early access to the cardiac catheterization laboratory is associated with a 10% to 15% absolute higher functionally favorable survival rate compared with more conservative approaches of late or no access to the cardiac catheterization laboratory. In patients with VF/pVT OHCA refractory to standard treatment, a new treatment paradigm is also emerging that uses venoarterial extracorporeal membrane oxygenation to facilitate return of normal perfusion and to support further resuscitation efforts, including coronary angiography and percutaneous coronary intervention. The burden of coronary artery disease is high in this patient population, presumably causative in most patients. The strategy of venoarterial extracorporeal membrane oxygenation, coronary angiography, and percutaneous coronary intervention has resulted in functionally favorable survival rates ranging from 9% to 45% in observational studies in this patient population. Patients with VF/pVT should be considered at the highest severity in the continuum of acute coronary syndromes. These patients have a significant burden of coronary artery disease and acute coronary thrombotic events. Evidence from randomized trials will further define optimal clinical practice.
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Kumar K, Lotun K. The Role of Coronary Catheterization Laboratory in Post-Resuscitation Care of Patients Without ST Elevation Myocardial Infarction. Curr Cardiol Rev 2018; 14:92-96. [PMID: 29737261 PMCID: PMC6088445 DOI: 10.2174/1573403x14666180507154107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/31/2018] [Accepted: 04/25/2018] [Indexed: 11/22/2022] Open
Abstract
Background: Out of hospital cardiac arrest management of patients with non-ST myocardial infarction per current American Heart Association and European Resuscitation Council guidelines leave the decision in regard to early angiography up to the physician operators. Guidelines are clear on the positive impact of early intervention on survival and improvement on left ventricular function in patients presenting with cardiac arrest and ST elevation myocardial infarction on electrocardiogram. This review aims to analyze the data that current guidelines are based upon in regards to out of hospital cardiac arrest with electrocardiogram findings of non-ST elevation myocardial infarction as well as review of other clinical trials that support early angiography and reperfusion strategies. Conclusion: Analysis of current literature shows that early coronary evaluation in patients with no finding of ST elevation on ECG can help improve survival in patients suffering out of hospital cardiac arrest.
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Affiliation(s)
- Kris Kumar
- Department of Internal Medicine, University of Arizona, Tucson, AZ, United States
| | - Kapil Lotun
- Division of Cardiology, University of Arizona, Tucson, AZ, United States
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Radsel P, Noc M. Immediate coronary angiography after cardiac arrest-Friend or foe? Resuscitation 2018; 132:A5-A6. [PMID: 30172692 DOI: 10.1016/j.resuscitation.2018.08.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 08/26/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Peter Radsel
- Department of Intensive Internal Medicine, University Medical Center Ljubljana, Zaloska 7, Ljubljana, Slovenia.
| | - Marko Noc
- Department of Intensive Internal Medicine, University Medical Center Ljubljana, Zaloska 7, Ljubljana, Slovenia
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Coronary angiography in out-of-hospital cardiac arrest without ST elevation on ECG-Short- and long-term survival. Am Heart J 2018; 200:90-95. [PMID: 29898854 DOI: 10.1016/j.ahj.2018.03.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 03/09/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND The potential benefit of early coronary angiography in out-of-hospital cardiac arrest (OHCA) patients without ST elevation on ECG is unclear. The aim of this study was to evaluate the association between early coronary angiography and survival in these patients. METHODS Nationwide observational study between 2008 and 2013. Included were patients admitted to hospital after witnessed OHCA, with shockable rhythm, age 18 to 80 years and unconscious. Patients with ST-elevation on ECG were excluded. Patients that underwent early CAG (within 24 hours) were compared with no early CAG (later during the hospital stay or not at all). Outcomes were survival at 30 days, 1 year, and 3 years. Multivariate analysis included pre-hospital factors, comorbidity and ECG-findings. RESULTS In total, 799 OHCA patients fulfilled the inclusion criteria, of which 275 (34%) received early CAG versus 524 (66%) with no early CAG. In the early CAG group, the proportion of patients with an occluded coronary artery was 27% and 70% had at least one significant coronary stenosis (defined as narrowing of coronary lumen diameter of ≥50%). The 30-day survival rate was 65% in early CAG group versus 52% with no early CAG (P < .001). The adjusted OR was 1.42 (95% CI 1.00-2.02). The one-year survival rate was 62% in the early CAG group versus 48% in the no early CAG group with the adjusted hazard ratio of 1.35 (95% CI 1.04-1.77). CONCLUSION In this population of bystander-witnessed cases of out-of-hospital cardiac arrest with shockable rhythm and ECG without ST elevation, early coronary angiography may be associated with improved short and long term survival.
