Limited External Applicability of the COACT and TOMAHAWK Trials: A Multicenter Study

Early coronary angioplasty fails to lower all-cause mortality in patients with out-of-hospital cardiac arrest without ST-segment elevation: A systematic review and meta-analysis

Introduction

Out-of-hospital cardiac arrest (OHCA) is defined as the loss of functional mechanical activity of the heart in association with an absence of systemic circulation, occurring outside of a hospital. Immediate coronary angiography (CAG) with percutaneous coronary intervention is recommended for OHCA with ST-elevation. We aimed to evaluate the effect of early CAG on mortality and neurological outcomes in OHCA patients without ST-elevation.

Methods

This meta-analysis and systemic review was conducted as per principles of Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) group. A protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO, Ref No. = CRD42022327833). A total of 674 studies were retrieved after scanning several databases (PubMed Central, EMBASE, Medline, and Cochrane Central Register of Controlled Trials).

Results

A total of 18 studies were selected for the final analysis, including 6 randomized control trials and 12 observational studies. Statistically, there was no significant difference in primary outcome, i.e., mortality, between early and delayed CAG. In terms of the grade of neurological recovery as a secondary outcome, early and delayed CAG groups also showed no statistically significant difference.

Conclusion

Early CAG has no survival benefits in patients with no ST elevations on ECG after OHCA.

Indications for Cardiac Catheterization and Percutaneous Coronary Intervention in Patients with Resuscitated Out-of-Hospital Cardiac Arrest

PURPOSE OF REVIEW

The role of emergent cardiac catheterization after resuscitated out-of-hospital cardiac arrest (OHCA) has evolved based on recent randomized evidence. This review aims to discuss the latest evidence and current indications for emergent coronary angiography (CAG) and mechanical circulatory support (MCS) use following OHCA.

RECENT FINDINGS

In contrast to previous observational data, recent RCTs evaluating early CAG in resuscitated OHCA patients without ST elevation have uniformly demonstrated a lack of benefit in terms of survival or neurological outcome. There is currently no randomized evidence supporting MCS use specifically in patients with resuscitated OHCA and cardiogenic shock. Urgent CAG should be considered in all patients with ST elevation, recurrent electrical or hemodynamic instability, those who are awake following resuscitated OHCA, and those receiving extracorporeal cardiopulmonary resuscitation (ECPR). Recent evidence suggests that CAG may be safely delayed in hemodynamically stable patients without ST-segment elevation following resuscitated OHCA.

British Cardiovascular Interventional Society Consensus Position Statement on Out-of-Hospital Cardiac Arrest 1: Pathway of Care

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.