Therapeutic hypothermia and coronary angiography are mandatory after out-of-hospital cardiac arrest: Yes

Targeted Temperature Management for In-Hospital Cardiac Arrest: 6 Years of Experience

Targeted temperature management (TTM) is widely used for postcardiac arrest management of patients with out-of-hospital cardiac arrest. However, the use of TTM for patients with in-hospital cardiac arrest (IHCA) is controversial. The aim of this study was to investigate the role of TTM in the management of patients with IHCA. The medical records of all IHCA patients who were resuscitated and returned to spontaneous circulation from January 2011 to December 2016 were reviewed. After excluding patients with new do not resuscitate orders and those who died within 24 hours, 262 patients were eligible for analysis. Thirty-five of the 262 patients (13.3%) received TTM after IHCA. Patients who received TTM and standard supportive care (SSC) had similar baseline epidemiological status. The TTM patients were older and had a longer cardiac pulmonary resuscitation duration; however, the differences were not statistically significant. The 28-day survival rate was not significantly different between groups (12/35 in the TTM group [34%] vs. 114/225 in the SSC group [50%], p = 0.079). In the patients with good neurological status before arrest (Glasgow-Pittsburgh cerebral performance category [GP-CPC] scores: 1-2), there was no significant difference in the 28-day survival between groups (11/26 in the TTM group [42.3%] vs. 81/154 [52.6%] in the SSC group; p = 0.332). In this subgroup, the TTM patients had poorer neurological outcomes at discharge (GP-CPC score 1-2) than the SSC patients (1/26 in the TTM group [3.8%] vs. 57/154 in the SSC group [37%]; p = 0.001). TTM was not associated with better 28-day survival than usual care among the patients with IHCA in this study, and the TTM patients had less favorable neurological outcomes at discharge. Randomized clinical trials are needed to assess the efficacy of TTM for IHCA patients.

Hyperglycemia Alters Expression of Cerebral Metabolic Genes after Cardiac Arrest

BACKGROUND

Survivors of cardiac arrest often experience neurologic deficits. To date, treatment options are limited. Associated hyperglycemia is believed to further worsen the neurologic outcome. The aim with this study was to characterize expression pathways induced by hyperglycemia in conjunction with global brain ischemia.

METHODS

Pigs were randomized to high or normal glucose levels, as regulated by glucose and insulin infusions with target levels of 8.5-10 mM and 4-5.5 mM, respectively. The animals were subjected to 5-minute cardiac arrest followed by 8 minutes of cardiopulmonary resuscitation and direct-current shock to restore spontaneous circulation. Global expression profiling of the cortex using microarrays was performed in both groups.

RESULTS

A total of 102 genes differed in expression at P < .001 between the hyperglycemic and the normoglycemic pigs. Several of the most strongly differentially regulated genes were involved in transport and metabolism of glucose. Functional clustering using bioinformatics tools revealed enrichment of multiple biological processes, including membrane processes, ion transport, and glycoproteins.

CONCLUSIONS

Hyperglycemia during cardiac arrest leads to differential early gene expression compared with normoglycemia. The functional relevance of these expressional changes cannot be deduced from the current study; however, the identified candidates have been linked to neuroprotective mechanisms and constitute interesting targets for further studies.

Immediate coronary angiography in survivors of out-of-hospital cardiac arrest without obvious extracardiac cause: Who benefits?

BACKGROUND

Immediate coronary angiography (iCA) and primary percutaneous coronary angioplasty (pPCI) in patients successfully resuscitated after out-of-hospital cardiac arrest (OHCA) of suspected cardiac cause is controversial. Our aims were to assess the results of iCA, the prognostic impact of pPCI after OHCA, and to identify subgroups most likely to benefit from this strategy.

METHODS

In this single-centre retrospective study, patients aged ≥18 years with sustained return of spontaneous circulation after OHCA and no evidence of a non-cardiac cause underwent routine iCA at admission, with pPCI if indicated. Results of iCA, and factors associated with in-hospital survival were analysed.

RESULTS

Between 2006 and 2013, 160 survivors from OHCA presumed of cardiac origin were included (median age, 60 years; 85% males). iCA showed significant coronary-artery lesions in 75% of patients, and acute occlusion or unstable lesion in only 41%. pPCI was performed in 34% of patients and was not associated with survival by univariate or multivariate analysis (P=0.67). ST-segment elevation predicted acute coronary occlusion in 40%. An initial shockable rhythm was associated with higher in-hospital survival (52% vs. 19%; P<0.001). After initial defibrillation, the first rhythm recorded by 12-lead electrocardiography was highly associated with prognosis: secondary asystole had a very low survival rate (5%, 1/21) despite PCI in 43% of patients, compared to sustained ventricular tachycardia/fibrillation (42%, 15/36) and supraventricular rhythm (71%, 50/70) (P<0.001).

CONCLUSIONS

In our experience, the prevalence of acute coronary occlusion or unstable lesion immediately after OHCA of likely cardiac cause is only 41%. Immediate CA in OHCA survivors, with pPCI if indicated, should be restricted to highly selected patients.

Post-Resuscitation ECG for Selection of Patients for Immediate Coronary Angiography in Out-of-Hospital Cardiac Arrest

BACKGROUND

We aimed to investigate coronary angiographic findings in unselected out-of-hospital cardiac arrest patients referred to immediate coronary angiography (ICA) irrespective of their first postresuscitation ECG and to determine whether this ECG is useful to select patients with no need of ICA.

METHODS AND RESULTS

All resuscitated patients admitted after out-of-hospital cardiac arrest without a clear noncardiac cause underwent ICA. Patients were retrospectively grouped according to the postresuscitation ECG blinded for ICA results: (1) ST elevation or presumably new left bundle branch block, (2) other ECG signs indicating myocardial ischemia, and (3) no ECG signs indicating myocardial ischemia. All coronary angiograms were reevaluated blinded for postresuscitation ECGs. Two hundred and ten patients were included with mean age 62±12 years. Six-months survival with good neurological outcome was 54%. Reduced Thrombolysis in Myocardial Infarction flow (0-2) was found in 55%, 34%, and 18% and a ≥90% coronary stenosis was present in 25%, 27%, and 19% of patients in group 1, 2, and 3, respectively. An acute coronary occlusion was found in 11% of patients in group 3. ST elevation/left bundle branch block identified patients with reduced Thrombolysis in Myocardial Infarction (0-2) flow with 70% sensitivity and 62% specificity. Among patients with initial nonshockable rhythms (24%), 32% had significantly reduced Thrombolysis in Myocardial Infarction flow.

CONCLUSIONS

Initial ECG findings are not reliable in detecting patients with an indication for ICA after experiencing a cardiac arrest. Even in the absence of ECG changes indicating myocardial ischemia, an acute culprit lesion may be present and patients may benefit from emergent revascularization. CLINICAL TRIAL REGISTRATIONURL: http://www.clinicaltrials.gov. Unique identifier: NCT01239420.