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Nick Johnson Department of Emergency Medicine University of Pennsylvania

This study analyzes if post-cardiac arrest patients should undergo cardiac catheterization regardless of EKG changes, with emphasis on ST-elevation. Findings indicate emergent angiography in STEMI cases and urgent invasive strategy for non-STEMI group are beneficial. Limitations include subjective selection for angiography and variations in coronary lesion judgment. Immediate PCI shows survival benefits in OHCA patients, irrespective of ECG pattern. Results suggest poor predictive value of post-resuscitation ECG. Limitations include selection bias and lack of control group.

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Nick Johnson Department of Emergency Medicine University of Pennsylvania

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  1. Evidence in the ED:Should post-cardiac arrest patients undergo cardiac catheterization regardless of EKG changes? Nick Johnson Department of Emergency Medicine University of Pennsylvania

  2. References • Radsel P et al. Angiographic Characteristics of Coronary Disease and Post-resuscitation Electrocardiograms in Patients with Aborted Cardiac Arrest Outside a Hospital. Am J Cardiol. 2011;108:634-63 • Dumas F, et al. Immediate Percutaneous Coronary Intervention is Associated with Better Survival After Out-of-HospitalCardiac Arrest: Insights from the PROCAT (Parisian Region Out-of-Hospital Cardiac Arrest) Registry. Circ CardiovascInterv. 2010;3:200-207 • Gonzalez M, Abella B, et al. Initial predictors of coronary lesions post cardiac arrest Therapeutic Hypothermia and Temp Mgmt. 2012;2(2). In press.

  3. Radsel et al. 2011 Angiographic Characteristics of Coronary Disease and Post-resuscitation Electrocardiograms in Patients with Aborted Cardiac Arrest Outside a Hospital Am J Cardiol. 2011;108:634-63 Do EKG changes predict coronary lesions on angiography in post-arrest patients?

  4. Radsel et al. 2011Methods • Design: Retrospective cohort study • Population: • Included: Patients with OHCA with ROSC of presumed cardiac origin who underwent coronary angiography • Excluded: Obvious non-ischemic cause of arrest, no realistic hope for neurologic recovery, prolonged arrest/downtime, prior CABG • Predictor variables: STEMI or not-STEMI • Outcome: Obstructive coronary disease (>50%) • Data analysis: Univariate and multivariate analysis

  5. Radsel et al. 2011Results • Of 335 consecutive pts with OHCA and ROSC, 212 were included • 158 of 179 (88%) STEMI pts included and underwent PCI • 54 of 156 (35%) not-STEMI pts included and underwent PCI • STEMI group: 97% had obstructive CAD • 89% were acute lesions • Not-STEMI group: 59% had obstructive CAD • 24% were acute lesions

  6. Radsel et al. 2011Conclusions • Emergent coronary angiography should be performed in post-arrest pts with STEMI • An acute lesion was found also in 24% in the absence of STEMI, which argues for an urgent invasive coronary strategy in this subgroup

  7. Radsel et al. 2011Limitations • Selection for angiography was subjective • “Presumed cardiac origin” • “No realistic hope for neurologic recovery” • Most patients with STEMI underwent cath (88%), but only 35% of not-STEMI pts did • Likely differences in judgment of presumed coronary causes of cardiac arrest • “Not-STEMI” group likely had a higher pre-test probability of coronary lesion than all-comers with OHCA

  8. Dumas et al. 2011 Immediate Percutaneous Coronary Intervention is Associated with Better Survival After Out-of- Hospital Cardiac Arrest: Insights from the PROCAT (Parisian Region Out-of-Hospital Cardiac Arrest) Registry Circ CardiovascInterv. 2010;3:200-207 Is immediate PCI associated with improved survival in OHCA?

