Resuscitation 85 (2014) 1533–1540
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Clinical paper
Cardiac catheterization is associated with superior outcomes for survivors of out of hospital cardiac arrest: Review and meta-analysis夽 Anthony C. Camuglia a,b,c,∗ , Varinder K. Randhawa d , Shahar Lavi d , Darren L. Walters c,e a
Mater Health Cardiovascular Unit, South Brisbane, QLD, Australia Princess Alexandra Hospital, Department of Cardiology, Brisbane, QLD, Australia University of Queensland, Brisbane, QLD, Australia d London Health Sciences Centre, University of Western Ontario, London, ON, Canada e The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia b c
a r t i c l e
i n f o
Article history: Received 2 May 2014 Received in revised form 3 August 2014 Accepted 16 August 2014 Keywords: Out-of-hospital cardiac arrest Coronary angiography Cardiac catheterization
a b s t r a c t Aims: Survivors of out-of-hospital cardiac arrest (OHCA) have a high rate of morbidity and mortality. Invasive cardiac assessment with coronary angiography offers the potential for improving outcomes by facilitating early revascularization. The aim of the present study was to review the published data on early coronary angiography for survivors of OHCA, and its impact on survival and neurological outcomes. Methods: Medline, Embase and PubMed were searched with a structured search query. The primary outcome was in-hospital (or if not available, 30 day or 6 month) survival. Rates of survival with good neurological outcome were a secondary endpoint. The time period of the search was from 1 January 1980 to 1 January 2014. Data was pooled with means and 95% CI interval calculated. Meta-analysis of the main outcomes was performed using a weighted random effects model. Results: Following review of all identified records, 105 relevant full text articles were retrieved. Fifty had adequate outcome information stratified by the use of coronary angiography for analysis. In studies where a control group was available for comparison, the overall survival in the acute angiography group was 58.8% versus 30.9% in the control group (Odds ratio 2.77, 95% CI 2.06–3.72). Survival with good neurological outcome (as per the Utstein framework) in the early angiography group was 58% versus 35.8% in the control group (Odds ratio 2.20, 95% CI 1.46–3.32). Conclusions: Early coronary angiography in patients following OHCA is associated with improved outcome and better survival. Crown Copyright © 2014 Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Out-of-hospital cardiac arrest (OHCA) is an important source of death and disability; and ischemic heart disease is recognized as the most frequent cause of OHCA.1 In patients with acute coronary syndrome who do not experience OHCA, a routine early invasive strategy has been shown to improve patient outcomes.2 Survivors of OHCA represent a group with high rates of morbidity and mortality.3 However, owing to a lack of randomized clinical trial
夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.08.025. ∗ Corresponding author at: Mater Health, Cardiovascular Unit, 301 Vulture Street, South Brisbane, QLD 4101, Australia. Fax: +64 7 3217 2550. E-mail address: [email protected] (A.C. Camuglia).
evidence uncertainty remains concerning the role of early invasive cardiac assessment. An analysis of non-randomized studies showed that significant coronary artery disease is highly prevalent among OHCA patients who did not have an obvious non-cardiac etiology. Early angiography in these patients is feasible and may improve outcomes.4 There has been considerable work published in the area since this analysis, as well as the continued adoption of mild therapeutic hypothermia (MTH) in comatose patients in conjunction with invasive assessment and management pathways.5 Part of the rationale for a benefit of routine acute angiography is the identification and appropriate revascularization of patients with acute coronary occlusions that occur without attendant significant ischemic changes on ECG.6,7 On this basis, the current study is a systematic review and meta-analysis of the potential role of acute coronary angiography in the management pathway of patients who are survivors of OHCA.
http://dx.doi.org/10.1016/j.resuscitation.2014.08.025 0300-9572/Crown Copyright © 2014 Published by Elsevier Ireland Ltd. All rights reserved.
