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

Individualized decision making in on-scene resuscitation time for out-of-hospital cardiac arrest using reinforcement learning

On-scene resuscitation time is associated with out-of-hospital cardiac arrest (OHCA) outcomes. We developed and validated reinforcement learning models for individualized on-scene resuscitation times, leveraging nationwide Korean data. Adult OHCA patients with a medical cause of arrest were included (N = 73,905). The optimal policy was derived from conservative Q-learning to maximize survival. The on-scene return of spontaneous circulation hazard rates estimated from the Random Survival Forest were used as intermediate rewards to handle sparse rewards, while patients' historical survival was reflected in the terminal rewards. The optimal policy increased the survival to hospital discharge rate from 9.6% to 12.5% (95% CI: 12.2-12.8) and the good neurological recovery rate from 5.4% to 7.5% (95% CI: 7.3-7.7). The recommended maximum on-scene resuscitation times for patients demonstrated a bimodal distribution, varying with patient, emergency medical services, and OHCA characteristics. Our survival analysis-based approach generates explainable rewards, reducing subjectivity in reinforcement learning.

Race, Ethnicity, and Gender Disparities in Acute Myocardial Infarction

Cardiovascular disease continues to be the leading cause of morbidity and mortality in the United States. Despite advancements in medical care, there remain persistent racial, ethnic, and gender disparity in the diagnosis, treatment, and prognosis of individuals with cardiovascular disease. In this review we seek to discuss differences in pathophysiology, clinical course, and risk profiles in the management and outcomes of acute myocardial infarction and related high-risk states. We also seek to highlight the demographic and psychosocial inequities that cause disparities in acute cardiovascular care.

Management of patients with an electrical storm or clustered ventricular arrhythmias: a clinical consensus statement of the European Heart Rhythm Association of the ESC-endorsed by the Asia-Pacific Heart Rhythm Society, Heart Rhythm Society, and Latin-American Heart Rhythm Society

Electrical storm (ES) is a state of electrical instability, manifesting as recurrent ventricular arrhythmias (VAs) over a short period of time (three or more episodes of sustained VA within 24 h, separated by at least 5 min, requiring termination by an intervention). The clinical presentation can vary, but ES is usually a cardiac emergency. Electrical storm mainly affects patients with structural or primary electrical heart disease, often with an implantable cardioverter-defibrillator (ICD). Management of ES requires a multi-faceted approach and the involvement of multi-disciplinary teams, but despite advanced treatment and often invasive procedures, it is associated with high morbidity and mortality. With an ageing population, longer survival of heart failure patients, and an increasing number of patients with ICD, the incidence of ES is expected to increase. This European Heart Rhythm Association clinical consensus statement focuses on pathophysiology, clinical presentation, diagnostic evaluation, and acute and long-term management of patients presenting with ES or clustered VA.

2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve outcomes. This "2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support" summarizes the most recent published evidence for and recommendations on the use of medications, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation, and seizure management in this population. We discuss the lack of data in recent cardiac arrest literature that limits our ability to evaluate diversity, equity, and inclusion in this population. Last, we consider how the cardiac arrest population may make up an important pool of organ donors for those awaiting organ transplantation.

Urgent coronary angiography in out-of-hospital cardiac arrest: a retrospective single centre investigation

AIMS

The role of immediate coronary angiography (CAG) with percutaneous coronary intervention (PCI) in patients who present with ST-segment elevation myocardial infarction (STEMI) and cardiac arrest is well recognized. However, the role of immediate angiography in patients after cardiac arrest without STEMI is less clear. We assessed whether urgent (<6 h) CAG and PCI (whenever needed) was associated with improved early survival in out-of-hospital cardiac arrest (OHCA).

METHODS

In our single-centre, retrospective, observational study, we included all consecutive OHCA patients admitted to the A&E of the Careggi University Hospital between 1 June 2016 and 31 July 2020. One hundred and forty-four OHCA patients were submitted to CAG and constituted our study population.

RESULTS

Among the 221 consecutive OHCA patients, 69 (31%) had refractory cardiac arrest treated with extracorporeal cardiopulmonary resuscitation (eCPR) in 37 (37/69, 56%) patients. The mortality rate was significantly higher in the no CAG subgroup (P < 0.00001). In the CAG subgroup, coronary artery disease was detected in the 70% (92 patients), among whom the left main coronary artery was involved in 10 patients (10.8%). At multivariable regression analysis (CAG subgroup, outcome ICU survival), witnessed cardiac arrest was independently associated with survival.

CONCLUSION

A high incidence of coronary artery disease was observed at CAG in the real-world of OHCA patients. Better planning of revascularization and treatment in patients studied with CAG may explain, at least in part, their lower mortality rate.

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.

