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Rashid K, Waheed MA, Ansar F, Makram AM, Hasan A, Ahmed S, Khan ST, Ubaid A, Ibad AA, Basri R, Makram OM, Khan Y, Rashad N, Elzouki A. Early coronary angioplasty fails to lower all-cause mortality in patients with out-of-hospital cardiac arrest without ST-segment elevation: A systematic review and meta-analysis. Health Sci Rep 2024; 7:e1379. [PMID: 38299209 PMCID: PMC10828130 DOI: 10.1002/hsr2.1379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/25/2023] [Accepted: 06/18/2023] [Indexed: 02/02/2024] Open
Abstract
Introduction Out-of-hospital cardiac arrest (OHCA) is defined as the loss of functional mechanical activity of the heart in association with an absence of systemic circulation, occurring outside of a hospital. Immediate coronary angiography (CAG) with percutaneous coronary intervention is recommended for OHCA with ST-elevation. We aimed to evaluate the effect of early CAG on mortality and neurological outcomes in OHCA patients without ST-elevation. Methods This meta-analysis and systemic review was conducted as per principles of Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) group. A protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO, Ref No. = CRD42022327833). A total of 674 studies were retrieved after scanning several databases (PubMed Central, EMBASE, Medline, and Cochrane Central Register of Controlled Trials). Results A total of 18 studies were selected for the final analysis, including 6 randomized control trials and 12 observational studies. Statistically, there was no significant difference in primary outcome, i.e., mortality, between early and delayed CAG. In terms of the grade of neurological recovery as a secondary outcome, early and delayed CAG groups also showed no statistically significant difference. Conclusion Early CAG has no survival benefits in patients with no ST elevations on ECG after OHCA.
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Affiliation(s)
- Khalid Rashid
- Internal MedicineJames Cook University HospitalMiddlesbroughUK
| | | | - Farrukh Ansar
- Department of MedicineQuaid e Azam International HospitalIslamabadPakistan
| | - Abdelrahman M. Makram
- Public health, School of Public HealthImperial College LondonLondonUK
- Department of Anesthesia and Intensive Care MedicineOctober 6 University HospitalGizaEgypt
| | - Ahmedyar Hasan
- Department of MedicineMohammed Bin Rashid University of Medicine and Health SciencesDubaiUAE
| | - Shahab Ahmed
- MedicineKing Abdullah Teaching HospitalMansehraPakistan
| | | | - Aamer Ubaid
- Internal MedicineUniversity of Missouri Kansas CityKansas CityMissouriUSA
| | | | - Rabia Basri
- Department of MedicineHamad Medical CorporationDohaQatar
| | - Omar Mohamed Makram
- Public health, Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Medicine, Center for Health & NatureHouston Methodist HospitalHoustonTexasUSA
- Department of CardiologyOctober 6 University HospitalGizaEgypt
| | | | - Nabhan Rashad
- Department of MedicineKhyber Teaching HospitalPeshawarPakistan
| | - Abdelnaser Elzouki
- Department of Medicine, Hamad General HospitalWeill Cornell MedicineAr‐RayyanQatar
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Takahashi M, Ogura K, Goto T, Hayakawa M. Electrocardiogram monitoring as a predictor of neurological and survival outcomes in patients with out-of-hospital cardiac arrest: a single-center retrospective observational study. Front Neurol 2023; 14:1210491. [PMID: 37470005 PMCID: PMC10352613 DOI: 10.3389/fneur.2023.1210491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 06/19/2023] [Indexed: 07/21/2023] Open
Abstract
Introduction This study hypothesized that monitoring electrocardiogram (ECG) waveforms in patients with out-of-hospital cardiac arrest (OHCA) could have predictive value for survival or neurological outcomes. We aimed to establish a new prognostication model based on the single variable of monitoring ECG waveforms in patients with OHCA using machine learning (ML) techniques. Methods This observational retrospective study included successfully resuscitated patients with OHCA aged ≥ 18 years admitted to an intensive care unit in Japan between April 2010 and April 2020. Waveforms from ECG monitoring for 1 h after admission were obtained from medical records and examined. Based on the open-access PTB-XL dataset, a large publicly available 12-lead ECG waveform dataset, we built an ML-supported premodel that transformed the II-lead waveforms of the monitoring ECG into diagnostic labels. The ECG diagnostic labels of the patients in this study were analyzed for prognosis using another model supported by ML. The endpoints were favorable neurological outcomes (cerebral performance category 1 or 2) and survival to hospital discharge. Results In total, 590 patients with OHCA were included in this study and randomly divided into 3 groups (training set, n = 283; validation set, n = 70; and test set, n = 237). In the test set, our ML model predicted neurological and survival outcomes, with the highest areas under the receiver operating characteristic curves of 0.688 (95% CI: 0.682-0.694) and 0.684 (95% CI: 0.680-0.689), respectively. Conclusion Our ML predictive model showed that monitoring ECG waveforms soon after resuscitation could predict neurological and survival outcomes in patients with OHCA.
