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Morton S, Gough C. Can the MIRACLE 2 Score Be Used in the Prehospital Environment and Is It Useful? An Observational Study. Air Med J 2024; 43:146-150. [PMID: 38490778 DOI: 10.1016/j.amj.2023.11.008] [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: 07/26/2023] [Revised: 09/28/2023] [Accepted: 11/12/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE The MIRACLE2 score has been developed for use in a primary percutaneous coronary intervention center. It is unclear if it is feasible in the helicopter emergency medical service (HEMS) setting. METHODS The computerized system at 1 UK HEMS was interrogated between December 1, 2020, and May 1, 2022, for the components of the MIRACLE2 score (recorded contemporaneously) plus demographics and outcomes in all post-return of spontaneous circulation patients conveyed to the hospital. pH was excluded because of no point-of-care testing resulting in a modified MIRACLE2 score (maximum score of 9). Data were analyzed using the chi-square test; P < .05 was statistically significant. RESULTS Three hundred thirty patients (240 males) with out-of-hospital cardiac arrests were reviewed. Ninety-two adult patients with nontraumatic out-of-hospital cardiac arrests had sustained return of spontaneous circulation and a median MIRACLE2 score of 4 (range, 0-7). Forty-seven patients died before hospital discharge; the median MIRACLE2 score was higher in those who died (4) than those who survived (1.5, P < .01); 90.3% of those with a score ≥ 5 were triaged to an emergency department rather than directly to a catheterization laboratory. CONCLUSION A modified MIRACLE2 score can be calculated in the HEMS setting. The benefit of point-of-care testing pH requires investigation. There may be a benefit in predicting outcomes in this nondifferentiated group, but additional research is required.
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Affiliation(s)
- Sarah Morton
- Lincs & Notts Air Ambulance, Lincoln, United Kingdom; Imperial College London, London, United Kingdom
| | - Chris Gough
- Lincs & Notts Air Ambulance, Lincoln, United Kingdom; Department of Research and Education in Emergency Medicine, Acute Medicine and Major Trauma, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Emergency Department, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
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2
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Park MJ, Choi YJ, Shim M, Cho Y, Park J, Choi J, Kim J, Lee E, Kim SY. Performance of ECG-Derived Digital Biomarker for Screening Coronary Occlusion in Resuscitated Out-of-Hospital Cardiac Arrest Patients: A Comparative Study between Artificial Intelligence and a Group of Experts. J Clin Med 2024; 13:1354. [PMID: 38592195 PMCID: PMC10932362 DOI: 10.3390/jcm13051354] [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: 01/30/2024] [Revised: 02/16/2024] [Accepted: 02/26/2024] [Indexed: 04/10/2024] Open
Abstract
Acute coronary syndrome is a significant part of cardiac etiology contributing to out-of-hospital cardiac arrest (OHCA), and immediate coronary angiography has been proposed to improve survival. This study evaluated the effectiveness of an AI algorithm in diagnosing near-total or total occlusion of coronary arteries in OHCA patients who regained spontaneous circulation. Conducted from 1 July 2019 to 30 June 2022 at a tertiary university hospital emergency department, it involved 82 OHCA patients, with 58 qualifying after exclusions. The AI used was the Quantitative ECG (QCG™) system, which provides a STEMI diagnostic score ranging from 0 to 100. The QCG score's diagnostic performance was compared to assessments by two emergency physicians and three cardiologists. Among the patients, coronary occlusion was identified in 24. The QCG score showed a significant difference between occlusion and non-occlusion groups, with the former scoring higher. The QCG biomarker had an area under the curve (AUC) of 0.770, outperforming the expert group's AUC of 0.676. It demonstrated 70.8% sensitivity and 79.4% specificity. These findings suggest that the AI-based ECG biomarker could predict coronary occlusion in resuscitated OHCA patients, and it was non-inferior to the consensus of the expert group.
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Affiliation(s)
- Min Ji Park
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon-si 16499, Republic of Korea; (M.J.P.); (M.S.); (S.-Y.K.)
| | - Yoo Jin Choi
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon-si 16499, Republic of Korea; (M.J.P.); (M.S.); (S.-Y.K.)
| | - Moonki Shim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon-si 16499, Republic of Korea; (M.J.P.); (M.S.); (S.-Y.K.)
| | - Youngjin Cho
- Department of Cardiology, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea; (Y.C.); (J.P.); (J.C.)
| | - Jiesuck Park
- Department of Cardiology, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea; (Y.C.); (J.P.); (J.C.)
| | - Jina Choi
- Department of Cardiology, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea; (Y.C.); (J.P.); (J.C.)
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea; (J.K.); (E.L.)
- Big Data Center, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea
| | - Eunkyoung Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea; (J.K.); (E.L.)
- Big Data Center, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea
| | - Seo-Yoon Kim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon-si 16499, Republic of Korea; (M.J.P.); (M.S.); (S.-Y.K.)
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3
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Tamis-Holland JE, Menon V, Johnson NJ, Kern KB, Lemor A, Mason PJ, Rodgers M, Serrao GW, Yannopoulos D. Cardiac Catheterization Laboratory Management of the Comatose Adult Patient With an Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e274-e295. [PMID: 38112086 DOI: 10.1161/cir.0000000000001199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Out-of-hospital cardiac arrest is a leading cause of death, accounting for ≈50% of all cardiovascular deaths. The prognosis of such individuals is poor, with <10% surviving to hospital discharge. Survival with a favorable neurologic outcome is highest among individuals who present with a witnessed shockable rhythm, received bystander cardiopulmonary resuscitation, achieve return of spontaneous circulation within 15 minutes of arrest, and have evidence of ST-segment elevation on initial ECG after return of spontaneous circulation. The cardiac catheterization laboratory plays an important role in the coordinated Chain of Survival for patients with out-of-hospital cardiac arrest. The catheterization laboratory can be used to provide diagnostic, therapeutic, and resuscitative support after sudden cardiac arrest from many different cardiac causes, but it has a unique importance in the treatment of cardiac arrest resulting from underlying coronary artery disease. Over the past few years, numerous trials have clarified the role of the cardiac catheterization laboratory in the management of resuscitated patients or those with ongoing cardiac arrest. This scientific statement provides an update on the contemporary approach to managing resuscitated patients or those with ongoing cardiac arrest.
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4
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Smith D, Kenigsberg BB. Management of Patients After Cardiac Arrest. Crit Care Clin 2024; 40:57-72. [PMID: 37973357 DOI: 10.1016/j.ccc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Cardiac arrest remains a significant cause of morbidity and mortality, although contemporary care now enables potential survival with good neurologic outcome. The core acute management goals for survivors of cardiac arrest are to provide organ support, sustain adequate hemodynamics, and evaluate the underlying cause of the cardiac arrest. In this article, the authors review the current state of knowledge and clinical intensive care unit practice recommendations for patients after cardiac arrest, particularly focusing on important areas of uncertainty, such as targeted temperature management, neuroprognostication, coronary evaluation, and hemodynamic targets.
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Affiliation(s)
- Damien Smith
- Department of Medicine, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA
| | - Benjamin B Kenigsberg
- Department of Critical Care, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA; Division of Cardiology, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA.
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5
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Ferraz Costa G, Santos I, Sousa J, Beirão S, Teixeira R. Coronary angiography after out-of-hospital cardiac arrest without ST-segment elevation: a systematic review and meta-analysis of randomised trials. Coron Artery Dis 2024; 35:67-75. [PMID: 37861181 DOI: 10.1097/mca.0000000000001298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) has a poor prognosis. The optimal timing and role of early coronary angiography (CAG) in OHCA patients without ST-segment elevation remains unclear. The goal of this study is to compare an early CAG versus delayed CAG strategy in OHCA patients without ST elevation. METHODS We systematically searched PubMed, Embase and Cochrane databases, in June 2022, for randomised controlled trials (RCTs) comparing early versus delayed early CAG. A random effects meta-analysis was performed. RESULTS A total of seven RCTs were included, providing a total of 1625 patients: 816 in an early strategy and 807 in a delayed strategy. In terms of outcomes assessed, our meta-analysis revealed a similar rate of all-cause mortality (pooled odds ratio [OR] 1.22 [0.99-1.50], P = 0.06, I 2 = 0%), neurological status (pooled OR 0.94 [0.74-1.21], = 0.65, I 2 = 0%), need of renal replacement therapy (pooled OR 1.11 [0.78-1.74], P = 0.47, I 2 = 0%) and major bleeding events (pooled OR 1.51 [0.95-2.40], P = 0.08, I 2 = 69%). CONCLUSION According to our meta-analysis, in patients who experienced OHCA without ST elevation, early CAG is not associated with reduced mortality or an improved neurological status.
