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INVASIVE STRATEGIES FOR PATIENTS WITH RESUSCITATED SUDDEN CARDIAC ARREST

INVASIVE STRATEGIES FOR PATIENTS WITH RESUSCITATED SUDDEN CARDIAC ARREST. Marko Noc, MD, PhD, FESC University Medical Center Ljubljana-Slovenia . NO CONFLICT OF INTEREST TO DECLARE. SUDDEN CARDIAC ARREST IS A MAJOR HEALTH PROBLEM. Incidence of EMS treated sudden out-of-hospital

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INVASIVE STRATEGIES FOR PATIENTS WITH RESUSCITATED SUDDEN CARDIAC ARREST

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  1. INVASIVE STRATEGIES FOR PATIENTS WITH RESUSCITATED SUDDEN CARDIAC ARREST Marko Noc, MD, PhD, FESC University Medical Center Ljubljana-Slovenia

  2. NO CONFLICT OF INTEREST TO DECLARE

  3. SUDDEN CARDIAC ARREST ISA MAJOR HEALTH PROBLEM Incidence of EMS treated sudden out-of-hospital cardiac arrest is 36-81/100.000 Cugh SS. JACC 2004;44:1268-75 Cobb SS. JAMA 2002;288:3009-13 Urgent transport to hospital CPR on the field Reestablishment of Spontaneous circulation ROSC (40-50%) Ristagno G, et al. Brain microcirculation in pigs. Resuscitation 2008;77:229-34.

  4. SUDDEN CARDIAC ARREST-WHY AN ISSUE FOR INTERVENTIONAL CARDIOLOGIST? Urgent CAG (84) Normal 17 (20%) Nonobstructive CAD 7 (8%) Obstructive CAD 60 (71%) Single vessel 22 Multivessel 37 Isolated LM 1 Coronary occlusion 40 (48%) • Sudden cardiac arrest is usually a coronary event Spaulding CM. N Engl J Med 1997;336:1629-33.

  5. OUR STRATEGY- IMMEDIATELY DEFINE A CORONARY SUBSTRATE Urgent coronary angiography regardless of ECG and level of consciousness after ROSC unless: • Nonishemic etiology of cardiac arrest is obvious • Severe pre-arrest comorbidities • Comatose survivor with no realstic hope for neurological recovery

  6. SCIENTIFIC SUPPORT FOR URGENT INVASIVE STARTEGY ? • No randomized trials • Multivariante analysis of registries Author n Multivariante predictor of survival Spaulding 85 Successful PCI (OR 5.2; p=0.004) Anafantakis 72 Not PCI attempt Reynolds 241 CAG/PCI strategy (OR 2.16; p=0.02) Nielsen 986 CAG/PCI strategy (OR 1.56; p=0.008) Dumas 714 Successful PCI (OR 2.06; p=0.013) • Spaulding CM. N Engl J Med 1997;336:1629-33 • Anyfantakis ZA. Am Heart J 2009;157:312-8. • Reynolds JC. J Intensive Care Med 2009;March 25, • doi;1177 • Nielsen N, et al. Acta Anaesthesiol Scand • 2009;53:926-934 • Dumas. Circ Cardiovasc Interv 2010;3:200-7

  7. Consecutive patients with resuscitated cardiac arrest of pressumed cardiac origin (2003-2008) n=462 No STEMI 220 (48%) STEMI 242 (52%) Excluded (136) -65 Nonischemic cause -12 prearrest comorbidities -26 CNS recovery unlikely -26 Decision of an attending -7 Death before cath lab • Excluded (18) • -1 Nonischemic cause • -14 CNS recovery not likely • - 2 Decision of attending • 1 Death before cath lab ROSC to CAG: 128+/-67 min Urgent CAG 224 (93%) Urgent CAG 84 (38%) Radsel P, et al. Submitted 2011

  8. STEMI No STEMI p (n=224) (n=84) Normal angiogram 1% 33% <.001 Nonobstuctive disease 1% 1% 0.679 >1 obstructive stenosis 97% 66% <.001 >1 Stable 8% 40% <.001 > 1 Pressumed acute 89% 26% <.001 Unprotected LM 7% 13% 0.115 Multivessel CAD 51% 57% 0.395 >1 Occlusion 80% 44% <.001 >1 CTO 20% 34% 0.011 > 1 Pressumed acute 69% 13% <.001 URGENT CORONARY ANGIOGRAPHY IN PATIENTS WITH RESUSCITATED SUDDEN CARDIAC ARREST Radsel P, et al. Submitted 2011

  9. ABSENCE OF “STEMI” IN POSTRESUSCITION ECG DOES NOT EXCLUDE PRESENCE OF ACUTE OCLUSION Predictive value PositiveNegative Chest discomfort and ST-elevation 87%61% Spaulding CM. N Engl J Med 1997;336:1629-33.