Temporal Change in the Remaining Life Expectancy in People Who Underwent Percutaneous Coronary Intervention

Whether percutaneous coronary intervention (PCI) is effective in improving long-term survival in an Australian PCI cohort remains unclear. We aimed to examine the change in the remaining life expectancy for patients who underwent PCI over the past decade. Patient data from the Melbourne Interventional Group were divided into four 3-year periods (2005 to 2007, 2008 to 2010, 2011 to 2013, and 2014 to 2016) for survival analysis. The primary outcome was time to death after PCI. Kaplan-Meier survival curves for overall survival were constructed to estimate the 5-year survival. To extrapolate the overall survival curve to the lifetime time horizon, 6 parametric survival distributions were fitted to the individual patient-level data against the Kaplan-Meier curve. The best fit distribution was selected based on goodness-of-fit statistics and expert opinion. The combination of annual mortality post-PCI from the parametric survival analysis and the background mortality by age informed the overall mortality rate. The life expectancy was compared with the general Australians. In addition, the utility weight of post-PCI patients was used to estimate the quality-adjusted life years gained. A total of 27,301 patients with a mean age of 64.4 ± 12 years were included. The base-case results showed that over the 4 time periods, the remaining life expectancy for patients aged 64.4 years on average at the time of PCI remained relatively stable except for period 4: 18.12 years (2005 to 2007), 17.56 years (2008 to 2010), 18.39 years (2011 to 2013), and 17.25 years (2014 to 2016), respectively. The quality-adjusted life years gained showed a similar trend: 14.86 (2005 to 2007), 14.40 (2008 to 2010), 15.07 (2011 to 2013), and 14.13 (2014 to 2016) separately. In conclusion, the widened gap in life expectancy in post-PCI patients versus the general Australian over the 2014 to 2016 period suggests the need for improved implementation of prevention strategies for coronary heart disease. Enhanced disease management after PCI that lowers residual mortality risk is recommended to extend the survival of patients with coronary heart disease.

Coronary Angiography in Patients With Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation on Electrocardiograms: A Comprehensive Review

Out-of-hospital cardiac arrest (OHCA) is among the most common causes of death in the United States. Early coronary angiography (CAG) and percutaneous coronary intervention (PCI) have been associated with improved long-term outcomes in patients with ST-segment elevation (STE) on prearrest or postarrest electrocardiograms. However, data on the utility of catheterization and PCI for improving outcomes after OHCA in patients without STE on electrocardiograms are heterogeneous, with variable results. Although older data have suggested that there is a benefit, recent randomized controlled trials have demonstrated that performing early CAG in patients with OHCA without STE on electrocardiograms may not improve outcomes. In recognition that neurologic devastation and multiorgan failure are common in these patients, physicians face the challenge of selecting appropriate patients for cardiac catheterization and PCI. This review aims to summarize the current data on this topic, with the goal to guide decision making regarding the timing and appropriateness of CAG in patients with OHCA without STE on electrocardiograms, utilizing an evidence-based approach to streamline the patient selection process.

Contemporary Management of Concomitant Cardiac Arrest and Cardiogenic Shock Complicating Myocardial Infarction

Cardiogenic shock (CS) and cardiac arrest (CA) are the most life-threatening complications of acute myocardial infarction. Although there is a significant overlap in the pathophysiology with approximately half the patients with CS experiencing a CA and approximately two-thirds of patients with CA developing CS, comprehensive guideline recommendations for management of CA + CS are lacking. This paper summarizes the current evidence on the incidence, pathophysiology, and short- and long-term outcomes of patients with acute myocardial infarction complicated by concomitant CA + CS. We discuss the hemodynamic factors and unique challenges that need to be accounted for while developing treatment strategies for these patients. A summary of expert-based step-by-step recommendations to the approach and treatment of these patients, both in the field before admission and in-hospital management, are presented.

Outcome after out-of-hospital cardiac arrest in patients with ischaemic and non-ischaemic heart disease: A Danish tertiary-center cohort study

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Approximately half of patients with out-of-hospital cardiac arrest had died within five years.

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Most working patients returned to work within five years.

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No significant difference in all-cause mortality, cardiac death, and return to work.

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A non-significant trend toward a higher mortality was shown in patients with non-ischaemic heart disease driven by non-cardiac causes; suggesting ischaemic heart disease may be a favourable cause of cardiac arrest compared with other causes.

Background

Mortality following out-of-hospital cardiac arrest (OHCA) is high, and studies on return to work show varying results. It remains uncertain whether mortality and return to work differs between patients with ischaemic heart disease (IHD) and non-ischaemic heart disease (non-IHD).

Aim

To investigate all-cause mortality, cardiac death, and return to work among patients admitted after OHCA with IHD and non-IHD.

Methods

We included 234 consecutive patients admitted to Aarhus University Hospital with OHCA, who were not declared dead in the prehospital setting or upon arrival. Patients were divided into an IHD and a non-IHD group based on history of myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft surgery, or signs of obstructive IHD on the admission coronary angiography. Outcome in terms of all-cause mortality, cardiac death, and return to work was evaluated.

Results

All-cause mortality after one month, one year, and five years was 41.9%, 49.1%, and 54.3%. There was no difference in all-cause mortality or cardiac death between IHD and non-IHD patients (all-cause mortality: adjusted HR 0.78, 95% CI, 0.53–1.14; P = 0.19) and cardiac death: adjusted HR 0.93, 95% CI, 0.60–1.43; P = 0.73). Among patients working prior to OHCA the cumulative incidence of patients returning to work was 62.3% after five years with no statistically significant difference between groups.

Conclusion

A favourable outcome was observed in patients admitted after OHCA with a non-significant trend toward a higher mortality in non-IHD patients, possibly indicating that IHD is a favourable cause of cardiac arrest.

Long-term Survival After Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-analysis

Importance

Data on long-term survival beyond 12 months after out-of-hospital cardiac arrest (OHCA) of a presumed cardiac cause are scarce.

Objective

To investigate the long-term survival of adult patients after surviving the initial hospital stay for an OHCA.