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Affiliation(s)
- Gonçalo Ferraz Costa
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra
| | - Iolanda Santos
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - João Sousa
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Sofia Beirão
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Rogério Teixeira
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra
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Cheng Y, Huang B, Chen M. The authors reply: ST elevation and echocardiography. Am J Emerg Med 2023; 74:175-176. [PMID: 37838566 DOI: 10.1016/j.ajem.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 10/16/2023] Open
Affiliation(s)
- Yang Cheng
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, PR China
| | - Baotao Huang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, PR China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, PR China.
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Savastano S, Baldi E, Schnaubelt S, Auricchio A. Post resuscitation ST-segment elevation: When a few minutes make the difference between a class I and a class III indication for immediate coronary angiography. Resuscitation 2023; 192:109971. [PMID: 37730098 DOI: 10.1016/j.resuscitation.2023.109971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 09/22/2023]
Affiliation(s)
- Simone Savastano
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Cardiac Arrest and Resuscitation Science Research Team (RESTART), Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Enrico Baldi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Cardiac Arrest and Resuscitation Science Research Team (RESTART), Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Angelo Auricchio
- Fondazione Ticino Cuore, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland; Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
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8
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Macherey-Meyer S, Heyne S, Meertens MM, Braumann S, Niessen SF, Baldus S, Lee S, Adler C. Outcome of Out-of-Hospital Cardiac Arrest Patients Stratified by Pre-Clinical Loading with Aspirin and Heparin: A Retrospective Cohort Analysis. J Clin Med 2023; 12:3817. [PMID: 37298012 PMCID: PMC10253358 DOI: 10.3390/jcm12113817] [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: 05/02/2023] [Revised: 05/19/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
Background: Out-of-hospital cardiac arrest (OHCA) has a high prevalence of obstructive coronary artery disease and total coronary occlusion. Consequently, these patients are frequently loaded with antiplatelets and anticoagulants before hospital arrival. However, OHCA patients have multiple non-cardiac causes and high susceptibility for bleeding. In brief, there is a gap in the evidence for loading in OHCA patients. Objective: The current analysis stratified the outcome of patients with OHCA according to pre-clinical loading. Material and Methods: In a retrospective analysis of an all-comer OHCA registry, patients were stratified by loading with aspirin (ASA) and unfractionated heparin (UFH). Bleeding rate, survival to hospital discharge and favorable neurological outcomes were measured. Results: Overall, 272 patients were included, of whom 142 were loaded. Acute coronary syndrome was diagnosed in 103 patients. One-third of STEMIs were not loaded. Conversely, 54% with OHCA from non-ischemic causes were pretreated. Loading was associated with increased survival to hospital discharge (56.3 vs. 40.3%, p = 0.008) and a more favorable neurological outcome (80.7 vs. 62.6% p = 0.003). Prevalence of bleeding was comparable (26.8 vs. 31.5%, p = 0.740). Conclusions: Pre-clinical loading did not increase bleeding rates and was associated with favorable survival. Overtreatment of OHCA with non-ischemic origin, but also undertreatment of STEMI-OHCA were documented. Loading without definite diagnosis of sustained ischemia is debatable in the absence of reliable randomized controlled data.
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Affiliation(s)
- Sascha Macherey-Meyer
- Clinic III for Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50931 Cologne, Germany; (S.H.); (M.M.M.); (S.B.); (S.F.N.); (S.B.); (S.L.); (C.A.)
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9
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Pareek N, Frohmaier C, Smith M, Kordis P, Cannata A, Nevett J, Fothergill R, Nichol RC, Sullivan M, Sunderland N, Johnson TW, Noc M, Byrne J, MacCarthy P, Shah AM. A machine learning algorithm to predict a culprit lesion after out of hospital cardiac arrest. Catheter Cardiovasc Interv 2023. [PMID: 37191312 DOI: 10.1002/ccd.30677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 04/03/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND We aimed to develop a machine learning algorithm to predict the presence of a culprit lesion in patients with out-of-hospital cardiac arrest (OHCA). METHODS We used the King's Out-of-Hospital Cardiac Arrest Registry, a retrospective cohort of 398 patients admitted to King's College Hospital between May 2012 and December 2017. The primary outcome was the presence of a culprit coronary artery lesion, for which a gradient boosting model was optimized to predict. The algorithm was then validated in two independent European cohorts comprising 568 patients. RESULTS A culprit lesion was observed in 209/309 (67.4%) patients receiving early coronary angiography in the development, and 199/293 (67.9%) in the Ljubljana and 102/132 (61.1%) in the Bristol validation cohorts, respectively. The algorithm, which is presented as a web application, incorporates nine variables including age, a localizing feature on electrocardiogram (ECG) (≥2 mm of ST change in contiguous leads), regional wall motion abnormality, history of vascular disease and initial shockable rhythm. This model had an area under the curve (AUC) of 0.89 in the development and 0.83/0.81 in the validation cohorts with good calibration and outperforms the current gold standard-ECG alone (AUC: 0.69/0.67/0/67). CONCLUSIONS A novel simple machine learning-derived algorithm can be applied to patients with OHCA, to predict a culprit coronary artery disease lesion with high accuracy.
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Affiliation(s)
- Nilesh Pareek
- King's College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular and Metabolic Medicine and Sciences, BHF Center of Excellence, King's College London, London, UK
| | - Christopher Frohmaier
- Institute of Cosmology and Gravitation, University of Portsmouth, Portsmouth, UK
- Department of Physics and Astronomy, University of Southampton, Southampton, UK
| | - Mathew Smith
- Department of Physics and Astronomy, University of Southampton, Southampton, UK
| | | | - Antonio Cannata
- King's College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular and Metabolic Medicine and Sciences, BHF Center of Excellence, King's College London, London, UK
| | - Jo Nevett
- London Ambulance Service NHS Trust, London, UK
| | | | - Robert C Nichol
- Institute of Cosmology and Gravitation, University of Portsmouth, Portsmouth, UK
| | - Mark Sullivan
- Department of Physics and Astronomy, University of Southampton, Southampton, UK
| | | | | | - Marko Noc
- Centre for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
| | - Jonathan Byrne
- King's College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular and Metabolic Medicine and Sciences, BHF Center of Excellence, King's College London, London, UK
| | - Philip MacCarthy
- King's College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular and Metabolic Medicine and Sciences, BHF Center of Excellence, King's College London, London, UK
| | - Ajay M Shah
- School of Cardiovascular and Metabolic Medicine and Sciences, BHF Center of Excellence, King's College London, London, UK
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Gentile FR, Baldi E, Klersy C, Schnaubelt S, Caputo ML, Clodi C, Bruno J, Compagnoni S, Fasolino A, Benvenuti C, Domanovits H, Burkart R, Primi R, Ruzicka G, Holzer M, Auricchio A, Savastano S. Association Between Postresuscitation 12-Lead ECG Features and Early Mortality After Out-of-Hospital Cardiac Arrest: A Post Hoc Subanalysis of the PEACE Study. J Am Heart Assoc 2023; 12:e027923. [PMID: 37183852 DOI: 10.1161/jaha.122.027923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Background Once the return of spontaneous circulation after out-of-hospital cardiac arrest is achieved, a 12-lead ECG is strongly recommended to identify candidates for urgent coronary angiography. ECG has no apparent role in mortality risk stratification. We aimed to assess whether ECG features could be associated with 30-day survival in patients with out-of-hospital cardiac arrest. Methods and Results All the post-return of spontaneous circulation ECGs from January 2015 to December 2018 in 3 European centers (Pavia, Lugano, and Vienna) were collected. Prehospital data were collected according to the Utstein style. A total of 370 ECGs were collected: 287 men (77.6%) with a median age of 62 years (interquartile range, 53-70 years). After correction for the return of spontaneous circulation-to-ECG time, age >62 years (hazard ratio [HR], 1.78 [95% CI, 1.21-2.61]; P=0.003), female sex (HR, 1.5 [95% CI, 1.05-2.13]; P=0.025), QRS wider than 120 ms (HR, 1.64 [95% CI, 1.43-1.87]; P<0.001), the presence of a Brugada pattern (HR, 1.49 [95% CI, 1.39-1.59]; P<0.001), and the presence of ST-segment elevation in >1 segment (HR, 1.75 [95% CI, 1.59-1.93]; P<0.001) were independently associated with 30-day mortality. A score ranging from 0 to 26 was created, and by dividing the population into 3 tertiles, 3 classes of risk were found with significantly different survival rate at 30 days (score 0-4, 73%; score 5-7, 66%; score 8-26, 45%). Conclusions The post-return of spontaneous circulation ECG can identify patients who are at high risk of mortality after out-of-hospital cardiac arrest earlier than other forms of prognostication. This provides important risk stratification possibilities in postcardiac arrest care that could help to direct treatments and improve outcomes in patients with out-of-hospital cardiac arrest.