  9. Dumas et al. 2010 Methods • Design: Retrospective cohort study • Population: • Included: Patients with OHCA with ROSC • Excluded: Obvious non-cardiac cause of arrest • Data collection: • All patients underwent routine testing, mild therapeutic hypothermia (if not contraindicated), plus cardiac catheterization • >50% coronary stenosis considered clinically significant • Pts classified as ST-elevation or Other • Outcome: Survival at hospital discharge • Data analysis: Univariate and multivariate analysis

  10. Dumas et al. 2010 Results • Of 745 admitted OHCA pts over 5 years, 435 were included • Median age 59 years, 4:1 male: female • Nearly 85% of the population had therapeutic hypothermia • Single coronary vessel disease was found in 104 (34%) patients, double-vessel disease in 88 (29%), and triple-vessel disease in 112 (37%)

  11. Dumas et al. 2010 Results • In the ST-elevation group (n=134), 96% of patients had ≥1 coronary stenosis • PCI attempted in 110 patients and was successful in 99 (90%) • In the 301 patients with other ECG patterns, 176 (58%) had at least one significant stenosis • PCI attempted in 92 patients and was successful in 78 (85%) • Successful PCI was associated with increased odds of survival (OR 2.06; 95% CI, 1.16 to 3.66)

  12. Dumas et al. 2010 Conclusions • The predictive value of post-resuscitation ECG data was poor • Immediate PCI offers survival benefit in patients with OHCA with no obvious noncardiac cause, regardless of the ECG pattern

  13. Dumas et al. 2010 Limitations • No control group • Selection bias • Patients survived because they were selected for interventions based on individualized prognostic features • Interventions were not applied evenly across the population • Pts who were unable to undergo successful PCI may have been higher risk • Subjective inclusion/exclusion criteria • More survivors received therapeutic hypothermia than non-survivors • Highly specialized center and system • TH performed in 85%

  14. Gonzales, Abella et al. 2012 Initial predictors of coronary lesions post cardiac arrest Therapeutic Hypothermia and Temp Mgmt. 2012;2(2). In press. Which post-arrest patient variables predict significant coronary lesions?

  15. Gonzales, Abella et al. 2012 Methods • Design: Retrospective chart review • Population: • Included: Adults with OHCA, ED arrest, or transfers with cardiac arrest with ROSC who underwent angiography • Excluded: None • Data collection: • Patient demographics, PMH, lab data, EKGs, cath reports reviewed • >75% coronary stenosis was considered clinically significant • Outcome: coronary stenosis • Data analysis • Univariate and multivariate logistic regression to identify factors associated with significant coronary stenosis

  16. Gonzales, Abella et al. 2012 Results • 527 patients with cardiac arrest over 5 years • 267 with ROSC • 106 underwent coronary angiography • Mean age 58, 29% female • 73% VF/VT initial rhythm • 75% therapeutic hypothermia • 64% with significant coronary lesions

  17. Gonzales, Abella et al. 2012 Results Univariate analysis • Significant coronary lesions associated with • History of CAD/MI (OR 7.2, 95%CI 2.0–25.9, p = 0.002) • VF/VT rhythm (OR 3.0, 95% CI 1.2–7.3, p = 0.018) • No significant correlation • Age • Presence of diabetes mellitus, hypertension, tobacco use • Abnormal initial troponin • ST/T wave abnormalities on initial postarrest ECG

  18. Gonzales, Abella et al. 2012 Results Multivariate analysis • Significant coronary lesions associated with • History of prior CAD/MI (OR 6.2, 95% CI 1.6–24.4, p = 0.009) • VF/VT initial rhythm (OR 2.9, 95% CI 1.1–7.7, p = 0.033)

  19. Gonzales, Abella et al. 2012 Conclusions • Prior history of CAD and VT/VF rhythm were associated with coronary occlusion on post-arrest angiography • Other clinical data, EKG, and biomarkers were not associated with coronary occlusion on post-arrest angiography

  20. Gonzales, Abella et al. 2012 Limitations • Timing of post-arrest angiography not addressed • Retrospective study with biased cohort • All pts were selected to undergo angiography for some reason • Two hospitals, one health system, one city

  21. HUPism • Because of the poor sensitivity of post-arrest EKGs for acute coronary occlusion, patients with OHCA and ROSC without STEMI should be considered for urgent cardiac catheterization, especially if • Initial rhythm is VF/VT and/or • There is prior history of CAD/MI AND No obvious non-cardiac cause is identified

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