Cardiac catheterization is associated with superior outcomes for survivors of out of hospital cardiac arrest: Review and meta-analysis

Post-resuscitation care of patients with return of spontaneous circulation after out-of-hospital cardiac arrest at the emergency department

INTRODUCTION

Out-of-hospital-cardiac-arrest (OHCA) is a major public health challenge and post-return-of-spontaneous-circulation (ROSC) goals have shifted from just survival to survival with intact neurology. Although post-ROSC care is crucial for survival with intact neurology, there are insufficient well-established protocols for post-resuscitation care. We aimed to evaluate post-resuscitation care in the emergency department (ED) of adult (aged ≥16 years) OHCA patients with sustained ROSC and its associated neurologically intact survival.

METHODS

A retrospective review of electronic medical records was conducted for OHCA patients with sustained ROSC at the ED. Data including demographics, pre-hospital resuscitation, ED resuscitation, post-resuscitation care and eventual outcomes were analysed.

RESULTS

Among 921 OHCA patients, 85 (9.2%) had sustained ROSC at the ED. Nineteen patients (19/85, 22.4%) survived, with 13 (13/85, 15.3%) having intact neurology at discharge. Electrocardiogram and chest X-ray were performed in all OHCA patients, whereas computed tomography (CT) was performed inconsistently, with CT brain being most common (74/85, 87.1%), while CT pulmonary angiogram (6/85, 7.1%), abdomen and pelvis (4/85, 4.7%) and aortogram (2/85, 2.4%) were done infrequently. Only four patients (4.7%) had all five neuroprotective goals of normoxia, normocarbia, normotension, normothermia and normoglycaemia achieved in the ED. The proportion of all five neuroprotective goals being met was significantly higher ( P = 0.01) among those with neurologically intact survival (3/13, 23.1%) than those without (1/72, 1.4%).

CONCLUSION

Post-resuscitation care at the ED showed great variability, indicating gaps between recommended guidelines and clinical practice. Good quality post-resuscitation care, centred around neuroprotection goals, must be initiated promptly to achieve meaningful survival with intact neurology.

Post-Cardiac Arrest Care in Adult Patients After Extracorporeal Cardiopulmonary Resuscitation

OBJECTIVES

Extracorporeal cardiopulmonary resuscitation (ECPR) serves as a lifesaving intervention for patients experiencing refractory cardiac arrest. With its expanding usage, there is a burgeoning focus on improving patient outcomes through optimal management in the acute phase after cannulation. This review explores systematic post-cardiac arrest management strategies, associated complications, and prognostication in ECPR patients.

DATA SOURCES

A PubMed search from inception to 2023 using search terms such as post-cardiac arrest care, ICU management, prognostication, and outcomes in adult ECPR patients was conducted.

STUDY SELECTION

Selection includes original research, review articles, and guidelines.

DATA EXTRACTION

Information from relevant publications was reviewed, consolidated, and formulated into a narrative review.

DATA SYNTHESIS

We found limited data and no established clinical guidelines for post-cardiac arrest care after ECPR. In contrast to non-ECPR patients where systematic post-cardiac arrest care is shown to improve the outcomes, there is no high-quality data on this topic after ECPR. This review outlines a systematic approach, albeit limited, for ECPR care, focusing on airway/breathing and circulation as well as critical aspects of ICU care, including analgesia/sedation, mechanical ventilation, early oxygen/C o2 , and temperature goals, nutrition, fluid, imaging, and neuromonitoring strategy. We summarize common on-extracorporeal membrane oxygenation complications and the complex nature of prognostication and withdrawal of life-sustaining therapy in ECPR. Given conflicting outcomes in ECPR randomized controlled trials focused on pre-cannulation care, a better understanding of hemodynamic, neurologic, and metabolic abnormalities and early management goals may be necessary to improve their outcomes.

CONCLUSIONS

Effective post-cardiac arrest care during the acute phase of ECPR is paramount in optimizing patient outcomes. However, a dearth of evidence to guide specific management strategies remains, indicating the necessity for future research in this field.

Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors

As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.

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.

Early versus deferred coronary angiography following cardiac arrest. A systematic review and meta-analysis

Aim

The role of early coronary angiography (CAG) in the evaluation of patients presenting with out of hospital cardiac arrest (OHCA) and no ST-elevation myocardial infarction (STE) pattern on electrocardiogram (ECG) has been subject to considerable debate. We sought to assess the impact of early versus deferred CAG on mortality and neurological outcomes in patients with OHCA and no STE.

Methods

OVID MEDLINE, EMBASE, Web of Science and Cochrane Library Register were searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines from inception until July 18, 2022. Randomized clinical trials (RCTs) of patients with OHCA without STE that compared early CAG with deferred CAG were included. The primary endpoint was 30-day mortality. Secondary endpoints included mortality at discharge or 30-days, favourable neurology at 30-days, major bleeding, renal failure and recurrent cardiac arrest.

Results

Of the 7,998 citations, 5 RCTs randomizing 1524 patients were included. Meta-analysis showed no difference in 30-day mortality with early versus deferred CAG (OR 1.17, CI 0.91 - 1.49, I² = 27%). There was no difference in favourable neurological outcome at 30 days (OR 0.88, CI 0.52 - 1.49, I² = 63%), major bleeding (OR 0.94, CI 0.33 - 2.68, I² = 39%), renal failure (OR 1.14, CI 0.77 - 1.69, I² = 0%), and recurrent cardiac arrest (OR 1.39, CI 0.79 - 2.43, I² = 0%).

Conclusions

Early CAG was not associated with improved survival and neurological outcomes among patients with OHCA without STE. This meta-analysis does not support routinely performing early CAG in this select patient cohort.

Intracoronary imaging in addition to coronary angiography for patients with out-of-hospital cardiac arrest: More information for better care?

About 70% of out-of-hospital cardiac arrests are related to an ischaemic heart disease in Western countries. Percutaneous coronary intervention has been shown to improve the prognosis of survivors when an unstable coronary lesion is identified as the potential cause of the cardiac arrest. Acute complete coronary occlusion is often demonstrated among patients with ST-segment elevation on electrocardiogram after the return of spontaneous circulation. In patients without ST-segment elevation, routine coronary angiography has been shown to be not superior to conservative management. However, an electrocardiogram-based decision to perform immediate coronary angiography could be insufficient to identify unstable coronary lesions, which are frequently associated with intermediate coronary stenosis. Intracoronary imaging can be helpful to detect plaque rupture or erosion and intracoronary thrombus, but could also lead to better stent implantation, and help to reduce the risk of stent thrombosis. In patients with coronary lesions without the instability characteristic, conservative management should be the default strategy, and a search for another cause of the cardiac arrest should be systematic. In the present review, we sought to describe the potential benefit of intracoronary imaging in patients with out-of-hospital cardiac arrest.

