Outcomes following primary percutaneous coronary intervention in the setting of cardiac arrest: a registry database study

Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association

Diagnostic and therapeutic advances during the past decades have substantially improved health outcomes for patients with acute coronary syndrome. Both age-related physiological changes and accumulated cardiovascular risk factors increase the susceptibility to acute coronary syndrome over a lifetime. Compared with younger patients, outcomes for acute coronary syndrome in the large and growing demographic of older adults are relatively worse. Increased atherosclerotic plaque burden and complexity of anatomic disease, compounded by age-related cardiovascular and noncardiovascular comorbid conditions, contribute to the worse prognosis observed in older individuals. Geriatric syndromes, including frailty, multimorbidity, impaired cognitive and physical function, polypharmacy, and other complexities of care, can undermine the therapeutic efficacy of guidelines-based treatments and the resiliency of older adults to survive and recover, as well. In this American Heart Association scientific statement, we (1) review age-related physiological changes that predispose to acute coronary syndrome and management complexity; (2) describe the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes; and (3) recommend age-appropriate and guideline-concordant revascularization and acute coronary syndrome management strategies, including transitions of care, the use of cardiac rehabilitation, palliative care services, and holistic approaches. The primacy of individualized risk assessment and patient-centered care decision-making is highlighted throughout.

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.

Short- and long-term outcomes of out-of-hospital cardiac arrest following ST-elevation myocardial infarction managed with percutaneous coronary intervention

AIM

Out-of-hospital cardiac arrest (OHCA) is frequently associated with ST-elevation myocardial infarction (STEMI) and has a high mortality. We aimed to identify differences in characteristics and very long-term outcomes for STEMI patients with and without OHCA managed with percutaneous coronary intervention (PCI).

METHODS

We analysed data from 12,637 PCI patient procedures for STEMI in the multi-centre Melbourne Interventional Group registry between January 2005 and December 2018. Multivariable models examined associations with OHCA presentation and 30-day mortality. Long-term outcomes were assessed through linkage with the Australian National Death Index.

RESULTS

Compared with patients without OHCA (N = 11,580), patients with OHCA (N = 1057) were younger, more often male, had less cardiovascular risk factors, and more often presented with cardiogenic shock. OHCA preceded an increasing proportion of STEMI PCI cases from 2005 to 2018 (2.4% vs. 9.2%). Factors independently associated with OHCA presentation were younger age, male gender, prior valve surgery, multi-vessel disease, LAD culprit, small vessel diameter, and renal impairment on presentation. Patients with OHCA had lower procedural success, higher rates of bleeding and stroke, larger infarct size (measured by peak CK), and higher 30-day mortality (37% vs. 5%; all p < 0.05). Cardiogenic shock, renal impairment and lower ejection fraction were independently associated with 30-day mortality. Long-term mortality was 44% vs. 20% (median follow-up 4.6 years), with Cox regression analysis demonstrating no difference in survival if patients survived beyond 30 days (HR 1.18, 95% CI 0.95-1.47).

CONCLUSIONS

OHCA has a high short-term mortality and precedes an increasing proportion of STEMI PCI cases. Thirty-day survivors have an excellent long-term prognosis.

Vulnerability to cardiac arrest in patients with ST elevation myocardial infarction: Is it time or patient dependent? Results from a nationwide observational study

AIM

Cardiac arrest is a common complication of ST elevation myocardial infarction and is associated with high mortality. We evaluated whether vulnerability to cardiac arrest follows a circadian rhythm and whether it is related to specific patient characteristics.

METHODS

A total of 24,164 ST elevation myocardial infarction patients who were admitted to 60 Belgian hospitals between 2008-2017 were analysed. The proportion of patients with cardiac arrest before initiation of reperfusion therapy was calculated for different time periods (hour of the day, months, seasons) and related to patient characteristics using stepwise logistic regression analysis.

RESULTS

Cardiac arrest occurred in 10.8% of the ST elevation myocardial infarction patients at a median of 65 min (interquartile range 33-138 min) after onset of pain. ST elevation myocardial infarction patients with cardiac arrest showed a biphasic pattern with one peak in the morning and one peak in the late afternoon. Multivariate analysis identified the following independent factors associated with cardiac arrest: cardiogenic shock (odds ratio=28), left bundle branch block (odds ratio=3.7), short (<180 min) ischaemic period (odds ratio=2.2), post-meridiem daytime presentation (odds ratio=1.4), anterior infarction (odds ratio=1.3). Overall in-hospital mortality was 30% for cardiac arrest patients versus 3.7% for non-cardiac arrest patients (p<0.0001).

CONCLUSION

In the present study population, cardiac arrest in ST elevation myocardial infarction showed an atypical circadian rhythm with not only a morning peak but also a second peak in the late afternoon, suggesting that cardiac arrest and ST elevation myocardial infarction triggers are, at least partially, different. In addition, specific patient characteristics, such as short ischaemic period, cardiogenic shock and left bundle branch block, increase the vulnerability to cardiac arrest.

Association of acute myocardial infarction cardiac arrest patient volume and in-hospital mortality in the United States: Insights from the National Cardiovascular Data Registry Acute Coronary Treatment And Intervention Outcomes Network Registry

BACKGROUND

Little is known about how differences in out of hospital cardiac arrest patient volume affect in-hospital myocardial infarction (MI) mortality.