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Wester A, Mohammad MA, Andell P, Rylance R, Dankiewicz J, Friberg H, James S, Omerovic E, Erlinge D, Koul S. Coronary angiographic findings and outcomes in patients with sudden cardiac arrest without ST-elevation myocardial infarction: A SWEDEHEART study. Resuscitation 2018; 126:172-178. [DOI: 10.1016/j.resuscitation.2018.01.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/16/2018] [Accepted: 01/29/2018] [Indexed: 01/23/2023]
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Cournoyer A, Notebaert É, de Montigny L, Ross D, Cossette S, Londei-Leduc L, Iseppon M, Lamarche Y, Sokoloff C, Potter BJ, Vadeboncoeur A, Larose D, Morris J, Daoust R, Chauny JM, Piette É, Paquet J, Cavayas YA, de Champlain F, Segal E, Albert M, Guertin MC, Denault A. Impact of the direct transfer to percutaneous coronary intervention-capable hospitals on survival to hospital discharge for patients with out-of-hospital cardiac arrest. Resuscitation 2018; 125:28-33. [DOI: 10.1016/j.resuscitation.2018.01.048] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/11/2018] [Accepted: 01/29/2018] [Indexed: 01/22/2023]
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Association between coronary angiography with or without percutaneous coronary intervention and outcomes after out-of-hospital cardiac arrest. Resuscitation 2018; 127:21-25. [PMID: 29549024 DOI: 10.1016/j.resuscitation.2018.03.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/12/2018] [Accepted: 03/12/2018] [Indexed: 11/21/2022]
Abstract
AIM The aim of our study was to assess the impact of coronary angiography (CAG) after out-of-hospital cardiac arrest (OHCA) without ST-elevation (STE). METHODS Prospective observational study of adult (age ≥ 18) OHCA of presumed cardiac etiology from 1/01/2010-12/31/2014 admitted to one of 40 recognized cardiac receiving centers within a statewide resuscitation network. RESULTS Among 11,976 cases, 1881 remained for analysis after exclusions. Of the 1230 non-STE cases, 524 (43%) underwent CAG with resultant PCI in 157 (30%). Survival in non-STE cases was: 56% in cases without CAG; 82% in cases with CAG but without PCI; and 78% in those with PCI (p < 0.0001). In cases without STE the aOR for survival with CAG alone was 2.34 (95% CI 1.69-3.24) and for CAG plus PCI was 1.98 (95% CI 1.26-3.09). The aOR for CPC 1/2 with CAG alone was 6.89 (95% CI 3.99-11.91) and for CAG plus PCI was 2.95 (95% CI 1.59-5.47). After propensity matching, CAG was associated with an aOR for survival of 2.10 (95% CI 1.30-3.55) and for CPC 1/2 it was 5.06 (95% CI 2.29-11.19). CONCLUSION In OHCA without STE, CAG was strongly and independently associated with survival regardless of whether PCI was performed. The association between CAG and positive outcomes remained after propensity matching.
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Abstract
The prognosis after out-of-hospital cardiac arrest (OHCA) has improved in the past few decades because of advances in interventions used outside and in hospital. About half of patients who have OHCA with initial ventricular tachycardia or ventricular fibrillation and who are admitted to hospital in coma after return of spontaneous circulation will survive to discharge with a reasonable neurological status. In this Series paper we discuss in-hospital management of patients with post-cardiac-arrest syndrome. In most patients, the most important in-hospital interventions other than routine intensive care are continuous active treatment (in non-comatose and comatose patients and including circulatory support in selected patients), cooling of core temperature to 32-36°C by targeted temperature management for at least 24 h, immediate coronary angiography with or without percutaneous coronary intervention, and delay of final prognosis until at least 72 h after OHCA. Prognosis should be based on clinical observations and multimodal testing, with focus on no residual sedation.
