Can early cardiac troponin I measurement help to predict recent coronary occlusion in out-of-hospital cardiac arrest survivors?

High-sensitivity troponin T for detection of culprit lesions in patients with out-of-hospital cardiac arrest

BACKGROUND

Patients with an out-of-hospital cardiac arrest (OHCA) often undergo coronary angiography, although a culprit lesion is found in only 30%-40% of patients. The aim of this study was to investigate high-sensitivity troponin T (hsTnT) levels in post cardiac arrest patients with and without coronary culprit lesions; factors affecting hsTnT levels after return of spontaneous circulation (ROSC); and the diagnostic ability of hsTnT in identifying patients with culprit lesions. We hypothesized that peak hsTnT levels were higher during the initial 48 h after cardiac arrest in patients with a coronary culprit lesion.

METHODS

This was a retrospective observational study, which included patients admitted to the Intensive Care Unit after an OHCA and who received a coronary angiography. Peak values and dynamic changes in hsTnT were analyzed in relation to the presence of a culprit lesion at coronary angiography.

RESULTS

A total of 238 patients were studied, of whom 140 had a culprit lesion. HsTnT levels during the initial 48 h were higher in patients with culprit lesions, longer time to ROSC and an unwitnessed cardiac arrest. At 6 to 12 h after ROSC, a hsTnT cut-off level of 1690 ng/L had a sensitivity of 64% and specificity of 84% to identify a culprit lesion. In patients without ST-elevations, hsTnT measured between 6 and 12 h after ROSC had a specificity above 90%, with a sensitivity of 46%.

CONCLUSION

HsTnT levels after cardiac arrest are higher in patients with coronary culprit lesions. Presence of a culprit lesion, witnessed status and the duration of CPR are important factors affecting hsTnT levels. Repeated measurement of hsTnT within the first 12 h after admission improved diagnostic accuracy but the value of hsTnT as a predictor of culprit lesions early after OHCA is limited.

The Prognostic Value of Troponin-T in Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: A COACT Substudy

Background

In out-of-hospital cardiac arrest (OHCA) without ST-elevation, predictive markers that can identify those with a high risk of acute coronary syndrome are lacking.

Methods

In this post hoc analysis of the Coronary Angiography after Cardiac Arrest (COACT) trial, the baseline, median, peak, and time-concentration curves of troponin-T (cTnT) (T-AUC) in OHCA patients without ST-elevation were studied. cTnT values were obtained at predefined time points at 0, 3, 6, 12, 24, 36, 28, and 72 hours after admission. All patients who died within the measurement period were not included. The primary outcome was the association between cTnT and 90-day survival. Secondary outcomes included the association of cTnT and acute thrombotic occlusions, acute unstable lesions, and left ventricular function.

Results

In total, 352 patients were included in the analysis. The mean age was 64 ± 13 years (80.4% men). All cTnT measures were independent prognostic factors for mortality after adjustment for potential confounders age, sex, history of coronary artery disease, witnessed arrest, time to BLS, and time to return of spontaneous circulation (eg, for T-AUC: hazard ratio, 1.44; 95% CI, 1.06-1.94; P = .02; P value for all variables ≤.02). Median cTnT (odds ratio [OR], 1.58; 95% CI, 1.18-2.12; P = .002) and T-AUC (OR, 2.03; 95% CI, 1.25-3.29; P = .004) were independent predictors for acute unstable lesions. Median cTnT (OR, 1.62; 95% CI, 1.17-2.23; P = .003) and T-AUC (OR, 2.16; 95% CI, 1.27-3.68; P = .004) were independent predictors for acute thrombotic occlusions. CTnT values were not associated with the left ventricular function (eg, for T-AUC: OR, 2.01; 95% CI, 0.65-6.19; P = .22; P value for all variables ≥.14).

Conclusion

In OHCA patients without ST-segment elevation, cTnT release during the first 72 hours after return of spontaneous circulation was associated with clinical outcomes.

Diagnostic Value of High-Sensitivity Cardiac Troponin-I in Patients After Out-of-Hospital Cardiac Arrest

Knowing the etiology of cardiac arrest (CA) is important for treatment decisions. Results of previous studies on the diagnostic role of cardiac troponin in patients resuscitated from CA are controversial, few studies were done during the era of high-sensitivity cardiac troponin-I (hs-cTnI), and kinetics of hs-cTnI was not thoroughly investigated. We aimed to explore the diagnostic value of hs-cTnI in patients resuscitated from out-of-hospital CA (OHCA). This retrospective study included 201 consecutive patients after OHCA admitted to the intensive cardiac care unit at Rambam Health Care Campus from 2016 to 2021. Patients were divided into 2 groups according to etiology of CA: group 1-patients with definite acute myocardial infarction (AMI), group 2-patients in whom AMI was excluded. Values of hs-cTnI on admission, peak hs-cTnI, and hs-cTnI upslope were compared between patients with AMI and non-AMI. Peak hs-cTnI and hs-cTnI upslope differed significantly between patients with non-AMI versus AMI CA (median 1,424 vs 32,558 ng/L, p <0.0001 and median 109 vs 2,322 ng/L/h, p <0.0001, respectively). Moreover, peak hs-cTnI and hs-cTnI upslope were found to have good discrimination performance between patients with non-AMI and AMI, with area under the curve receiver operating characteristics (ROC) curves of 0.83 and 0.80, respectively. In conclusion, in patients resuscitated from OHCA values of peak hs-cTnI and hs-cTnI upslope could be helpful in the diagnosis of etiology of CA as adjunct to other diagnostic methods.

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.

Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: One-Year Outcomes of a Randomized Clinical Trial

Importance

Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest (OHCA). The long-term effect of early coronary angiography on patients with OHCA with possible coronary trigger but no ST-segment elevation remains unclear.

Objective

To compare the clinical outcomes of early unselective angiography with the clinical outcomes of a delayed or selective approach for successfully resuscitated patients with OHCA of presumed cardiac origin without ST-segment elevation at 1-year follow-up.

Design, Setting, and Participants

The TOMAHAWK trial was a multicenter, international (Germany and Denmark), investigator-initiated, open-label, randomized clinical trial enrolling 554 patients between November 23, 2016, to September 20, 2019. Patients with stable return of spontaneous circulation after OHCA of presumed cardiac origin but without ST-segment elevation on the postresuscitation electrocardiogram were eligible for inclusion. A total of 554 patients were randomized to either immediate coronary angiography after hospital admission or an initial intensive care assessment with delayed or selective angiography after a minimum of 24 hours. All 554 patients were included in survival analyses during the follow-up period of 1 year. Secondary clinical outcomes were assessed only for participants alive at 1 year to account for the competing risk of death.

Interventions

Early vs delayed or selective coronary angiography and revascularization if indicated.

Main Outcomes and Measures

Evaluations in this secondary analysis included all-cause mortality after 1 year, as well as severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure in survivors at 1 year.