Coronary angiography in patients without ST-segment elevation following out-of-hospital cardiac arrest. COUPE clinical trial

INTRODUCTION AND OBJECTIVES

The role of emergency coronary angiography (CAG) and percutaneous coronary intervention (PCI) following out-of-hospital cardiac arrest (OHCA) in patients without ST-segment elevation myocardial infarction (STEMI) remains unclear. We aimed to assess whether emergency CAG and PCI would improve survival with good neurological outcome in this population.

METHODS

In this multicenter, randomized, open-label, investigator-initiated clinical trial, we randomly assigned 69 survivors of OHCA without STEMI to undergo immediate CAG or deferred CAG. The primary efficacy endpoint was a composite of in-hospital survival free of severe dependence. The safety endpoint was a composite of major adverse cardiac events including death, reinfarction, bleeding, and ventricular arrhythmias.

RESULTS

A total of 66 patients were included in the primary analysis (95.7%). In-hospital survival was 62.5% in the immediate CAG group and 58.8% in the delayed CAG group (HR, 0.96; 95%CI, 0.45-2.09; P=.93). In-hospital survival free of severe dependence was 59.4% in the immediate CAG group and 52.9% in the delayed CAG group (HR, 1.29; 95%CI, 0.60-2.73; P=.4986). No differences were found in the secondary endpoints except for the incidence of acute kidney failure, which was more frequent in the immediate CAG group (15.6% vs 0%, P=.002) and infections, which were higher in the delayed CAG group (46.9% vs 73.5%, P=.003).

CONCLUSIONS

In this underpowered randomized trial involving patients resuscitated after OHCA without STEMI, immediate CAG provided no benefit in terms of survival without neurological impairment compared with delayed CAG.

CLINICALTRIALS

gov Identifier: NCT02641626.

Extracorporeal cardiopulmonary resuscitation location, coronary angiography and survival in out-of-hospital cardiac arrest

INTRODUCTION

The best location for safe and timely implementation of extracorporeal cardiopulmonary resuscitation (ECPR) is currently uncertain. We aimed to evaluate the association between the location of ECPR and survival outcomes in out-of-hospital cardiac arrest (OHCA) patients. We also evaluated whether the effects of ECPR location on survival differed between patients who underwent coronary angiography (CAG) and those who did not.

METHODS

We used data collected between 2013 and 2020 from a nationwide OHCA database. Adult OHCA patients with presumed cardiac etiology who underwent ECPR were included in the study. The primary outcome was survival to discharge. The main exposure was the ECPR location (emergency department [ED] or cardiac catheterization laboratory [Cath lab]). We compared primary outcomes of ECPR between the ED and Cath lab using multivariable logistic regression. The interaction between ECPR location and CAG was also evaluated.

RESULTS

Of 564 ECPR patients, 448 (79.4%) and 116 (20.6%) underwent ECPR in the ED and Cath lab, respectively. CAG was observed in 52.5% and 72.4% of the patients in the ED and Cath lab groups, respectively. There were no significant differences in survival to discharge between the ED and Cath lab groups (14.1% vs. 12.9%, p = 0.75, adjusted odds ratio [AOR] [95% confidence interval] 1.87 [0.85-4.11]). AOR of interaction analysis (95% CI) for survival to discharge of the ED group was 2.34 (1.02-5.40) in patients with CAG and 0.28 (0.04-1.84) in patients without CAG (p for interaction was 0.04).

CONCLUSION

In adult OHCA patients who underwent ECPR and CAG, ECPR in the ED shortened time to ECMO pump-on time and increased survival to discharge compared to ECPR in the Cath lab.

Post-Cardiac Arrest: Mechanisms, Management, and Future Perspectives

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.

Sex and out-of-hospital cardiac arrest survival: a systematic review

BACKGROUND

The literature is unresolved on whether female receive advanced cardiac life support less than do male and on whether female have a survival advantage over male after cardiopulmonary resuscitation.

METHODS

We systematically searched PubMed, Embase and Web of Science databases (from inception to 23-April-2022) for papers reporting outcomes in adult male and female after out-of-hospital cardiac arrest. The main study outcome was the rate of adjusted survival to hospital discharge or 30 days. Secondary outcomes included unadjusted survival to hospital discharge and favourable neurological outcome.

RESULTS

A total of 28 studies were included, involving 1,931,123 patients. Female were older than male, their cardiac arrests were less likely to be witnessed and less likely to present with a shockable rhythm. Unadjusted analysis showed that females had a lower likelihood of survival than males (OR 0.68 [0.62-0.74], I2 = 97%). After adjustment, no significant difference was identified between male and female in survival at hospital discharge/30 days (OR 1.01 [0.93-1.11], I2 = 87%). Data showed that male had a significantly higher likelihood of favorable neurological outcome in unadjusted analysis but this trend disappeared after adjustment. Both the primary outcome (adjusted for several variables) and the secondary outcomes were associated with substantial heterogeneity. The variables examined using meta-regression, subgroup and sensitivity analyses (i.e., study type, location, years, population, quality of adjustment, risk of bias) did not reduce heterogeneity.

CONCLUSIONS

The adjusted rate of survival to hospital discharge/30 days was similar for male and female despite an initial seeming survival advantage for male. The validity of this finding is limited by substantial heterogeneity despite in-depth investigation of its causes, which raises concerns regarding latent inequalities in some reports nonetheless. Further study on this topic may require inclusion of factors not reported in the Utstein template and in-depth analysis of decision-making processes.

The Impact of Prehospital and Hospital Care on Clinical Outcomes in Out-of-Hospital Cardiac Arrest

Background: In recent years, several actions have been made to shorten the chain of survival in out-of-hospital cardiac arrest (OHCA). These include placing defibrillators in public places, training first responders, and providing dispatcher-assisted CPR (DA-CPR). In this work, we aimed to evaluate the impact of these changes on patients' outcomes, including achieving return of spontaneous circulation (ROSC), survival to discharge, and survival with favorable neurological function. Methods: We retrospectively retrieved data of all calls to the national emergency medical service in Ashdod city, Israel, of individuals who underwent OHCA at the age of 18 and older between the years 2018 and 2021. Data was collected on prehospital and hospital interventions. The association between pre-hospital and hospital interventions to ROSC, survival to discharge, and neurological outcomes was evaluated. Logistic regression was used for multivariable analysis. Results: During the years 2018-2021, there were 1253 OHCA cases in the city of Ashdod. ROSC was achieved in 207 cases (32%), survival to discharge was attained in 48 cases (7.4%), and survival with favorable neurological function was obtained in 26 cases (4%). Factors significantly associated with good prognosis were shockable rhythm, witnessed arrest, DA-CPR, use of AED, and treatment for STEMI. All patients that failed to achieve ROSC outside of the hospital setting had a poor prognosis. Conclusions: This study demonstrates the prognostic role of the initial rhythm and the use of AED in OHCA. Hospital management, including STEMI documentation and catheterization, was also an important prognostication factors. Additionally, when ROSC is not achieved in the field, hospital transfer should be considered.