Data Sources

A systematic search of the EMBASE and MEDLINE databases was performed from database inception to March 25, 2021.

Study Selection

Clinical studies reporting long-term survival after OHCA were selected based on predefined inclusion and exclusion criteria according to a preregistered study protocol.

Data Extraction and Synthesis

Patient data were reconstructed from Kaplan-Meier curves using an iterative algorithm and then pooled to generate survival curves. As a separate analysis, an aggregate data meta-analysis was performed.

Main Outcomes and Measures

The primary outcome was long-term survival (>12 months) after OHCA for patients surviving to hospital discharge or 30 days after OHCA.

Results

The search identified 15 347 reports, of which 21 studies (11 800 patients) were included in the Kaplan-Meier-based meta-analysis and 33 studies (16 933 patients) in an aggregate data meta-analysis. In the Kaplan-Meier-based analysis, the median survival time for patients surviving to hospital discharge was 5.0 years (IQR, 2.3-7.9 years). The estimated survival rates were 82.8% (95% CI, 81.9%-83.7%) at 3 years, 77.0% (95% CI, 75.9%-78.0%) at 5 years, 63.9% (95% CI, 62.3%-65.4%) at 10 years, and 57.5% (95% CI, 54.8%-60.1%) at 15 years. Compared with patients with a nonshockable initial rhythm, patients with a shockable rhythm had a lower risk of long-term mortality (hazard ratio, 0.30; 95% CI, 0.23-0.39; P < .001). Different analyses, including an aggregate data meta-analysis, confirmed these results.

Conclusions and Relevance

In this comprehensive systematic review and meta-analysis, long-term survival after 10 years in patients surviving the initial hospital stay after OHCA was between 62% and 64%. Additional research is needed to understand and improve the long-term survival in this vulnerable patient population.

Percutaneous Coronary Revascularization after Out-of-Hospital Cardiac Arrest: A Review of the Literature and a Case Series

Out-of-hospital cardiac arrest (OHCA) is still associated with high mortality and severe complications, despite major treatment advances in this field. Ischemic heart disease is a common cause of OHCA, and current guidelines clearly recommend performing immediate coronary angiography (CAG) in patients whose post-resuscitation electrocardiogram shows ST-segment elevation (STE). Contrarily, the optimal approach and the advantage of early revascularization in cases of no STE is less clear, and decisions are often based on the individual experience of the center. Numerous studies have been conducted on this topic and have provided contradictory evidence; however, more recently, results from several randomized clinical trials have suggested that performing early CAG has no impact on overall survival in patients without STE.

Long-term outcomes after out-of-hospital cardiac arrest: a systematic review and meta-analysis

AIMS

Long term outcomes after out-of-hospital cardiac arrest (OHCA) are not well understood. This study aimed to evaluate the long-term (1-year and beyond) survival outcomes, including overall survival and survival with favorable neurological status and the quality-of-life (QOL) outcomes, among patients who survived the initial OHCA event (30 days or till hospital discharge).

METHODS

Embase, Medline and PubMed were searched for primary studies (randomized controlled trials, cohort and cross-sectional studies) which reported the long-term survival outcomes of OHCA patients. Data abstraction and quality assessment was conducted, and survival at predetermined timepoints were assessed via single-arm meta-analyses of proportions, using generalized linear mixed models. Comparative meta-analyses were conducted using the Mantel-Haenszel Risk Ratio (RR) estimates, using the DerSimonian and Laird model.

RESULTS

67 studies were included, and among patients that survived to hospital discharge or 30-days, 77.3% (CI=71.2-82.4), 69.6% (CI=54.5-70.3), 62.7% (CI=54.5-70.3), 46.5% (CI=32.0-61.6), and 20.8% (CI=7.8-44.9) survived to 1-, 3-, 5-, 10- and 15-years respectively. Compared to Asia, the probability of 1-year survival was greater in Europe (RR=2.1, CI=1.8-2.3), North America (RR=2.0, CI=1.7-2.2) and Oceania (RR=1.9,CI=1.6-2.1). Males had a higher 1-year survival (RR:1.41, CI=1.25-1.59), and patients with initial shockable rhythm had improved 1-year (RR=3.07, CI=1.78-5.30) and 3-year survival (RR=1.45, CI=1.19-1.77). OHCA occurring in residential locations had worse 1-year survival (RR=0.42, CI=0.25-0.73).

CONCLUSION

Our study found that up to 20.8% of OHCA patients survived to 15-years, and survival was lower in Asia compared to the other regions. Further analysis on the differences in survival between the regions are needed to direct future long-term treatment of OHCA patients.

Impact of Pre-Revascularization and Post-Revascularization Cardiac Arrest on Survival Prognosis in Patients With Acute Myocardial Infarction and Following Emergency Percutaneous Coronary Intervention

Objectives: To evaluate the effects of occurrence and timing of sudden cardiac arrest (SCA) on survival in patients with acute myocardial infarction (AMI) who underwent emergency percutaneous coronary intervention (PCI).

Methods: We analyzed 1,956 consecutive patients with AMI with emergency PCI from 2014 to 2018. Patients with cardiac arrest events were identified, and their medical records were reviewed.