Results

A total of 281 patients were randomized to the immediate angiography group and 273 to the delayed or selective group, with a median age of 70 years (IQR, 60-78 years). A total of 369 of 530 patients (69.6%) were male, and 268 of 483 patients (55.5%) had a shockable arrest rhythm. At 1 year, all-cause mortality was 60.8% (161 of 265) in the immediate angiography group and 54.3% (144 of 265) in the delayed or selective angiography group without significant difference between the treatment strategies, trending toward an increase in mortality with immediate angiography (hazard ratio, 1.25; 95% CI, 0.99-1.57; P = .05). For patients surviving until 1 year, the rates of severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure were similar between the groups.

Conclusions and Relevance

This study found that a strategy of immediate coronary angiography does not provide clinical benefit compared with a delayed or selective invasive approach for patients 1 year after resuscitated OHCA of presumed coronary cause and without ST-segment elevation.

Trial Registration

ClinicalTrials.gov Identifier: NCT02750462.

A machine learning algorithm to predict a culprit lesion after out of hospital cardiac arrest

BACKGROUND

We aimed to develop a machine learning algorithm to predict the presence of a culprit lesion in patients with out-of-hospital cardiac arrest (OHCA).

METHODS

We used the King's Out-of-Hospital Cardiac Arrest Registry, a retrospective cohort of 398 patients admitted to King's College Hospital between May 2012 and December 2017. The primary outcome was the presence of a culprit coronary artery lesion, for which a gradient boosting model was optimized to predict. The algorithm was then validated in two independent European cohorts comprising 568 patients.

RESULTS

A culprit lesion was observed in 209/309 (67.4%) patients receiving early coronary angiography in the development, and 199/293 (67.9%) in the Ljubljana and 102/132 (61.1%) in the Bristol validation cohorts, respectively. The algorithm, which is presented as a web application, incorporates nine variables including age, a localizing feature on electrocardiogram (ECG) (≥2 mm of ST change in contiguous leads), regional wall motion abnormality, history of vascular disease and initial shockable rhythm. This model had an area under the curve (AUC) of 0.89 in the development and 0.83/0.81 in the validation cohorts with good calibration and outperforms the current gold standard-ECG alone (AUC: 0.69/0.67/0/67).

CONCLUSIONS

A novel simple machine learning-derived algorithm can be applied to patients with OHCA, to predict a culprit coronary artery disease lesion with high accuracy.

Early Versus Delayed Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation-A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The optimal timing of coronary angiography remains unclear following out-of-hospital cardiac arrest (OHCA) without ST elevation on electrocardiogram. The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of early angiography versus delayed angiography following OHCA without ST elevation.

DATA SOURCES

The databases MEDLINE, PubMed EMBASE, and CINHAL, as well as unpublished sources from inception to March 9, 2022.

STUDY SELECTION

A systematic search was performed for randomized controlled trials of adult patients after OHCA without ST elevation who were randomized to early as compared to delayed angiography.

DATA EXTRACTION

Reviewers screened and abstracted data independently and in duplicate. The certainty of evidence was assessed for each outcome using the Grading Recommendations Assessment, Development and Evaluation approach. The protocol was preregistered (CRD 42021292228).

DATA SYNTHESIS

Six trials were included (n = 1,590 patients). Early angiography probably has no effect on mortality (relative risk [RR] 1.04; 95% CI 0.94-1.15; moderate certainty) and may have no effect on survival with good neurologic outcome (RR 0.97; 95% CI 0.87-1.07; low certainty) or ICU length of stay (LOS) (mean difference 0.41 days fewer; 95% CI -1.3 to 0.5 d; low certainty). Early angiography has an uncertain effect on adverse events.

CONCLUSIONS

In OHCA patients without ST elevation, early angiography probably has no effect on mortality and may have no effect on survival with good neurologic outcome and ICU LOS. Early angiography has an uncertain effect on adverse events.

Acute Coronary Occlusion in Patients With Non-ST-Segment Elevation Out-of-Hospital Cardiac Arrest

BACKGROUND

According to current guidelines, hemodynamic status should guide the decision between immediate and delayed coronary angiography (CAG) in out-of-hospital cardiac arrest (OHCA) patients without ST-segment elevation. A delayed strategy is advised in hemodynamically stable patients, and an immediate approach is recommended in unstable patients.

OBJECTIVES

This study sought to assess the frequency, predictors, and clinical impact of acute coronary occlusion in hemodynamically stable and unstable OHCA patients without ST-segment elevation.

METHODS

Consecutive unconscious OHCA patients without ST-segment elevation who were undergoing CAG at Bern University Hospital (Bern, Switzerland) between 2011 and 2019 were included. Frequency and predictors of acute coronary artery occlusions and their impact on all-cause and cardiovascular mortality at 1 year were assessed.

RESULTS

Among the 386 patients, 169 (43.8%) were hemodynamically stable. Acute coronary occlusions were found in 19.5% of stable and 24.0% of unstable OHCA patients (P = 0.407), and the presence of these occlusions was predicted by initial chest pain and shockable rhythm, but not by hemodynamic status. Acute coronary occlusion was associated with an increased risk of cardiovascular death (adjusted HR: 2.74; 95% CI: 1.22-6.15) but not of all-cause death (adjusted HR: 0.72; 95% CI: 0.44-1.18). Hemodynamic instability was not predictive of fatal outcomes.

CONCLUSIONS

Acute coronary artery occlusions were found in 1 in 5 OHCA patients without ST-segment elevation. The frequency of these occlusions did not differ between stable and unstable patients, and the occlusions were associated with a higher risk of cardiovascular death. In OHCA patients without ST-segment elevation, chest pain or shockable rhythm rather than hemodynamic status identifies patients with acute coronary occlusion.

Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation

BACKGROUND

Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest. However, the benefits of early coronary angiography and revascularization in resuscitated patients without electrocardiographic evidence of ST-segment elevation are unclear.

METHODS

In this multicenter trial, we randomly assigned 554 patients with successfully resuscitated out-of-hospital cardiac arrest of possible coronary origin to undergo either immediate coronary angiography (immediate-angiography group) or initial intensive care assessment with delayed or selective angiography (delayed-angiography group). All the patients had no evidence of ST-segment elevation on postresuscitation electrocardiography. The primary end point was death from any cause at 30 days. Secondary end points included a composite of death from any cause or severe neurologic deficit at 30 days.

RESULTS

A total of 530 of 554 patients (95.7%) were included in the primary analysis. At 30 days, 143 of 265 patients (54.0%) in the immediate-angiography group and 122 of 265 patients (46.0%) in the delayed-angiography group had died (hazard ratio, 1.28; 95% confidence interval [CI], 1.00 to 1.63; P = 0.06). The composite of death or severe neurologic deficit occurred more frequently in the immediate-angiography group (in 164 of 255 patients [64.3%]) than in the delayed-angiography group (in 138 of 248 patients [55.6%]), for a relative risk of 1.16 (95% CI, 1.00 to 1.34). Values for peak troponin release and for the incidence of moderate or severe bleeding, stroke, and renal-replacement therapy were similar in the two groups.

