Using the Zwolle Risk Score at Time of Coronary Angiography to Triage Patients With ST-Elevation Myocardial Infarction Following Primary Percutaneous Coronary Intervention or Thrombolysis

Background The Zwolle Risk Score was designed to identify the risk of complications in patients with ST-segment‒elevation myocardial infarction (STEMI) following percutaneous coronary intervention (PCI). Its utility following PCI in STEMI treated with thrombolysis is unknown. The objective was to evaluate the safety of using the Zwolle Risk Score to triage patients with STEMI following PCI, including patients receiving thrombolysis. Methods and Results Patients aged ≥18 years with STEMI and primary PCI or PCI after thrombolysis were included. A triage protocol was developed, with high-risk patients those with Zwolle Risk Score ≥4 triaged to the cardiac intensive care unit. A prospective evaluation of the triaging protocol was performed on 452 patients, mean age 65±12 years, 73% men. Median Zwolle Risk Score was 3 (interquartile range, 2‒5), with 257 low-risk (57%), and 195 high-risk (43%) patients. Adherence to the protocol was 91%. In-hospital mortality was 0.4% in low-risk and 13% in high-risk patients (P<0.001). Seventy-two patients (16%) received thrombolysis. Median time post-thrombolysis to PCI was 281 minutes (interquartile range, 219‒376). In-hospital mortality was 0% versus 9% (P=0.083) for low- and high-risk patients, respectively. High-risk patients had higher rates of cardiogenic shock (34% versus 1%, P<0.001), pulmonary edema (60% versus 9%, P<0.001), arrhythmia (25% versus 2%, P<0.001), blood transfusion (10% versus 2%, P<0.001), and stroke (4% versus 0.4%, P=0.011). Median hospital costs decreased by $1419 per low-risk patient after protocol implementation. Conclusions For patients with STEMI following primary PCI or PCI following thrombolysis, a Zwolle-based triaging system is safe and may decrease cardiac intensive care unit usage costs.

Outcomes of extracorporeal membrane oxygenation support in the cardiac catheterization laboratory

OBJECTIVES

The aims of this single-center retrospective study were to characterize and determine predictors of 30-day survival in a cohort of patients requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) supported cardiopulmonary resuscitation (E-CPR) in the cardiac catheterization laboratory (CCL) for cardiac arrest (CA) or refractory cardiogenic shock (CS).

BACKGROUND

While safety in the CCL has improved, periprocedural mortality from CA remains high. The application of VA-ECMO is an emerging form of resuscitation with a paucity of data evaluating its use in the CCL for CA or CS.

METHODS

All consecutive patients aged 18 years or older presenting to a single CCL from October 2010 to May 2018 who required E-CPR for CA or refractory CS were included. The primary outcome of our study was overall survival 30 days from VA-ECMO initiation. Secondary outcomes included 1-year survival, hospital length of stay, and ECMO related complications.

RESULTS

Sixty-two patients with a mean age of 60 ± 9 years, 63% male, were included. VA-ECMO was initiated for CA in 39 patients (63%) and for CS in 23 patients (37%). The median ECMO duration was 48 hr. Overall 30-day survival was 47% (CA group 44% vs. CS group 52%; p = .414). One-year survival was 44%. Initial serum creatinine (OR 1.18 per 10 μmol/L increase; p = .016; AUC = 0.65) was the only multivariate predictor of 30-day mortality.

CONCLUSIONS

The use of VA-ECMO in the CCL is feasible, demonstrating 47% 30-day survival, largely persistent to 1 year, in a cohort that otherwise has extremely high mortality.