Impact of early coronary angiography on the survival to discharge after out-of-hospital cardiac arrest

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.

Impact of emergent coronary angiography after out-of-the-hospital cardiac arrest without ST-segment elevation - a systematic review and meta-analysis

INTRODUCTION

Coronary artery disease is a leading cause of out-of-the-hospital cardiac arrest (OHCA). However, there is no consensus on whether OHCA patients without ST-segment elevation (STE) benefit from emergent (ie < 2 h) coronary angiography (CAG). Our aim was to assess the impact of emergent CAG in no-STE OHCA patients.

METHODS

We performed a systematic review and meta-analysis by searching the MEDLINE, Cochrane, Scopus, CINAHL and JBI databases for randomized controlled trials (RCTs) comparing emergent CAG versus standard of care (ie CAG >2 h after OHCA or not performed) in no-STE OHCA patients of presumed cardiac aetiology. The primary outcome was short term survival. Secondary outcomes included survival with good neurological outcome, mid-term survival, left ventricle ejection fraction (LVEF), acute kidney injury (AKI) and renal replacement therapy (RRT), ventricular arrhythmias and major bleeding during hospital stay.

RESULTS

Seven RCTs met the inclusion and exclusion criteria and were included; one was included only in the analysis of mid-term survival and another in the LVEF analysis. Five studies (1278 patients, 643 with early CAG and 635 with no early CAG) were included in the analysis of the primary endpoint. The groups were balanced for all baseline characteristics but previous PCI, which was more frequent in the standard of care groups. There were no significant differences between groups for short-term survival (57 vs 61%; OR0.85, 95% CI0.68-1.07; I² = 0%). There were also no differences for any of the secondary endpoints.

CONCLUSION

Routine emergent CAG did not improve survival in comatose survivors of OHCA with shockable rhythm and no-STE.

Gender difference in the clinical outcomes of patients with out-of-hospital cardiac arrest: A report using data from a national Korean registry

We explored gender differences in the characteristics and outcomes of patients with out-of-hospital cardiac arrest (OHCA) in Korea.We retrospectively analyzed a nationwide multicenter registry of out-of-hospital cardiac arrest patients that prospectively collected from January to December 2014, and explored the clinical outcomes of 670 successfully resuscitated adult patients with OHCA who were transferred to 27 hospitals. The effect of gender on the 30-day neurologically favorable survival (cerebral performance category 1 or 2) was analyzed after propensity score matching (PSM) of each patient in terms of clinical characteristics.We included 670 patients with OHCA, of whom 482 (72%) were male and 182 (28%) were female. The frequency of witnessed arrests and proportion of home arrests were similar between men and women (73.7% vs 71.3%, P = .59, and 55.0% vs 60.6% P = .21, respectively). Women were older than men (mean age, 65.9 vs 59.7 years, P < .001) and less likely to present with an initial shockable rhythm (27.7% vs 45.0%, P < .001). Women were less likely to undergo targeted temperature management (19.1% vs 35.9%, P < .001), coronary angiography (14.9% vs 36.1%, P < .001), or revascularization (7.4% vs 19.3%, P < .001). Compared with men, women exhibited poorer 30-day neurologically favorable survival (69.7% vs 83.0%, P = .001). However, the gender difference was not significant on PSM or inverse probability of treatment weighting (IPTW) analyses (P = .48 and P = .63, respectively).Female patients with OHCA exhibited poorer clinical characteristics and were less likely to receive treatment than men. After accounting for these differences, clinical outcomes did not differ by gender.

Coronary Angiography in Patients With Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: A Systematic Review and Meta-Analysis

OBJECTIVES

The authors conducted a meta-analysis to study clinical outcomes in patients who underwent early versus nonearly coronary angiography (CAG) in the setting of out-of-hospital cardiac arrest (OHCA) without ST-segment elevation.

BACKGROUND

The benefit of performing early CAG in patients with OHCA without STE remains disputed.

METHODS

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from inception until February 21, 2020. Early and nonearly CAG patients were identified on the basis of the definitions mentioned in respective published studies. The primary outcome studied was 30-day mortality. Secondary outcomes were neurological status and the rate of percutaneous coronary intervention (PCI) following cardiac arrest.