CONCLUSIONS

Among patients with resuscitated out-of-hospital cardiac arrest without ST-segment elevation, a strategy of performing immediate angiography provided no benefit over a delayed or selective strategy with respect to the 30-day risk of death from any cause. (Funded by the German Center for Cardiovascular Research; TOMAHAWK ClinicalTrials.gov number, NCT02750462.).

Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia)

Background Occlusion myocardial infarctions (OMIs) of the posterolateral walls are commonly missed by ST-segment-elevation myocardial infarction (STEMI) criteria, with >50% of patients with circumflex occlusion not receiving emergent reperfusion and experiencing increased mortality. ST-segment depression maximal in leads V1-V4 (STDmaxV1-4) has been suggested as an indicator of posterior OMI. Methods and Results We retrospectively reviewed a high-risk population with acute coronary syndrome. OMI was defined from prior studies as a culprit lesion with TIMI (Thrombolysis in Myocardial Infarction) 0 to 2 flow or TIMI 3 flow plus peak troponin T >1.0 ng/mL or troponin I >10 ng/mL. STEMI was defined by the Fourth Universal Definition of Myocardial Infarction. ECGs were interpreted blinded to outcomes. Among 808 patients, there were 265 OMIs, 108 (41%) meeting STEMI criteria. A total of 118 (15%) patients had "suspected ischemic" STDmaxV1-4, of whom 106 (90%) had an acute culprit lesion, 99 (84%) had OMI, and 95 (81%) underwent percutaneous coronary intervention. Suspected ischemic STDmaxV1-4 had 97% specificity and 37% sensitivity for OMI. Of the 99 OMIs detected by STDmaxV1-4, 34% had <1 mm ST-segment depression, and only 47 (47%) had accompanying STEMI criteria, of which 17 (36%) were identified a median 1.00 hour earlier by STDmaxV1-4 than STEMI criteria. Despite similar infarct size, TIMI flow, and coronary interventions, patients with STEMI(-) OMI and STDmaxV1-4 were less likely than STEMI(+) patients to undergo catheterization within 90 minutes (46% versus 68%; P=0.028). Conclusions Among patients with high-risk acute coronary syndrome, the specificity of ischemic STDmaxV1-4 was 97% for OMI and 96% for OMI requiring emergent percutaneous coronary intervention. STEMI criteria missed half of OMIs detected by STDmaxV1-4. Ischemic STDmaxV1-V4 in acute coronary syndrome should be considered OMI until proven otherwise.

Timing of coronary angiography in patients following out-of-hospital cardiac arrest without ST-segment elevation: A systematic review and Meta-analysis of randomized trials

INTRODUCTION

Out-of-hospital cardiac arrest (OHCA) has a poor prognosis. The timing and role of early coronary angiography (CAG) in OHCA patients without ST elevation remains unclear.

OBJECTIVE

We performed a meta-analysis of randomized controlled trials (RCTs) that compared early CAG to delayed CAG in OHCA patients without ST elevation.

METHODS

We searched PubMed, Cochrane, and ClinicalTrials.gov databases (from inception to September 2021) for studies comparing early CAG to delayed CAG in OHCA patients without ST elevation. We used a random-effect model to calculate relative ratio (RR) with 95% confidence interval (CI). The primary outcome was all-cause mortality at 30 days. Secondary outcomes included neurological status with cerebral performance category ≤2 (CPC) and the rate of percutaneous coronary intervention (PCI) following CAG.

RESULTS

A total of 6 RCTs including 1822 patients, of whom 895 underwent early CAG, and 927 underwent delayed CAG, were included in this meta-analysis. There was no statistically significant difference between the 2 groups in terms of 30-day all-cause mortality (Relative risk [RR] 1.06; 95%CI 0.94-1.20; P = 0.32; I² = 13%), neurological status (CPC ≤2) (RR 1.01; 95%CI 0.90-1.13; P = 0.85, I² = 37%), and rates of PCI following CAG (RR 1.08; 95%CI 0.84-1.39; P = 0.56; I² = 49%).

CONCLUSION

In patients suffering OHCA without ST-elevation, early CAG is not associated with reduced 30-day mortality when compared to patients who underwent delayed CAG. Given our meta-analysis results including multiple trials that have not shown a benefit, it is likely that updated guidelines will not support early angiography in patients suffering OHCA without ST-elevation.

Predictors of coronary artery disease in cardiac arrest survivors: coronary angiography for everyone? A single-center retrospective analysis

Objective

To identify predictors of coronary artery disease in survivors of cardiac arrest, to define the best timing for coronary angiography and to establish the relationship between coronary artery disease and mortality.

Methods

This was a single-center retrospective study including consecutive patients who underwent coronary angiography after cardiac arrest.

Results

A total of 117 patients (63 ± 13 years, 77% men) were included. Most cardiac arrest incidents occurred with shockable rhythms (70.1%), and the median duration until the return of spontaneous circulation was 10 minutes. Significant coronary artery disease was found in 68.4% of patients, of whom 75% underwent percutaneous coronary intervention. ST-segment elevation (OR 6.5, 95%CI 2.2 - 19.6; p = 0.001), the presence of wall motion abnormalities (OR 22.0, 95%CI 5.7 - 84.6; p < 0.001), an left ventricular ejection fraction ≤ 40% (OR 6.2, 95%CI 1.8 - 21.8; p = 0.005) and elevated high sensitivity troponin T (OR 3.04, 95%CI 1.3 - 6.9; p = 0.008) were predictors of coronary artery disease; the latter had poor accuracy (area under the curve 0.64; p = 0.004), with an optimal cutoff of 170ng/L. Only ST-segment elevation and the presence of wall motion abnormalities were independent predictors of coronary artery disease. The duration of cardiac arrest (OR 1.015, 95%CI 1.0 - 1.05; p = 0.048) was an independent predictor of death, and shockable rhythm (OR 0.4, 95%CI 0.4 - 0.9; p = 0.031) was an independent predictor of survival. The presence of coronary artery disease and the performance of percutaneous coronary intervention had no impact on survival; it was not possible to establish the best cutoff for coronary angiography timing.

Conclusion

In patients with cardiac arrest, ST-segment elevation, wall motion abnormalities, left ventricular dysfunction and elevated high sensitivity troponin T were predictive of coronary artery disease. Neither coronary artery disease nor percutaneous coronary intervention significantly impacted survival.

Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction

OBJECTIVE

In the STEMI paradigm of Acute Myocardial Infarction (AMI), many NSTEMI patients have unrecognized acute coronary occlusion MI (OMI), may not receive emergent reperfusion, and have higher mortality than NSTEMI patients without occlusion. We have proposed a new OMI vs. Non-Occlusion MI (NOMI) paradigm shift. We sought to compare the diagnostic accuracy of OMI ECG findings vs. formal STEMI criteria for the diagnosis of OMI. We hypothesized that blinded interpretation for predefined OMI ECG findings would be more accurate than STEMI criteria for the diagnosis of OMI.

