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Spirito A, Vaisnora L, Papadis A, Iacovelli F, Sardu C, Selberg A, Bär S, Kavaliauskaite R, Temperli F, Asatryan B, Pilgrim T, Hunziker L, Heg D, Valgimigli M, Windecker S, Räber L. Acute Coronary Occlusion in Patients With Non-ST-Segment Elevation Out-of-Hospital Cardiac Arrest. J Am Coll Cardiol 2023; 81:446-456. [PMID: 36725173 DOI: 10.1016/j.jacc.2022.10.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/28/2022] [Accepted: 10/31/2022] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Alessandro Spirito
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lukas Vaisnora
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Athanasios Papadis
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fortunato Iacovelli
- Division of University Cardiology, Cardiothoracic Department, Polyclinic University Hospital, Bari, Italy
| | - Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Alexandra Selberg
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sarah Bär
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raminta Kavaliauskaite
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabrice Temperli
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Babken Asatryan
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lukas Hunziker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dik Heg
- Bern Clinical Trials Unit, University of Bern, Bern, Switzerland
| | - Marco Valgimigli
- Cardiocentro Ticino, Ente Ospedaliero Cantonale, Università della Svizzera Italiana, University of Lugano, Lugano, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Seret G, Pham V, Laghlam D, Diefenbronn M, Brunet T, Varenne O, Dumas F, Cariou A, Picard F. Performance of stent thrombosis and bleeding risk scores in out-of-hospital cardiac arrest due to acute coronary syndromes. Arch Cardiovasc Dis 2022; 115:552-561. [DOI: 10.1016/j.acvd.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/02/2022]
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Gall E, Lafont A, Varenne O, Dumas F, Cariou A, Picard F. Balancing thrombosis and bleeding after out-of-hospital cardiac arrest related to acute coronary syndrome: A literature review. Arch Cardiovasc Dis 2021; 114:667-679. [PMID: 34565694 DOI: 10.1016/j.acvd.2021.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 12/29/2022]
Abstract
Balance between thrombosis and bleeding is now well recognized in patients treated for acute coronary syndrome, with impact on short- and long-term prognosis, including survival. Recent data suggest that patients who are resuscitated after out-of-hospital cardiac arrest related to myocardial infarction are at an even higher risk of bleeding and thrombosis than those with uncomplicated acute coronary syndrome. Delayed enteral absorption of medication due to induced hypothermia and systemic inflammation increases thrombosis risk, whereas transfemoral access site, cardiopulmonary resuscitation manoeuvres and mechanical circulatory support devices increase bleeding risk. In addition, post-resuscitation syndrome and renal or hepatic impairment are potential risk factors for both bleeding and thrombotic complications. There are currently no randomized controlled trials comparing various P2Y12 inhibitor and/or anticoagulation strategies in the setting of out-of-hospital cardiac arrest, and current practice is largely derived from management of patients with uncomplicated acute coronary syndrome. The aim of this review is therefore to describe the bleeding and thrombosis risk factors in this specific population, and to review recent data on antithrombotic drugs in this patient subset.
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Affiliation(s)
- Emmanuel Gall
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Alexandre Lafont
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France
| | - Olivier Varenne
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France
| | - Florence Dumas
- Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France; Emergency Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Alain Cariou
- Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France; Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Fabien Picard
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France.
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