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Affiliation(s)
- Masaki Takahashi
- Division of Acute and Critical Care Medicine, Department of Anaesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Kentaro Ogura
- Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tadahiro Goto
- Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mineji Hayakawa
- Division of Acute and Critical Care Medicine, Department of Anaesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
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Tateishi K, Kondo Y, Saito Y, Kitahara H, Fukushima K, Takahashi H, Yamashita D, Ohashi K, Suzuki K, Hashimoto O, Sakai Y, Kobayashi Y. Implantable cardioverter-defibrillator therapy after resuscitation from cardiac arrest in vasospastic angina: A retrospective study. PLoS One 2022; 17:e0277034. [PMID: 36315563 PMCID: PMC9621437 DOI: 10.1371/journal.pone.0277034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022] Open
Abstract
Patients with vasospastic angina (VSA) who are resuscitated from sudden cardiac arrest (SCA) are at a high risk of recurrent lethal arrhythmia and cardiovascular events. However, the benefit of the implantable cardioverter-defibrillator (ICD) therapy in this population has not been fully elucidated. The present study aimed to analyze the prognostic impact of ICD therapy on patients with VSA and SCA. A total of 280 patients who were resuscitated from SCA and received an ICD for secondary prophylaxis were included in the present multicenter registry. The patients were divided into two groups on the basis of the presence of VSA. The primary endpoint was a composite of all-cause death and appropriate ICD therapy (appropriate anti-tachycardia pacing and shock) for recurrent ventricular arrhythmias. Of 280 patients, 51 (18%) had VSA. Among those without VSA, ischemic cardiomyopathy was the main cause of SCA (38%), followed by non-ischemic cardiomyopathies (18%) and Brugada syndrome (7%). Twenty-three (8%) patients were dead and 72 (26%) received appropriate ICD therapy during a median follow-up period of 3.8 years. There was no significant difference in the incidence of the primary endpoint between patients with and without VSA (24% vs. 33%, p = 0.19). In a cohort of patients who received an ICD for secondary prophylaxis, long-term clinical outcomes were not different between those with VSA and those with other cardiac diseases after SCA, suggesting ICD therapy may be considered in patients with VSA and those with other etiologies who were resuscitated from SCA.
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Affiliation(s)
- Kazuya Tateishi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Chiba, Japan
- * E-mail:
| | - Yusuke Kondo
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Chiba, Japan
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Chiba, Japan
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Chiba, Japan
| | - Kenichi Fukushima
- Department of Cardiovascular Medicine, Matsudo City General Hospital, Matsudo, Chiba, Japan
| | - Hidehisa Takahashi
- Department of Cardiovascular Medicine, Matsudo City General Hospital, Matsudo, Chiba, Japan
| | - Daichi Yamashita
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Chiba, Japan
| | - Koichi Ohashi
- Department of Cardiology, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Ko Suzuki
- Department of Cardiology, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Osamu Hashimoto
- Department of Cardiovascular Medicine, Chiba Emergency Medical Center, Chiba, Chiba, Japan
| | - Yoshiaki Sakai
- Department of Cardiovascular Medicine, Chiba Emergency Medical Center, Chiba, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Chiba, Japan
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Ohashi K, Itagaki R, Mukaida T, Miyazaki K, Ohashi K, Kawada M, Abe D. Cardiac Arrest in a 33-year-old Marathon Runner with Anomalous Right Coronary Artery Originating from the Pulmonary Artery. Intern Med 2022; 61:673-677. [PMID: 34471018 PMCID: PMC8943370 DOI: 10.2169/internalmedicine.7612-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 33-year-old marathon runner presented with anomalous right coronary artery originating from the pulmonary artery after being admitted for cardiac arrest. Surgical re-implantation of the right coronary artery to the aortic root to re-establish right coronary ostial circulation was successful. The patient resumed exercise and required no further medical therapy.