METHODS

We performed a retrospective case-control study of patients with suspected acute coronary syndrome. The primary definition of OMI was either 1) acute TIMI 0-2 flow culprit or 2) TIMI 3 flow culprit with peak troponin T ≥ 1.0 ng/mL or I ≥ 10.0 ng/mL.

RESULTS

808 patients were included, of whom 49% had AMI (33% OMI; 16% NOMI). Sensitivity, specificity, and accuracy of STEMI criteria vs Interpreter 1 using OMI ECG findings among 808 patients were 41% vs 86%, 94% vs 91%, and 77% vs 89%, and for Interpreter 2 among 250 patients were 36% vs 80%, 91% vs 92%, and 76% vs 89%. STEMI(-) OMI patients had similar infarct size and mortality as STEMI(+) OMI patients, but greater delays to angiography.

CONCLUSIONS

Blinded interpretation using predefined OMI ECG findings was superior to STEMI criteria for the ECG diagnosis of Occlusion MI. These data support further investigation into the OMI vs. NOMI paradigm and suggest that STEMI(-) OMI patients could be identified rapidly and noninvasively for emergent reperfusion using more accurate ECG interpretation.

Diagnostic test accuracy of the initial electrocardiogram after resuscitation from cardiac arrest to indicate invasive coronary angiographic findings and attempted revascularization: A systematic review and meta-analysis

AIM

Conduct a diagnostic test accuracy systematic review and meta-analysis of the post-return of spontaneous circulation (ROSC) electrocardiogram (ECG) to indicate an acute-appearing coronary lesion and revascularization.

METHODS

We searched PubMed, EMBASE, CINAHL, Cochrane Library, and Web of Science through February 18, 2020. Two investigators screened titles and abstracts, extracted data, and assessed risks of bias using QUADAS-2. We estimated sensitivity (Sn), specificity (Sp), and likelihood ratios (LR) for all reported ECG features to indicate all reported reference standards. Random-effects meta-analysis pooled comparable studies without critical risk of bias. GRADE methodology evaluated the certainty of evidence.

RESULTS

Overall, 48 studies reported 94 combinations of ECG features and reference standards with wide variation in their definitions. Most studies had risks of bias from selection for coronary angiography and blinding to the ECG and/or reference standard. Meta-analysis combined 6 studies for STE and acute coronary lesion (Sn 0.70 [95% CI 0.54-0.82]; Sp 0.85 [95% CI 0.78-0.90]; LR + 4.7 [95% CI 3.3-6.7]; LR- 0.4 [95% CI 0.2-0.6]) and 4 studies for STE and revascularization (Sn 0.53 [95% CI 0.47-0.58]; Sp 0.86 [95% CI 0.80-0.91]; LR + 3.9 [95% CI 2.8-5.5]; LR- 0.5 [95% CI 0.5-0.6]). Overall certainty of evidence was low with substantial heterogeneity.

CONCLUSIONS

Based on low certainty evidence, STE had good classification for acute coronary lesion and fair classification for revascularization. STE was more specific than sensitive for these outcomes and no single ECG feature excluded them. Uniform definitions and terminology would greatly facilitate the interpretation of subsequent studies.

Computerized Analysis of the Ventricular Fibrillation Waveform Allows Identification of Myocardial Infarction: A Proof-of-Concept Study for Smart Defibrillator Applications in Cardiac Arrest

Background

In cardiac arrest, computerized analysis of the ventricular fibrillation (VF) waveform provides prognostic information, while its diagnostic potential is subject of study. Animal studies suggest that VF morphology is affected by prior myocardial infarction (MI), and even more by acute MI. This experimental in‐human study reports on the discriminative value of VF waveform analysis to identify a prior MI. Outcomes may provide support for in‐field studies on acute MI.

Methods and Results

We conducted a prospective registry of implantable cardioverter defibrillator recipients with defibrillation testing (2010–2014). From 12‐lead surface ECG VF recordings, we calculated 10 VF waveform characteristics. First, we studied detection of prior MI with lead II, using one key VF characteristic (amplitude spectrum area [AMSA]). Subsequently, we constructed diagnostic machine learning models: model A, lead II, all VF characteristics; model B, 12‐lead, AMSA only; and model C, 12‐lead, all VF characteristics. Prior MI was present in 58% (119/206) of patients. The approach using the AMSA of lead II demonstrated a C‐statistic of 0.61 (95% CI, 0.54–0.68). Model A performance was not significantly better: 0.66 (95% CI, 0.59–0.73), P=0.09 versus AMSA lead II. Model B yielded a higher C‐statistic: 0.75 (95% CI, 0.68–0.81), P<0.001 versus AMSA lead II. Model C did not improve this further: 0.74 (95% CI, 0.67–0.80), P=0.66 versus model B.

Conclusions

This proof‐of‐concept study provides the first in‐human evidence that MI detection seems feasible using VF waveform analysis. Information from multiple ECG leads rather than from multiple VF characteristics may improve diagnostic accuracy. These results require additional experimental studies and may serve as pilot data for in‐field smart defibrillator studies, to try and identify acute MI in the earliest stages of cardiac arrest.

Comprehensive Cardiac Care After Cardiac Arrest

Cardiac arrest (CA) results in multiorgan ischemia until return of spontaneous circulation and often is followed by a low-flow shock state. Upon restoration of circulation and organ perfusion, resuscitative teams must act quickly to achieve clinical stability while simultaneously addressing the underlying etiology of the initial event. Optimal cardiovascular care demands focused management of the post-cardiac arrest syndrome and associated shock. Acute coronary syndrome should be considered and managed in a timely manner, because early revascularization improves patient outcomes and may suppress refractory arrhythmias. This review outlines the diagnostic and therapeutic considerations that define optimal cardiovascular care after CA.

DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction (DIFOCCULT Study)

Background

Although ST-segment elevation (STE) has been used synonymously with acute coronary occlusion (ACO), current STE criteria miss nearly one-third of ACO and result in a substantial amount of false catheterization laboratory activations. As many other electrocardiographic (ECG) findings can reliably indicate ACO, we sought whether a new ACO/non-ACO myocardial infarction (MI) paradigm would result in better identification of the patients who need acute reperfusion therapy.

Methods

A total of 3000 patients were enrolled in STEMI, non-STEMI and control groups. All ECGs were reviewed by two cardiologists, blinded to any outcomes, for the current STEMI criteria and other subtle signs. A combined ACO endpoint was composed of peak troponin level, troponin rise within the first 24 h and angiographic appearance. The dead or alive status was checked from hospital records and from the electronic national database.

Results

In non-STEMI group, 28.2% of the patients were re-classified by the ECG reviewers as having ACO. This subgroup had a higher frequency of ACO, myocardial damage, and both in-hospital and long-term mortality compared to non-STEMI group. A prospective ACOMI/non-ACOMI approach to the ECG had superior diagnostic accuracy compared to the STE/non-STEMI approach in the prediction of ACO and long-term mortality. In Cox-regression analysis early intervention in patients with non-ACO-predicting ECGs was associated with a higher long-term mortality.

Conclusions

We believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI. (DIFOCCULT study; ClinicalTrials.gov number, NCT04022668.).