Results: Patients were divided into non-cardiac arrest group (NCA group, n = 1,724), pre-revascularization cardiac arrest (PRCA group, n = 175), and post-revascularization SCA (POCA group, n = 57) according to SCA timing. Compared to NCA group, PRCA group and POCA group presented with higher brain natriuretic polypeptide (BNP), more often Killip class 3/4, atrial fibrillation, and less often completed recovery of coronary artery perfusion (all p < 0.05). Both patients with PRCA and POCA showed increased 30-day all-cause mortality when compared to patients with NCA (8.0 and 70.2% vs. 2.9%, both p < 0.001). However, when compared to patients with NCA, patients with PRCA did not lead to higher mortality during long-term follow-up (median time 917 days) (16.3 vs. 18.6%, p = 0.441), whereas patients with POCA were associated with increased all-cause mortality (36.3 vs. 18.6%, p < 0.001). Multivariate analysis identified Killip class 3/4, atrial fibrillation, high maximum MB isoenzyme of creatine kianse, and high creatinine as predictive factors for POCA. In Cox regression analysis, POCA was found as a strong mortality-increase predictor (HR, 8.87; 95% CI, 2.26–34.72; p = 0.002) for long-term all-cause death.

Conclusions: POCA appeared to be a strong life-threatening factor for 30-day and long-term all-cause mortality among patients with AMI who admitted alive and underwent emergency PCI. However, PRCA experience did not lead to a poorer long-term survival in patients with AMI surviving the first 30 days.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

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.

Percutaneous Coronary Intervention After Return of Spontaneous Circulation Reduces the In-Hospital Mortality in Patients with Acute Myocardial Infarction Complicated by Cardiac Arrest

Background and Objective

The role of percutaneous coronary intervention (PCI) after return of spontaneous circulation (ROSC) in patients with acute myocardial infarction (AMI) complicated by cardiac arrest (CA) is controversial. This study aimed to evaluate the effects of PCI on the in-hospital mortality after ROSC in patients with AMI complicated by CA.

Methods

The clinical data of 66 consecutive patients with ROSC after CA caused by AMI from January 2006 to December 2015 at the First Affiliated Hospital of Sun Yat-sen University were collected. Among these patients, 21 underwent urgent PCI. We analyzed the clinical characteristics of the patients during hospitalization.

Results

The patients who underwent PCI had a higher rate of ST-segment elevation, and their initial recorded heart rhythms were more likely to have a shockable rhythm. Further, they had a high PCI success rate of 100%. The in-hospital mortality in the patients who did not undergo PCI was significantly higher than that in the patients who underwent PCI (68.9% vs 9.5%, P<0.05). Multivariate logistic regression analysis showed that cardiogenic shock (odds ratio [OR], 3.537; 95% CI, 1.047–11.945; P=0.042) and Glasgow Coma Scale score of ≤8 after ROSC (OR, 14.992; 95% CI, 2.815–79.843; P=0.002) were the independent risk factors for in-hospital mortality among the patients. Meanwhile, PCI was a protective factor against in-hospital mortality (OR, 0.063; 95% CI, 0.012–0.318; P=0.001). After propensity matching analysis, the results still showed that PCI (OR, 0.226; 95% CI, 0.028–1.814; P=0.0162) was a protective factor for in-hospital death.

Conclusion

The patients with ROSC after CA caused by AMI who underwent PCI had a lower in-hospital mortality than those who did not undergo PCI.

Precision Cardiac Arrest Resuscitation Based on Etiology

Cardiac arrest results from a broad range of etiologies that can be broadly grouped as sudden and asphyxial. Animal studies point to differences in injury pathways invoked in the heart and brain that drive injury and outcome after these different forms of cardiac arrest. Present guidelines largely ignore etiology in their management recommendations. Existing clinical data reveal significant heterogeneity in the utility of presently employed resuscitation and postresuscitation strategies based on etiology. The development of future neuroprotective and cardioprotective therapies should also take etiology into consideration to optimize the chances for successful translation.

Manual der Arbeitsgruppe Interventionelle Kardiologie (AGIK) der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung e. V. (DGK)

Dieses Manual zur diagnostischen Herzkatheteruntersuchung (Teil 1) ist eine Anwendungsempfehlung für interventionell tätige Ärzte, die den gegenwärtigen Kenntnisstand unter Berücksichtigung neuester Studienergebnisse wiedergibt. Hierzu wurde in den einzelnen Kapiteln speziell auf die Alltagstauglichkeit der Empfehlungen geachtet, sodass dieses Manual jedem interventionell tätigen Kardiologen als Entscheidungshilfe im Herzkatheterlabor dienen soll. Trotz der von vielen Experten eingebrachten praktischen Hinweise kann dieses Manual dennoch nicht die ärztliche Evaluation des individuellen Patienten ersetzen und damit eine Anpassung der Diagnostik bzw. Therapie ersetzen.

Effectiveness of fondaparinux vs unfractionated heparin following percutaneous coronary intervention in survivors of out-of-hospital cardiac arrest due to acute myocardial infarction

AIM

There is no specific evidence on the antithrombotic management of survivors of out-of-hospital cardiac arrest (OHCA) due to acute myocardial infarction (AMI). We sought to compare the short-term outcome of unfractioned heparin (UFH) vs fondaparinux in OHCA survivors due to AMI admitted in our Institution in the last decade.

METHODS

We performed a retrospective cohort study on survivors of OHCA due to AMI managed with UFH or fondaparinux during the hospitalization. The primary outcome was the occurrence of any bleeding, all-cause mortality, cerebrovascular accidents, re-MI, and unplanned revascularization at 1 month. A propensity-score matching was performed to compare the outcome between UFH and fondaparinux.

