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Spoormans EM, Lemkes JS, Janssens GN, Soultana O, van der Hoeven NW, Jewbali LSD, Dubois EA, Meuwissen M, Rijpstra TA, Bosker HA, Blans MJ, Bleeker GB, Baak R, Vlachojannis GJ, Eikemans BJW, van der Harst P, van der Horst ICC, Voskuil M, van der Heijden JJ, Beishuizen A, Stoel M, Camaro C, van der Hoeven H, Henriques JP, Vlaar APJ, Vink MA, van den Bogaard B, Heestermans TACM, de Ruijter W, Delnoij TSR, Crijns HJGM, Oemrawsingh PV, Gosselink MTM, Plomp K, Magro M, Elbers PWG, van de Ven PM, van Royen N. Ischaemic electrocardiogram patterns and its association with survival in out-of-hospital cardiac arrest patients without ST-segment elevation myocardial infarction: a COACT trials’ post-hoc subgroup analysis. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:535-543. [PMID: 35656797 PMCID: PMC9302930 DOI: 10.1093/ehjacc/zuac060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/12/2022] [Accepted: 05/16/2022] [Indexed: 11/25/2022]
Abstract
Aims ST-depression and T-wave inversion are frequently present on the post-resuscitation electrocardiogram (ECG). However, the prognostic value of ischaemic ECG patterns is unknown. Methods and results In this post-hoc subgroup analysis of the Coronary Angiography after Cardiac arrest (COACT) trial, the first in-hospital post-resuscitation ECG in out-of-hospital cardiac arrest patients with a shockable rhythm was analysed for ischaemic ECG patterns. Ischaemia was defined as ST-depression of ≥0.1 mV, T-wave inversion in ≥2 contiguous leads, or both. The primary endpoint was 90-day survival. Secondary endpoints were rate of acute unstable lesions, levels of serum troponin-T, and left ventricular function. Of the 510 out-of-hospital cardiac arrest patients, 340 (66.7%) patients had ischaemic ECG patterns. Patients with ischaemic ECG patterns had a worse 90-day survival compared with those without [hazard ratio 1.51; 95% confidence interval (CI) 1.08–2.12; P = 0.02]. A higher sum of ST-depression was associated with lower survival (log-rank = 0.01). The rate of acute unstable lesions (14.5 vs. 15.8%; odds ratio 0.90; 95% CI 0.51–1.59) did not differ between the groups. In patients with ischaemic ECG patterns, maximum levels of serum troponin-T (μg/L) were higher [0.595 (interquartile range 0.243–1.430) vs. 0.359 (0.159–0.845); ratio of geometric means 1.58; 1.13–2.20] and left ventricular function (%) was worse (44.7 ± 12.5 vs. 49.9 ± 13.3; mean difference −5.13; 95% CI −8.84 to −1.42). Adjusted for age and time to return of spontaneous circulation, ischaemic ECG patterns were no longer associated with survival. Conclusion Post-arrest ischaemic ECG patterns were associated with worse 90-day survival. A higher sum of ST-depression was associated with lower survival. Adjusted for age and time to return of spontaneous circulation, ischaemic ECG patterns were no longer associated with survival.
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Affiliation(s)
- Eva M Spoormans
- Department of Cardiology, Amsterdam University Medical Centre , location VUmc, ZH 5F 19, De Boelelaan 1117, 1081 HV Amsterdam , The Netherlands
| | - Jorrit S Lemkes
- Department of Cardiology, Amsterdam University Medical Centre , location VUmc, ZH 5F 19, De Boelelaan 1117, 1081 HV Amsterdam , The Netherlands
| | - Gladys N Janssens
- Department of Cardiology, Amsterdam University Medical Centre , location VUmc, ZH 5F 19, De Boelelaan 1117, 1081 HV Amsterdam , The Netherlands
| | - Ouissal Soultana
- Department of Cardiology, Amsterdam University Medical Centre , location VUmc, ZH 5F 19, De Boelelaan 1117, 1081 HV Amsterdam , The Netherlands
| | - Nina W van der Hoeven
- Department of Cardiology, Amsterdam University Medical Centre , location VUmc, ZH 5F 19, De Boelelaan 1117, 1081 HV Amsterdam , The Netherlands
| | - Lucia S D Jewbali
- Department of Cardiology, Erasmus Medical Centre , Rotterdam , The Netherlands
| | - Eric A Dubois
- Department of Cardiology, Erasmus Medical Centre , Rotterdam , The Netherlands
- Department of Intensive Care Medicine, Erasmus Medical Centre , Rotterdam , The Netherlands
| | | | - Tom A Rijpstra
- Department of Intensive Care Medicine, Amphia Hospital , Breda , The Netherlands
| | - Hans A Bosker
- Department of Cardiology, Rijnstate Hospital , Arnhem , The Netherlands
| | - Michiel J Blans
- Department of Intensive Care Medicine, Rijnstate Hospital , Arnhem , The Netherlands
| | - Gabe B Bleeker
- Department of Cardiology, HAGA Hospital , Den Haag , The Netherlands
| | - Remon Baak
- Department of Intensive Care Medicine, HAGA Hospital , Den Haag , The Netherlands
| | - Georgios J Vlachojannis
- Department of Cardiology, Maasstad Hospital , Rotterdam , The Netherlands
- Department of Cardiology, University Medical Centre Utrecht , Utrecht , The Netherlands
| | - Bob J W Eikemans
- Department of Intensive Care Medicine, Maasstad Hospital , Rotterdam , The Netherlands
| | - Pim van der Harst
- Department of Cardiology, University Medical Centre Utrecht , Utrecht , The Netherlands