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Table 1 STEMI complicated by out of hospital cardiac arrest. Published
Period
Study type
Country
OHCA (%)
Witnessed (%)
Bendz [25] Fothergill [26] Garot [27] Gorjup [28] Hosmane [29] Hovdenes [30] Kahn [31] Keelan [32] Knafelj [33] Koeth [34] Lee [35] Lettieri [36] Lim [37] Liu [38] Mager [39] Markusohn [40] Maze [41] McCullough [42] Mylotte [43] Peels [44] Quintero-Moran [45] Richling[46] Siudak [47] Valente [48] Velders [49] Wolfrum [50] Zimmerman [51]
2004 2013 2007 2007 2009 2007 1995 2003 2007 2012 2005 2012 2013 2013 2008 2007 2013 2002 2013 2008 2006 2007 2012 2008 2013 2008 2013
1998–2001 2011–2012 1995–2005 2000–2004 2002–2006 2003–2005 1989–1994 1991–2000 2003–2005 2003–2004 2000–2002 2005 2004–2009 2004–2008 2001–2006 1998–2006 2004–2011 1989–1996 1998–2010 2004–2005 2000–2003 1997–2003 2005–2007 2005–2006 2006–2009 2003–2008 2001–2008
Prospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Prospective Retrospective Prospective Prospective Prospective Prospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective
Norway United Kingdom France Slovenia USA Norway USA USA Slovenia Germany The Netherlands Italy Australia China Israel Israel Canada USA France The Netherlands Spain Austria Multinational Italy The Netherlands Germany Germany
100 100 84 77 68 100 100 100 ND 100 100 100 100 100 100 100 100 100 100 100 100 98 100 100 100 100 100
85 86.4 67 100 90 94 ND ND 100 ND ND 69 ND ND ND 92 84 100 22 ND 100 98 ND ND 93.8 91 100
VF/VT (%)
90 85.4 ND 83 ND 100 100 100 100 ND 100 88 83 ND ND 84 96 91 70 ND 77.8 100 83 73.9 93.8 100 ND
Comatose (%) 90 ND ND 64 ND 100 64 86.7 100 ND ND ND ND 28.6 42.9 72 100 ND ND ND ND ND ND 100 71 100 ND
HT (%)
ST elevation or LBBB (%)
ND ND 18 22.2 ND 100 0 0 56 ND ND 12 ND
100 100 100 100 100 ND ND 80 100 100 100 100 90.9 100 100 100 100 ND 100 100 100 100 100 100 100 100 100
4.8 8 100 ND 22.2 ND ND 37 ND ND 71 48.5 26.4
Size (n)
40 206 186 135 98 50 11 15 72 52 22 99 88 49 21 25 50 22 266 44 27 46 42 31 224 33 72
PCI (%)
Survival (%)
Good neuro (%)
Survival type
100 ND 100 80 65.3 72 100 100 ND ND 100 ND ND ND 100 100 100 100 100 100 ND 100 100 100 100 100 100 Mean 95% CI
72.5 66 55 68.9 60 82 51 73.3 61 69.2 77.3 78 62.5 63.3 85.7 76 68 59 34.6 50 66.7 55 92.9 65.3 83.5 69.7 73.6 67.4 62.5–72.3
ND ND 69.7 ND ND 85.7 54.8 ND 96.1 92 68 100 81.8 37.5 81.8 68 60 63.6 32 ND 77.1 58.3 ND 57.6 ND 47.8 ND 68.4 59.5–77.3
DC DC DC DC DC 30D DC DC DC DC 6M DC DC DC DC DC DC DC 6M DC DC 30D 30D 6M DC 6M DC
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Fig. 1. Flow chart of paper identification for inclusion in review and meta-analysis.
2. Methods
collected from the appropriately selected studies were generated with reference to the Utstein style reporting template.9
2.1. Inclusion criteria Data collection was performed using the method outlined in the preferred reporting items for systematic reviews and metaanalyses (PRISMA) statement.8 The focus of the systematic review and meta-analysis was to quantitatively describe the outcomes associated with early coronary angiography in the setting of OHCA, and where possible to compare these outcomes to contemporaneously reported controls. The primary outcome measure was the pooled outcome data of survival (to hospital discharge), and thus only studies allowing for calculation of outcomes stratified by coronary angiography were included.
2.3. Statistics Analysis was performed using SAS JMP 10.0.2 and RevMan 5.2.7. Pooled data for the comparison between OHCA survivors having early coronary angiography compared to controls was analyzed using a weighted random effects model and study heterogeneity assessed with the I2 statistic. Where there was single group data only (no control or comparison group), outcomes were expressed as mean and 95% confidence interval (CI). 3. Results
2.2. Database search
3.1. Studies included
Embase, Medline and PubMed were interrogated using the search term [(‘coronary angiography’ OR ‘coronary angiogram’ OR ‘coronary angioplasty’ OR ‘percutaneous coronary intervention’ OR ‘cardiac catheterization’) AND (‘out of hospital cardiac arrest’ OR ‘cardiac arrest’ OR ‘heart arrest’)]. The time period of the search was from 1 January 1980 to 1 January 2014. Data points to be
After removing duplicates, 2361 articles were identified. Following filtering to exclude letters to the editor, meeting abstracts, reviews and non-human studies, 1317 articles were then screened (title and abstract), resulting in a list of 105 full manuscripts that were then retrieved. These manuscripts were assessed in full, resulting in 50 articles that were included
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Fig. 2. Weighted hazard effects model of the relationship between acute coronary angiography and survival after OHCA.