A new electrocardiographic pattern indicating inferior myocardial infarction

BACKGROUND

We identified a specific pattern that does not display contiguous ST-segment elevation (STE), indicating acute inferior myocardial infarction (MI) with concomitant critical stenoses on the other coronary arteries. We sought to define the frequency, underlying anatomic substrate, diagnostic power and prognostic implications of this pattern.

METHODS

One thousand patients with a diagnosis of non-STEMI were enrolled as the study group. Within the same date range, all patients with inferior STEMI and 1000 patients, who had been excluded for MI (no-MI), were also enrolled. The coronary angiograms were reviewed by two interventional cardiologists, who were blinded to the ECGs. Echocardiographic wall motion bullseye displays and coronary angiography maps were constructed for each group. The dead or alive status was checked from the electronic national database.

RESULTS

The final study population consisted 2362 patients. The prespecified ECG pattern was observed in 6.3% (61/966) of the non-STEMI cohort and 0.5% (5/1000) of no-MI patients. These patients had a larger infarct size as evidenced by 24-hour troponin levels, higher frequency of angiographic culprit lesion, and higher frequency of composite acute coronary occlusion endpoint compared to their non-STEMI counterparts. On the other hand, they had a similar in-hospital (5% vs. 4%, respectively; P = 0.675) and one-year mortality compared to the patients with inferior STEMI (11% vs. 8%, respectively; P = 0.311).

CONCLUSION

We here define a new ECG pattern indicating inferior MI in patients with concomitant critical lesion(s) in coronary arteries other than the infarct-related artery. Patients with this pattern have multivessel disease and higher mortality.

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.

Coronary artery calcification as a novel predictive marker of unstable coronary lesion in survivors of out-of-hospital cardiac arrest without ST-segment elevation

AIM

Acute myocardial infarction (AMI) is the leading cause of out-of-hospital cardiac arrest (OHCA). A highly predictive marker is needed to identify AMI in survivors of OHCA without ST-segment elevation because the appropriate indication for emergency coronary artery angiography in patients without ST-segment segment elevation has not been determined. Accordingly, the aim of this study was to elucidate the clinical significance of coronary artery calcification in identifying survivors of OHCA without ST-segment elevation who could benefit from emergency coronary artery angiography.

METHODS

Survivors of OHCA without ST-segment elevation with no obvious extra-cardiac cause who underwent emergency computed tomography and coronary artery angiography were enrolled. Unstable coronary lesion was diagnosed using coronary artery angiography, and presence of coronary artery calcification and coronary artery calcium score were evaluated by non-contrast, non-electrocardiography gated computed tomography.

RESULTS

Thirty of 100 consecutive survivors of OHCA were diagnosed to have unstable coronary lesion. Sensitivity and specificity of coronary artery calcification in identifying unstable coronary lesion were 87% and 60%, respectively. Multivariate logistic regression analysis revealed that coronary artery calcification was an independent predictor of unstable coronary lesion (odds ratio: 7.28, 95% confidence interval: 2.00-26.56, p < 0.001).

CONCLUSION

Evaluation of coronary artery calcification by computed tomography is useful in identifying patients with unstable coronary lesion who could benefit from emergency coronary artery angiography among survivors of OHCA without ST-segment elevation on post-resuscitation electrocardiography.

Association of Cyr61-cysteine-rich protein 61 and short-term mortality in patients with acute heart failure and coronary heart disease

Aim: The protein CCN1/CYR61 exerts critical functions in myocardial ischemic injury. We sought to investigate the prognostic value of CCN1 in patients with acute heart failure (AHF) and coronary heart disease (CAD). Methodology: We prospectively enrolled 113 patients with AHF and CAD. Patients were followed for all-cause mortality during a 30-day follow-up. Logistic models were used to estimate the association of CCN1 concentrations with 30-day mortality. Results: In multivariate logistic regression model, CCN1 was a significant predictor of 30-day mortality independent of current markers. Enhanced Feedback for Effective Cardiac Treatment risk score was recommended as one of the selected multivariable risk scores to predict outcome in AHF. CCN1 improved risk stratification for all-cause mortality when added to the Enhanced Feedback for Effective Cardiac Treatment risk scores at 30 days. Conclusion: We found CCN1 is independently associated with 30-day mortality in patients with AHF and CAD.

Phenotyping Cardiac Arrest: Bench and Bedside Characterization of Brain and Heart Injury Based on Etiology

OBJECTIVES

Cardiac arrest etiology may be an important source of between-patient heterogeneity, but the impact of etiology on organ injury is unknown. We tested the hypothesis that asphyxial cardiac arrest results in greater neurologic injury than cardiac etiology cardiac arrest (ventricular fibrillation cardiac arrest), whereas ventricular fibrillation cardiac arrest results in greater cardiovascular dysfunction after return of spontaneous circulation.

DESIGN

Prospective observational human and randomized animal study.

SETTING

University laboratory and ICUs.

PATIENTS

Five-hundred forty-three cardiac arrest patients admitted to ICU.

SUBJECTS

Seventy-five male Sprague-Dawley rats.

INTERVENTIONS

We examined neurologic and cardiovascular injury in Isoflurane-anesthetized rat cardiac arrest models matched by ischemic time. Hemodynamic and neurologic outcomes were assessed after 5 minutes no flow asphyxial cardiac arrest or ventricular fibrillation cardiac arrest. Comparison was made to injury patterns observed after human asphyxial cardiac arrest or ventricular fibrillation cardiac arrest.

MEASUREMENTS AND MAIN RESULTS

In rats, cardiac output (20 ± 10 vs 45 ± 9 mL/min) and pH were lower and lactate higher (9.5 ± 1.0 vs 6.4 ± 1.3 mmol/L) after return of spontaneous circulation from ventricular fibrillation cardiac arrest versus asphyxial cardiac arrest (all p < 0.01). Asphyxial cardiac arrest resulted in greater early neurologic deficits, 7-day neuronal loss, and reduced freezing time (memory) after conditioned fear (all p < 0.05). Brain antioxidant reserves were more depleted following asphyxial cardiac arrest. In adjusted analyses, human ventricular fibrillation cardiac arrest was associated with greater cardiovascular injury based on peak troponin (7.8 ng/mL [0.8-57 ng/mL] vs 0.3 ng/mL [0.0-1.5 ng/mL]) and ejection fraction by echocardiography (20% vs 55%; all p < 0.0001), whereas asphyxial cardiac arrest was associated with worse early neurologic injury and poor functional outcome at hospital discharge (n = 46 [18%] vs 102 [44%]; p < 0.0001). Most ventricular fibrillation cardiac arrest deaths (54%) were the result of cardiovascular instability, whereas most asphyxial cardiac arrest deaths (75%) resulted from neurologic injury (p < 0.0001).

CONCLUSIONS

In transcending rat and human studies, we find a consistent phenotype of heart and brain injury after cardiac arrest based on etiology: ventricular fibrillation cardiac arrest produces worse cardiovascular dysfunction, whereas asphyxial cardiac arrest produces worsened neurologic injury associated with greater oxidative stress.