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Affiliation(s)
- Koichi Ohashi
- Department of Cardiology, Tokyo Metropolitan Bokutoh Hospital, Japan
| | - Ryo Itagaki
- Department of Cardiovascular surgery, Tokyo Metropolitan Bokutoh Hospital, Japan
| | - Takuto Mukaida
- Department of Cardiology, Tokyo Metropolitan Bokutoh Hospital, Japan
| | - Kazuki Miyazaki
- Tertiary Emergency Medical Center (Trauma and Critical Care), Tokyo Metropolitan Bokutoh Hospital, Japan
| | - Keiko Ohashi
- Tertiary Emergency Medical Center (Trauma and Critical Care), Tokyo Metropolitan Bokutoh Hospital, Japan
| | - Masaaki Kawada
- Division of Pediatric and Congenital Cardiovascular Surgery, Jichi Children's Medical Center Tochigi, Japan
| | - Daisuke Abe
- Department of Cardiology, Tokyo Metropolitan Bokutoh Hospital, Japan
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Aufderheide TP, Engel TW, Saleh HO, Gutterman DD, Weston BW, Pepe PE, Baker JE, Labinski J, Debaty G, Tang L, Szabo A, Kalra R, Yannopoulos D, Colella MR. Change in out-of-hospital 12-lead ECG diagnostic classification following resuscitation from cardiac arrest. Resuscitation 2021; 169:45-52. [PMID: 34666124 DOI: 10.1016/j.resuscitation.2021.10.012] [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: 09/23/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION We evaluated the incidence of change in serial 12-lead electrocardiogram (ECG) diagnostic classifications in patients resuscitated from out-of-hospital (OH) cardiac arrest (OHCA) comparing OH to emergency department (ED) ECGs. METHODS This retrospective case series included: 1) adults (≥ 18 years old), 2) resuscitated from OHCA, 3) ≥ 1 OH and 1 ED ECG/patient, and 4) emergency medical services (EMS) transport to the study hospital. OH and ED ECGs were classified as: 1) STEMI (ST-segment Elevation Myocardial Infarction), 2) Ischemic, and 3) Non-ischemic. Two ED physicians and one cardiologist independently classified all ECGs, then generated a consensus opinion classification for each ECG based on American Heart Association's 2018 Expert Consensus criteria. The most ischemic OH ECG classification was compared with the last ED ECG classification. RESULTS From 7/27/12 to 7/18/19, 176 patients were entered with a mean age of 61.2 ± 16.6 years; 102/176 (58%) were male. Overall, 504 OH and ED 12-lead ECGs were acquired (2.9 ECGs/patient). ECG classification inter-rater reliability kappa score was 0.63 ± 0.02 (substantial agreement). Overall, 86/176 (49%) changed ECG classification from the OH to ED setting; 69/86 (80%) of these ECGs changed from more to less ischemic classifications. Of 49 OH STEMI ECG classifications, 33/49 (67%) changed to a less ischemic (non-STEMI) ED ECG classification. CONCLUSIONS Change in 12-lead ECG classification from OH to ED setting in patients resuscitated from OHCA was common (49%). The OH STEMI classification changed to a less ischemic (non-STEMI) ED classification in 67% of cases.
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Affiliation(s)
- Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Thomas W Engel
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; Division of EMS Medicine, Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Hadi O Saleh
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - David D Gutterman
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; Department of Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, WI, USA; The Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Benjamin W Weston
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; Division of EMS Medicine, Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Paul E Pepe
- Dallas County Emergency Medical Services and County Public Safety Agencies, Dallas, TX, USA.
| | - John E Baker
- Division of Congenital Heart Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA; Department of Biochemistry, Medical College of Wisconsin, Milwaukee, WI, USA; Department of Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, WI, USA; Radiation Biosciences Laboratory, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Jacob Labinski
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Guillaume Debaty
- Department of Emergency Medicine, University Hospital of Grenoble Alps, University Grenoble Alps, France.
| | - Lujia Tang
- International Research Fellow, Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Aniko Szabo
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Rajat Kalra
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA.
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA.