The impact of lesion complexity on predicting mortality of coronary artery disease patients after out-of-hospital cardiac arrest

INTRODUCTION

Coronary artery disease (CAD) is the most frequent cause of out-of-hospital cardiac arrest (OHCA). Nevertheless, there have been limited studies focusing on the impact of lesion complexity on resuscitated CAD patients. The purpose of the present study was to investigate the association between coronary lesion complexity and the mortality of CAD patients after OHCA.

METHODS

From pooled database of two centers, which comprised 706 successfully resuscitated OHCA patients, 172 patients undergoing coronary angiography were retrospectively investigated. A total of 148 patients exhibited coronary stenosis on angiogram and were included in the final analysis. Baseline characteristics, pre-and post-hospital care, general status after resuscitation and angiographical findings were compared between the patients who deceased within 30 days and those who survived and the predictors of 30-day mortality were determined.

RESULTS

Ninety-four patients (63.5%) survived at 30 days. Bystander cardiopulmonary resuscitation (CPR) (Odds ratio (OR) 0.36; 95% confidence interval (CI) 0.14-0.96; P = 0.041), revascularization of coronary stenosis (OR 0.15; 95% CI 0.19-0.86; P < 0.001), GRACE risk score (OR 1.04; 95% CI 1.02-1.05; P < 0.001) and SYNTAX score (OR 1.07; 95% CI 1.01-1.13; P = 0.025) were independent predictors of 30-day mortality. As multiple predictors such as bystander CPR, GRACE score and SYNTAX score were combined, the 30-day mortality gradually deteriorated.

CONCLUSIONS

In addition to bystander CPR, GRACE score and revascularization, SYNTAX score independently predicted 30-day mortality of CAD patients after OHCA.

MIRACLE2 Score and SCAI Grade to Identify Patients With Out-of-Hospital Cardiac Arrest for Immediate Coronary Angiography

OBJECTIVES

The purpose of this study was to evaluate the impact of performing immediate coronary angiography (CAG) after out-of-hospital cardiac arrest (OHCA) with stratification of predicted neurologic injury and cardiogenic shock on arrival to a center.

BACKGROUND

The role of immediate CAG for patients with OHCA is unclear, which may in part be explained by the majority of patients dying of hypoxic brain injury.

METHODS

Between May 2012 and July 2020, patients from 5 European centers were included in the EUCAR (European Cardiac Arrest Registry). Patients were retrospectively classified into low vs high neurologic risk (MIRACLE₂ score 0-3 vs ≥4) and degree of cardiogenic shock on arrival (Society for Cardiovascular Angiography and Interventions [SCAI] grade A vs B-E). A multivariable logistic regression analysis including immediate CAG was performed for the primary outcome of survival with good neurologic outcome (Cerebral Performance Category 1 or 2) at hospital discharge.

RESULTS

Nine hundred twenty-six patients were included in the registry, with 405 (43.7%) in the low-risk group and 521 (56.3%) in the high-risk group. Immediate CAG was independently associated with improved survival with good neurologic outcome in the low MIRACLE₂ risk group with ST-segment elevation myocardial infarction (OR: 11.80; 95% CI: 2.24-76.74; P = 0.048) and with SCAI grade B to E shock (OR: 3.23; 95% CI: 1.10-9.50; P = 0.031). No subgroups, including those with ST-segment elevation myocardial infarction and with SCAI grade B to E shock, achieved any benefit from early CAG in the high MIRACLE₂ group.

CONCLUSIONS

Combined classification of patients with OHCA with 12-lead electrocardiography, MIRACLE₂ score 0 to 3, and SCAI grade B to E identifies a potential cohort of patients at low risk for neurologic injury who benefit most from immediate CAG.

Clinical factors associated with significant coronary lesions following out-of-hospital cardiac arrest

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.

Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications

Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy.

A Risk-Adjustment Model for Patients Presenting to Hospitals with Out-of-Hospital Cardiac Arrest and ST-Elevation Myocardial Infarction

BACKGROUND

Patients with ST-elevation myocardial infarction (STEMI) complicated by an out-of-hospital-cardiac-arrest (OHCA) may vary widely in their probability of dying. Large variation in mortality may have implications for current national efforts to benchmark operator and hospital mortality rates for coronary angiography. We aimed to build a risk-adjustment model of in-hospital mortality among OHCA survivors with concurrent STEMI.

METHODS

Within the Cardiac Arrest Registry to Enhance Survival (CARES), we included adults with OHCA and STEMI who underwent emergent angiography within 2 hours of hospital arrival between January 2013 and December 2019. Using multivariable logistic regression to adjust for patient and cardiac arrest factors, we developed a risk-adjustment model for in-hospital mortality and examined variation in patients' predicted mortality.

RESULTS

Of 2,999 patients (mean age 61.2 ±12.0, 23.1% female, 64.6% white), 996 (33.2%) died during their hospitalization. The final risk-adjustment model included higher age (OR per 10-year increase, 1.50 [95% CI: 1.39-1.63]), unwitnessed OHCA (OR, 2.51 [1.99-3.16]), initial non-shockable rhythm [OR, 5.66 [4.52-7.13]), lack of sustained pulse for >20 minutes (OR, 2.52 [1.88-3.36]), and longer resuscitation time (c-statistic=0.804 with excellent calibration). There was large variability in predicted mortality: median, 25.2%, inter-quartile-range: 14.0% to 47.8%, 10^th-90^th percentile: 8.2 % to 74.1%.

CONCLUSIONS

In a large national registry, we identified 5 key predictors for mortality in patients with STEMI and OHCA and found wide variability in mortality risk. Our findings suggest that current national benchmarking efforts for coronary angiography, which simply adjusts for the presence of OHCA, may not adequately capture patient case-mix severity.

Early Coronary Angiography Is Associated with Improved 30-Day Outcomes among Patients with Out-of-Hospital Cardiac Arrest

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.

Cardiac Arrest Survival Postresuscitation In-Hospital (CASPRI) Score Predicts Neurological Favorable Survival in Emergency Department Cardiac Arrest

Background: This study was conducted to identify the predictive factors for survival and favorable neurological outcome in patients with emergency department cardiac arrest (EDCA). Methods: ED patients who suffered from in-hospital cardiac arrest (IHCA) from July 2014 to June 2019 were enrolled. The electronic medical records were retrieved and data were extracted according to the IHCA Utstein-style guidelines. Results: The cardiac arrest survival post-resuscitation in-hospital (CASPRI) score was associated with survival, and the CASPRI scores were lower in the survival group. Three components of the CASPRI score were associated with favorable neurological survival, and the CASPRI scores were lower in the favorable neurological survival group of patients who were successfully resuscitated. The independent predictors of survival were presence of hypotension/shock, metabolic illnesses, short resuscitation time, receiving coronary angiography, and TTM. Receiving coronary angiography and low CASPRI score independently predicted favorable neurological survival in resuscitated patients. The performance of a low CASPRI score for predicting favorable neurological survival was fair, with an AUROCC of 0.77. Conclusions: The CASPRI score can be used to predict survival and neurological status of patients with EDCA. Post-cardiac arrest care may be beneficial for IHCA, especially in patients with EDCA.