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Affiliation(s)
- Christian Hassager
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Ken Nagao
- Cardiovascular Centre, Nihon University Hospital, Tokyo, Japan
| | - David Hildick-Smith
- Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton and Hove, UK
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Wallace DJ, Coppler P, Callaway C, Rittenberger JC, Dezfulian C, Mohan D, Toma C, Elmer J. Selection bias, interventions and outcomes for survivors of cardiac arrest. Heart 2018; 104:1356-1361. [PMID: 29463613 DOI: 10.1136/heartjnl-2017-312528] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/19/2018] [Accepted: 01/22/2018] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Cardiac catheterisation and implantable cardioverter defibrillator (ICD) insertion are increasingly common following cardiac arrest survival. However, much of the evidence for the benefit is observational, leaving open the possibility that biased patient selection confounds the association between these invasive procedures and improved outcome. We evaluated the likelihood of selection bias in the association between cardiac catheterisation or ICD placement and outcome by measuring long-term outcomes overall and in a cause-specific approach that separated cardiac mortality from non-cardiac mortality. METHODS We performed a multivariable survival analysis of a clinical cohort between 2005 and 2013, with follow-up through 2015. We included patients who had out-of-hospital or inhospital cardiac arrest that survived to discharge, and evaluated the association between cardiac catheterisation or ICD insertion and all-cause, cardiovascular and non-cardiovascular mortality. RESULTS Among 678 patients who survived cardiac arrest, we observed lower all-cause mortality among patients who underwent cardiac catheterisation (adjusted HR (aHR) 0.40; P<0.01) or ICD insertion (aHR 0.55; P<0.01). However, cause-specific analysis showed that the benefits of cardiac catheterisation and ICD insertion resulted from reduced non-cardiac causes of death (cardiac catheterisation: aHR 0.24, P<0.01; ICD: aHR 0.58, P<0.01), while reduced cardiac cause of death was not associated with cardiac catheterisation (cardiac catheterisation: aHR 0.75, P=0.33). CONCLUSIONS There is evidence of selection bias in the secondary prevention survival benefit attributable to cardiac catheterisation for patients who survive cardiac arrest. Observational studies that consider its effects on all-cause mortality likely overestimate the potential benefit of this procedure.
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Affiliation(s)
- David J Wallace
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick Coppler
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Clifton Callaway
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jon C Rittenberger
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cameron Dezfulian
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Deepika Mohan
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Catalin Toma
- Division of Cardiology, Department of Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan Elmer
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Welsford M, Bossard M, Shortt C, Pritchard J, Natarajan MK, Belley-Côté EP. Does Early Coronary Angiography Improve Survival After out-of-Hospital Cardiac Arrest? A Systematic Review With Meta-Analysis. Can J Cardiol 2018; 34:180-194. [PMID: 29275998 DOI: 10.1016/j.cjca.2017.09.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/04/2017] [Accepted: 09/11/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND In patients with out-of-hospital cardiac arrest who achieve return of spontaneous circulation, coronary angiography (CAG) might improve outcomes. We conducted a systematic review and meta-analysis to elucidate the benefit and optimal timing of early CAG in comatose out-of-hospital cardiac arrest patients with return of spontaneous circulation. METHODS We searched MEDLINE, EMBASE, and Cochrane from 1990 to May 2017. Studies reporting survival and/or neurological survival in early (< 24-hour) vs late/no CAG were selected. We used the Clinical Advances Through Research and Information Translation (CLARITY) risk of bias in cohort studies tool and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria to assess risk of bias and quality of evidence, respectively. Results were pooled using random effects and presented as risk ratios (RRs) with 95% confidence intervals (CIs). RESULTS After screening 9185 titles/abstracts and 631 full-text articles, we included 23 nonrandomized studies. Short (to discharge or 30 days) and long-term (1-5 years) survival were significantly improved (52% and 56%, respectively) in the early < 24-hour CAG group compared with the late/no CAG group (RR, 1.52; 95% CI, 1.32-1.74; P < 0.00001; I2, 94% and RR, 1.56; 95% CI, 1.14-2.14; P = 0.006; I2, 86%). Survival with good neurological outcome was also improved by 69% in the < 24-hour CAG group at short- (RR, 1.69; 95% CI, 1.40-2.04; P < 0.00001; I2, 93%) and intermediate-term (3-11 months; RR, 1.49; 95% CI, 1.27-1.76; P < 0.00001; I2, 67%). We found consistent benefits in the < 2-hour and < 6-hour subgroups. Early CAG was associated with significantly better outcomes in studies of patients without ST-elevation, but the results did not reach statistical significance in studies of patients with ST-elevation. CONCLUSIONS On the basis of very low quality, but consistent evidence, early CAG (< 24 hours) was associated with significantly higher survival and better neurologic outcomes.