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Affiliation(s)
- Francesca Romana Gentile
- Department of Molecular Medicine, Section of Cardiology University of Pavia Pavia Italy
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Enrico Baldi
- Department of Molecular Medicine, Section of Cardiology University of Pavia Pavia Italy
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Catherine Klersy
- Clinical Epidemiology and Biometry Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | | | | | - Christian Clodi
- Department of Emergency Medicine Medical University of Vienna Wien Austria
| | | | - Sara Compagnoni
- Department of Molecular Medicine, Section of Cardiology University of Pavia Pavia Italy
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Alessandro Fasolino
- Department of Molecular Medicine, Section of Cardiology University of Pavia Pavia Italy
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | | | - Hans Domanovits
- Clinical Epidemiology and Biometry Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | | | - Roberto Primi
- Division of Cardiology Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Gerhard Ruzicka
- Department of Emergency Medicine Medical University of Vienna Wien Austria
| | - Michael Holzer
- Department of Emergency Medicine Medical University of Vienna Wien Austria
| | | | - Simone Savastano
- Division of Cardiology Fondazione IRCCS Policlinico San Matteo Pavia Italy
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11
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Leeper B, Kern KB, Liu S, Sun X. Electrocardiographic Characteristics Fail to Predict Acute Coronary Occlusions in Out-of-Hospital Cardiac-Arrest Patients Without ST-Segment Elevation. Resuscitation 2023; 188:109826. [PMID: 37178897 DOI: 10.1016/j.resuscitation.2023.109826] [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: 02/17/2023] [Revised: 04/05/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND A minority of out-of-hospital cardiac arrest patients have an acutely occluded coronary artery without manifesting ST-segment elevation on their post-resuscitation ECG. Identifying such patients is an issue to providing timely reperfusion therapy. We aimed to evaluate the usefulness of the initial post-resuscitation electrocardiogram in out-of-hospital-cardiac-arrest patients for selection to perform early coronary angiography. METHODS The study population consisted of 74 of the 99 randomized patients from the PEARL clinical trial with both ECG and angiographic data. The purpose of this study was to investigate initial post-resuscitation electrocardiogram findings from out-of-hospital cardiac arrest patients without ST-segment elevation for any association with the presence of acute coronary occlusions. Secondarily, we aimed to observe the distribution of abnormal electrocardiogram findings and survival to hospital discharge of subjects. RESULTS Initial post-resuscitation electrocardiogram findings, including ST-depression, T-wave inversion, bundle branch block, non-specific changes, were not associated with the presence of an acutely occluded coronary. Normal post-resuscitation electrocardiogram findings were associated with patient survival to hospital discharge but were not associated with the presence or absence of an acute coronary occlusion. CONCLUSIONS Electrocardiogram findings cannot exclude or identify the presence of an acutely occluded coronary in out-of-hospital-cardiac-arrest patients without ST-segment elevation. An acutely occluded coronary may be present regardless of normal electrocardiogram findings.
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Affiliation(s)
| | - Karl B Kern
- University of Arizona Sarver Heart Center and
| | - Shen Liu
- College of Public Health, 1501 N. Campbell Avenue, Tucson, Arizona 85724
| | - Xiaoxiao Sun
- College of Public Health, 1501 N. Campbell Avenue, Tucson, Arizona 85724
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12
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Yoshimura S, Kiguchi T, Irisawa T, Yamada T, Yoshiya K, Park C, Nishimura T, Ishibe T, Kobata H, Kishimoto M, Kim SH, Ito Y, Sogabe T, Morooka T, Sakamoto H, Suzuki K, Onoe A, Matsuyama T, Matsui S, Nishioka N, Okada Y, Makino Y, Kimata S, Kawai S, Zha L, Kiyohara K, Kitamura T, Iwami T. Diagnostic test accuracy of life-threatening electrocardiographic findings (ST-elevation myocardial infarction equivalents) for acute coronary syndrome after out-of-hospital cardiac arrest without ST-segment elevation. Resuscitation 2023; 184:109700. [PMID: 36702338 DOI: 10.1016/j.resuscitation.2023.109700] [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: 10/28/2022] [Revised: 01/04/2023] [Accepted: 01/15/2023] [Indexed: 01/25/2023]
Abstract
AIM Life-threatening electrocardiographic (ECG) findings aid in the diagnosis of acute coronary syndrome (ACS), which has not been well-evaluated in patients with out-of-hospital cardiac arrest (OHCA). This study aimed to evaluate the diagnostic test accuracy (DTA) of ST-elevation myocardial infarction (STEMI) equivalents following the return of spontaneous circulation (ROSC) in patients with OHCA to identify patients with ACS. METHODS Using the database of the Comprehensive Registry of In-Hospital Intensive Care for OHCA Survival study from 2012 to 2017, patients aged ≥18 years with non-traumatic OHCA and ventricular fibrillation or pulseless ventricular tachycardia on the arrival of emergency medical service personnel or arrival at the emergency department, who achieved ROSC, were included. Patients without ST-segment elevation or complete left bundle branch block on ECG and those who did not undergo ECG or coronary angiography, were excluded from the study. We evaluated the DTA of STEMI equivalents for the diagnosis of ACS: isolated T-wave inversion, ST-segment depression, Wellens' signs, and ST-segment elevation in lead aVR. RESULTS Isolated T-wave inversion and Wellens' signs had high specificity for ACS with 0.95 (95% confidence interval [CI], 0.87-0.99) and 0.92 (95% CI, 0.82-0.97), respectively, but their positive likelihood ratios were low, with a wide range of 95% CI: 1.89 (95% CI, 0.51-7.02) and 0.81 (95% CI, 0.25-2.68), respectively. CONCLUSION The DTA of STEMI equivalents for the diagnosis of ACS was low among patients with OHCA. Further investigation considering the measurement timing of the ECG after ROSC is required.