RESULTS

Out of 2083 AMI patients undergoing successful PCI, OHCA was present in 94 (4.5%): 41 (43.6%) treated with UFH and 53 (56.4%) with fondaparinux. At clinical follow-up, the incidence of the primary outcome was 65.9% in UFH and 35.8% in fondaparinux group (p = 0.007). More than half of the events included in the primary outcome were related to bleeding complications. In the matched cohort of 56 patients, the primary outcome occurred in 46.4% and 25.0% (p = 0.16), while bleeding was present in 32.1% and 7.1% (p = 0.04), in the UFH and fondaparinux group, respectively.

CONCLUSIONS

The present analysis suggests that fondaparinux is safer than UFH in the management of OHCA due to AMI by reducing early bleeding complications at one month.

A systematic review and meta-analysis of the effect of routine early angiography in patients with return of spontaneous circulation after Out-of-Hospital Cardiac Arrest

BACKGROUND

Early coronary angiography (CAG) has been reported in individual studies and systematic reviews to significantly improve outcomes of patients with return of spontaneous circulation (ROSC) after cardiac arrest (CA).

METHODS

We undertook a systematic review and meta-analysis to evaluate the impact of early CAG on key clinical outcomes in comatose patients after ROSC following out-of-hospital CA of presumed cardiac origin. We searched the PubMED, EMBASE, CINAHL, ERIC and Cochrane Central Register of Controlled Trials databases from 1990 until April 2020. Eligible studies compared patients undergoing early CAG to patients with late or no CAG. When randomized controlled trials (RCTs) existed for a specific outcome, we used their results to estimate the effect of the intervention. In the absence of randomized data, we used observational data. We excluded studies at high risk of bias according to the Robins-I tool from the meta-analysis. The GRADE system was used to assess certainty of evidence at an outcome level.

RESULTS

Of 3738 citations screened, 3 randomized trials and 41 observational studies were eligible for inclusion. Evidence certainty across all outcomes for the RCTs was assessed as low. Randomized data showed no benefit from early as opposed to late CAG across all critical outcomes of survival and survival with favourable neurologic outcome for undifferentiated patients and for patient subgroups without ST-segment-elevation on post ROSC ECG and shockable initial rhythm.

CONCLUSION

These results do not support routine early CAG in undifferentiated comatose patients and patients without STE on post ROSC ECG after OHCA.

REVIEW REGISTRATION

PROSPERO - CRD42020160152.

European Resuscitation Council Guidelines 2021: Epidemiology of cardiac arrest in Europe

In this section of the European Resuscitation Council Guidelines 2021, key information on the epidemiology and outcome of in and out of hospital cardiac arrest are presented. Key contributions from the European Registry of Cardiac Arrest (EuReCa) collaboration are highlighted. Recommendations are presented to enable health systems to develop registries as a platform for quality improvement and to inform health system planning and responses to cardiac arrest.

Out-of-Hospital Cardiac Arrest Does Not Affect Post-Discharge Survival in Patients With Acute Myocardial Infarction

Background: Acute myocardial infarction (AMI) patients complicated by out-of-hospital cardiac arrest (OHCA) show poor in-hospital outcomes. However, the post-discharge outcomes of survivors of OHCA have not been well studied. Methods and Results: Data for patients admitted to The Jikei University Kashiwa Hospital with AMI between April 2012 and March 2020 were examined retrospectively. The Jikei University Kashiwa Hospital is a tertiary emergency medical facility, so the frequency of OHCA in this hospital is higher than in an ordinary AMI population. Of 803 patients, 92 (11.5%) were complicated by OHCA. Of the 92 OHCA patients, 37 died in hospital, compared with 45 of 711 non-OHCA patients who died in hospital (P<0.001). OHCA was more frequent in men than in women. The estimated glomerular filtration rate was lower in those with than without OHCA. Long-term mortality was evaluated in patients discharged alive and followed-up at an outpatient clinic (n=635; median follow-up period 607 days). The long-term post-discharge mortality was comparable between AMI patients with and without OHCA. Conclusions: The post-discharge mortality of AMI patients with OHCA was comparable that of patients without OHCA.

Sex differences in acute cardiovascular care: a review and needs assessment

Despite significant progress in the care of patients suffering from cardiovascular disease, there remains a persistent sex disparity in the diagnosis, management, and outcomes of these patients. These sex disparities are seen across the spectrum of cardiovascular care, but, are especially pronounced in acute cardiovascular care. The spectrum of acute cardiovascular care encompasses critically ill or tenuous patients with cardiovascular conditions that require urgent or emergent decision-making and interventions. In this narrative review, the disparities in the clinical course, management, and outcomes of six commonly encountered acute cardiovascular conditions, some with a known sex-predilection will be discussed within the basis of underlying sex differences in physiology, anatomy, and pharmacology with the goal of identifying areas where improvement in clinical approaches are needed.

Bystander interventions and survival following out-of-hospital cardiac arrest at Copenhagen International Airport

AIM

To examine incidence and outcome following out-of-hospital cardiac (OHCA) arrest in a high-risk area characterised by high density of potential bystanders and easy access to nearby automated external defibrillators (AEDs).

METHODS

This retrospective observational study investigated pre-hospital and in-hospital treatment, as well as survival amongst persons with OHCA at Copenhagen International Airport between May 25, 2015 and May 25, 2019. OHCA data from pre- and in-hospital medical records were obtained and compared with public bystander witnessed OHCAs in Denmark.