Predictive Model of Good Clinical Outcomes in Patients Undergoing Coronary Angiography after Out-of-Hospital Cardiac Arrest: A Prospective, Multicenter Observational Study Conducted by the Korean Cardiac Arrest Research Consortium

This observational study aimed to develop novel nomograms that predict the benefits of coronary angiography (CAG) after resuscitating patients with out-of-hospital cardiac arrest (OHCA) regardless of the electrocardiography findings and to perform an external validation of these models. Data were extracted from a prospective, multicenter registry of resuscitated patients with OHCA (October 2015–June 2018). New nomograms were developed based on variables associated with survival discharge and neurologic outcomes; their analysis included 723 and 709 patients, respectively. Patient age (p < 0.001), prehospital defibrillation by emergency medical technicians (EMTs) (p = 0.003), prehospital return of spontaneous circulation (ROSC) (p = 0.02), and time from collapse to ROSC (p < 0.001) were associated with survival discharge. Patient age (p < 0.001), prehospital defibrillation by EMTs (p < 0.001), and time from collapse to ROSC (p < 0.001) were associated with neurologic outcomes. The new nomogram had a good predictive performance, with an area under the curve (AUC) of 0.8832 (95% confidence interval (CI): 0.8358–0.9305) for survival discharge and an AUC of 0.9048 (95% CI: 0.8627–0.9469) for neurologic outcomes. Novel nomograms that predict survival discharge and good neurological outcomes after CAG in patients with OHCA were developed and validated; they can be quickly and easily applied to identify patients who will benefit from CAG.

Association between thrombolysis in myocardial infarction grade and clinical outcome after emergent percutaneous coronary intervention in patients with acute myocardial infarction who have suffered out-of-hospital cardiac arrest: the Yamagata AMI registry

Despite improvements in the survival rate of acute myocardial infarction (AMI), out-of-hospital cardiac arrest (OHCA) due to AMI is still a devastating condition. Thrombolysis in myocardial infarction (TIMI) grade is used to classify coronary reperfusion after percutaneous coronary intervention (PCI), but it remains unclear whether TIMI grade after emergent PCI is associated with short-term mortality in patients with AMI who have suffered OHCA. We analyzed data collected from 2012 to 2017 and recorded in the Yamagata AMI registry, which is a multicenter surveillance conducted in all institutions in Yamagata prefecture. Among 3332 patients with AMI, 254 had suffered OHCA. There were 564 deaths during the 30 days after the onset of AMI. The survival rate was lower in patients who had suffered OHCA than in those who had not (40% vs. 87%; P < 0.0001). Patients with AMI who had suffered OHCA were divided into three groups based on TIMI grade (TIMI III group, n = 70; TIMI ≤ II group, n = 21; and no coronary angiography [non-CAG] group, n = 163). The survival rates in the TIMI III, TIMI ≤ II, and non-CAG groups were 87%, 38%, and 5%, respectively. Kaplan-Meier analysis demonstrated that the survival rate was highest in the TIMI III group. Multivariate Cox proportional hazard regression analysis demonstrated that TIMI III was closely associated with survival after adjustment for confounding factors. Achieving TIMI grade III during emergent PCI is crucial to improve survival in patients with AMI who have suffered OHCA.

Double external defibrillation for shock-refractory ventricular fibrillation cardiac arrest: A step towards standardization

Double (or dual) external defibrillation (DED) has increasingly been used in the last few years by a number of emergency medical services (EMS) as a last resort to terminate ventricular fibrillation and pulseless ventricular tachycardia in adult patients who remain refractory to standard defibrillation. However, no randomized controlled trials comparing DED with standard defibrillation focusing on patient-oriented outcomes as the primary objective have been published to date. Selection criteria, procedure techniques, and protocol are not clearly defined and vary across observational studies. The terms and/or nomenclature used to describe DED are confusing and vary throughout the literature. Despite increased use of DED, many questions remain as to which patients will derive the most benefit from DED, when to implement DED, and the optimal form of delivering DED. The present paper provides a brief overview of the background, procedure techniques, pad placement, and factors affecting how DED is delivered. A further objective of this paper is to offer a proposal for a uniform nomenclature and a standardized protocol in the form of a flowchart for EMS agencies to guide further clinical trials and best practices. This paper should not only help give background on novel definitions and clarify nomenclature for this practice, but more importantly should help institutions lay the groundwork for performing EMS-based large trials to further investigate the effectiveness of DED.

Development and Testing of an Ultrasound-Compatible Cardiac Phantom for Interventional Procedure Simulation Using Direct Three-Dimensional Printing

Organ phantoms are widely used for evaluating medical technologies, training clinical practitioners, as well as surgical planning. In the context of cardiovascular disease, a patient-specific cardiac phantom can play an important role for interventional cardiology procedures. However, phantoms with complicated structures are difficult to fabricate by conventional manufacturing methods. The emergence of three-dimensional (3D) printing with soft materials provides the opportunity to produce phantoms with complex geometries and realistic properties. In this work, the aim was to explore the use of a direct 3D printing technique to produce multimodal imaging cardiac phantoms and to test the physical properties of the new materials used, namely the Poro-Lay series and TangoPlus. The cardiac phantoms were first modeled using real data segmented from a patient chest computer tomography (CT) scan and then printed with the novel materials. They were then tested quantitatively in terms of stiffness and ultrasound (US) acoustic values and qualitatively with US, CT, and magnetic resonance imaging systems. From the stiffness measurements, Lay-fomm 40 had the closest Young's modulus to real myocardium with an error of 29-54%, while TangoPlus had the largest difference. From the US acoustics measurements, Lay-fomm 40 also demonstrated the closest soft tissue-mimicking properties with both the smallest attenuation and impedance differences. Furthermore, the imaging results show that the phantoms are compatible with multiple imaging modalities and thus have potential to be used for interventional procedure simulation and testing of novel interventional devices. In conclusion, direct 3D printing with Poro-Lay and TangoPlus is a promising method for manufacture of multimodal imaging phantoms with complicated structures, especially for soft patient-specific phantoms.

Rationale and methods of the Advanced R2Eperfusion STrategies for Refractory Cardiac Arrest (ARREST) trial

BACKGROUND

Venoarterial extracorporeal membrane oxygenation has emerged as a prominent therapy for patients with refractory cardiac arrest. However, the optimal time of initiation remains unknown.

AIM

The aim was to assess the rate of survival to hospital discharge in adult patients with refractory ventricular fibrillation/pulseless ventricular tachycardia out-of-hospital cardiac arrest treated with 1 of 2 local standards of care: (1) early venoarterial extracorporeal membrane oxygenation-facilitated resuscitation for circulatory support and percutaneous coronary intervention, when needed, or (2) standard advanced cardiac life support resuscitation.

DESIGN

Phase II, single-center, partially blinded, prospective, intention-to-treat, safety and efficacy clinical trial.

POPULATION

Adults (aged 18-75), initial out-of-hospital cardiac arrest rhythm of ventricular fibrillation/pulseless ventricular tachycardia, no ROSC following 3 shocks, body morphology to accommodate a Lund University Cardiac Arrest System automated cardiopulmonary resuscitation device, and transfer time of <30 minutes.