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Affiliation(s)
- Satoshi Yoshimura
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Takeyuki Kiguchi
- Critical Care and Trauma Centre, Osaka General Medical Centre, Osaka, Japan
| | - Taro Irisawa
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomoki Yamada
- Emergency and Critical Care Medical Centre, Osaka Police Hospital, Osaka, Japan
| | - Kazuhisa Yoshiya
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Takii Hospital, Moriguchi, Japan
| | - Changhwi Park
- Department of Emergency Medicine, Tane General Hospital, Osaka, Japan
| | - Tetsuro Nishimura
- Department of Critical Care Medicine, Osaka City University, Osaka, Japan
| | - Takuya Ishibe
- Department of Emergency and Critical Care Medicine, Kindai University School of Medicine, Osaka-Sayama, Japan
| | - Hitoshi Kobata
- Osaka Mishima Emergency Critical Care Centre, Takatsuki, Japan
| | - Masafumi Kishimoto
- Osaka Prefectural Nakakawachi Medical Centre of Acute Medicine, Higashi-Osaka, Japan
| | - Sung-Ho Kim
- Senshu Trauma and Critical Care Centre, Osaka, Japan
| | - Yusuke Ito
- Senri Critical Care Medical Centre, Saiseikai Senri Hospital, Suita, Japan
| | - Taku Sogabe
- Traumatology and Critical Care Medical Centre, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Takaya Morooka
- Emergency and Critical Care Medical Centre, Osaka City General Hospital, Osaka, Japan
| | - Haruko Sakamoto
- Department of Pediatrics, Osaka Red Cross Hospital, Osaka, Japan
| | - Keitaro Suzuki
- Emergency and Critical Care Medical Centre, Kishiwada Tokushukai Hospital, Osaka, Japan
| | - Atsunori Onoe
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Matsui
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Norihiro Nishioka
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Yohei Okada
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan; Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Yuto Makino
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Shunsuke Kimata
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Shunsuke Kawai
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan
| | - Ling Zha
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kosuke Kiyohara
- Department of Food Science, Otsuma Women's University, Tokyo, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Taku Iwami
- Department of Preventive Services, Kyoto University School of Public Health, Kyoto, Japan.
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13
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Helber AR, Helfer DR, Ferko AR, Klein DD, Elchediak D, Deaner TS, Slagle D, White WB, Buckler DG, Mitchell OJL, Fiorilli PN, Isenberg DL, Nomura JT, Murphy KA, Sigal A, Saif H, Reihart MJ, Vernon TM, Abella BS. Timing and Outcomes After Coronary Angiography Following Out-of-Hospital Cardiac Arrest Without Signs of ST-Segment Elevation Myocardial Infarction. J Emerg Med 2023; 64:439-447. [PMID: 36997434 DOI: 10.1016/j.jemermed.2023.01.006] [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: 09/06/2022] [Revised: 12/15/2022] [Accepted: 01/06/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND There is broad consensus that resuscitated out-of-hospital cardiac arrest (OHCA) patients with ST-segment elevation myocardial infarction (STEMI) should receive immediate coronary angiography (CAG); however, factors that guide patient selection and optimal timing of CAG for post-arrest patients without evidence of STEMI remain incompletely described. OBJECTIVE We sought to describe the timing of post-arrest CAG in actual practice, patient characteristics associated with decision to perform immediate vs. delayed CAG, and patient outcomes after CAG. METHODS We conducted a retrospective cohort study at seven U.S. academic hospitals. Resuscitated adult patients with OHCA were included if they presented between January 1, 2015 and December 31, 2019 and received CAG during hospitalization. Emergency medical services run sheets and hospital records were analyzed. Patients without evidence of STEMI were grouped and compared based on time from arrival to CAG performance into "early" (≤ 6 h) and "delayed" (> 6 h). RESULTS Two hundred twenty-one patients were included. Median time to CAG was 18.6 h (interquartile range [IQR] 1.5-94.6 h). Early catheterization was performed on 94 patients (42.5%) and delayed catheterization was performed on 127 patients (57.5%). Patients in the early group were older (61 years [IQR 55-70 years] vs. 57 years [IQR 47-65] years) and more likely to be male (79.8% vs. 59.8%). Those in the early group were more likely to have clinically significant lesions (58.5% vs. 39.4%) and receive revascularization (41.5% vs. 19.7%). Patients were more likely to die in the early group (47.9% vs. 33.1%). Among survivors, there was no significant difference in neurologic recovery at discharge. CONCLUSIONS OHCA patients without evidence of STEMI who received early CAG were older and more likely to be male. This group was more likely to have intervenable lesions and receive revascularization.
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Affiliation(s)
- Andrew R Helber
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David R Helfer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aarika R Ferko
- Department of Emergency Medicine, Reading Hospital, Reading, Pennsylvania
| | - Daniel D Klein
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Daniel Elchediak
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Traci S Deaner
- Department of Emergency Medicine, Reading Hospital, Reading, Pennsylvania
| | - Dustin Slagle
- Department of Emergency Medicine, ChristianaCare, Newark, Delaware
| | - William B White
- Department of Pulmonary and Critical Care, Maine Medical Center, Portland, Maine
| | - David G Buckler
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Oscar J L Mitchell
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul N Fiorilli
- Department of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Derek L Isenberg
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Jason T Nomura
- Department of Emergency Medicine, ChristianaCare, Newark, Delaware
| | | | - Adam Sigal
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Emergency Medicine, Reading Hospital, Reading, Pennsylvania
| | - Hassam Saif
- Lehigh Valley Heart and Vascular Institute, Allentown, Pennsylvania
| | - Michael J Reihart
- Department of Emergency Services, Penn State Health, Lancaster Medical Center, Lancaster, Pennsylvania
| | - Tawnya M Vernon
- Penn Medicine Lancaster General Hospital, Lancaster, Pennsylvania
| | - Benjamin S Abella
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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14
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Lazzarin T, Tonon CR, Martins D, Fávero EL, Baumgratz TD, Pereira FWL, Pinheiro VR, Ballarin RS, Queiroz DAR, Azevedo PS, Polegato BF, Okoshi MP, Zornoff L, Rupp de Paiva SA, Minicucci MF. Post-Cardiac Arrest: Mechanisms, Management, and Future Perspectives. J Clin Med 2022; 12:jcm12010259. [PMID: 36615059 PMCID: PMC9820907 DOI: 10.3390/jcm12010259] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Cardiac arrest is an important public health issue, with a survival rate of approximately 15 to 22%. A great proportion of these deaths occur after resuscitation due to post-cardiac arrest syndrome, which is characterized by the ischemia-reperfusion injury that affects the role body. Understanding physiopathology is mandatory to discover new treatment strategies and obtain better results. Besides improvements in cardiopulmonary resuscitation maneuvers, the great increase in survival rates observed in recent decades is due to new approaches to post-cardiac arrest care. In this review, we will discuss physiopathology, etiologies, and post-resuscitation care, emphasizing targeted temperature management, early coronary angiography, and rehabilitation.
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15
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End-tidal carbon dioxide (ETCO2) at intubation and its increase after 10 minutes resuscitation predicts survival with good neurological outcome in out-of-hospital cardiac arrest patients. Resuscitation 2022; 181:197-207. [PMID: 36162612 DOI: 10.1016/j.resuscitation.2022.09.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/07/2022] [Accepted: 09/20/2022] [Indexed: 02/01/2023]
Abstract
AIM To evaluate whether end-tidal carbon dioxide (ETCO2) value at intubation and its early increase (10 min) after intubation predict both the survival to hospital admission and the survival at hospital discharge, including good neurological outcome (CPC 1-2), in patients with out-of-hospital cardiac arrest (OHCA). METHODS All consecutive OHCA patients of any etiology between 2015 and 2018 in Pavia Province (Italy) and Ticino Region (Switzerland) were considered. Patients died before ambulance arrival, with a "do-not-resuscitate" order, without ETCO2 value or with incomplete data were excluded. RESULTS The study population consisted of 668 patients. An ETCO2 value at intubation > 20 mmHg and its increase 10 min after intubation were independent predictors (after correction for known predictors of OHCA outcome) of survival to hospital admission and survival at hospital discharge. Relative to hospital discharge with good neurological outcome, ETCO2 at intubation and its 10-min change were confirmed predictors both individually and in a bivariable analysis (OR 1.83, 95 %CI 1.02-3.3; p = 0.04 and OR 3.9, 95 %CI 1.97-7.74; p < 0.001, respectively). This was confirmed also when accounting for gender, age, etiology and location. After further adjustment for bystander and CPR status, presenting rhythm and EMS arrival time, the ETCO2 change remained an independent predictor. CONCLUSIONS ETCO2 value > 20 mmHg at intubation and its increase during resuscitation improve the prediction of survival at hospital discharge with good neurological outcome of OHCA patients. ETCO2 increase during resuscitation is a more powerful predictor than ETCO2 at intubation. A larger prospective study to confirm this finding appears warranted.
