Coronary angiography findings in patients with shock-resistant ventricular fibrillation cardiac arrest

Association of coronary angiography with ST-elevation and no ST-elevation in patients with refractory ventricular fibrillation - A substudy of the DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE-VF randomized control trial)

BACKGROUND

Refractory ventricular fibrillation or pulseless ventricular tachycardia (rVF/pVT) during out-of-hospital cardiac arrest (OHCA) is associated with poor survival. Double sequential defibrillation (DSED) and vector change (VC) improved survival for rVF/pVT in the DOSE-VF RCT. However, the role of angiography and percutaneous coronary intervention (angiography/PCI) during the trial is unknown.

OBJECTIVES

To determine the incidence of ST-elevation (STE) and no ST-elevation (NO-STE) on post-arrest ECG and the use of angiography/PCI in patients with rVF/pVT during the DOSE-VF RCT.

METHOD

Adults (≥18-years) with rVF/pVT OHCA randomized in the DOSE-VF RCT who survived to hospital admission were included. The primary analysis compared the proportion of angiography in STE and NO-STE. We performed regression modelling to examine association between STE, the interaction with defibrillation strategy, and survival to discharge controlling for known covariates.

RESULTS

We included 151 patients, 74 (49%) with STE and 77 (51%) with NO-STE. The proportion of angiography was higher in the STE cohort than NO-STE (87.8% vs 44.2%, p < 0.001); similarly the proportion of PCI was also higher (75.7% vs 9.1%, p < 0.001). Survival to discharge was similar between STE and NO-STE (63.5% vs 51.9%, p = 0.15). Use of angiography/PCI did not differ between defibrillation strategies. Decreased age (OR 0.95, 95% CI 0.92-0.98; p = 0.001) and angiography (OR 9.33, 95% CI 3.60-26.94; p < 0.001) were predictors of survival; however, STE was not.

CONCLUSION

We found high rates of angiography/PCI in patients with STE compared to NO-STE, however similar rates of survival. Angiography was an independent predictor of survival. Improved rates of survival employing DSED and VC were independent of angiography/PCI.

Clinical Features and Outcomes Among Patients With Refractory Out-of-Hospital Cardiac Arrest and an Initial Shockable Rhythm

BACKGROUND

Clinical features among patients with refractory out-of-hospital cardiac arrest (OHCA) and initial shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia are not well-characterized.

METHODS

We compared clinical characteristics and coronary angiographic findings between patients with refractory OHCA (incessant ventricular fibrillation/pulseless ventricular tachycardia after ≥3 direct-current shocks) and those without refractory OHCA.

RESULTS

Between 2014 and 2018, a total of 204 patients with ventricular fibrillation/pulseless ventricular tachycardia OHCA (median age 62; males 78%) were divided into groups with (36%, 74/204) and without refractory arrest (64%, 130/204). Refractory OHCA patients had longer cardiopulmonary resuscitation (23 versus 15 minutes), more frequently required ≥450 mg amiodarone (34% versus 3.8%), and had cardiogenic shock (80% versus 55%) necessitating higher adrenaline dose (4.0 versus 1.0 mg) and higher rates of mechanical ventilation (92% versus 74%; all P<0.01). Of 167 patients (82%) selected for coronary angiography, 33% (n=55) had refractory OHCA (P=0.035). Significant coronary artery disease (≥1 major vessel with >70% stenosis) was present in >70% of patients. Refractory OHCA patients frequently had acute coronary occlusion (64% versus 47%), especially left circumflex (20% versus 6.4%) and graft vessel (7.3% versus 0.9%; all P<0.05) compared with those without refractory OHCA. Refractory OHCA group had higher in-hospital mortality (45% versus 30%, P=0.036) and greater new requirement for dialysis (18% versus 6.3%, P=0.011). After adjustment, refractory OHCA was associated with over 2-fold higher odds of in-hospital mortality (odds ratio, 2.28 [95% CI, 1.06-4.89]; P=0.034).

CONCLUSIONS

Refractory ventricular fibrillation/pulseless ventricular tachycardia OHCA was associated with more intensive resuscitation, higher rates of acute coronary occlusion, and poorer in-hospital outcomes, underscoring the need for future studies in this extreme-risk subgroup.

Coronary angiography findings in resuscitated and refractory out-of-hospital cardiac arrest: A systematic review and meta-analysis

INTRODUCTION

Coronary angiography (CAG) frequently reveals coronary artery disease (CAD) after out-of-hospital cardiac arrest (OHCA), but its use is not standardized and often reported in different subpopulations. This systematic review and meta-analysis accurately describes angiographic features in resuscitated and refractory OHCA.

METHODS

PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched up to October 31, 2022. Studies reporting coronary angiography findings after OHCA were considered eligible. The primary outcome was location and rate of coronary lesions. Coronary angiography findings with 95% confidence intervals were pooled with a meta-analysis of proportion.

RESULTS

128 studies (62,845 patients) were included. CAG, performed in 69% (63-75%) of patients, found a significant CAD in 75% (70-79%), a culprit lesion in 63% (59-66%), and a multivessel disease in 46% (41-51%). Compared to patients with return of spontaneous circulation, refractory OHCA was associated with more severe CAD due to a higher rate of left main involvement (17% [12-24%] vs 5.7% [3.1-10%]; p = 0.002) and acute occlusion of left anterior descending artery (27% [17-39%] vs 15% [13-18%]; p = 0.02). Nonshockable patients without ST-elevation were those receiving CAG less frequently, despite significant disease in 54% (31-76%). Left anterior descending artery was the most frequently involved (34% [30-39%]).