| | - M Riccardo Colella
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; Division of EMS Medicine, Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
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Bosson N, Tolles J, Shavelle D, Niemann JT, Thomas JL, French WJ, Gausche-Hill M. Variation in Post-Cardiac Arrest Care Within a Regional EMS System. PREHOSP EMERG CARE 2021; 26:772-781. [PMID: 34369840 DOI: 10.1080/10903127.2021.1965681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: Within Emergency Medical Systems (EMS) regional systems, there may be significant differences in the approach to patient care despite efforts to promote standardization. Identifying hospital-level factors that contribute to variations in care can provide opportunities to improve patient outcomes. The purpose of this analysis was to evaluate variation in post-cardiac arrest care within a large EMS system and explore the contribution of hospital-level factors.Methods: This was a retrospective analysis from a regional cardiac system serving over 10 million persons. Patients with out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) are transported to 36 cardiac arrest centers with 24/7 emergent coronary angiography (CAG) capabilities and targeted temperature management (TTM) policies based on regional guidelines. We included adult patients ≥18 years with non-traumatic OHCA from 2016-2018. Patients with a Do-Not-Resuscitate order and those who died in the emergency department (ED) were excluded. For the TTM analysis, we also excluded patients who were alert in the ED. The primary outcome was receiving CAG or TTM after cardiac arrest. The secondary outcome was neurologic recovery (dichotomized to define a "good" outcome as cerebral performance category (CPC) 1 or 2). We used generalized estimating equations including patient-level factors (age, sex, witnessed arrest, initial rhythm) and hospital-level factors (academic status, hospital size based on licensed beds, annual OHCA patient volume) to estimate the odds ratios associated with these variables.Results: There were 7831 patients with OHCA during the study period; 4694 were analyzed for CAG and 3903 for TTM. The median and range for treatment with CAG and TTM after OHCA was 23% (12-49%) and 58% (17-92%) respectively. Hospital size was associated with increased likelihood of CAG, adjusted odds ratio 1.71, 95% CI 1.05-2.86, p = 0.03. Academic status approached significance in its association with TTM, adjusted odds ratio 1.69, 95% CI 0.98-2.91, p = 0.06. Overall, 28% of patients survived with good neurologic outcome, ranging from 17 to 43% across hospitals.Conclusion: Within this regional cardiac system, there was significant variation in use of CAG and TTM after OHCA, which was not fully explained by patient-level factors. Hospital size was associated with increased CAG.
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Affiliation(s)
- Nichole Bosson
- Received June 6, 2021 from Los Angeles County Emergency Medical Service Agency, Santa Fe Springs, CA, USA (NB, MGH); Department of Emergency Medicine, Harbor UCLA Medical Center, Torrance, CA, USA (NB, JT, JTN, MGH); David Geffen School of Medicine at UCLA, Los Angeles, CA, USA (NB, JT, JTN, JLT, WJF, MGH); Department of Cardiology, Long Beach Medical Center, Long Beach, CA, USA (DS); Division of Cardiology, UCLA Medical Center, Torrance, CA, USA (JLT; WJF). Revision received July 27, 2021; accepted for publication August 3, 2021
| | - Juliana Tolles
- Received June 6, 2021 from Los Angeles County Emergency Medical Service Agency, Santa Fe Springs, CA, USA (NB, MGH); Department of Emergency Medicine, Harbor UCLA Medical Center, Torrance, CA, USA (NB, JT, JTN, MGH); David Geffen School of Medicine at UCLA, Los Angeles, CA, USA (NB, JT, JTN, JLT, WJF, MGH); Department of Cardiology, Long Beach Medical Center, Long Beach, CA, USA (DS); Division of Cardiology, UCLA Medical Center, Torrance, CA, USA (JLT; WJF). Revision received July 27, 2021; accepted for publication August 3, 2021
| | - David Shavelle
- Received June 6, 2021 from Los Angeles County Emergency Medical Service Agency, Santa Fe Springs, CA, USA (NB, MGH); Department of Emergency Medicine, Harbor UCLA Medical Center, Torrance, CA, USA (NB, JT, JTN, MGH); David Geffen School of Medicine at UCLA, Los Angeles, CA, USA (NB, JT, JTN, JLT, WJF, MGH); Department of Cardiology, Long Beach Medical Center, Long Beach, CA, USA (DS); Division of Cardiology, UCLA Medical Center, Torrance, CA, USA (JLT; WJF). Revision received July 27, 2021; accepted for publication August 3, 2021
| | - James T Niemann
- Received June 6, 2021 from Los Angeles County Emergency Medical Service Agency, Santa Fe Springs, CA, USA (NB, MGH); Department of Emergency Medicine, Harbor UCLA Medical Center, Torrance, CA, USA (NB, JT, JTN, MGH); David Geffen School of Medicine at UCLA, Los Angeles, CA, USA (NB, JT, JTN, JLT, WJF, MGH); Department of Cardiology, Long Beach Medical Center, Long Beach, CA, USA (DS); Division of Cardiology, UCLA Medical Center, Torrance, CA, USA (JLT; WJF). Revision received July 27, 2021; accepted for publication August 3, 2021