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16
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Pareek N, Rees P, Quinn T, Vopelius-Feldt JV, Gallagher S, Mozid A, Johnson T, Gudde E, Simpson R, Glover G, Davies J, Curzen N, Keeble TR. British Cardiovascular Interventional Society Consensus Position Statement on Out-of-Hospital Cardiac Arrest 1: Pathway of Care. Interv Cardiol 2022; 17:e18. [PMID: 36644626 PMCID: PMC9820135 DOI: 10.15420/icr.2022.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/10/2022] [Indexed: 11/11/2022] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) affects 80,000 patients per year in the UK; despite improvements in care, survival to discharge remains lower than 10%. NHS England and several societies recommend all resuscitated OHCA patients be directly transferred to a cardiac arrest centre (CAC). However, evidence is limited that all patients benefit from transfer to a CAC, and there are significant organisational, logistic and financial implications associated with such change in policies. Furthermore, there is significant variability in interventional cardiovascular practices for OHCA. Accordingly, the British Cardiovascular Interventional Society established a multidisciplinary group to address variability in practice and provide recommendations for the development of cardiac networks. In this position statement, we recommend: the formal establishment of dedicated CACs; a pathway of conveyance to CACs; and interventional practice to standardise our approach. Further research is needed to understand the role of CACs and which interventions benefit patients with OHCA to support wide-scale changes in networks of care across the UK.
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Affiliation(s)
- Nilesh Pareek
- King's College Hospital NHS Foundation TrustLondon, UK,School of Cardiovascular Medicine and Sciences, British Heart Failure Centre of Excellence, King's College LondonLondon, UK
| | - Paul Rees
- Barts Interventional Group, Barts Heart CentreLondon, UK,Academic Department of Military Medicine, Defence Medical ServicesLondon, UK
| | - Tom Quinn
- Emergency, Cardiovascular and Critical Care Research Group, Kingston University and St. George's, University of LondonLondon, UK
| | | | - Sean Gallagher
- Department of Cardiology, University Hospital of WalesCardiff, UK
| | - Abdul Mozid
- Leeds Teaching Hospitals NHS Foundation TrustLeeds, UK
| | - Tom Johnson
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation TrustUK
| | - Ellie Gudde
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
| | - Rupert Simpson
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
| | - Guy Glover
- Intensive Care Unit, Guy's and St Thomas' NHS Foundation TrustLondon, UK
| | - John Davies
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
| | - Nick Curzen
- Faculty of Medicine, University of SouthamptonSouthampton, UK,Cardiothoracic Care Group, University Hospital SouthamptonSouthampton, UK
| | - Thomas R Keeble
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
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17
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Yang N, Han X, Zhang J, Zhang S, Sun J. What can we find in QRS in patients with ST-segment-elevation myocardial infarction? J Electrocardiol 2022. [DOI: 10.1016/j.jelectrocard.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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18
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Kajana V, Baldi E, Gentile FR, Compagnoni S, Quilico F, Vicini Scajola L, Repetto A, Mandurino-Mirizzi A, Ferlini M, Marinoni B, Ferrario Ormezzano M, Primi R, Bendotti S, Currao A, Savastano S. Complete Revascularization and One-Year Survival with Good Neurological Outcome in Patients Resuscitated from an Out-of-Hospital Cardiac Arrest. J Clin Med 2022; 11:jcm11175071. [PMID: 36079003 PMCID: PMC9456720 DOI: 10.3390/jcm11175071] [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: 07/01/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background. The survival benefit of complete versus infarct-related artery (IRA)-only revascularization during the index hospitalization in patients resuscitated from an out-of-hospital cardiac arrest (OHCA) with multivessel disease is unknown. Methods. We considered all the OHCA patients prospectively enrolled in the Lombardia Cardiac Arrest Registry (Lombardia CARe) from 1 January 2015 to 1 May 2021 who underwent coronary angiography (CAG) at the Fondazione IRCCS Policlinico San Matteo (Pavia). Patients’ prehospital, angiographical and survival data were reviewed. Results. Out of 239 patients, 119 had a multivessel coronary disease: 69% received IRA-only revascularization, and 31% received a complete revascularization: 8 during the first procedure and 29 in a staged-procedure after a median time of 5 days [IQR 2.5−10.3]. The complete revascularization group showed significantly higher one-year survival with good neurological outcome than the IRA-only group (83.3% vs. 30.4%, p < 0.001). After correcting for cardiac arrest duration, shockable presenting rhythm, peak of Troponin-I, creatinine on admission and the need for circulatory support, complete revascularization was independently associated with the probability of death and poor neurological outcome [HR 0.3 (95%CI 0.1−0.8), p = 0.02]. Conclusions. This observation study shows that complete myocardial revascularization during the index hospitalization improves one-year survival with good neurological outcome in patients resuscitated from an OHCA with multivessel coronary disease.
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Affiliation(s)
- Vilma Kajana
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
- Humanitas Mater Domini, 21053 Castellanza, Italy
| | - Enrico Baldi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
- Correspondence: ; Tel.: +39-038-2501276
| | - Francesca Romana Gentile
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
- Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy
| | - Sara Compagnoni
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
- Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy
| | - Federico Quilico
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
- Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy
| | - Luca Vicini Scajola
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
- Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy
| | - Alessandra Repetto
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | | | - Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Barbara Marinoni
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | | | - Roberto Primi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Sara Bendotti
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Alessia Currao
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Simone Savastano
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
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19
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Desch S, Thiele H, Freund A. The clinical significance of ischaemic changes on the post-resuscitation electrocardiogram. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:544-545. [PMID: 35731575 DOI: 10.1093/ehjacc/zuac077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Steffen Desch
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at the University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at the University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
| | - Anne Freund
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at the University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
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20
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Hauw-Berlemont C, Lamhaut L, Diehl JL, Andreotti C, Varenne O, Leroux P, Lascarrou JB, Guerin P, Loeb T, Roupie E, Daubin C, Beygui F, Boissier F, Marjanovic N, Christiaens L, Vilfaillot A, Glippa S, Prat JD, Chatellier G, Cariou A, Spaulding C. Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest: Results of the Randomized, Multicentric EMERGE Trial. JAMA Cardiol 2022; 7:700-707. [PMID: 35675081 DOI: 10.1001/jamacardio.2022.1416] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Although an emergency coronary angiogram (CAG) is recommended for patients who experience an out-of-hospital cardiac arrest (OHCA) with ST-segment elevation on the postresuscitation electrocardiogram (ECG), this strategy is still debated in patients without ST-segment elevation. Objective To assess the 180-day survival rate with Cerebral Performance Category (CPC) 1 or 2 of patients who experience an OHCA without ST-segment elevation on ECG and undergo emergency CAG vs delayed CAG. Design, Setting, and Participants The Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest (EMERGE) trial randomly assigned survivors of an OHCA without ST-segment elevation on ECG to either emergency or delayed (48 to 96 hours) CAG in 22 French centers. The trial took place from January 19, 2017, to November 23, 2020. Data were analyzed from November 24, 2020, to July 30, 2021. Main Outcomes and Measures The primary outcome was the 180-day survival rate with CPC of 2 or less. The secondary end points were occurrence of shock, ventricular tachycardia, and/or fibrillation within 48 hours, change in left ventricular ejection fraction between baseline and 180 days, CPC scale at intensive care unit discharge and day 90, survival rate, and hospital length of stay. Results A total of 279 patients (mean [SD] age, 64.7 [14.6] years; 195 men [69.9%]) were enrolled, with 141 (50.5%) in the emergency CAG group and 138 (49.5%) in the delayed CAG group. The study was underpowered. The mean (SD) time delay between randomization and CAG was 0.6 (3.7) hours in the emergency CAG group and 55.1 (37.2) hours in the delayed CAG group. The 180-day survival rates among patients with a CPC of 2 or less were 34.1% (47 of 141) in the emergency CAG group and 30.7% (42 of 138) in the delayed CAG group (hazard ratio [HR], 0.87; 95% CI, 0.65-1.15; P = .32). There was no difference in the overall survival rate at 180 days (emergency CAG, 36.2% [51 of 141] vs delayed CAG, 33.3% [46 of 138]; HR, 0.86; 95% CI, 0.64-1.15; P = .31) and in secondary outcomes between the 2 groups. Conclusions and Relevance In this randomized clinical trial, for patients who experience an OHCA without ST-segment elevation on ECG, a strategy of emergency CAG was not better than a strategy of delayed CAG with respect to 180-day survival rate and minimal neurologic sequelae. Trial Registration ClinicalTrials.gov Identifier: NCT02876458.