  10. STEMI No STEMI p (n=204) (n=23) Proximal location 46% 48% 0.824 Mean stenosis, % 98+6 98+3 0.839 Thrombus score 2.7+2.1 1.2+1.8 0.004 TIMI 0-1 77% 48% <0.001 Rentrop (0-3) 0.25+0.60 0.37+0.90 0.464 ANGIOGRAPHIC CHARACTERISTICS OF PRESUMED ACUTE CULPRIT LESION Radsel P, et al. Submitted 2011

  11. OUR REVASCULARIZATION STRATEGY Urgent coronary angigraphy Nonobstructive CAD/no CAD Stable obstructive CAD with normal flow Presumed acute culprit lesion PCI of culprit Additional non-culprit PCI only if patient unstable* Search for aletrnative cause of cardiac arrest Comatose after ROSC None or PCI of obvious lesion** Conscious after ROSC Urgent PCI/CABG * If ischemia/hemodynamic instability after successful IRA PCI and IABP **If considered responsible for cardiac arrest (?) or beneficial for hemodyanmic stability

  12. URGENT PCI STEMI No STEMI p (n=224) (n=84) PCI/Urgent CAG 94% 38% <0.001 PCI-acute lesion 94% 69% <0.001 Stenting 85% 78% 0.329 TIMI 3 83% 84% 0.896 IABP 22% 17% 0.497 Radsel P, et al. Submitted 2011

  13. IF THE “CHAIN OF SURVIVAL” WORKED, THE PATIENT WOKE UP IMMEDIATELY AFTER ROSC (28%) Survival STEMI 97% No STEMI 100% Take home message:“Conscious” survivor of cardiac arrest – treat him as a “very high” risk ACS

  14. IF PATIENT REMAINED COMATOSE DESPITE ROSC (72%), POSTRESUSCITATION BRAIN INJURY WILL OCCUR Survival CPC 1-2 STEMI 65% 44% No STEMI 69% 47% • Severity of postresuscitation brain injury can not be securely predicted on hospital admission

  15. IMMEDIATE EMS CONTACT VERSUS SELF-PRESENTATION IN ACS In case of prehospital sudden cardiac arrest... ...emergency medical team is present and “converts” comatose into conscious survivor of sudden cardiac arrest

  16. MILD INDUCED HYPOTHERMIA (32-34 C) IS „EVIDENCE BASED“ TREATMENT OF POSTRESUSCITATION BRAIN INJURY Independent randomized clinical trials N Engl J Med 2002; 346:549-56. N Engl J Med 2002; 346:557-63 Number needed to treat 7 !!!

  17. WE COMBINED PPCI AND MILD INDUCED HYPOTHERMIA IN COMATOSE SURVIVORS OF CARDIAC ARREST WITH STEMI • 40 patients undergoing PPCI+MIH (2003-2005) were compared • to 32 historical controls undergoing only PPCI and no MIH (2000-2003) • Combination of PPCI+MIH was feasable and safe without increase in • arrhythmias, hemodynamic instability, oxygen reqirements for mechanical ventilation, renaly dysfunction…. • Addition of MIH to PPCI significantly improved survival with good • neurological recovery compared to historical controls Knafelj R, et al. Resuscitation 2007; 74;227-34.

  18. MIH (40) No MIH (32) p Post PCI TIMI 2/3,% 9088 .41 >70% ST resolution,% 6859 .64 Stent thrombosis 2.50 1.0 Sustained VT,% 1319 .69 Repeat VF,% 2019 .87 P- AF,% 1816 .92 DC/cardioversion,% 3034 .89 Antiarrhytmics,% 3353 .13 Need for IAPB,% 2022 .92 Vasopressors,% 6553 .44 Inotropes,% 4859 .44 ADDITION OF “MIH” IN COMATOSE SURVIVORS OF CARDIAC ARREST DOES NOT COMPROMISE RESULTS OF PCI Knafelj R, et al. Resuscitation 2007; 74;227-34. Knafelj R, et al. Resuscitation 2007;74:227-34.

  19. Author PPCI llb///a Stent Open IRA IABP Knafelj 36 18 32 36 8 Hovdenes 36 NA NA NA 23 Koutouzis 1 NA 1 1 0 Wolfrum 16 15 16 16 5 Schefold 25 16 16 NA NA Together 114 64% 93% 93% 34% PPCI AND “MIH” IN COMATOSE SURVIVORS OF CARDIAC ARREST WITH STEMI-FEASALBLE AND SAFE Noc M. Interventional Cardiology 2008; (Volume 9, Number 4);123-5.

  20. CATH LAB FOR COMATOSE SURVIVORS OF CARDIAC ARREST ?

  21. GET A CICU INTENSIVIST TO THE CATH LAB ! -Control of respiration, hemodynamics, rhythm, hypothermia, IABP… -ACLS due to reccurent cardiac arrest -Portable echo to identify cause of hemodynamic instability if present

  22. COMPETENT CARDIAC INTENSIVE CARE UNIT- ESSENTIAL FOR SURVIVAL OF COMATOSE PATIENTS AFTER RESUSCITATED CARDIAC ARREST

  23. “FAST TRACK” FOR COMATOSE SURVIVORS OF OUT-OF-HOSPITAL CARDIAC ARREST 1. 2. 3. 4. Urgent CAG+PCI during ongoing hypothermia Urgent transport to „24-7“ PCI center without unneccesary stops Hypotermia and intensive care support Start effective hypotermia already on the field

  24. CONSECUTIVE COMATOSE SURVIVORS OF OUT-OF-HOSPITAL CARDIAC ARREST ADMITTED TO LJUBLJANA UNIVESITY MEDICAL CENTER 1995-7 (78) 2006-8 (149) p Urgent CAG/PCI 0% 70% <.001 Hypotermia 0% 90% <.001 p<.0001 62% 40% Tadel KS, et al. Acute Cardiac Care, 2010 24% 15%

  25. COMPLEMENT „STEMI NETWORK“ TO BECOME “ACUTE CARDIAC NETWORK” NSTE-ACS with high risk features Resuscitated sudden cardiac arrest + + STEMI

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