SETTING

Hospital-based.

OUTCOMES

Primary: survival to hospital discharge. Secondary: safety, survival, and functional assessment at hospital discharge and 3 and 6 months, and cost.

SAMPLE SIZE

Assuming success rates of 12% versus 37% in the 2 arms and 90% power, a type 1 error rate of .05, and a 15% rate of withdrawal prior to hospital discharge, the required sample size is N = 174 evaluated patients.

CONCLUSIONS

The ARREST trial will generate safety/effectiveness data and comparative costs associated with extracorporeal cardiopulmonary resuscitation, informing broader implementation and a definitive Phase III clinical trial.

Coronary angiography or not after cardiac arrest without ST segment elevation: A systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to review the available evidence and evaluate the necessity of immediate coronary angiography (CAG) to obtain positive outcomes for out-of-hospital cardiac arrest (OHCA) patients without ST segment elevation.

DATA SOURCES

Web of Science, PubMed, Embase, Chinese National Knowledge Infrastructure, Wanfang, and SinoMed databases.

STUDY SELECTION

We included observational and case-control studies of outcomes among individuals without ST segment elevation experiencing OHCA who had immediate, delayed, or no CAG.

DATA EXTRACTION

We extracted study details, as well as patient characteristics and outcomes.

DATA SYNTHESIS

Six studies (n = 2665) investigating mortality until discharge demonstrated a significant increase in survival benefit with early CAG (odds ratio [OR] = 1.78; 95%CI = 1.51-2.11; I = 81%; P < .0001). Seven studies (n = 2909) showed a significant preservation of neurological functions with early CAG at discharge (OR = 1.66; 95%CI = 1.37-2.02; P < .00001). Four studies (n = 1357) investigating survival outcomes with middle-term follow-up revealed no significant benefit with early CAG (OR = 1.21; 95%CI = 0.93-1.57; I = 66%; P = .15).

CONCLUSIONS

Our meta-analysis demonstrates that there may be significant benefits in performing immediate CAG on patients who experience OHCA without ST segment elevation.

Extracorporeal cardiopulmonary resuscitation for in- and out-of-hospital cardiac arrest: systematic review and meta-analysis of propensity score-matched cohort studies

INTRODUCTION

In this systematic review and meta-analysis of propensity score-matched cohort studies, we quantitatively summarize whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) used as extracorporeal cardiopulmonary resuscitation (ECPR), compared with conventional cardiopulmonary resuscitation (CCPR), is associated with improved rates of 30-day and long-term favorable neurological outcomes and survival in patients resuscitated from in- and out-of-hospital cardiac arrest.

METHODS

We searched MEDLINE via PubMed, Embase, Scopus, and Google Scholar for eligible studies on January 14, 2019. All searches were limited to studies published between January 2000 and January 2019. Two investigators independently evaluated the quality (or certainty) of evidence according to GRADE guidelines. Pooled results are presented as relative risks (RRs) with 95% confidence intervals (CIs).

RESULTS

Six cohort studies using propensity score-matched analysis were included, totaling 1108 matched patients. Pooled analyses showed that ECPR was likely associated with improved 30-day and long-term favorable neurological outcome in adults compared to CCPR for in- and out-of-hospital cardiac arrest (RR = 2.02, 95% CI = 1.29-3.16; I2 = 20%, P = 0.002; very low-quality evidence) and (RR = 2.86, 95% CI = 1.64-5.01; I2 = 0%, P = 0.0002; moderate-quality evidence), respectively. When we analyzed in- and out-of-hospital cardiac arrest separately, ECPR was likely associated with improved 30-day favorable neurological outcome compared to CCPR for in-hospital cardiac arrest (RR = 2.18, 95% CI = 1.24-3.81; I2 = 9%, P = 0.006; very low-quality evidence), but not for out-of-hospital cardiac arrest (RR = 2.61, 95% CI = 0.56-12.20; I2 = 59%, P = 0.22; very low-quality evidence). ECPR was also likely associated with improved long-term favorable neurological outcome compared to CCPR for in-hospital cardiac arrest (RR = 2.50, 95% CI = 1.33-4.71; I2 = 0%, P = 0.005; moderate-quality evidence) and out-of-hospital cardiac arrest (RR = 4.64, 95% CI = 1.41-15.25; I2 = 0%, P = 0.01; moderate-quality evidence).

CONCLUSIONS

Our analysis suggests that VA-ECMO used as ECPR may improve long-term favorable neurological outcomes and survival when compared to the best standard of care in a selected patient population. Therefore, it is imperative for well-designed randomized clinical trials to obtain a higher level of scientific evidence to ensure optimal outcomes for cardiac arrest patients.

Utility and Challenges of an Early Invasive Strategy in Patients Resuscitated From Out-of-Hospital Cardiac Arrest

Out-of-hospital cardiac arrest (OHCA) is frequently triggered by acute myocardial ischemia. Coronary angiography is an important component of post-resuscitation care for patients with OHCA without an evident noncardiac cause, to identify underlying coronary artery disease and allow revascularization. Most patients undergoing coronary angiography after OHCA have obstructive coronary artery disease, and nearly one-half of patients have acute coronary occlusion. Early coronary angiography and percutaneous coronary intervention after OHCA have been associated with improved survival in observational studies, but these studies demonstrate selection bias, and randomized trials are lacking. Selection of patients for coronary angiography after OHCA can be challenging, particularly in comatose patients whose outcomes are driven primarily by anoxic brain injury. As for other patients with acute coronary syndromes, patients with ST-segment elevation after OHCA have a high probability of acute coronary occlusion warranting emergent coronary angiography. Patients with cardiogenic shock after OHCA are a high-risk population also requiring emergent coronary angiography. Among patients in stable condition after OHCA without ST-segment elevation, other clinical predictors can be used to identify those needing early coronary angiography to identify obstructive coronary artery disease. Despite the challenges with early neurological prognostication in comatose patients with OHCA, those with multiple objective markers of poor prognosis appear less likely to benefit from revascularization, and early coronary angiography may be reasonably deferred in appropriately selected patients meeting these criteria. The authors propose an algorithm to guide patient selection for coronary angiography after OHCA that combines clinical predictors of acute coronary occlusion and early clinical predictors of severe brain injury.

Prehospital Double Defibrillation for Refractory Ventricular Fibrillation: A Scoping Review Protocol

Double defibrillation (DD) has been proposed as an alternative treatment for patients with refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) out-of-hospital cardiac arrest (OHCA) nonresponsive to the best current standard of care. Treatment results are promising, but the efficacy and safety of the procedure remain unclear. Currently, there is a paucity of evidence in the literature on DD suggesting the optimal strategy for treating this challenging patient population. Thus, we aim to perform a scoping review to explore the current literature addressing resuscitative parameters, survival rates, and neurological outcomes in refractory VF/pVT OHCA patients treated with DD as well as to identify gaps in the literature that may require further research. Here, we discuss the anticipated study protocol.