Age-Dependent Myocardial Dysfunction in Critically Ill Patients: Role of Mitochondrial Dysfunction

Myocardial dysfunction is common in septic shock and post-cardiac arrest but manifests differently in pediatric and adult patients. By conventional echocardiographic parameters, biventricular systolic dysfunction is more prevalent in children with septic shock, though strain imaging reveals that myocardial injury may be more common in adults than previously thought. In contrast, diastolic dysfunction in general and post-arrest myocardial systolic dysfunction appear to be more widespread in the adult population. A growing body of evidence suggests that mitochondrial dysfunction mediates myocardial depression in critical illness; alterations in mitochondrial electron transport system function, bioenergetic production, oxidative and nitrosative stress, uncoupling, mitochondrial permeability transition, fusion, fission, biogenesis, and autophagy all may play key pathophysiologic roles. In this review we summarize the epidemiologic and clinical phenotypes of myocardial dysfunction in septic shock and post-cardiac arrest and the multifaceted manifestations of mitochondrial injury in these disease processes. Since neonatal and pediatric-specific data for mitochondrial dysfunction remain sparse, conclusive age-dependent differences are not clear; instead, we highlight what evidence exists and identify gaps in knowledge to guide future research. Finally, since focal ischemic injury (with or without reperfusion) leading to myocardial infarction is predominantly an atherosclerotic disease of the elderly, this review focuses specifically on septic shock and global ischemia-reperfusion injury occurring after resuscitation from cardiac arrest.

Diagnostic and prognostic utility of cardiac troponin in post-cardiac arrest care

BACKGROUND

Cardiac troponin is routinely tested in the post-cardiac arrest setting, but its utility in identifying ischaemic aetiology and predicting left ventricular systolic dysfunction (LVSD) and survival is not known.

METHODS

In a retrospective single center registry, we identified 145 consecutive patients who had achieved return of spontaneous circulation after cardiac arrest and had undergone serial cardiac troponin T (cTnT) testing, echocardiogram, and expert adjudication of aetiology. Initial and peak cTnT were evaluated for assessing ischaemic aetiology, LVSD, and survival to discharge using area under the receiver operating characteristic curve (AUROC).

RESULTS

Mean age was 61 ± 14 years and 71% were men. Of the 145 arrests, 19% had an ischaemic aetiology, 68% had LVSD post-arrest, and 55% survived to discharge. All patients had a positive initial cTnT at 0.01 ng/mL (clinical cut-off). Even at higher cut-offs of 10×, 100× and 1000×, initial cTnT performed poorly (AUROC 0.57, 0.56, and 0.56) and peak cTnT performed modestly (AUROC 0.55, 0.61, and 0.62) as diagnostic tests for ischaemic aetiology. Similarly, even at higher cut-offs, initial (AUROC 0.60, 0.62, 0.55) and peak (AUROC 0.57, 0.61, and 0.62) cTnT performed poorly to modestly at predicting LVSD. The test performed poorly for predicting survival to discharge (AUROC for all <0.6).

CONCLUSIONS

At both current and several-fold higher thresholds, cTnT does not perform sufficiently well to guide clinical decision-making or predict patient outcomes. Routine post-cardiac arrest testing of cTnT should be reevaluated.

Immediate unselected coronary angiography versus delayed triage in survivors of out-of-hospital cardiac arrest without ST-segment elevation: Design and rationale of the TOMAHAWK trial

Patients experiencing out-of-hospital cardiac arrest (OHCA) without ST-segment elevation are a heterogenic group with a variety of underlying causes. Up to one-third of patients display a significant coronary lesion compatible with myocardial infarction as OHCA trigger. There are no randomized data on patient selection and timing of invasive coronary angiography after admission. METHODS AND RESULTS: The TOMAHAWK trial randomly assigns 558 patients with return of spontaneous circulation after OHCA with no obvious extracardiac origin of cardiac arrest and no ST-segment elevation/left bundle-branch block on postresuscitation electrocardiogram to either immediate coronary angiography or initial intensive care assessment with delayed/selective angiography in a 1:1 ratio. The primary end point is 30-day all-cause mortality. Secondary analyses will be performed with respect to initial rhythm, electrocardiographic patterns, myocardial infarction as underlying cause, neurological outcome, as well as clinical and laboratory markers. Clinical follow-up will be performed at 6 and 12 months. Safety end points include bleeding and stroke. CONCLUSION: The TOMAHAWK trial will address the unresolved issue of timing and general indication of angiography after OHCA without ST-segment elevation.

Does Early Coronary Angiography Improve Survival After out-of-Hospital Cardiac Arrest? A Systematic Review With Meta-Analysis

BACKGROUND

In patients with out-of-hospital cardiac arrest who achieve return of spontaneous circulation, coronary angiography (CAG) might improve outcomes. We conducted a systematic review and meta-analysis to elucidate the benefit and optimal timing of early CAG in comatose out-of-hospital cardiac arrest patients with return of spontaneous circulation.

METHODS

We searched MEDLINE, EMBASE, and Cochrane from 1990 to May 2017. Studies reporting survival and/or neurological survival in early (< 24-hour) vs late/no CAG were selected. We used the Clinical Advances Through Research and Information Translation (CLARITY) risk of bias in cohort studies tool and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria to assess risk of bias and quality of evidence, respectively. Results were pooled using random effects and presented as risk ratios (RRs) with 95% confidence intervals (CIs).

RESULTS

After screening 9185 titles/abstracts and 631 full-text articles, we included 23 nonrandomized studies. Short (to discharge or 30 days) and long-term (1-5 years) survival were significantly improved (52% and 56%, respectively) in the early < 24-hour CAG group compared with the late/no CAG group (RR, 1.52; 95% CI, 1.32-1.74; P < 0.00001; I2, 94% and RR, 1.56; 95% CI, 1.14-2.14; P = 0.006; I2, 86%). Survival with good neurological outcome was also improved by 69% in the < 24-hour CAG group at short- (RR, 1.69; 95% CI, 1.40-2.04; P < 0.00001; I2, 93%) and intermediate-term (3-11 months; RR, 1.49; 95% CI, 1.27-1.76; P < 0.00001; I2, 67%). We found consistent benefits in the < 2-hour and < 6-hour subgroups. Early CAG was associated with significantly better outcomes in studies of patients without ST-elevation, but the results did not reach statistical significance in studies of patients with ST-elevation.

CONCLUSIONS

On the basis of very low quality, but consistent evidence, early CAG (< 24 hours) was associated with significantly higher survival and better neurologic outcomes.

Coronary angiography findings in cardiac arrest patients with non-diagnostic post-resuscitation electrocardiogram: A comparison of shockable and non-shockable initial rhythms

AIM

To investigate the impact of coronary artery disease in a cohort of patients resuscitated from cardiac arrest with non-diagnostic electrocardiogram.