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Affiliation(s)
- Caroline Hauw-Berlemont
- Medical Intensive Care Unit, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Lionel Lamhaut
- Paris Cité University, Paris, France.,Service d'Aide Médicale D'Urgence 75, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM U970; Paris Cardiovascular Research Centre, Paris, France
| | - Jean-Luc Diehl
- Medical Intensive Care Unit, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France.,INSERM Unité Mixte de Recherche-S1140, Paris Cité University, Paris, France
| | - Christophe Andreotti
- Service Mobile d'Urgence et de Réanimation, Emergency Department Cochin Hôtel Dieu, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Olivier Varenne
- Interventional Cardiology, Department of Cardiology, Groupe Hospitalier Cochin-Saint Vincent de Paul-Hôtel Dieu, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Pierre Leroux
- Service d'Aide Médicale d' Urgence 44, University Hospital of Nantes, Nantes, France
| | | | - Patrice Guerin
- Unité d'Hémodynamique, L'Institut du Thorax, University Hospital of Nantes, Nantes, France
| | - Thomas Loeb
- Service d'Aide Médicale d'Urgence 92, Hôpitaux Universitaires Paris-Saclay, Site Raymond Poincaré, Garches, France
| | - Eric Roupie
- Service d'Aide Médicale d'Urgence 14, University Hospital of Caen, Caen, France
| | - Cédric Daubin
- Medical Intensive Care Unit, University Hospital of Caen, Caen, France
| | - Farzin Beygui
- Department of Cardiology, University Hospital of Caen, Caen, France
| | - Florence Boissier
- Medical Intensive Care Unit, University Hospital of Poitiers, INSERM CIC 1402, Poitiers University, Poitiers, France
| | - Nicolas Marjanovic
- Service d'Aide Médicale d'Urgence 86, University of Poitiers, Poitiers, France
| | - Luc Christiaens
- Cardiology Department Poitiers University Hospital, University of Poitiers, Poitiers, France
| | - Aurélie Vilfaillot
- INSERM CIC1418 and Département d'Informatique, Biostatistique et Santé Publique, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sophie Glippa
- INSERM CIC1418 and Département d'Informatique, Biostatistique et Santé Publique, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Juliette Djadi Prat
- INSERM CIC1418 and Département d'Informatique, Biostatistique et Santé Publique, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Gilles Chatellier
- INSERM CIC1418 and Département d'Informatique, Biostatistique et Santé Publique, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Paris, France
| | - Christian Spaulding
- Department of Cardiology, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Sudden Cardiac Death Expert Center, INSERM U 971, PARCC, Paris, France
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21
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Chen WT, Tsai MS, Huang CH, Chang WT, Chen WJ. Protocolized Post-Cardiac Arrest Care with Targeted Temperature Management. ACTA CARDIOLOGICA SINICA 2022; 38:391-399. [PMID: 35673335 PMCID: PMC9121749 DOI: 10.6515/acs.202205_38(3).20211220a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/20/2021] [Indexed: 06/15/2023]
Abstract
Improvements in teamwork and resuscitation science have considerably increased the success rate of cardiopulmonary resuscitation. Cerebral injury, myocardial dysfunction, systemic ischemia and reperfusion response, and precipitating pathology after the return of spontaneous circulation (ROSC) constitute post-cardiac arrest syndrome. Because the entire body is involved in cardiac arrest and the early post-arrest period, protocolized post-arrest care consisting of cardiovascular optimization, ventilation and oxygenation adjustment, coronary revascularization, targeted temperature management (TTM), and control of seizures and blood sugar would benefit survival and neurological outcomes. Emergent coronary angiography is suggested for cardiac arrest survivors suspected of having ST-elevation myocardial infarction, however the superiority of culprit or complete revascularization in patients with multivessel coronary lesions remains undetermined. High-quality TTM should be considered for comatose patients who are successfully resuscitated from cardiac arrest, however the optimal target temperature may depend on the severity of their condition. The optimal timing for making prognostication should be no earlier than 72 h after rewarming in TTM patients, and 72 h following ROSC in non-TTM patients. To predict neurological recovery correctly may need the use of several prognostic tools together, including clinical neurological examinations, brain images, neurological studies and biomarkers.
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Affiliation(s)
| | | | | | | | - Wen-Jone Chen
- Department of Emergency Medicine
- Department of Internal Medicine (Cardiology division), National Taiwan University Medical College and Hospital, Taipei, Taiwan
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22
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Helfer DR, Helber AR, Ferko AR, Klein DD, Elchediak D, Deaner TS, Slagle D, White WB, Buckler DG, Mitchell OJL, Fiorilli PN, Isenberg D, Nomura J, Murphy KA, Sigal A, Saif H, Reihart MJ, Vernon TM, Abella BS. Clinical factors associated with significant coronary lesions following out-of-hospital cardiac arrest. Acad Emerg Med 2022; 29:456-464. [PMID: 34767692 DOI: 10.1111/acem.14416] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/31/2021] [Accepted: 11/09/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Out-of-hospital cardiac arrest (OHCA) afflicts >350,000 people annually in the United States. While postarrest coronary angiography (CAG) with percutaneous coronary intervention (PCI) has been associated with improved survival in observational cohorts, substantial uncertainty exists regarding patient selection for postarrest CAG. We tested the hypothesis that symptoms consistent with acute coronary syndrome (ACS), including chest discomfort, prior to OHCAs are associated with significant coronary lesions identified on postarrest CAG. METHODS We conducted a multicenter retrospective cohort study among eight regional hospitals. Adult patients who experienced atraumatic OHCA with successful initial resuscitation and subsequent CAG between January 2015 and December 2019 were included. We collected data on prehospital documentation of potential ACS symptoms prior to OHCA as well as clinical factors readily available during postarrest care. The primary outcome in multivariable regression modeling was the presence of significant coronary lesions (defined as >50% stenosis of left main or >75% stenosis of other coronary arteries). RESULTS Four-hundred patients were included. Median (interquartile range) age was 59 (51-69) years; 31% were female. At least one significant stenosis was found in 62%, of whom 71% received PCI. Clinical factors independently associated with a significant lesion included a history of myocardial infarction (adjusted odds ratio [aOR] = 6.5, [95% confidence interval {CI} = 1.3 to 32.4], p = 0.02), prearrest chest discomfort (aOR = 4.8 [95% CI = 2.1 to 11.8], p ≤ 0.001), ST-segment elevations (aOR = 3.2 [95% CI = 1.7 to 6.3], p < 0.001), and an initial shockable rhythm (aOR = 1.9 [95% CI = 1.0 to 3.4], p = 0.05). CONCLUSIONS Among survivors of OHCA receiving CAG, history of prearrest chest discomfort was significantly and independently associated with significant coronary artery lesions on postarrest CAG. This suggests that we may be able to use prearrest symptoms to better risk stratify patients following OHCA to decide who will benefit from invasive angiography.