- Department of Cardiology, University of Groningen, University Medical Centre Groningen , Groningen , The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, University of Groningen, University Medical Centre Groningen , Groningen , The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Centre, University Maastricht , Maastricht , The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Centre Utrecht , Utrecht , The Netherlands
| | - Joris J van der Heijden
- Department of Intensive Care Medicine, University Medical Centre Utrecht , Utrecht , The Netherlands
| | | | - Martin Stoel
- Department of Cardiology, Medisch Spectrum Twente , Enschede , The Netherlands
| | - Cyril Camaro
- Department of Cardiology, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Hans van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - José P Henriques
- Department of Cardiology, Amsterdam University Medical Centre , location AMC, Amsterdam , The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Centre , location AMC, Amsterdam , The Netherlands
| | - Maarten A Vink
- Department of Cardiology, OLVG , Amsterdam , The Netherlands
| | | | | | - Wouter de Ruijter
- Department of Intensive Care Medicine, Noord West Ziekenhuisgroep , Alkmaar , The Netherlands
| | - Thijs S R Delnoij
- Department of Intensive Care Medicine, Maastricht University Medical Centre, University Maastricht , Maastricht , The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre , Maastricht , The Netherlands
| | | | | | - Koos Plomp
- Department of Cardiology, Tergooi Hospital , Blaricum , The Netherlands
| | - Michael Magro
- Department of Cardiology, Elisabeth-Tweesteden Hospital , Tilburg , The Netherlands
| | - Paul W G Elbers
- Department of Intensive care medicine, Amsterdam University Medical Centre , location VUmc, Amsterdam , The Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre , location VUmc, Amsterdam , The Netherlands
| | - Niels van Royen
- Department of Cardiology, Amsterdam University Medical Centre , location VUmc, ZH 5F 19, De Boelelaan 1117, 1081 HV Amsterdam , The Netherlands
- Department of Cardiology, Radboud University Medical Centre , Nijmegen , The Netherlands
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Sharma A, Miranda DF, Rodin H, Bart BA, Smith SW, Shroff GR. Interobserver Variability Among Experienced Electrocardiogram Readers To Diagnose Acute Thrombotic Coronary Occlusion In Patients with Out of Hospital Cardiac Arrest: Impact of Metabolic Milieu and Angiographic Culprit. Resuscitation 2022; 172:24-31. [PMID: 35041876 DOI: 10.1016/j.resuscitation.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/18/2021] [Accepted: 01/06/2022] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We sought to evaluate interobserver concordance among experienced electrocardiogram (ECG) readers in predicting acute thrombotic coronary occlusion (ATCO) in the context of abnormal metabolic milieu (AMM) following resuscitated out of hospital cardiac arrest (OHCA). METHODS OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA) were included. AMM was defined as one of: pH < 7.1, lactate > 2 mmol/L, serum potassium < 2.8 or > 6.0 mEq/L. The initial ECG following ROSC but prior to ICA was adjudicated by 2 experienced readers using classic ST elevation myocardial infarction [STEMI] and expanded criteria and their combination to predict ATCO on ICA. RESULTS 152 consecutive patients (mean age 58 years, 76% male) met inclusion criteria. AMM was present in 77%; and 42% had ATCO on ICA. Sensitivity, specificity, PPV, NPV using classic STEMI criteria were 50%, 98%, 94%, 72% (c-statistic 0.74); whereas for combined (STEMI + expanded) criteria they were 69%, 88%, 81%, 79% respectively (c-statistic 0.79). Inter-observer agreement (kappa) was 0.7 for classic STEMI criteria, and 0.66 for combined criteria. Agreement between readers was consistently higher when ATCO was absent and with NMM (kappa 0.78), but lower in AMM (kappa 0.6). CONCLUSIONS Despite experienced ECG readers, there was only modest overall concordance in predicting ATCO in the context of resuscitated OHCA. Significant interobserver variations were noted dependent on metabolic milieu and angiographic ATCO. These observations fundamentally question the role of the 12-lead ECG as primary triaging tool for early angiography among patients with OHCA.
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Affiliation(s)
- Amit Sharma
- Regions Hospital, St. Paul, MN, United States
| | - David F Miranda
- CentraCare Heart and Vascular Center, St. Cloud, United States
| | - Holly Rodin
- Analytic Center of Excellence, Hennepin Healthcare System, HCMC, Minneapolis, MN, United States.
| | - Bradley A Bart
- Division of Cardiology, Department of Medicine, Veterans Affairs Medical Center and University of Minnesota Medical School, Minneapolis, MN, United States.
| | - Stephen W Smith
- Emergency Department, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, United States.
| | - Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, United States.
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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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