METHODS

From March 2004 to February 2016, 203 consecutive patients resuscitated from in or out-of-hospital sudden cardiac arrest and non-diagnostic post-resuscitation electrocardiogram (defined as ST segment elevation or pre-sumably new left bundle branch block) who underwent invasive coronary angiogram during hospitalization were included. For purpose of analysis and comparison, patients were classified in two groups: Initial shockable rhythm (ventricular tachycardia or ventricular fibrillation; n = 148, 72.9%) and initial non-shockable rhythm (n = 55, 27.1%). Baseline characteristics, coronary angiogram findings including Syntax Score and long-term survival rates were compared.

RESULTS

Sudden cardiac arrest was witnessed in 95.2% of cases, 66.7% were out-of-hospital patients and 72.4% were male. There were no significant differences in baseline characteristics between groups except for higher mean age (68.1 years vs 61 years, P = 0.001) in the non-shockable rhythm group. Overall 5-year mortality of the resuscitated patients was 37.4%. Patients with non-shockable rhythms had higher mortality (60% vs 29.1%, P < 0.001) and a worst neurological status at hospital discharge based on cerebral performance category score (CPC 1-2: 32.7% vs 53.4%, P = 0.02). Although there were no significant differences in global burden of coronary artery disease defined by Syntax Score (mean Syntax Score: 10.2 vs 10.3, P = 0.96) there was a trend towards a higher incidence of acute coronary lesions in patients with shockable rhythm (29.7% vs 16.4%, P = 0.054). There was also a higher need for ad-hoc percutaneous coronary intervention in this group (21.9% vs 9.1%, P = 0.03).

CONCLUSION

Initial shockable group of patients had a trend towards higher incidence of acute coronary lesions and higher need of ad-hoc percutaneous intervention vs non-shockable group.

Recent developments in the management of patients resuscitated from cardiac arrest

Cardiac arrest is the leading cause of death in Europe and the United States. Many patients who are initially resuscitated die in the hospital, and hospital survivors often have substantial neurologic dysfunction. Most cardiac arrests are caused by coronary artery disease; patients with coronary artery disease likely benefit from early coronary angiography and intervention. After resuscitation, cardiac arrest patients remain critically ill and frequently suffer cardiogenic shock and multiorgan failure. Early cardiopulmonary stabilization is important to prevent worsening organ injury. To achieve best patient outcomes, comprehensive critical care management is needed, with primary goals of stabilizing hemodynamics and preventing progressive brain injury. Targeted temperature management is frequently recommended for comatose survivors of cardiac arrest to mitigate the neurologic injury that drives outcomes. Accurate neurologic assessment is central to managing care of cardiac arrest survivors and should combine physical examination with objective neurologic testing, with the caveat that delaying neurologic prognosis is essential to avoid premature withdrawal of supportive care. A combination of clinical findings and diagnostic results should be used to estimate the likelihood of functional recovery. This review focuses on recent advances in care and specific cardiac intensive care strategies that may improve morbidity and mortality for patients after cardiac arrest.

Role of coronary angiography for out-of-hospital cardiac arrest survivors according to postreturn of spontaneous circulation on an electrocardiogram

Survivors of out-of-hospital cardiac arrest (OHCA) have high mortality and morbidity. An acute coronary event is the most common cause of sudden cardiac death. For this reason, coronary angiography is an important diagnostic and treatment strategy for patients with postcardiac arrest. This study aimed to identify the correlation between postreturn of spontaneous circulation (ROSC) on an electrocardiogram (ECG) and results of coronary angiography of OHCA survivors.We collected data from our OHCA registry from January 2010 to November 2014. We categorized OHCA survivors into 2 groups according to post-ROSC ECG results. Emergent coronary artery angiography (CAG) (CAG performed within 12 hours after cardiac arrest) was performed in patients who showed ST segment elevation or new onset of left bundle branch block (LBBB) in post-ROSC ECG. For other patients, the decision for performing CAG was made according to agreement between the emergency physician and the cardiologist.During the study period, 472 OHCA victims visited our emergency department and underwent cardiopulmonary resuscitation. Among 198 OHCA survivors, 82 patients underwent coronary artery intervention. Thirty-one (70.4%) patients in the ST segment elevation or LBBB group and 10 (24.4%) patients in the nonspecific ECG group had coronary artery lesions (P < .01). Seven (18.4%) patients in the nonspecific ECG group showed coronary spasm.OHCA survivors without ST segment elevation or new onset LBBB still have significant coronary lesions in CAG. If there is no other obvious arrest cause in patients without significant changes in post ROSC ECG, CAG should be considered to rule out the possibility of coronary artery problems, including coronary spasm.

Global Registry of Acute Coronary Events risk score predicts mortality and neurological outcome in out-of hospital cardiac arrest

PURPOSE

The aim of this study was to assess the usefulness of the Global Registry of Acute Coronary Events (GRACE) risk score in predicting in-hospital mortality and neurological outcome of patients resuscitated after out-of-hospital cardiac arrest (OHCA).

METHODS

We retrospectively analyzed the data of patients admitted to our hospital between October 2009 and October 2015 with OHCA and shockable initial cardiac rhythm who were resuscitated via conventional cardiopulmonary resuscitation. We calculated the GRACE risk score on admission and assessed its usefulness in predicting in-hospital mortality and neurological outcome.

RESULTS

Among 91 patients, 42 (46%) had acute myocardial infarction (AMI), 19 (21%) died in-hospital, and 52 (57%) had favorable neurological outcome. Among all the study patients, GRACE risk score was lower in survivors than in non-survivors (median 211 [interquartile range 176-240] vs. 266 [219-301], p<0.001, respectively) and in favorable than in unfavorable neurological outcome group (202 [167-237] vs. 242 [219-275], p<0.001, respectively). Multivariate analysis showed significant association between GRACE risk score and favorable neurological outcome (odds ratio, 0.975; 95% confidence interval, 0.961-0.990). Areas under receiver-operating characteristic curves, that describe the accuracy of GRACE risk score in predicting in-hospital mortality and favorable neurological outcome, were both 0.79.

CONCLUSION

GRACE risk score may predict the in-hospital mortality and neurological outcome associated with resuscitated patients with OHCA and shockable initial cardiac rhythm, regardless of the cause of arrest.

The association of maximum Troponin values post out-of-hospital cardiac arrest with electrocardiographic findings, cardiac reperfusion procedures and survival to discharge: A sub-study of ROC PRIMED

BACKGROUND

The role of Troponin (Tn) levels in the management of patients post out-of-hospital cardiac arrest (OHCA) is unclear.

METHODS

All OHCA patients enrolled in the Resuscitation Outcomes Consortium Prehospital Resuscitation using an IMpedance valve and Early versus Delayed analysis trial and admitted to hospital with a Tn level and a 12-lead electrocardiogram were stratified by ST elevation (STE) or no STE in a regression model for survival to discharge adjusted for Utstein predictors and site.

RESULTS

Of the 15,617 enrolled OHCA patients, 4118 (26%) survived to admission to hospital; 17% (693) were STE and 77% (3188) were no STE with 6% unknown; 83% (3460) had at least one Tn level. Reperfusion rates were higher when Tn level >2ng/ml (p>0.1ng/ml) improved with a diagnostic cardiac catheterization (p<0.001).