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Affiliation(s)
- David R. Helfer
- Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Andrew R. Helber
- Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Aarika R. Ferko
- Department of Emergency Medicine Reading Hospital Reading Pennsylvania USA
| | - Daniel D. Klein
- Lewis Katz School of Medicine Temple University Philadelphia Pennsylvania USA
| | - Daniel S. Elchediak
- Lewis Katz School of Medicine Temple University Philadelphia Pennsylvania USA
| | - Traci S. Deaner
- Department of Emergency Medicine Reading Hospital Reading Pennsylvania USA
| | - Dustin Slagle
- Department of Emergency Medicine ChristianaCare Newark Delaware USA
| | - William B. White
- Department of Emergency Medicine ChristianaCare Newark Delaware USA
| | - David G. Buckler
- Department of Emergency Medicine Icahn School of Medicine at Mount Sinai Mount Sinai New York USA
| | - Oscar J. L. Mitchell
- Department of Emergency Medicine Center for Resuscitation Science University of Pennsylvania Philadelphia Pennsylvania USA
- Division of Pulmonary, Allergy and Critical Care Medicine Department of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Paul N. Fiorilli
- Cardiovascular Division Department of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Derek Isenberg
- Lewis Katz School of Medicine Temple University Philadelphia Pennsylvania USA
| | - Jason Nomura
- Department of Emergency Medicine ChristianaCare Newark Delaware USA
| | | | - Adam Sigal
- Department of Emergency Medicine Reading Hospital Reading Pennsylvania USA
| | - Hassam Saif
- Department of Cardiology Reading Hospital West Reading Pennsylvania USA
| | | | | | - Benjamin S. Abella
- Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Department of Emergency Medicine Center for Resuscitation Science University of Pennsylvania Philadelphia Pennsylvania USA
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23
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Abramson TM, Bosson N, Whitfield D, Gausche-Hill M, Niemann JT. Elevated prehospital point-of-care glucose is associated with worse neurologic outcome after out-of-hospital cardiac arrest. Resusc Plus 2022; 9:100204. [PMID: 35141573 PMCID: PMC8814821 DOI: 10.1016/j.resplu.2022.100204] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/16/2021] [Accepted: 01/08/2022] [Indexed: 11/29/2022] Open
Abstract
Objectives Hyperglycemia is associated with poor outcomes in critically-ill patients. This has implications for prognostication of patients with out-of-hospital cardiac arrest (OHCA) and for post-resuscitation care. We assessed the association of hyperglycemia, on field point-of-care (POC) testing, with survival and neurologic outcome in patients with return of spontaneous circulation (ROSC) after OHCA. Methods This was a retrospective analysis of data in a regional cardiac care system from April 2011 through December 2017 of adult patients with OHCA and ROSC who had a field POC glucose. Patients were excluded if they were hypoglycemic (glucose <60 mg/dl) or received empiric dextrose. We compared hyperglycemic (glucose >250 mg/dL) with euglycemic (glucose 60–250 mg/dL) patients. Primary outcome was survival to hospital discharge (SHD). Secondary outcome was survival with good neurologic outcome (cerebral performance category 1 or 2 at discharge). We determined the adjusted odds ratios (AORs) for SHD and survival with good neurologic outcome. Results Of 9008 patients with OHCA and ROSC, 6995 patients were included; 1941 (28%) were hyperglycemic and 5054 (72%) were euglycemic. Hyperglycemic patients were more likely to be female, of non-White race, and have an initial non-shockable rhythm compared to euglycemic patients (p < 0.0001 for all). Hyperglycemic patients were less likely to have SHD compared to euglycemic survivors, 24.4% vs 32.9%, risk difference (RD) −8.5% (95 %CI −10.8%, −6.2%), p < 0.0001. Hyperglycemic survivors were also less likely to have good neurologic outcome compared to euglycemic survivors, 57.0% vs 64.6%, RD −7.6% (95 %CI −12.9%, −2.4%), p = 0.004. The AOR for SHD was 0.72 (95 %CI 0.62, 0.85), p < 0.0001 and for good neurologic outcome, 0.70 (95 %CI 0.57, 0.86), p = 0.0005. Conclusion In patients with OHCA, hyperglycemia on field POC glucose was associated with lower survival and worse neurologic outcome.
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24
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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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25
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Udi J, Sekandarzad A, Supady A, Biever P, Bode C, Zehender M, Busch HJ, Wengenmayer T, Staudacher DL, Duerschmied D. Coronary angiography following out-of-hospital cardiac arrest (OHCA): a review of outcomes and clinical considerations. Expert Rev Cardiovasc Ther 2021; 19:1045-1051. [PMID: 34860633 DOI: 10.1080/14779072.2021.2013815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION In patients suffering a sudden out-of-hospital cardiac arrest (OHCA), the prevalence of a coronary artery lesion as the underlying cause is relatively high, but many other causes have been described. For this reason, identifying patients who would benefit from an emergency coronary angiography is important. AREAS COVERED In the present manuscript, we reviewed the literature covering some relevant studies regarding the role of coronary angiography in patients with OHCA, including our local algorithm for the management of patients with OHCA. We particularly focused on the selection of patients who would benefit from an emergency coronary angiography, the time period until the performance of the angiography, the role of extracorporeal cardiopulmonary resuscitation (ECPR), the identification of a coronary artery lesion as the underlying cause of cardiac arrest and clinical outcomes. EXPERT OPINION In summary, a local standard algorithm for the management of patients with OHCA appears favorable. An emergency coronary angiography should be advised in patients with a presumed cardiac cause and without obvious non-cardiac cause. A shockable initial rhythm, ST elevation in the post-resuscitation ECG, a previously known coronary artery disease, and ECPR are important predictors of cardiac cause of OHCA.
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Affiliation(s)
- Josefina Udi
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Freiburg Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - Asieb Sekandarzad
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Freiburg Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - Alexander Supady
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Freiburg Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany.,Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Paul Biever
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Freiburg Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Freiburg Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Freiburg Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - Hans-Jörg Busch
- Department of Emergency Medicine, University Hospital of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Freiburg Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Freiburg Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Freiburg Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
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26
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Nehme Z, Stub D. Triage of post-cardiac arrest patients: To PCI or not to PCI, that is the question. Resuscitation 2021; 170:335-338. [PMID: 34822936 DOI: 10.1016/j.resuscitation.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Ziad Nehme
- Centre of Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia; Department of Paramedicine, Monash University, Frankston, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Prahran, Victoria, Australia.
| | - Dion Stub
- Centre of Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Prahran, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Alfred Hospital, Prahran, Victoria, Australia
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27
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Lim SL, Lau YH, Chan MY, Chua T, Tan HC, Foo D, Lim ZY, Liew BW, Shahidah N, Mao DR, Cheah SO, Chia MYC, Gan HN, Leong BSH, Ng YY, Yeo KK, Ong MEH. Early Coronary Angiography Is Associated with Improved 30-Day Outcomes among Patients with Out-of-Hospital Cardiac Arrest. J Clin Med 2021; 10:jcm10215191. [PMID: 34768711 PMCID: PMC8584598 DOI: 10.3390/jcm10215191] [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: 10/21/2021] [Accepted: 11/04/2021] [Indexed: 11/16/2022] Open
Abstract
We evaluated the association between early coronary angiography (CAG) and outcomes in resuscitated out-of-hospital cardiac arrest (OHCA) patients, by linking data from the Singapore Pan-Asian Resuscitation Outcomes Study, with a national registry of cardiac procedures. The 30-day survival and neurological outcome were compared between patients undergoing early CAG (within 1-calender day), versus patients not undergoing early CAG. Inverse probability weighted estimates (IPWE) adjusted for non-randomized CAG. Of 976 resuscitated OHCA patients of cardiac etiology between 2011–2015 (mean(SD) age 64(13) years, 73.7% males), 337 (34.5%) underwent early CAG, of whom, 230 (68.2%) underwent PCI. Those who underwent early CAG were significantly younger (60(12) vs. 66(14) years old), healthier (42% vs. 59% with heart disease; 29% vs. 44% with diabetes), more likely males (86% vs. 67%), and presented with shockable rhythms (69% vs. 36%), compared with those who did not. Early CAG with PCI was associated with better survival and neurological outcome (adjusted odds ratio 1.91 and 1.82 respectively), findings robust to IPWE adjustment. The rates of bleeding and stroke were similar. CAG with PCI within 24 h was associated with improved clinical outcomes after OHCA, without increasing complications. Further studies are required to identify the characteristics of patients who would benefit most from this invasive strategy.
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Affiliation(s)
- Shir Lynn Lim
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore; (M.Y.C.); (H.C.T.)