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Affiliation(s)
- Michelle Welsford
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada; Centre for Paramedic Education and Research, Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Matthias Bossard
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada; Cardiology Division, Heart Centre, Luzerner Kantonsspital, Luzern, Switzerland
| | - Colleen Shortt
- Centre for Paramedic Education and Research, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jodie Pritchard
- Emergency Medicine Residency Program, McMaster University, Hamilton, Ontario, Canada
| | - Madhu K Natarajan
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada; Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Emilie P Belley-Côté
- Emergency Medicine Residency Program, McMaster University, Hamilton, Ontario, Canada; Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
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Khan MS, Shah SMM, Mubashir A, Khan AR, Fatima K, Schenone AL, Khosa F, Samady H, Menon V. Early coronary angiography in patients resuscitated from out of hospital cardiac arrest without ST-segment elevation: A systematic review and meta-analysis. Resuscitation 2017; 121:127-134. [DOI: 10.1016/j.resuscitation.2017.10.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 09/07/2017] [Accepted: 10/22/2017] [Indexed: 12/29/2022]
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Fisher MB, Messerli A, Whayne TF. Characteristics, Management, and Results of Out-of-Hospital Cardiac Arrest (OHCA) With or Without ST-Segment Elevation Myocardial Infarction (STEMI). Angiology 2017; 69:189-191. [PMID: 28502185 DOI: 10.1177/0003319717709686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Mary Beth Fisher
- 1 Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA
| | - Adrian Messerli
- 1 Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA
| | - Thomas F Whayne
- 1 Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA
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40
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Quinn T. Where do I take my patient post ROSC in the absence of ST elevation on the ECG? Resuscitation 2017; 115:A10-A11. [PMID: 28342958 DOI: 10.1016/j.resuscitation.2017.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 03/20/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Tom Quinn
- Centre for Health and Social Care Research, Faculty of Health, Social Care and Education, Kingston University and St. George's, University of London, London, UK.
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Intensive care medicine research agenda on cardiac arrest. Intensive Care Med 2017; 43:1282-1293. [PMID: 28285322 DOI: 10.1007/s00134-017-4739-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/23/2017] [Indexed: 12/21/2022]
Abstract
Over the last 15 years, treatment of comatose post-cardiac arrest patients has evolved to include therapeutic strategies such as urgent coronary angiography with percutaneous coronary intervention (PCI), targeted temperature management (TTM)-requiring mechanical ventilation and sedation-and more sophisticated and cautious prognostication. In 2015, collaboration between the European Resuscitation Council (ERC) and the European Society for Intensive Care Medicine (ESICM) resulted in the first European guidelines on post-resuscitation care. This review addresses the major recent advances in the treatment of cardiac arrest, recent trials that have challenged current practice and the remaining areas of uncertainty.
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Resuscitation highlights in 2016. Resuscitation 2017; 114:A1-A7. [PMID: 28212838 DOI: 10.1016/j.resuscitation.2017.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/05/2017] [Indexed: 11/21/2022]
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