| | - Joseph L Thomas
- Received June 6, 2021 from Los Angeles County Emergency Medical Service Agency, Santa Fe Springs, CA, USA (NB, MGH); Department of Emergency Medicine, Harbor UCLA Medical Center, Torrance, CA, USA (NB, JT, JTN, MGH); David Geffen School of Medicine at UCLA, Los Angeles, CA, USA (NB, JT, JTN, JLT, WJF, MGH); Department of Cardiology, Long Beach Medical Center, Long Beach, CA, USA (DS); Division of Cardiology, UCLA Medical Center, Torrance, CA, USA (JLT; WJF). Revision received July 27, 2021; accepted for publication August 3, 2021
| | - William J French
- Received June 6, 2021 from Los Angeles County Emergency Medical Service Agency, Santa Fe Springs, CA, USA (NB, MGH); Department of Emergency Medicine, Harbor UCLA Medical Center, Torrance, CA, USA (NB, JT, JTN, MGH); David Geffen School of Medicine at UCLA, Los Angeles, CA, USA (NB, JT, JTN, JLT, WJF, MGH); Department of Cardiology, Long Beach Medical Center, Long Beach, CA, USA (DS); Division of Cardiology, UCLA Medical Center, Torrance, CA, USA (JLT; WJF). Revision received July 27, 2021; accepted for publication August 3, 2021
| | - Marianne Gausche-Hill
- Received June 6, 2021 from Los Angeles County Emergency Medical Service Agency, Santa Fe Springs, CA, USA (NB, MGH); Department of Emergency Medicine, Harbor UCLA Medical Center, Torrance, CA, USA (NB, JT, JTN, MGH); David Geffen School of Medicine at UCLA, Los Angeles, CA, USA (NB, JT, JTN, JLT, WJF, MGH); Department of Cardiology, Long Beach Medical Center, Long Beach, CA, USA (DS); Division of Cardiology, UCLA Medical Center, Torrance, CA, USA (JLT; WJF). Revision received July 27, 2021; accepted for publication August 3, 2021
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Verma BR, Sharma V, Shekhar S, Kaur M, Khubber S, Bansal A, Singh J, Ahuja KR, Nazir S, Chetrit M, Menon V, Reed G, Kapadia S. Coronary Angiography in Patients With Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: A Systematic Review and Meta-Analysis. JACC Cardiovasc Interv 2021; 13:2193-2205. [PMID: 33032706 DOI: 10.1016/j.jcin.2020.07.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/09/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The authors conducted a meta-analysis to study clinical outcomes in patients who underwent early versus nonearly coronary angiography (CAG) in the setting of out-of-hospital cardiac arrest (OHCA) without ST-segment elevation. BACKGROUND The benefit of performing early CAG in patients with OHCA without STE remains disputed. METHODS MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from inception until February 21, 2020. Early and nonearly CAG patients were identified on the basis of the definitions mentioned in respective published studies. The primary outcome studied was 30-day mortality. Secondary outcomes were neurological status and the rate of percutaneous coronary intervention (PCI) following cardiac arrest. RESULTS Of 4,516 references, 11 studies enrolling 3,581 patients were included in the final meta-analysis. Random-effects analysis showed no differences in 30-day mortality (risk ratio [RR]: 0.86; 95% confidence interval [CI]: 0.71 to 1.04; p = 0.12; I2 = 74%), neurological status (RR: 1.08; 95% CI: 0.94 to 1.24; p = 0.28; I2 = 69%), and rate of PCI (RR: 1.22; 95% CI: 0.94 to 1.59; p = 0.13; I2 = 67%) between the 2 groups. Diabetes mellitus, chronic renal failure, previous PCI, and lactate level were found to be significant predictors of 30-day mortality on meta-regression (p < 0.05). CONCLUSIONS This analysis shows that there is no significant difference in 30-day mortality, neurological status, or rate of PCI among patients with OHCA without STE treated with early versus nonearly CAG. Thirty-day mortality is determined by presentation comorbidities rather than revascularization.
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Affiliation(s)
- Beni R Verma
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Vikram Sharma
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Shashank Shekhar
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Manpreet Kaur
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Shameer Khubber
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Agam Bansal
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Jarmanjeet Singh
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Keerat Rai Ahuja
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Salik Nazir
- Department of Cardiology, University of Toledo, Toledo, Ohio
| | - Michael Chetrit
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Venu Menon
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Grant Reed
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Samir Kapadia
- Heart and Vascular Institute, Department of Cardiology, Cleveland Clinic, Cleveland, Ohio.