HYPOTHESIS

Hospitals accepting cardiac arrest transfers will have increased hospital MI mortality.

METHODS

MI patients (ST elevation MI [STEMI] and non-ST elevation MI [NSTEMI]) in the Acute Coronary Treatment Intervention Outcomes Network Registry were included. Hospital variation of cardiac arrest and temporal trend of the proportion of cardiac arrest MI patients were explored. Hospitals were divided into tertiles based on the proportion of cardiac arrest MI patients, and association between in-hospital mortality and hospital tertiles of cardiac arrest was compared using logistic regression adjusting for case mix.

RESULTS

A total of 252 882 patients from 224 hospitals were included, of whom 9682 (3.8%) had cardiac arrest (1.6% of NSTEMI and 7.5% of STEMI patients). The proportion of MI patients who had cardiac arrest admitted to each hospital was relatively low (median 3.7% [25th, 75th percentiles: 3.0%, 4.5%]).with a range of 4.2% to 12.4% in the high-volume tertiles. Unadjusted in-hospital mortality increased with tertile: low 3.8%, intermediate 4.6%, and high 4.7% (P < 0.001); this was no longer significantly different after adjustment (intermediate vs high tertile odds ratio (OR) = 1.02; 95% confidence interval [0.90-1.16], low vs high tertile OR = 0.93 [0.83, 1.05]).

CONCLUSIONS

The proportion of MI patients who have cardiac arrest is low. In-hospital mortality among all MI patients did not differ significantly between hospitals that had increased proportions of cardiac arrest MI patients. For most hospitals, overall MI mortality is unlikely to be adversely affected by treating cardiac arrest patients with MI.

Incidence of coronary intervention in cardiac arrest survivors with non-shockable initial rhythms and no evidence of ST-elevation MI (STEMI)

OBJECTIVE

With the demonstrated benefit of an early-invasive strategy for STEMI and VF/VT arrest patients, there is interest in assessing the potential benefit of early angiography for non-shockable (PEA/Asystole) arrest patients. We hypothesized that in cardiac arrest patients who obtain return of spontaneous circulation (ROSC) after a non-shockable initial rhythm and do not have STEMI the incidence of coronary intervention would be clinically insignificant (<5%).

METHODS

Retrospective multicenter US clinical registry study of post-cardiac arrest patients at 18 hospitals between 1/00 and 5/14. The incidence of significant coronary artery disease (CAD) as defined by documented coronary intervention (i.e. PCI, angioplasty, stent or CABG) was assessed.

RESULTS

There were 1396 arrest patients with ROSC and known initial rhythms (517/1396=37% shockable; 879/1396=63% nonshockable). 440 (299/440=58% shockable; 141/440=32% nonshockable) of these patients received angiography. In the 141 non-shockable patients that received angiography, 97 patients did not have STEMI listed as an indication for catheterization and 24 (25%) of those had a coronary intervention documented yielding an observed incidence of coronary intervention in non-shockable post-arrest patients without STEMI who received angiography of 24.7% (24/97). Of note, the overall incidence of coronary intervention in all ROSC patients with non-shockable initial rhythms was 5.5% (48/879).

CONCLUSIONS

In this large multi-center retrospective analysis there is a high incidence of coronary intervention in post-arrest patients with initially non-shockable rhythms and without STEMI on ECG who are taken for angiography.

The effect of high-risk ST elevation myocardial infarction transfer patients on risk-adjusted in-hospital mortality: A report from the American Heart Association Mission: Lifeline program

BACKGROUND

Hospital mortality is an important quality measure for acute myocardial infarction care. There is a concern that despite risk adjustment, percutaneous coronary intervention hospitals accepting a greater volume of high-risk ST elevation myocardial infarction (STEMI) transfer patients may have their reported mortality rates adversely affected.

METHODS

The STEMI patients in the National Cardiovascular Data RegistryAcute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines from April 2011 to December 2013 were included. High-risk STEMI was defined as having either cardiogenic shock or cardiac arrest on first medical contact. Receiving hospitals were divided into tertiles based on the ratio of high-risk STEMI transfer patients to the total number of STEMI patients treated at each hospital. Using the Action Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines in-hospital mortality risk model, we calculated the difference in risk-standardized in-hospital mortality before and after excluding high-risk STEMI transfers in each tertile.

RESULTS

Among 119,680 STEMI patients treated at 539 receiving hospitals, 37,028 (31%) were transfer patients, of whom 4,500 (12%) were highrisk. The proportion of high-risk STEMI transfer patients ranged from 0% to 12% across hospitals. Unadjusted mortality rates in the low-, middle-, and high-tertile hospitals were 6.0%, 6.0%, and 5.9% among all STEMI patients and 6.0%, 5.5%, and 4.6% after excluding high-risk STEMI transfers. However, risk-standardized hospital mortality rates were not significantly changed after excluding high-risk STEMI transfer patients in any of the 3 hospital tertiles (low, -0.04%; middle, -0.05%; and high, 0.03%).

CONCLUSIONS

Risk-adjusted in-hospital mortality rates were not adversely affected in STEMI-receiving hospitals who accepted more high-risk STEMI transfer patients when a clinical mortality risk model was used for risk adjustment.