CONCLUSIONS

Patients with OHCA have a high prevalence of significant CAD caused by acute and treatable coronary lesions. Refractory OHCA was associated with more severe coronary lesions. CAD was also present in patients with nonshockable rhythm and without ST elevation. However, heterogeneity of studies and selection of patients undergoing CAG limit the certainty of findings.

Initial rhythm and survival in refractory out-of-hospital cardiac arrest. Post-hoc analysis of the Prague OHCA randomized trial

BACKGROUND

The prognosis of refractory out-of-hospital cardiac arrest (OHCA) is generally poor. A recent Prague OHCA study has demonstrated that an invasive approach (including extracorporeal cardiopulmonary resuscitation, ECPR) is a feasible and effective treatment strategy in refractory OHCA. Here we present a post-hoc analysis of the role of initial rhythm on patient outcomes.

METHODS

The study enrolled patients who had a witnessed OHCA of presumed cardiac cause without early recovery of spontaneous circulation. The initial rhythm was classified as either a shockable or a non-shockable rhythm. The primary outcome was a composite of 180 day-survival with Cerebral Performance in Category 1 or 2.

RESULTS

256 (median age 58y, 17% females) patients were enrolled. The median (IQR) duration of resuscitation was 52 (33-68) minutes. 156 (61%) and 100 (39%) of patients manifested a shockable and non-shockable rhythm, respectively. The primary outcome was achieved in 63 (40%) patients with a shockable rhythm and in 5 (5%) patients with a non-shockable rhythm (p < 0.001). When patients were analyzed separately based on whether the treatment was invasive (n = 124) or standard (n = 132), the difference in the primary endpoint between shockable and non-shockable initial rhythms remained significant (35/72 (49%) vs 4/52 (8%) in the invasive arm and 28/84 (33%) vs 1/48 (2%) in the standard arm; p < 0.001).

CONCLUSION

An initial shockable rhythm and treatment with an invasive approach is associated with a reasonable neurologically favorable survival for 180 days despite refractory OHCA. Non-shockable initial rhythms bear a poor prognosis in refractory OHCA even when ECPR is readily available.

Immediate coronary angiography and systematic targeted temperature management are associated with improved outcome in comatose survivors of cardiac arrest

Rapid and systematic access to coronary angiography (CAG) and target temperature management (TTM) might improve outcome in comatose patients who survive cardiac arrest (CA). However, there is controversy around indicating immediate CAG in the absence of transmural ischemia on the electrocardiogram after return of spontaneous circulation (ROSC). We evaluated the short- and long-term outcome of patients undergoing systematic CAG and TTM, based on whether culprit lesion percutaneous coronary intervention (PCI) was performed. All consecutive comatose CA survivors without obvious extra-cardiac causes undergoing TTM were included. Analysis involved the entire population and subgroups, namely patients with initial unshockable rhythm, no ST elevation on electrocardiogram, and good neurological recovery. We enrolled 107 patients with a median age of 64.9 (57.7-73.6) years. The initial rhythm was shockable in 83 (77.6%). Sixty-six (61.7%) patients underwent PCI. In-hospital survival was 71%. It was 78.8% and 58.5% in those undergoing or not PCI (p = 0.022), respectively. Age, time from CA to ROSC and culprit lesion PCI were independent predictors of in-hospital survival. Long-term survival was significantly higher in patients who underwent PCI (respectively 61.5% vs 34.1%; Log-rank: p = 0.002). Revascularization was associated with better outcomes regardless of initial rhythm (shockable vs non-shockable) and ST deviation (elevation vs no-elevation), and improved the long-term survival of patients discharged with good neurological recovery. Systematic CAG and revascularization, when indicated, were associated with higher survival in comatose patients undergoing TTM, regardless of initial rhythm and ST deviation in the post-ROSC electrocardiogram. The benefit was sustained at long-term particularly in those with neurological recovery.

Coronary angiography and percutaneous coronary intervention in cardiac arrest patients without return of spontaneous circulation

OBJECTIVES

This study aimed to examine coronary angiography (CAG) findings, percutaneous coronary intervention (PCI) results and outcomes in out-of-hospital cardiac arrest patients (OHCA) without return of spontaneous circulation (ROSC) on admission to hospital.

METHODS

We analyzed the OHCA register and compared CAG, PCI, and outcome data in patients with and without ROSC on admission to hospital.

RESULTS

Between January 2012 and December 2020, 697 OHCA patients were analyzed. Of these, 163 (23%) did not have ROSC at admission. Patients without ROSC were younger (59 vs. 61 years, p=0.001) and had a longer resuscitation time (62 vs. 18 minutes, p<0.001) than patients with ROSC. Significant coronary artery disease was highly prevalent in both groups (65% vs. 68%, p=0.48). Patients without ROSC had higher rates of acute coronary occlusions (42% vs. 33%, p=0.046), specifically affecting the left main stem (16% vs. 1%, p<0.001). PCI was performed in 81 patients (50%) without ROSC and in 295 (55%) with ROSC (p=0.21). The success rate was 86% in patients without ROSC and 90% in patients with ROSC (p=0.33). Thirty-day survival was 24% in patients without ROSC and 70% in patients with ROSC.

CONCLUSIONS

OHCA patients without ROSC on admission to hospital had higher acute coronary occlusion rates than patients with prehospital ROSC. PCI is feasible with a high success rate in patients without ROSC. Despite prolonged resuscitation times, meaningful survival in patients admitted without ROSC is achievable.