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McFadden P, Reynolds JC, Madder RD, Brown M. Diagnostic test accuracy of the initial electrocardiogram after resuscitation from cardiac arrest to indicate invasive coronary angiographic findings and attempted revascularization: A systematic review and meta-analysis. Resuscitation 2021; 160:20-36. [PMID: 33444708 DOI: 10.1016/j.resuscitation.2020.11.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/16/2020] [Accepted: 11/27/2020] [Indexed: 02/07/2023]
Abstract
AIM Conduct a diagnostic test accuracy systematic review and meta-analysis of the post-return of spontaneous circulation (ROSC) electrocardiogram (ECG) to indicate an acute-appearing coronary lesion and revascularization. METHODS We searched PubMed, EMBASE, CINAHL, Cochrane Library, and Web of Science through February 18, 2020. Two investigators screened titles and abstracts, extracted data, and assessed risks of bias using QUADAS-2. We estimated sensitivity (Sn), specificity (Sp), and likelihood ratios (LR) for all reported ECG features to indicate all reported reference standards. Random-effects meta-analysis pooled comparable studies without critical risk of bias. GRADE methodology evaluated the certainty of evidence. RESULTS Overall, 48 studies reported 94 combinations of ECG features and reference standards with wide variation in their definitions. Most studies had risks of bias from selection for coronary angiography and blinding to the ECG and/or reference standard. Meta-analysis combined 6 studies for STE and acute coronary lesion (Sn 0.70 [95% CI 0.54-0.82]; Sp 0.85 [95% CI 0.78-0.90]; LR + 4.7 [95% CI 3.3-6.7]; LR- 0.4 [95% CI 0.2-0.6]) and 4 studies for STE and revascularization (Sn 0.53 [95% CI 0.47-0.58]; Sp 0.86 [95% CI 0.80-0.91]; LR + 3.9 [95% CI 2.8-5.5]; LR- 0.5 [95% CI 0.5-0.6]). Overall certainty of evidence was low with substantial heterogeneity. CONCLUSIONS Based on low certainty evidence, STE had good classification for acute coronary lesion and fair classification for revascularization. STE was more specific than sensitive for these outcomes and no single ECG feature excluded them. Uniform definitions and terminology would greatly facilitate the interpretation of subsequent studies.
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Affiliation(s)
- Patrick McFadden
- Spectrum Health Department of Emergency Medicine, Grand Rapids, MI, USA
| | - Joshua C Reynolds
- Michigan State University College of Human Medicine, Department of Emergency Medicine, 15 Michigan Street NE, Suite 736D, Grand Rapids, MI 49503, USA.
| | - Ryan D Madder
- Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI, USA
| | - Michael Brown
- Michigan State University College of Human Medicine, Department of Emergency Medicine, 15 Michigan Street NE, Suite 736D, Grand Rapids, MI 49503, USA
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Vasospastic angina and overlapping cardiac disorders in patients resuscitated from cardiac arrest. Heart Vessels 2020; 36:321-329. [PMID: 32990791 DOI: 10.1007/s00380-020-01705-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Vasospastic angina (VSA) reportedly accounts for one form of sudden cardiac arrest (SCA). Intracoronary acetylcholine (ACh) testing is useful for diagnosing VSA although invasive provocation testing after SCA is a clinical challenge. In addition, even if the ACh test is positive, any causal relationship between VSA and SCA is often unclear because patients with VSA may have other underlying cardiac disorders. METHODS A total of 20 patients without overt structural heart disease who had been fully resuscitated from SCA were included. All patients underwent the ACh provocation test and scrutiny such as cardiac computed tomography or magnetic resonance imaging. Patients were followed up for all-cause death or recurrent SCA including appropriate implantable cardioverter defibrillator therapy. RESULTS An ACh provocation test was performed 20 ± 17 days after cardiac arrest. Fifteen out of 20 (75.0%) patients had a positive ACh test and 2 (10.0%) had adverse events such as ventricular tachycardia and transient cardiogenic shock during the test. In patients with a positive ACh test, 6 of 15 (40.0%) patients had other overlapping cardiac disorders such as long QT syndrome, Brugada syndrome, cardiac sarcoidosis, myocarditis, or cardiomyopathy. Long-term prognosis was not different regardless of a positive ACh test or the presence of other cardiac disorders overlapping with VSA. CONCLUSIONS Three-quarters of the patients who had been resuscitated from SCA had a positive ACh test. Further examinations revealed other overlapping cardiac disorders in addition to VSA in 40% of patients with a positive ACh test.