RESULTS

Of 4,516 references, 11 studies enrolling 3,581 patients were included in the final meta-analysis. Random-effects analysis showed no differences in 30-day mortality (risk ratio [RR]: 0.86; 95% confidence interval [CI]: 0.71 to 1.04; p = 0.12; I² = 74%), neurological status (RR: 1.08; 95% CI: 0.94 to 1.24; p = 0.28; I² = 69%), and rate of PCI (RR: 1.22; 95% CI: 0.94 to 1.59; p = 0.13; I² = 67%) between the 2 groups. Diabetes mellitus, chronic renal failure, previous PCI, and lactate level were found to be significant predictors of 30-day mortality on meta-regression (p < 0.05).

CONCLUSIONS

This analysis shows that there is no significant difference in 30-day mortality, neurological status, or rate of PCI among patients with OHCA without STE treated with early versus nonearly CAG. Thirty-day mortality is determined by presentation comorbidities rather than revascularization.

ST-Elevation Myocardial Infarction Complicated by Out-of-Hospital Cardiac Arrest

5-10% of ST-elevated myocardial infarctions (STEMI) present with out-of-hospital cardiac arrest (OHCA). Although this subgroup of patients carries the highest in-hospital mortality among the STEMI population, it is the least likely to undergo coronary angiography and revascularization. Due to the concomitant neurologic injury, patients with OHCA STEMI require prolonged hospitalization and adjustments to standard MI management. This review systematically assesses the course of patients with OHCA STEMI from development of the arrest to hospital discharge, assesses the limiting factors for their treatment access, and presents the evidence-based optimal intervention strategy for this high-risk MI population.

Management of post-cardiac arrest syndrome

Post-cardiac arrest syndrome is a complex and critical issue in resuscitated patients undergone cardiac arrest. Ischemic-reperfusion injury occurs in multiple organs due to the return of spontaneous circulation. Bundle of management practicies are required for post-cardiac arrest care. Early invasive coronary angiography should be considered to identify and treat coronary artery obstructive disease. Vasopressors such as norepinephrine and dobutamine are the first-line treatment for shock. Maintainance of oxyhemoglobin saturation greater than 94% but less than 100% is recommended to avoid fatality. Target temperature therapeutic hypothermia helps to resuscitated patients. Strict temperature control is required and is maintained with the help of cooling devices and monitoring the core temperature. Montorings include electrocardiogram, oxymetry, capnography, and electroencephalography (EEG) along with blood pressue, temprature, and vital signs. Seizure should be treated if EEG shows evidence of seizure or epileptiform activity. Clinical neurologic examination and magnetic resonance imaging are considered to predict neurological outcome. Glycemic control and metabolic management are favorable for a good neurological outcome. Recovery from acute kidney injury is essential for survival and a good neurological outcome.

Predictors of Obstructive Coronary Disease and Mortality in Adults Having Cardiac Arrest

Coronary angiography is a key component of systematic, multi-disciplinary post-cardiac arrest (CA) care, however, coronary angiogram is not routinely performed in the setting of CA. We sought to identify the predictors of obstructive coronary artery disease (CAD) and mortality in adults with CA undergoing coronary angiogram. The study population included 208 consecutive patients hospitalized with CA who underwent resuscitation and subsequent coronary angiogram at an academic tertiary medical center. The primary outcome of interest was presence of obstructive CAD, defined as >1 coronary artery with >70% stenosis or >1 coronary bypass graft with >70% stenosis. The secondary outcome of interest was in-hospital mortality. Of the 208 patients studied, 160 (76.9%) had obstructive CAD while 48 (23.1%) did not. In-hospital mortality occurred in 47 patients (22.6%). In multivariate analysis, ST-elevation myocardial infarction (STEMI) (OR 7.69, 95% CI 2.89 to 20.51), defibrillation (OR 4.90, 95% CI 1.19 to 20.17), vasopressors (OR 3.53, 95% CI 1.15 to 10.81), and absence of therapeutic hypothermia (OR 0.38, 95% CI 0.15 to 0.98) were independently associated with presence of obstructive CAD while STEMI (OR 3.21, 95% CI 1.01 to 10.24), vasopressors (OR 4.92, 95% CI 1.78 to 13.62), therapeutic hypothermia (OR 3.89, 95% CI 1.47 to 10.31), and admission blood urea nitrogen (OR 1.06, 95% CI 1.00 to 1.11) were independently associated with higher rates of in-hospital mortality. In this observational contemporary study, predictors of obstructive CAD and mortality exist in adults with CA undergoing coronary angiogram. Such risk models may aid in identification of CA patients who will benefit from early angiography and percutaneous coronary intervention.