The Sequential Organ Failure Assessment (SOFA) score predicts mortality and neurological outcome in patients with post-cardiac arrest syndrome

BACKGROUND

Patients experiencing out-of-hospital cardiac arrest (OHCA) and subsequent post-cardiac arrest syndrome are often compromised by multi-organ failure. The Sequential Organ Failure Assessment (SOFA) score has been used to predict clinical outcome of patients requiring intensive care for multi-organ failure. Thus, the assessment of SOFA score is recommended as a criterion for sepsis. Although post-cardiac arrest patients frequently develop sepsis-like status in ICU, there are limited reports evaluating the SOFA score in post-cardiac arrest patients. We investigated the predictive value of the SOFA score in survival and neurological outcomes in patients with post-cardiac arrest syndrome.

METHODS

A total of 231 cardiovascular arrest patients achieving return of spontaneous circulation (ROSC) were finally extracted from the institutional consecutive database comprised of 1218 OHCA patients transferred to the institution between January 2015 and July 2018. The SOFA score was calculated on admission and after 48h. Predictors of survival and neurological outcome defined as having cerebral-performance-category (CPC) 1 or 2 at 30 days were determined.

RESULTS

SOFA score was lower in survived patients (5.0 vs 10.0, p<0.001) and those with favorable neurological outcome (5.0 vs 8.0, p<0.001) as compared with the counterparts. The SOFA score on admission was an independent predictor of survival (OR 0.68, 95% confidence interval [CI] 0.59-0.78; p<0.001) and favorable neurological performance (OR 0.79; 95% CI 0.69-0.90; p<0.001) at 30 days. Furthermore, a change in SOFA score (48-0h) was predictive of favorable 30-day neurological outcome (OR 0.71, 95% CI 0.60-0.85; p<0.001).

CONCLUSIONS

Evaluation of the SOFA score in the ICU is useful to predict survival and neurological outcome in post-cardiac arrest patients.

Association of left anterior descending artery involvement on clinical outcomes among patients with STEMI presenting with and without out-of-hospital cardiac arrest

Background

ST-segment elevation myocardial infarction (STEMI) outcomes are influenced by the location of the culprit vessel with worse outcomes portended with a left anterior descending (LAD) culprit lesion. However, relatively little is known about the independent association of LAD involvement with clinical outcomes of patients with STEMI with and without out-of-hospital cardiac arrest (OHCA).

Methods

We identified 91 patients with and 929 without a preceding OHCA within the Vancouver Coastal Health Authority who presented with an acute STEMI and underwent primary percutaneous coronary intervention between 26 June 2007 and 31 March 2016.

Results

Patients with STEMI with OHCA had higher rates of in-hospital cardiac arrest (43.3% vs 8.3%, p<0.001), heart failure (50.5% vs 11.3%, p<0.001), cardiogenic shock (49.5% vs 5.7%, p<0.001), mortality (35.2% vs 3.3%, p<0.001) and reduced left ventricular ejection fraction (LVEF; 42.9% vs 47.3%, p<0.001) compared with those without OHCA. Among patients without OHCA, LAD involvement was associated with increased heart failure (18.1% vs 5.2%, p<0.001), in-hospital cardiac arrest (10.7% vs 6.2%, p<0.014), cardiogenic shock (8.4% vs 3.3%, p<0.001), reduced LVEF (43.0% vs 51.2%, p<0.001) and mortality (5.2% vs 1.3%, p=0.003) compared with patients without LAD involvement. With the exception of LVEF, these associations were not seen among patients with STEMI with OHCA and an LAD culprit. The presence of an LAD culprit was not independently associated with increased hospital mortality among patients with OHCA after adjusting for potential confounding factors.

Conclusion

Our study has demonstrated a differential impact of LAD involvement on clinical outcomes among patients with STEMI who present with and without OHCA. Our data highlight the complexity surrounding the prognostication following OHCA complicating STEMI and demonstrate that other mechanisms other than LAD involvement contribute to the high mortality associated with OHCA as a result of STEMI.

Predicting factors for long-term survival in patients with out-of-hospital cardiac arrest - A propensity score-matched analysis

Background

Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death worldwide, with acute coronary syndromes accounting for most of the cases. While the benefit of early revascularization has been clearly demonstrated in patients with ST-segment-elevation myocardial infarction (STEMI), diagnostic pathways remain unclear in the absence of STEMI. We aimed to characterize OHCA patients presenting to 2 tertiary cardiology centers and identify predicting factors associated with survival.

Methods

We retrospectively analyzed 519 patients after OHCA from February 2003 to December 2017 at 2 centers in Munich, Germany. Patients undergoing immediate coronary angiography (CAG) were compared to those without. Multivariate regression analysis and inverse probability treatment weighting (IPTW) were performed to identify predictors for improved outcome in a matched population.

Results

Immediate CAG was performed in 385 (74.1%) patients after OHCA with presumed cardiac cause of arrest. As a result of multivariate analysis after propensity score matching, we found that immediate CAG, return of spontaneous circulation (ROSC) at admission, witnessed arrest and former smoking were associated with improved 30-days-survival [(OR, 0.46; 95% CI, 0.26–0.84), (OR, 0.21; 95% CI, 0.10–0.45), (OR, 0.50; 95% CI, 0.26–0.97), (OR, 0.43; 95% CI, 0.23–0.81)], and 1-year-survival [(OR, 0.39; 95% CI, 0.19–0.82), (OR, 0.29; 95% CI, 0.12–0.7), (OR, 0.43; 95% CI, 0.2–1.00), (OR, 0.3; 95% CI, 0.14–0.63)].

Conclusions

In our study, immediate CAG, ROSC at admission, witnessed arrest and former smoking were independent predictors of survival in cardiac arrest survivors. Improvement in prehospital management including bystander CPR and best practice post-resuscitation care with optimized triage of patients to an early invasive strategy may help ameliorate overall outcome of this critically-ill patient population.

Management of Out-of-Hospital Cardiac Arrest Complicating Acute Coronary Syndromes

PURPOSE OF THE REVIEW

Out-of-hospital cardiac arrest (OHCA) complicating acute coronary syndromes (ACS) continues to carry a high rate of morbidity and mortality despite significant advances in EMS and interventional cardiology services. In this review, we discuss an evidence-based approach to the initial care and management of patients with OHCA complicating ACS from the pre-hospital response and initial resuscitation strategy, to advanced therapies such as coronary angiography, targeted-temperature management, neuro-prognostication, and care of the post-arrest patient.

RECENT FINDINGS

Early recognition of cardiac arrest and prompt initiation of bystander CPR are the most important factors associated with improved survival. A comprehensive and coordinated approach to in-hospital management, including PCI, targeted temperature management, critical care, and hemodynamic support represents a significant critical link in the chain of survival. OHCA complicated by ACS continues to be one of the most challenging disease states facing healthcare practitioners and maintains a high mortality rate despite substantial advancements in healthcare delivery. A comprehensive approach to in-hospital management and further exploration of novel interventions, including ECMO, may yield opportunities to optimize care and improve outcomes for cardiac arrest patients.