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Lee DH, Lee BK, Kim YH, Park YS, Sim MS, Kim SJ, Oh SH, Lee DH, Kim YJ, Kim WY. Vasospasm-related Sudden Cardiac Death Has Outcomes Comparable with Coronary Stenosis in Out-of-Hospital Cardiac Arrest. J Korean Med Sci 2020; 35:e131. [PMID: 32419397 PMCID: PMC7234855 DOI: 10.3346/jkms.2020.35.e131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 03/05/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Characteristics of coronary vasospasm-related sudden cardiac death are not well understood. We aimed to compare the characteristics and clinical outcomes between coronary vasospasm and stenosis, in out-of-hospital cardiac arrest (OHCA) survivors, who underwent coronary angiogram (CAG). METHODS We conducted a multicenter retrospective observational registry-based study at 8 Korean tertiary care centers. Data of OHCA survivors undergoing CAG between 2010 and 2015 were extracted. Patients were divided into vasospasm and stenosis (stenosis > 50%) groups based on CAG findings. The primary and the secondary outcomes were survival and a good neurologic outcome at 30 days after OHCA. Patients in the vasospasm and stenosis groups were propensity score matched. RESULTS Of the 413 included patients, vasospasm and stenosis groups comprised 87 and 326 patients, respectively. There were 279 (66.7%) survivors and 206 (49.3%) patients with good neurologic outcomes. The vasospasm group had better clinical characteristics for outcome (younger age, less diabetes and hypertension, more prehospital restoration of spontaneous circulation, higher Glasgow Coma Scale, less ST segment elevation, and less requirement of circulatory support). The vasospasm group had better survival (75/87 vs. 204/326, P < 0.001) and good neurologic outcomes (62/87 vs. 144/326, P < 0.001). However, vasospasm was not independently associated with survival (odds ratio [OR], 0.980; 95% confidence interval [CI], 0.400-2.406) or neurologic outcomes (OR, 0.870; 95% CI, 0.359-2.108) after adjustment and vasospasm was not associated with survival and neurologic outcome in propensity score-matched cohorts. CONCLUSION Our analysis of propensity score-matched cohorts finds that vasospasm OHCA survivors have survival and neurologic outcomes comparable with those of stenotic OHCA survivors.
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Affiliation(s)
- Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea.
| | - Yong Hwan Kim
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Min Seob Sim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Su Jin Kim
- Department of Emergency Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, Chung-Ang University, College of Medicine, Seoul, Korea
| | - Youn Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Pareek N, Kordis P, Webb I, Noc M, MacCarthy P, Byrne J. Contemporary Management of Out-of-hospital Cardiac Arrest in the Cardiac Catheterisation Laboratory: Current Status and Future Directions. ACTA ACUST UNITED AC 2019; 14:113-123. [PMID: 31867056 PMCID: PMC6918505 DOI: 10.15420/icr.2019.3.2] [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] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 07/22/2019] [Indexed: 02/06/2023]
Abstract
Out-of-hospital cardiac arrest (OHCA) is an important cause of mortality and morbidity in developed countries and remains an important public health burden. A primary cardiac aetiology is common in OHCA patients, and so patients are increasingly brought to specialist cardiac centres for consideration of coronary angiography, percutaneous coronary intervention and mechanical circulatory support. This article focuses on the management of OHCA in the cardiac catheterisation laboratory. In particular, it addresses conveyance of the OHCA patient direct to a specialist centre, the role of targeted temperature management, pharmacological considerations, provision of early coronary angiography and mechanical circulatory support.
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Affiliation(s)
- Nilesh Pareek
- King's College Hospital NHS Foundation Trust London, UK.,School of Cardiovascular Medicine & Sciences, BHF Centre of Excellence King's College London, UK
| | | | - Ian Webb
- King's College Hospital NHS Foundation Trust London, UK
| | - Marko Noc
- University Medical Centre Ljubljana, Slovenia
| | - Philip MacCarthy
- School of Cardiovascular Medicine & Sciences, BHF Centre of Excellence King's College London, UK
| | - Jonathan Byrne
- King's College Hospital NHS Foundation Trust London, UK.,School of Cardiovascular Medicine & Sciences, BHF Centre of Excellence King's College London, UK
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12
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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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13
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Tateishi K, Abe D, Suzuki K, Hamabe Y, Aonuma K, Sato A. Association Between Multivessel Coronary Artery Disease and Return of Spontaneous Circulation Interval in Acute Coronary Syndrome Patients with Out-of-Hospital Cardiac Arrest. Int Heart J 2019; 60:1043-1049. [PMID: 31484867 DOI: 10.1536/ihj.18-712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Acute coronary syndrome (ACS) is the major cause of out-of-hospital cardiac arrest (OHCA). The relationship between the findings from the study of coronary images and return of spontaneous circulation (ROSC) interval is still unknown. Hence, we investigated this relationship in ACS patients with OHCA.A cohort of 2779 patients was admitted to our emergency center due to cardiopulmonary arrest (CPA) between April 2011 and March 2015. We included ACS patients who had CPA with ventricular fibrillation (VF) as an initial rhythm, were successfully resuscitated, underwent coronary angiography (CAG), had a culprit lesion, and were diagnosed with ACS (n = 58; age, 63.7 ± 12.0 years; 93.1% male).We divided the 58 patients into two groups, an early ROSC group (ROSC ≤ 20 minutes: E-ROSC) and a late ROSC group (ROSC > 20 minutes: L-ROSC), and then analyzed their characteristics.The finding of a collateral artery for the culprit lesion location, Rentrop II-III, and TIMI III flow on CAG on arrival presented no significant differences between the two groups (Rentrop II-III: 25.0% versus 23.5%, P = 0.90; TIMI III: 33.3% versus 35.3%, P = 0.88). The incidence of multivessel coronary artery disease (MVD) was lower in the E-ROSC group than in the L-ROSC group (16.7% versus 58.8%, P = 0.001).Collateral and TIMI flow were not associated with ease of resuscitation, but MVD may have a negative impact on resuscitation, especially in VF patients.
