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Nick Johnson Department of Emergency Medicine University of Pennsylvania

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. References.

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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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