RESULTS

Of the 23 identified non-traumatic OHCAs, 91.3% were witnessed by bystanders, 73.9% received bystander cardiopulmonary resuscitation (CPR), and 43.5% were defibrillated by a bystander. Survival to hospital discharge was 56.5%, with 100% survival among persons with an initial shockable heart rhythm. Compared with nationwide bystander witnessed OHCAs, persons with OHCA at the airport were less likely to receive bystander CPR (73.9% vs. 89.4%, OR 0.33; 95% CI, 0.13-0.86), more likely to receive bystander defibrillation (43.5% vs. 24.8%, OR 2.32; 95% CI, 1.01-5.31), to achieve return of spontaneous circulation (78.2% vs. 50.6%, OR 3.51; 95% CI, 1.30-9.49), and survive to hospital discharge (56.5% vs. 45.2%, OR 1.58; 95% CI, 0.69-3.62).

CONCLUSION

We found a high proportion of bystander defibrillation indicating that bystanders will quickly apply an AED, when accessible. Importantly, 56% of all persons, and all persons with a shockable heart rhythm survived. These findings suggest increased potential for survival following OHCA and support current guidelines to strategically deploy accessible AEDs in high-risk OHCA areas.

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.

An observational study assessing the impact of a cardiac arrest centre on patient outcomes after out-of-hospital cardiac arrest (OHCA)

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a major cause of death worldwide. Recent guidelines recommend the centralisation of OHCA services in cardiac arrest centres to improve outcomes. In 2015, two major tertiary cardiac centres in London merged to form a large dedicated tertiary cardiac centre. This study aimed to compare the short-term mortality of patients admitted with an OHCA before-and-after the merger of services had taken place and admission criteria were relaxed, which led to managing OHCA in higher volume.

METHODS

We retrospectively analysed the data of OHCA patients pre- and post-merger. Baseline demographic and medical characteristics were recorded, along with factors relating to the cardiac arrest. The primary endpoint was in-hospital mortality.

RESULTS

OHCA patients (N =728; 267 pre- and 461 post-merger) between 2013 and 2018 were analysed. Patients admitted pre-merger were older (65.0 vs. 62.4 years, p=0.027), otherwise there were similar baseline demographic and peri-arrest characteristics. There was a greater proportion of non-acute coronary syndrome-related OHCA admission post-merger (10.1% vs. 23.4%, p=0.0001) and a corresponding decrease in those admitted with ST-elevation myocardial infarction (80.2% vs. 57.0%, p=0.0001) and those treated with percutaneous coronary intervention (78.8% vs. 54.0%, p=0.0001). Despite this, in-hospital mortality was lower post-merger (63.7% vs. 44.3%, p=0.0001), which persisted after adjustment for demographic and arrest-related characteristics using stepwise logistic regression (p=0.036) between the groups.

CONCLUSION

Despite an increase in non-acute coronary syndrome-related OHCA cases, the formation of a centralised invasive heart centre was associated with improved survival in OHCA patients. This suggests there may be a benefit of a cardiac arrest centre model of care.

Do not disregard the initial 12 lead ECG after out-of-hospital cardiac arrest: It predicts angiographic culprit despite metabolic abnormalities

Objectives

The initial 12 lead electrocardiogram (ECG) following return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), is often disregarded by clinicians in ability to predict acute thrombotic coronary occlusion (ATCO) due to markedly abnormal metabolic milieu (AMM). We sought to evaluate the accuracy of initial vs. follow-up ECG prior to invasive coronary angiography (ICA) to predict ATCO following resuscitated OHCA.

Methods

We included OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA). AMM was defined as one of: pH ​< ​7.1, lactate >2 ​mmol/L, serum potassium <2.8 or >6.0 mEq/L. Two ECGs A (initial) and B (follow-up) following ROSC but prior to ICA were adjudicated by 2 experienced readers using expanded ECG criteria to predict angiographic ATCO on ICA.

Results

152 consecutive patients (mean age 58 years, 75% male) met inclusion criteria, 77% had AMM. Among those with both ECGs (n ​= ​102), overall accuracy, sensitivity, specificity, positive predictive value, negative predictive value for correctly predicting angiographic ATCO for ECG A was 72%, 63%, 81%, 61%, 83% and for ECG B was 71%, 50%, 91%, 73%, 80% respectively. Predictive accuracy for angiographic ATCO was similar between ECG A [odds ratio (OR) 7.31, CI 2.87–18.62, p ​< ​0.0001) and ECG B [OR 10.67; CI 3.6–31.61, p ​< ​0.0001], and consistent in AMM.

Conclusions

In OHCA, despite AMM, the initial post ROSC ECG retains a statistically significant, and similar accuracy as the follow-up ECG to predict angiographic ATCO using expanded criteria.

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.

A service evaluation of transport destination and outcome of patients with post-ROSC STEMI in an English ambulance service

Background

In the UK, there are approximately 60,000 cases of out-of-hospital cardiac arrest (OHCA) each year. There is mounting evidence that post-resuscitation care should include early angiography and primary percutaneous coronary intervention (pPCI) in cases of OHCA where a cardiac cause is suspected. Yorkshire Ambulance Service (YAS) staff can transport patients with a return of spontaneous circulation (ROSC) directly to a pPCI unit if their post-ROSC ECG shows evidence of ST elevation myocardial infarction (STEMI). This service evaluation aimed to determine the factors that affect the transport destination, hospital characteristics and 30-day survival rates of post-ROSC patients with presumed cardiac aetiology.