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Affiliation(s)
- Kazuya Tateishi
- Department of Cardiovascular Medicine, Chiba University Hospital
| | - Daisuke Abe
- Department of Cardiology, Tokyo Metropolitan Bokutoh Hospital
| | - Kou Suzuki
- Department of Cardiology, Tokyo Metropolitan Bokutoh Hospital
| | - Yuichi Hamabe
- Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital
| | - Kazutaka Aonuma
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Akira Sato
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
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Elkaryoni A, Ramakrishnan D, Abdelkarim I, Noman A, Qintar M, Baweja P. Vasopressor-Induced Generalized Coronary Vasospasm Presenting as Inferior ST-Segment Elevation in Post-Cardiopulmonary Resuscitation. JACC Case Rep 2019; 1:94-98. [PMID: 34316757 PMCID: PMC8301242 DOI: 10.1016/j.jaccas.2019.05.023] [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: 04/03/2019] [Revised: 04/22/2019] [Accepted: 05/14/2019] [Indexed: 11/23/2022]
Abstract
ST-segment elevation in post-return of spontaneous circulation after cardiac arrest is a major concern for underlying acute coronary syndrome. This case report presents a rare case of vasopressor-induced coronary vasospasm as an underlying cause for this ST-segment elevation with complete reversal of EKG changes after reducing the vasopressor dose. (Level of Difficulty: Beginner.).
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Affiliation(s)
- Ahmed Elkaryoni
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Dushyant Ramakrishnan
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Islam Abdelkarim
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Anas Noman
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Mohammed Qintar
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
- Division of Cardiovascular Disease, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Paramdeep Baweja
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
- Division of Cardiovascular Disease, Truman Medical Center, Kansas City, Missouri
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15
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Kuroki N, Abe D, Suzuki K, Mikami M, Hamabe Y, Aonuma K, Sato A. Exercise-related resuscitated out-of-hospital cardiac arrest due to presumed myocardial ischemia: Result from coronary angiography and intravascular ultrasound. Resuscitation 2018; 133:40-46. [PMID: 30273611 DOI: 10.1016/j.resuscitation.2018.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 09/17/2018] [Accepted: 09/25/2018] [Indexed: 12/01/2022]
Abstract
AIM Possible causes of exercise-related out-of-hospital cardiac arrest (OHCA) in people with coronary artery disease (CAD) include atherosclerotic plaque rupture (PR) and intra-coronary thrombosis, exercise-induced myocardial ischaemia and other triggers. We investigated whether there are differences in the incidence of PR and/or intra-coronary thrombus and in clinical outcome between 'exercise-related' and 'non-exercise-related' OHCA. METHODS 219 consecutive resuscitated patients with CAD diagnosed by emergency coronary angiography (CAG) were enrolled. They were divided into the exercise group (≥6 METs; n = 35) and non-exercise group (<6 METs; n = 184), according to estimated METs immediately before OHCA using 2011 Compendium of Physical Activities. We investigated whether culprit lesions had PR and/or thrombus using CAG and intravascular ultrasound. The clinical outcome was 30-day survival with minimal neurologic impairment. RESULTS Acute PR and/or thrombus occurred in fewer of the exercise group than the non-exercise group (11% vs. 90%; P < 0.001). The exercise group had a higher incidence of favorable neurological outcome (94% vs. 47%; P < 0.001) than the non-exercise group. Multivariable Cox proportional hazards models revealed that exercise immediately before OHCA was one of the predictors of a good neurological outcome (HR, 0.19; P = 0.025). CONCLUSION The incidence of PR and/or thrombosis was lower in the group taking higher levels of exercise, than in the group taking less or no exercise. "Exercise-related" OHCA with CAD has better clinical outcomes than "non-exercise-related" with a greater proportion of witnessed arrests and early return of spontaneous circulation.
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Affiliation(s)
- Norihiro Kuroki
- Department of Cardiology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Daisuke Abe
- Department of Cardiology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.
| | - Kou Suzuki
- Department of Cardiology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Manabu Mikami
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yuichi Hamabe
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Kazutaka Aonuma
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Akira Sato
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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16
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Vrints CJ. Management of out-of-hospital cardiac arrest and electric storm. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2018; 7:395-396. [PMID: 30035627 DOI: 10.1177/2048872618791308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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17
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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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