- Correspondence: ; Tel.: +65-67-723-301
| | - Yee How Lau
- Department of Cardiology, National Heart Centre, Singapore 169609, Singapore; (Y.H.L.); (T.C.); (K.K.Y.)
| | - Mark Y. Chan
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore; (M.Y.C.); (H.C.T.)
| | - Terrance Chua
- Department of Cardiology, National Heart Centre, Singapore 169609, Singapore; (Y.H.L.); (T.C.); (K.K.Y.)
| | - Huay Cheem Tan
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore; (M.Y.C.); (H.C.T.)
| | - David Foo
- Department of Cardiology, Tan Tock Seng Hospital, Singapore 308433, Singapore;
| | - Zhan Yun Lim
- Department of Cardiology, Khoo Teck Puat Hospital, Singapore 768828, Singapore;
| | - Boon Wah Liew
- Department of Cardiology, Changi General Hospital, Singapore 529889, Singapore;
| | - Nur Shahidah
- Department of Emergency Medicine, Singapore General Hospital, Singapore 168753, Singapore; (N.S.); (M.E.H.O.)
| | - Desmond R. Mao
- Department of Acute & Emergency Care, Khoo Teck Puat Hospital, Singapore 768828, Singapore;
| | - Si Oon Cheah
- Emergency Medicine Department, Ng Teng Fong General Hospital, Singapore 609606, Singapore;
| | - Michael Y. C. Chia
- Emergency Department, Tan Tock Seng Hospital, Singapore 308433, Singapore; (M.Y.C.C.); (Y.Y.N.)
| | - Han Nee Gan
- Accident & Emergency, Changi General Hospital, Singapore 529889, Singapore;
| | - Benjamin S. H. Leong
- Emergency Medicine Department, National University Hospital, Singapore 119074, Singapore;
| | - Yih Yng Ng
- Emergency Department, Tan Tock Seng Hospital, Singapore 308433, Singapore; (M.Y.C.C.); (Y.Y.N.)
- Ministry of Home Affairs, Singapore 329560, Singapore
| | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre, Singapore 169609, Singapore; (Y.H.L.); (T.C.); (K.K.Y.)
| | - Marcus E. H. Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore 168753, Singapore; (N.S.); (M.E.H.O.)
- Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore
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28
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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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29
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Compagnoni S, Gentile FR, Baldi E, Contri E, Palo A, Primi R, Currao A, Bendotti S, Ziliani P, Ferrario Ormezzano M, Oltrona Visconti L, Savastano S. Peripheral perfusion index and diagnostic accuracy of the post-ROSC electrocardiogram in patients with medical out-of-hospital cardiac arrest. Resuscitation 2021; 168:19-26. [PMID: 34506876 DOI: 10.1016/j.resuscitation.2021.08.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/29/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
AIM A 12-lead electrocardiogram (ECG) after the return of spontaneous circulation (ROSC) is recommended to diagnose a ST-segment elevation myocardial infarction (STEMI). In the early post-ROSC phase, the ECG can show signs of ischemia not necessarily of coronary origin and post-ROSC hypoperfusion could affect ECG reliability. We sought for an association between peripheral perfusion index (PI) values after ROSC and the percentage of false-positive ECG for STEMI. METHODS We considered all the consecutive patients with sustained ROSC after OHCA, admitted to the Fondazione IRCCS Policlinico San Matteo (Pavia) between January 1st, 2015 and December 31st, 2020. ECGs were defined false-positive if meeting the STEMI criteria but without a critical obstructive coronary artery disease worthy of treatment. The mean value of PI over 30 min-monitoring (MPI30) were calculated. RESULTS Among 351 eligible patients post-ROSC ECG, PI monitoring and an invasive coronary angiography (ICA) were available in 84 cases. The rate of false positive was 16/54 (29.6%) and it differed significantly in the three MPI30 tertiles [T1 (0.2-1): 28.6%; T2 (1.1-2.5): 24.1%; T3 (2.6-6.9): 3.7%, p = 0.04; p for trend = 0.02]. Cardiac arrest duration [OR 1.06 (95 %CI 1-1.1), p = 0.007] and MPI30 [T3 vs T1: OR 0.09 (95 %CI 0.01-0.8), p = 0.03] were significantly associated with the probability of acquiring a false-positive ECG. This association was also confirmed when MPI30 was adjusted for cardiac arrest duration [OR 0.2 (95 %CI 0.1-0.6), p=<0.001]. CONCLUSIONS The rate of false-positive ECG for STEMI after ROSC is related with low perfusion. Our results could help to identify the adequate candidates for an immediate ICA.
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Affiliation(s)
- Sara Compagnoni
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy; Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesca Romana Gentile
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy; Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Enrico Baldi
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy; Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Enrico Contri
- AAT Pavia - Agenzia Regionale Emergenza Urgenza (AREU) c/o Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandra Palo
- AAT Pavia - Agenzia Regionale Emergenza Urgenza (AREU) c/o Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberto Primi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessia Currao
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Sara Bendotti
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paola Ziliani
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy
| | | | | | - Simone Savastano
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
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Abstract
PURPOSE OF REVIEW Early coronary angiogram (CAG) remains a cornerstone in postcardiac arrest management as coronary disease (CAD)-related cardiac arrest is the leading cause of sudden death in adults. The opportunity to treat the cause early on with immediate CAG may improve outcome in cardiac arrest patients with AMI. Identifying the patients who will benefit from such an early invasive strategy is an unanswered question. Recent and ongoing trials may improve the level of evidence on this problematic, especially for some subgroup; however, current guidelines remain founded upon a very heterogeneous level of evidence. RECENT FINDINGS The key variable to argue for immediate CAD remains the pattern of the ECG monitored after return of spontaneous of circulation (ROSC). ST-segment elevation (STE) on postresuscitation ECG is the strongest argument to rule for an early CAG strategy. In other situations, identifying the best candidates for early CAG is very challenging. Different approaches including elements, such as circumstances of cardiac arrest and expected outcomes. may also drive the strategy. SUMMARY This review aims to provide an overview of these different discussion points. The indication for early CAG should rely on multiple factors and an individual approach.
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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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Tabachnikov V, Zissman K, Sliman H, Flugelman MY. Five Hours of Resuscitation With 150 Electrical Shocks and Complete Recovery. Cureus 2021; 13:e14255. [PMID: 33954068 PMCID: PMC8088753 DOI: 10.7759/cureus.14255] [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: 11/20/2022] Open
Abstract
Background: Myocardial ischemia may lead to lethal arrhythmias. Treatment of these arrhythmias without addressing the cause of ischemia may be futile. The length of resuscitation is an important parameter for determining when to stop resuscitation but with shockable rhythms and reversible cause of the cardiac arrest, the decision to terminate resuscitation is complex. Case Summary: A patient with a three-month history of shortness of breath with effort developed pulseless ventricular tachycardia (VT) at the early stages of a stress test. In coronary angiography, a critical lesion in the right coronary artery (RCA) was observed and treated with two stents. During the procedure and for a total of five hours, the patient had more than 100 separate episodes of VT and ventricular fibrillation (VF) that were treated by 150 defibrillations, artificial ventilation, intra-aortic counter-pulsation balloon insertion, and multiple drugs. One hour after the initial stenting procedure, thrombosis of the RCA was demonstrated and treated successfully with angioplasty. Use of procainamide resolved the arrhythmias and the patient recovered completely without neurological deficit, ejection fraction of 45%, and is asymptomatic at one year following the event. Discussion: Our case shows that with a revisable cause of cardiac arrest, resuscitation should be directed at maintaining perfusion of essential organs and treating the reversible cause. Without re-opening the RCA, we could not have saved the patient's life. The use of an extracorporeal membrane oxygenator, if available, should be considered in similar cases. Finally, the quality of cardiopulmonary resuscitation determines the neurological outcome regardless of the length of resuscitation, as was evident in our patient who recovered completely.
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Affiliation(s)
- Rajat Kalra
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis
- Cardiovascular Division, University of Minnesota, Minneapolis
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis
- Cardiovascular Division, University of Minnesota, Minneapolis
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