Methods

All patient care records (PCRs) previously identified for the AIRWAYS-2 trial between January and July 2017 were reviewed. Patients were eligible for inclusion if they were an adult non-traumatic OHCA, achieved ROSC on scene and were treated and transported by (YAS). Descriptive statistics were used to analyse the data.

Results

478 patients met the inclusion criteria. 361/478 (75.6%) patients had a post-ROSC ECG recorded, with 149/361 (41.3%) documented cases of STEMI and 88/149 (59.1%) referred to a pPCI unit by the attending clinicians. 40/88 (45.5%) of referrals made were accepted by the pPCI units. Patients taken directly to pPCI were most likely to survive to 30 days (25/39, 53.8%), compared to patients taken to an emergency department (ED) at a pPCI-capable hospital (34/126, 27.0%), or an ED at a non-pPCI-capable hospital (50/310, 16.1%).

Conclusion

Staff should be encouraged to record a 12-lead ECG on all post-ROSC patients, and make a referral to the regional pPCI-capable centre if there is evidence of a STEMI, or a cardiac cause is likely, since 30-day survival is highest for patients who are taken directly for pPCI. Ambulance services should continue to work with regional pPCI-capable centres to ensure that suitable patients are accepted to maximise potential for survival.

Healthcare costs and resource utilization associated with treatment of out-of-hospital cardiac arrest

BACKGROUND

The management of out-of-hospital cardiac arrest (OHCA) patients requires the coordination of prehospital, in-hospital and post-discharge teams. Data reporting a comprehensive analysis of all costs associated with treating OHCA are scarce. We aimed to describe the total costs (and their components) related to the management of OHCA patients.

PATIENT AND METHODS

We performed an analysis on a merged database of the Toronto Regional RescuNet Epistry database (prehospital data) and administrative population-based databases in Ontario. All non-traumatic OHCA patients over 18 years of age treated by the EMS between January 1, 2006, and March 31, 2014, were included in this study. The primary outcome was per patient longitudinal cumulative healthcare costs, from time of collapse to a maximum follow-up until death or 30 days after the event. We included all available cost sectors, from the perspective of the health system payer. We used multivariable generalized linear models with a logarithmic link and a gamma distribution to determine predictors of healthcare costs.

RESULTS

25,826/44,637 patients were treated by EMS services for an OHCA (mostly male 64.4%, mean age 70.1). 11,727 (45%) were pronounced dead on scene, 8359 (32%) died in the emergency department, 3640 (14%) were admitted to hospital but died before day-30, and 2100 (8.1%) were still alive at day-30. Total cost was $690 [interquartile range (IQR) $308, $1742] per patient; ranging from $290 [IQR $188, $390] for patients who were pronounced on scene to $39,216 [IQR 21,802, 62,093] for patients who were still alive at day-30. In-hospital costs accounted for 93% of total costs. After adjustment for age and gender, rate of patient survival was the main driver of total costs: the rate ratio was 3.88 (95% confidence interval 3.80, 3.95), 49.46 and 148.89 for patients who died in the ED, patients who died after the ED but within 30 days, and patients who were still alive at day-30 compared to patients who were pronounced dead on scene, respectively. Factors independently associated with costs were the number of prehospital teams (rate ratio (RR) 5.50 [5.32, 5.67] for being treated by 4 teams vs. 1), the need for hospital transfer (RR 2.38 [2.01, 2.82]), coronary angiography (RR 1.43 [1.27, 1.62]) and targeted temperature management (RR 1.25 [1.09, 1.44]).

CONCLUSION

Survival is the main driver of total costs of treating OHCA patients in a large Canadian health system. Inpatient costs accounted for the majority of the total costs; potentially modifiable factors include the number of prehospital teams that arrive to the scene of the arrest and the need for between-hospital transfers after successful resuscitation.

Post resuscitation electrocardiogram for coronary angiography indication after out-of-hospital cardiac arrest

BACKGROUND

Coronary angiography is the standard of care after Out-of-Hospital Cardiac Arrest (OHCA), but its benefit for patients without persistent ST-segment elevation (STE) remains controversial.

METHODS

All patients admitted for coronary angiography after a resuscitated OHCA were consecutively included in this prospective study. Three patient groups were defined according to post-resuscitation ECG: STE or new left bundle branch block (LBBB) (group 1); other ST/T repolarization disorders (group 2) and no repolarisation disorders (group 3). The proportion and predictive factors of an acute coronary lesion, defined by acute coronary occlusion or thrombotic lesion or lesion associated with flow impairment, were evaluated according to different groups as well as thirty-day mortality.

RESULTS

Among 129 consecutive patients: 62 (48.1%), 30 (23.3%) and 30 (23.3%) patients were included in groups 1, 2 and 3 respectively. An acute coronary lesion was observed in 43% (n = 55) of patients, mainly in group 1 (n = 44, 70.9%). Initial coronary TIMI 0/1 flow was more frequently observed in group 1 than in group 2 (n = 25, 40.3% vs n = 1, 3.3%) and never in group 3. Chest pain and STE or new LBBB were independently associated with an acute coronary lesion (adj. OR = 7.14 [1.85-25.00]; p = 0.004 and adj. OR = 11.10 [3.70-33.33]; p < 0.001 respectively). In absence of any repolarization disorders, acute coronary lesion or occlusion were excluded with negative predictive values of 93.3% and 100% respectively. The one-month survival rate was 38.8% and was better in patients among the group 1 compared to those from the 2 other groups (n = 28, 45.2% vs n = 21, 35%, respectively; p = 0.014).

