Coronary angiography and percutaneous coronary intervention in cardiac arrest survivors with non-shockable rhythms and no STEMI: A systematic review

Percutaneous Coronary Intervention (PCI) Post Out-of-Hospital Cardiac Arrest: A Narrative Review

Cardiovascular disease is a leading cause of mortality worldwide; therefore, preventing death and improving patient outcomes are a priority. Increasing numbers of patients are surviving hospital admissions after an out-of-hospital cardiac arrest (OHCA). An OHCA has a poor prognosis, and myocardial infarctions (MIs) are the most common cause; hence, the use of emergency coronary angiography and percutaneous coronary intervention (PCI) is an important tool in trying to improve survival. This narrative review explores the role of PCI in OHCA management; understanding angiography findings in OHCA patients offers critical insights into underlying coronary artery disease burden, informing the necessity for PCI. Also, looking at specific subgroups, like females, is essential for equitable intervention access and outcome optimization. Understanding the role of support devices such as Impella and extracorporeal membrane oxygenation (ECMO), which show promise in enhancing outcomes by providing hemodynamic support during PCI and improved overall survival, is linked to better neurological outcomes, highlighting the significance of timely PCI and comprehensive post-PCI care.

Incidence of cardiac interventions and associated cardiac arrest outcomes in patients with nonshockable initial rhythms and no ST elevation post resuscitation

BACKGROUND

Out of Hospital Cardiac arrest (OHCA) survivors with ST elevation (STE) with or without shockable rhythms often benefit from coronary angiography (CAG) and, if indicated, percutaneous coronary intervention (PCI). However, the benefits of CAG and PCI in OHCA survivors with nonshockable rhythms (PEA/asystole) and no STE are debated.

METHODS

Using the International Cardiac Arrest Registry (INTCAR 2.0), representing 44 centers in the US and Europe, comatose OHCA survivors with known presenting rhythms and post resuscitation ECGs were identified. Survival to hospital discharge, neurological recovery on discharge, and impact of CAG with or without PCI on such outcome were assessed and compared with other groups (shockable rhythms with or without STE).

RESULTS

Total of 2113 OHCA survivors were identified and described as; nonshockable/no STE (Nsh-NST) (n = 940, 44.5%), shockable/no STE (Sh-NST) (n = 716, 33.9%), nonshockable/STE (Nsh-ST) (n = 110, 5.2%), and shockable/STE (Sh-ST) (n = 347, 16.4%). Of Nsh-NST, 13.7% (129) were previously healthy before CA and only 17.3% (161) underwent CAG; of those, 30.4% (52) underwent PCI. A total of 18.6% (174) Nsh-NST patients survived to hospital discharge, with 57.5% (100) of such survivors having good neurological recovery (cerebral performance category 1 or 2) on discharge. Coronary angiography was associated with improved odds for survival and neurological recovery among all groups, including those with NSh-NST.

CONCLUSIONS

Nonshockable initial rhythms with no ST elevation post resuscitation was the most common presentation after OHCA. Although most of these patients did not undergo coronary angiography, among those who did, 1 in 4 patients had a culprit lesion and underwent revascularization. Invasive CAG should be at least considered for all OHCA survivors, including those with nonshockable rhythms and no ST elevation post resuscitation.

BRIEF ABSTRACT

Out of hospital cardiac arrest (OHCA) survivors with ST elevation and/or shockable rhythms benefit from coronary angiography and revascularization. Nonshockable cardiac arrest survivors with no ST elevation have the worst prognosis and rarely undergo coronary angiography. Nonshockable rhythms with no ST elevation was the most common presentation after OHCA and among a small subgroup underwent coronary angiography, 1 in 4 patients with had culprit lesion and underwent revascularization. Coronary angiography was associated with high prevalence of acute culprit coronary lesions and should be considered for those with a probably cardiac cause for their arres.

Substantial variation exists in post-cardiac arrest outcomes across Michigan hospitals

AIM

Resuscitation from out of hospital cardiac arrest (OHCA) requires success across the entire chain of survival. Using a large state-wide registry, we characterized variation in clinical outcomes at hospital discharge in Michigan hospitals.

METHODS

We utilized the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) and included adult OHCA subjects with return of spontaneous circulation (ROSC) from 2014 - 2017 that survived to hospital admission. 39 Michigan hospitals were included which managed >30 cases during the study period. Multilevel logistic regression, controlling for both subject characteristics and clustering of subjects within hospitals, assessed variation across hospitals in survival to hospital discharge and survival with cerebral performance category (CPC 1-2).

RESULTS

There were 5,486 CARES subjects that survived to hospital admission, and 4,690 met inclusion for analysis. Of 39 included hospitals, median survival to discharge was 31.3% (range 12.5%-46.7%) and median survival to discharge with CPC 1-2 was 25.0% (range 5.2%-42.2%). We identified 12-fold variation in the utilization of TTM by hospital (median 47.9%, range 6.7%-80.0%) for all admitted subjects. Similarly, there was nearly an eight-fold variation in LHC for all post-arrest subjects (median 22.1%, range 5.4%-42.2%). In multivariable analyses, median adjusted survival to discharge was 26.9% (range 18.1%-42.1%) and median adjusted survival to discharge with CPC 1-2 was 21.3% (range 9.6%-32.1%).

CONCLUSION

We observed substantial variation in clinical outcomes at discharge between Michigan hospitals, including a four-fold range of survival and eight-fold range of survival with CPC 1-2. This variation was ameliorated but still persisted in adjusted modeling. Variation in post arrest survival by hospital was not fully explained by available covariates, which suggests the possibility of improving post-arrest clinical outcomes at some hospitals via quality improvement activities.