CONCLUSIONS

Elevated Tn levels >2ng/ml were associated with improved survival to discharge in patients post OHCA with STE. Survival in patients with no STE and Tn values >0.1ng/ml was higher when associated with diagnostic cardiac catheterization or treated with reperfusion or revascularization.

Immediate Percutaneous Coronary Intervention Is Associated With Improved Short- and Long-Term Survival After Out-of-Hospital Cardiac Arrest

BACKGROUND

Whether to perform or not an immediate percutaneous coronary intervention (PCI) after out-of-hospital cardiac arrest is still debated. We aimed to evaluate the impact of PCI on short- and long-term survival in out-of-hospital cardiac arrest patients admitted after successful resuscitation.

METHODS AND RESULTS

Between 2000 and 2013, all nontrauma out-of-hospital cardiac arrest patients admitted in a Parisian cardiac arrest center after return of spontaneous circulation were prospectively included. The association between immediate PCI and short- and long-term mortality was analyzed using logistic regression and Cox multivariate analysis, respectively. Propensity score-matching method was used to assess the influence of PCI on short- and long-term survival. During the study period, 1722 patients (71.5% male, median age 60 [49.6, 72.2] years) were analyzed: 628 (35.6%) without coronary angiography, 615 (35.7%) with coronary angiography without PCI, and 479 (27.8%) with both. Among these groups, day 30 and year-10 survival rates were 21% and 11.9%, 35% and 29%, 43% and 38%, respectively (P<0.01 for each). PCI as compared with no coronary angiography was associated with a lower day-30 and long-term mortality (adjORcoro with PCI versus no coro 0.71, 95% confidence interval [0.54, 0.92]; P=0.02 and adjHRcoro with PCI versus no coro 0.44, 95% confidence interval [0.27, 0.71]; P<0.01, respectively). PCI remained associated with a lower risk of long-term mortality (adjHR 0.29; 95% confidence interval [0.14, 0.61]; P<0.01) in propensity score-matching analysis.

CONCLUSIONS

Immediate PCI after out-of-hospital cardiac arrest was associated with significant reduced risk of short- and long-term mortality. These findings should suggest physicians to consider immediate coronary angiography and PCI if indicated in these patients.

Improving Survival From Cardiac Arrest: A Review of Contemporary Practice and Challenges

Cardiac arrest is a common and lethal condition frequently encountered by emergency medicine providers. Resuscitation of persons after cardiac arrest remains challenging, and outcomes remain poor overall. Successful resuscitation hinges on timely, high-quality cardiopulmonary resuscitation. The optimal method of providing chest compressions and ventilator support during cardiac arrest remains uncertain. Prompt and effective defibrillation of ventricular arrhythmias is one of the few effective therapies available for treatment of cardiac arrest. Despite numerous studies during several decades, no specific drug delivered during cardiac arrest has been shown to improve neurologically intact survival after cardiac arrest. Extracorporeal circulation can rescue a minority of highly selected patients with refractory cardiac arrest. Current management of pulseless electrical activity is associated with poor outcomes, but it is hoped that a more targeted diagnostic approach based on electrocardiography and bedside cardiac ultrasonography may improve survival. The evolution of postresuscitation care appears to have improved cardiac arrest outcomes in patients who are successfully resuscitated. The initial approach to early stabilization includes standard measures, such as support of pulmonary function, hemodynamic stabilization, and rapid diagnostic assessment. Coronary angiography is often indicated because of the high frequency of unstable coronary artery disease in comatose survivors of cardiac arrest and should be performed early after resuscitation. Optimizing and standardizing our current approach to cardiac arrest resuscitation and postresuscitation care will be essential for developing strategies for improving survival after cardiac arrest.

[Role of coronary intervention after successful cardiopulmonary resuscitation]

Immediate coronary angiography and intervention in suitable stenoses in patients resuscitated from cardiac arrest of presumed coronary origin and return of spontaneous circulation is widely established in interventional centers. The procedure is based on the analogy of positive results achieved with coronary intervention in many forms of acute coronary syndromes on the one hand and otherwise from registries showing promising data from coronary intervention of resuscitated patients. Results from randomized controlled studies, however, are not yet available. With respect to ST-elevation myocardial infarction, the diagnostic reliability of an ECG registered shortly after cardiopulmonary resuscitation is sufficient. The results of the registries are specifically promising for patients with ST-elevation myocardial infarction but less favorable for other forms of acute coronary syndromes. Moreover, insight into the results of the registries reveals that patients with the best prognostic conditions were preferentially selected for coronary intervention (e.g., younger patients, those with an initially shockable arrhythmia, bystander resuscitation), whereas those, for example, with cardiac or renal failure were excluded. For better definition of the actual benefit of coronary intervention after resuscitation from cardiac arrest and the optimal target groups, randomized controlled studies on patients with ST-elevation myocardial infarction are desirable, while for other forms of acute coronary syndromes these studies are essential.

Troponin Marker for Acute Coronary Occlusion and Patient Outcome Following Cardiac Arrest

INTRODUCTION

The utility of troponin as a marker for acute coronary occlusion and patient outcome after out-of-hospital cardiac arrest (OHCA) is unclear. We sought to determine whether initial or peak troponin was associated with percutaneous coronary intervention (PCI), OHCA survival or neurological outcome.

METHODS

Single-center retrospective-cohort study of OHCA patients treated in a comprehensive clinical pathway from November 2007 to October 2012. Troponin I levels were acquired at presentation, four and eight hours after arrest, and then per physician discretion. Cardiac catheterization was at the cardiologist's discretion. Survival and outcome were determined at hospital discharge, with cerebral performance category score 1-2 defined as a good neurological outcome.

RESULTS

We enrolled 277 patients; 58% had a shockable rhythm, 44% survived, 41% good neurological outcome. Of the 107 (38%) patients who underwent cardiac catheterization, 30 (28%) had PCI. Initial ED troponin (median, ng/mL) was not different in patients requiring PCI vs no PCI (0.32 vs 0.09, p=0.06), although peak troponin was higher (4.19 versus 1.57, p=0.02). Of the 85 patients who underwent cardiac catheterization without STEMI (n=85), there was no difference in those who received PCI vs no PCI in initial troponin (0.22 vs 0.06, p=0.40) or peak troponin (2.58 vs 1.43, p=0.27). Regarding outcomes, there was no difference in initial troponin in survivors versus non-survivors (0.09 vs 0.22, p=0.11), or those with a good versus poor neurological outcome (0.09 vs 0.20, p=0.11). Likewise, there was no difference in peak troponin in survivors versus non-survivors (1.64 vs 1.23, p=0.07), or in those with a good versus poor neurological outcome (1.57 vs 1.26, p=0.14).

CONCLUSION

In our single-center patient cohort, peak troponin, but not initial troponin, was associated with higher likelihood of PCI, while neither initial nor peak troponin were associated with survival or neurological outcome in OHCA patients.