CONCLUSION

Considering the high negative predictive value of post-resuscitation ECG to exclude acute coronary lesion and occlusion after OHCA, a delayed coronary angiography appears a reliable alternative for patients without repolarization disorders.

Association Between Hospital Teaching Status and Outcomes After Out-of-Hospital Cardiac Arrest

BACKGROUND

Controversy exists about how best to organize systems of care for patients with out-of-hospital cardiac arrest (OHCA), as little evidence exists to guide policy-makers. In Canada, teaching hospitals are mainly cardiac referral centers that are potentially well suited towards treating patients with OHCA. Our objective was to determine whether patients with OHCA are more likely to survive if they present to teaching hospitals.

METHODS AND RESULTS

We conducted a retrospective observational cohort study by linking several population-based administrative databases in Ontario, Canada. All patients >20 years old who arrived alive to hospital after OHCA between April 1, 2007, and March 31, 2014, were eligible for inclusion. Patients with ST-segment-elevation myocardial infarction were excluded. The primary outcome was survival at 30 days. To determine the association between teaching status and 30-day survival, logistic regression models were used to adjust for baseline differences in patient characteristics. Prespecified analysis was performed stratified by age: ≤65, 66 to 80, and >80 years old. A total of 25 346 patients were included: 5413 at teaching and 19 933 at nonteaching hospitals. Survival at 30 days was 13.9% in teaching and 11.0% (P<0.001) in nonteaching hospitals. Hospital teaching status was associated with a significantly higher adjusted odds of 30-day survival (odds ratio, 1.38 [95% CI, 1.14-1.67]). This improvement in survival was observed in younger patients (≤65 years: odds ratio, 1.41 [95% CI, 1.14-1.74]; 66 to 80 years: odds ratio,1.37 [95% CI, 1.13-1.67]), but there was no significant difference in the elderly (>80 years: odds ratio, 1.07 [95% CI, 0.79-1.44]).

CONCLUSIONS

Patients with OHCA treated at teaching hospitals were more likely to survive to 30 days. These findings support current recommendations suggesting that treatment of these patients should be provided at specialized hospitals.

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.

Functional outcomes associated with varying levels of targeted temperature management after out-of-hospital cardiac arrest - An INTCAR2 registry analysis

INTRODUCTION

Targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) has been recommended in international guidelines since 2005. The TTM-trial published in 2013 showed no difference in survival or neurological outcome for patients randomised to 33 °C or 36 °C, and many hospitals have changed practice. The optimal utilization of TTM is still debated. This study aimed to analyse if a difference in temperature goal was associated with outcome in an unselected international registry population.

METHODS

This is a retrospective observational study based on a prospective registry - the International Cardiac Arrest Registry 2. Patients were categorized as receiving TTM in the lower range at 32-34 °C (TTM-low) or at 35-37 °C (TTM-high). Primary outcome was good functional status defined as cerebral performance category (CPC) of 1-2 at hospital discharge and secondary outcome was adverse events related to TTM. A logistic regression model was created to evaluate the independent effect of temperature by correcting for clinical and demographic factors associated with outcome.

RESULTS

Of 1710 patients included, 1242 (72,6%) received TTM-low and 468 (27,4%) TTM-high. In patients receiving TTM-low, 31.3% survived with good outcome compared to 28.8% in the TTM-high group. There was no significant association between temperature and outcome (p = 0.352). In analyses adjusted for baseline differences the OR for a good outcome with TTM-low was 1.27, 95% CI (0.94-1.73). Haemodynamic instability leading to discontinuation of TTM was more common in TTM-low.

CONCLUSIONS

No significant difference in functional outcome at hospital discharge was found in patients receiving lower- versus higher targeted temperature management.

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.

Trends in Death Rate 2009 to 2018 Following Percutaneous Coronary Intervention Stratified by Acuteness of Presentation

Percutaneous coronary intervention (PCI) has evolved dramatically, along with patient complexity. We studied trends in in-hospital mortality with changes in patient complexity over the last decade stratified by clinical presentation. The study population included all patients presenting to the cardiac catheterization lab between January 2009 and July 2018. Expected in-hospital mortality was calculated using the National Cardiovascular Data Registry CathPCI risk scoring system. Yearly mean in-hospital mortality rates (%) were plotted and smoothed by weighted least squares regression for each presentation: ST-elevation myocardial infarction (STEMI), non-ST-elevation acute coronary syndrome (NSTE-ACS), and stable ischemic coronary artery disease (SI CAD). The overall cohort included 13,732 patients who underwent PCI during the study period, of whom 2,142 were for STEMI, 2,836 for NSTE-ACS, and 8,754 for SI CAD. Indications for PCI have changed over time, with more PCIs being performed for NSTE-ACS and STEMI than for SI CAD. NSTE-ACS and STEMI patients had a steady decrease in in-hospital mortality over time compared with SI CAD patients. Overall observed mortality continues to decrease in NSTE-ACS patients, with reduction in the observed mortality rate within the STEMI population to below expected since 2013. Patient complexity has not changed significantly. These results may be attributed to improved patient selection coupled with optimal pharmacotherapy with more robust therapies during procedure and hospitalization.