Contemporary Management of Out-of-hospital Cardiac Arrest in the Cardiac Catheterisation Laboratory: Current Status and Future Directions

Out-of-hospital cardiac arrest (OHCA) is an important cause of mortality and morbidity in developed countries and remains an important public health burden. A primary cardiac aetiology is common in OHCA patients, and so patients are increasingly brought to specialist cardiac centres for consideration of coronary angiography, percutaneous coronary intervention and mechanical circulatory support. This article focuses on the management of OHCA in the cardiac catheterisation laboratory. In particular, it addresses conveyance of the OHCA patient direct to a specialist centre, the role of targeted temperature management, pharmacological considerations, provision of early coronary angiography and mechanical circulatory support.

Out-of-Hospital Cardiac Arrest in Patients With and Without Psychiatric Disorders: Differences in Use of Coronary Angiography, Coronary Revascularization, and Implantable Cardioverter-Defibrillator and Survival

Background

Healthcare disparities for psychiatric patients are common. Whether these inequalities apply to postresuscitation management in out‐of‐hospital cardiac arrest (OHCA) is unknown. We investigated differences in in‐hospital cardiovascular procedures following OHCA between patients with and without psychiatric disorders.

Methods and Results

Using the Danish nationwide registries, we identified patients admitted to the hospital following OHCA of presumed cardiac cause (2001‐2015). Psychiatric disorders were identified using hospital diagnoses or redeemed prescriptions for psychotropic drugs. We calculated age‐ and sex‐standardized incidence rates and incidence rate ratios (IRRs) of cardiovascular procedures during post‐OHCA admission in patients with and without psychiatric disorders. Differences in 30‐day and 1‐year survival were assessed by multivariable logistic regression in the overall population and among 2‐day survivors who received acute coronary angiography (CAG). We included 7288 hospitalized patients who had experienced an OHCA: 1661 (22.8%) had a psychiatric disorder. Compared with patients without psychiatric disorders, patients with psychiatric disorders had lower standardized incidence rates for acute CAG (≤1 day post‐OHCA) (IRR, 0.51; 95% CI, 0.45–0.57), subacute CAG (2–30 days post‐OHCA) (IRR, 0.40; 95% CI, 0.30–0.52), and implantable cardioverter‐defibrillator implantation (IRR, 0.67; 95% CI, 0.48–0.95). Conversely, we did not detect differences in coronary revascularization among patients undergoing CAG (IRR, 1.11; 95% CI, 0.94–1.30). Patients with psychiatric disorders had lower survival even among 2‐day survivors who received acute CAG: (odds ratio of 30‐day survival, 0.68; 95% CI, 0.52–0.91; and 1‐year survival, 0.66; 95% CI, 0.50–0.88).

Conclusions

Psychiatric patients had a lower probability of receiving post‐OHCA CAG and implantable cardioverter‐defibrillator implantation compared with nonpsychiatric patients but the same probability of coronary revascularization among patients undergoing CAG. However, their survival was lower irrespective of angiographic procedures.

Turn-to-Shockable Rhythm Has Comparable Neurologic Outcomes to Initial Shockable Rhythm in Out-of-Hospital Cardiac Arrest Patients Who Underwent Targeted Temperature Management

Shockable rhythm in out-of-hospital cardiac arrest (OHCA) implies better outcome and underlying coronary stenosis. We investigated the neurologic outcome and coronary lesions between initial shockable rhythm and turn-to-shockable rhythm. This multicenter, retrospective observational study included adult nontraumatic OHCA survivors with any shockable rhythm during cardiopulmonary resuscitation (CPR) who underwent targeted temperature management between January 2010 and December 2016. Patients were divided into two groups according to the first monitored rhythm: initial shockable rhythm or turn-to-shockable rhythm. The primary outcome was good neurologic outcome at discharge based on cerebral performance categories, and the secondary outcomes were survival discharge, recurrent arrest, and coronary lesions. The two groups were matched in a 1:1 ratio using propensity score (PS). Of 426 patients, 137 and 289 patients were divided into the turn-to-shockable and initial shockable rhythm groups, respectively. Overall, 224 (52.6%) patients had good neurologic outcomes. The turn-to-shockable rhythm group had less patients with good neurologic outcome (57/137 vs. 167/289; p = 0.002) and less culprit lesions in the left anterior descending and left circumflex arteries. However, survival discharge and recurrent arrest were not different between the two groups, and the turn-to-shockable rhythm had no independent association with neurologic outcome (odds ratio, 1.874; 95% confidence interval, 0.909-3.863). In the PS-matched cohort, the turn-to-shockable rhythm group had similar good neurologic outcome (47/100 vs. 35/100, p = 0.083). Survival discharge, recurrent arrest, and coronary culprit lesions were not different between the two groups. In this PS-matched study, OHCA with any shockable rhythm during CPR had similar neurologic outcome and coronary culprit lesions, irrespective of the first monitored rhythm.

[Why do we need cardiac arrest centers?]

In patients with out-of-hospital cardiac arrest (OHCA) and return of spontaneous circulation (ROSC) following cardiopulmonary resuscitation (CPR), the prognosis is influenced by various factors. In the prehospital setting, the duration of ischemia from the time of onset of cardiac arrest to the beginning of effective resuscitation measures is by far the most critical and determining factor for outcome. This interval can be shortened by an increase in the rate of lay CPR measures. With respect to intrahospital follow-up care, a number of structural factors have a relevant influence on prognosis. According to the literature, case volume, size of the hospital and the number of post-OHCA patients treated per year also have a large influence on the further prognosis. The crucial factor here is the availability and permanent readiness of a catheterization laboratory with the possibility of an immediate coronary intervention. In OHCA patients with ST-segment elevation myocardial infarction (STEMI), the time passed until the reopening of the occluded infarcted vessel is of paramount importance for survival. The 24/7 around the clock availability of a catheterization laboratory is therefore one of the indispensable prerequisites for a cardiac arrest center (CAC). In addition, a number of technical, structural, and organizational arrangements must be implemented in the CAC clinics in order to fulfil the requirements for such a center. The certification of CACs is currently being implemented by the German Resuscitation Council (GRC) and the German Society of Cardiology (DGK). As an important aim the GRC and the medical societies involved are hoping to avoid misallocation of post-OHCA patients to the nearest hospital, which may not be a suitable center for the treatment of these patients. Future studies will show whether CACs can indeed comprehensively improve the prognosis of OHCA patients following successful prehospital resuscitation.

Role of coronary angiography in patients with a non-diagnostic electrocardiogram following out of hospital cardiac arrest: Rationale and design of the multicentre randomized controlled COUPE trial

BACKGROUND

Coronary artery disease (CAD) is a major cause of out-of-hospital cardiac arrest (OHCA). The role of emergency coronary angiography (CAG) and percutaneous coronary intervention (PCI) following cardiac arrest in patients without ST-segment elevation myocardial infarction (STEMI) remains unclear.

AIMS

We aim to assess whether emergency CAG and PCI, when indicated, will improve survival with good neurological outcome in post-OHCA patients without STEMI who remain comatose.

METHODS

COUPE is a prospective, multicentre and randomized controlled clinical trial. A total of 166 survivors of OHCA without STEMI will be included. Potentially non-cardiac aetiology of the cardiac arrest will be ruled out prior to randomization. Randomization will be 1:1 for emergency (within 2 h) or deferred (performed before discharge) CAG. Both groups will receive routine care in the intensive cardiac care unit, including therapeutic hypothermia. The primary efficacy endpoint is a composite of in-hospital survival free of severe dependence, which will be evaluated using the Cerebral Performance Category Scale. The safety endpoint will be a composite of major adverse cardiac events including death, reinfarction, bleeding and ventricular arrhythmias.

CONCLUSIONS

This study will assess the efficacy of an emergency CAG versus a deferred one in OHCA patients without STEMI in terms of survival and neurological impairment.

The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association

Coronary artery disease is prevalent in different causes of out-of-hospital cardiac arrest (OHCA), especially in individuals presenting with shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). The purpose of this report is to review the known prevalence and potential importance of coronary artery disease in patients with OHCA and to describe the emerging paradigm of treatment with advanced perfusion/reperfusion techniques and their potential benefits on the basis of available evidence. Although randomized clinical trials are planned or ongoing, current scientific evidence rests principally on observational case series with their potential confounding selection bias. Among patients resuscitated from VF/pVT OHCA with ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 70% to 85%. More than 90% of these patients have had successful percutaneous coronary intervention. Conversely, among patients resuscitated from VF/pVT OHCA without ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 25% to 50%. For these patients, early access to the cardiac catheterization laboratory is associated with a 10% to 15% absolute higher functionally favorable survival rate compared with more conservative approaches of late or no access to the cardiac catheterization laboratory. In patients with VF/pVT OHCA refractory to standard treatment, a new treatment paradigm is also emerging that uses venoarterial extracorporeal membrane oxygenation to facilitate return of normal perfusion and to support further resuscitation efforts, including coronary angiography and percutaneous coronary intervention. The burden of coronary artery disease is high in this patient population, presumably causative in most patients. The strategy of venoarterial extracorporeal membrane oxygenation, coronary angiography, and percutaneous coronary intervention has resulted in functionally favorable survival rates ranging from 9% to 45% in observational studies in this patient population. Patients with VF/pVT should be considered at the highest severity in the continuum of acute coronary syndromes. These patients have a significant burden of coronary artery disease and acute coronary thrombotic events. Evidence from randomized trials will further define optimal clinical practice.

Outcomes of in-hospital treatment of cardiac patients who survived cardiac arrest and experienced coronary angiography

Introduction

As coronary artery disease is the most frequent cause of cardiac arrest, early invasive strategies may be beneficial for such patients. This study analyses the impact of in-hospital treatment on short-term outcomes of out-of-hospital cardiac arrest (OHCA) survivors.

Material and methods

Patients admitted to the Cardiac Intensive Care Unit of our hospital within 2-year period were prospectively included in the study.

Results

One hundred thirty-one patients were included in the study, which showed that in-hospital mortality increases uniformly with the severity of the coronary artery lesion (p = 0.044), but an effect of revascularization on number of deaths was not observed (p = 0.64). The presence of coma (p = 0.005) and the combination of male sex and age above 60-year as 2.2-fold (p = 0.048) increasing in-hospital mortality were found. The highest mortality rate occurred during the first 3 days and the death rate of the patients who survived this period is low. We found reduced left ventricular ejection fraction (OR = 6.54; 95% CI: 1.98-21.63; p = 0.002), non-ventricular fibrillation initial rhythm (OR = 2.94; 95% CI: 1.25-6.90; p = 0.014), unconscious at admission (OR = 6.46; 95% CI: 1.96-21.24; p = 0.002) and post-resuscitation coma (OR = 6.00; 95% CI: 2.63-13.66; p < 0.001) or encephalopathy (OR = 2.71; 95% CI: 1.9-6.72; p = 0.031) to be significant prognostic factors for higher in-hospital mortality rate.

Conclusions

We recommend immediate coronary interventions for all survivors of OHCA regardless of their state of consciousness and absence of ischaemic changes on ECG. Early intensive treatment for OHCA patients is indispensable, as the highest mortality rate is within the first 3 days after an event.

Cardiac Intensive Care Unit Management of Patients After Cardiac Arrest: Now the Real Work Begins

Survival with a good quality of life after cardiac arrest continues to be abysmal. Coordinated resuscitative care does not end with the effective return of spontaneous circulation (ROSC)-in fact, quite the contrary is true. Along with identifying and appropriately treating the precipitating cause, various components of the post-cardiac arrest syndrome also require diligent observation and management, including post-cardiac arrest neurologic injury and myocardial dysfunction, systemic ischemia-reperfusion phenomenon with potential consequent multiorgan failure, and the various sequelae of critical illness. There is growing evidence that an early invasive approach to coronary reperfusion with percutaneous coronary intervention, together with active targeted temperature management and optimization of hemodynamic, ventilator, and metabolic parameters, may improve survival and neurologic outcomes in cardiac arrest survivors. Neuroprognostication is complex, as are survivorship issues and long-term rehabilitation. Our paramedics, emergency physicians, and resuscitation specialists are all to be congratulated for ever-increasing success with ROSC… but now the real work begins.

Long-term outcome of elderly out-of-hospital cardiac arrest survivors as compared with their younger counterparts and the general population

BACKGROUND:

Over the past decade, prehospital and in-hospital treatment for out-of-hospital cardiac arrest (OHCA) has improved considerably. There are sparse data on the long-term outcome, especially in elderly patients. We studied whether elderly patients benefit to the same extent compared with younger patients and at long-term follow up as compared with the general population.

METHODS:

Between 2001 and 2010, data from all patients presented to our hospital after OHCA were recorded. Elderly patients (⩾75 years) were compared with younger patients. Neurological outcome was classified as cerebral performance category (CPC) at hospital discharge and long-term survival was compared with younger patients and predicted survival rates of the general population.

RESULTS:

Of the 810 patients admitted after OHCA, a total of 551 patients (68%) achieved return of spontaneous circulation, including 125 (23%) elderly patients with a mean age of 81 ± 5 years. In-hospital survival was lower in elderly patients compared with younger patients with rates of 33% versus 57% ( p < 0.001). A CPC of 1 was present in 73% of the elderly patients versus 86% of the younger patients ( p = 0.031). In 7.3% of the elderly patients, a CPC >2 was observed versus 2.5% of their younger counterparts ( p = 0.103). Elderly patients had a median survival of 6.5 [95% confidence interval (CI) 2.0-7.9] years compared with 7.7 (95% CI 7.5-7.9) years of the general population ( p = 0.019).

CONCLUSIONS:

The survival rate after OHCA in elderly patients is approximately half that of younger patients. Elderly patients who survive to discharge frequently have favorable neurological outcomes and a long-term survival that approximates that of the general population.