in the systematic review and meta-analysis. This is shown in Fig. 1. 3.2. Patients with STEMI and OHCA Patients with STEMI and OHCA with ongoing coma represent a high-risk subgroup of ACS patients and are frequently excluded from mainstream randomized controlled trials. There are no dedicated randomized controlled trials assessing the role of angiography with a view to primary percutaneous coronary intervention (PCI) in this subgroup. Table 1 highlights the 27 identified studies that report survival data for patients with STEMI admitted following OHCA that allowed calculation of survival in patients undergoing invasive assessment. Most studies reported survival to hospital discharge, with others reporting 30 day and 6 month data. TH was employed variably in these studies, and largely in those studies from the latter part of the last decade onward. Mean survival was 67.4% (95% CI 62.5–72.3%). Neurological outcomes were not reported to allow analysis in 9 studies. From the studies that did report neurological outcomes the mean survival with good neurological outcome was 68.4% (95% CI 59.5–77.3%). The study by Stub et al. was of satisfactory quality for analysis but was unable to be included because outcome data stratified by angiography was not published in a raw format.10 3.3. Patients with OHCA not restricted to STEMI with no control group Seven studies (Table 2) reported outcome data for heterogeneous patient groups with OHCA with and without STEMI. Among these patients STEMI was a frequent finding on the post
arrest ECG (mean = 52%) and a significant proportion of patients underwent PCI (mean = 47.9%). Overall mean survival was 47.5% (95% CI 35.5–59.5%) and survival with a good neurological outcome (reported in four studies) with reference to the Utstein definitions was 50.4% (95% CI 20.8–79.6%). 3.4. Studies of OHCA with data on patients undergoing and not undergoing angiography Fifteen studies were identified that compared OHCA patients who underwent angiography against those who did not. None of these studies were randomized. Eleven of the studies were retrospective in nature. Table 3 shows the characteristics of the included studies. Most of the patients were comatose and 71% had VF or VT on the ECG. Not surprisingly, more patients in the angiography group had a STEMI pattern on ECG. Overall survival in the early angiography group was 58.8% versus 30.9% in the conservative management group (Odds ratio 2.77, 95% CI 2.06–3.72), shown in Fig. 1. Survival with good neurological outcome in the acute angiography group was 58% versus 35.8% in the conservative management group (Odds ratio 2.20, 95% CI 1.46–3.32), shown in Figs. 2 and 3 4. Discussion The results of the current analysis support the current American Heart Association (AHA) class I guideline recommendation that in the setting of resuscitated OHCA with an initial ECG showing STEMI, immediate coronary angiography and PCI is the appropriate management strategy.11 Given the body of evidence around STEMI and reperfusion therapies and the relatively good neurological
Fig. 3. Weighted hazard effects model of the relationship between acute coronary angiography and good neurological outcome after OHCA.
Table 2 Out of hospital cardiac arrest not stratified by STEMI. Year
Period
Type
Country
OHCA (%)
Witnessed (%)
VF/VT (%)
Comatose (%)
HT (%)
ST elevation or LBBB (%)
Anyfantakis [52] Chelly [53] Dumas [54] Gonzalez [55] Mollman [56] Sideris [57] Spaulding [58]
2009 2012 2010 2012 2011 2011 1997
2001–2006 2000–2010 2003–2008 2007–2012 2003–2005 2002–2008 1994–1996
Retrospective Prospective Prospective Retrospective Prospective Retrospective Prospective
France France France USA Germany France France
100 100 100 100 100 100 100
84.7 ND ND ND ND ND ND
50 66.6 68 73 ND 50.9 93
ND ND ND ND ND 99 ND
ND 72.5 86 75 ND 76 0 MEAN 95% CI
55.6 ND 31 ND 55.4 55 63 52 41.3–62.7
Size (n) 72 896 435 103 65 165 84
PCI (n) 49 344 201 43 38 52 37
PCI (%)
Survival (%)
Good neuro (%)
Survival type
68 46.2 46.4 40.6 58.5 31.6 44 47.9 39.1–56.8
48.6 36 39 69 71 31 38.1 47.5 35.5–59.5
45.8 ND 94 ND ND 26.1 35.7 50.4 20.8–79.6
DC DC DC DC 6M DC DC
Table 3 Studies of OHCA with data on patients undergoing and not undergoing angiography. Author
Year
Period
Type
Country
OHCA (%)
Witnessed (%)
VF/VT (%)
Comatose (%)
HT (%)
STEMI or LBBB all (%)
STEMI or LBBB in angio group
STEMI or LBBB in control
Size total
Angio group size
Control size
PCI size (n)
PCI % (of total cohort)
Survival type
Aurore [59] Bulut [60]
2011 1999
2000–2006 ND
Retrospective Retrospective
100 ND
ND 68
31.7 69
ND 61
ND ND
28.3 ND
63 ND
4 ND
445 37
133 10
312 27
71 10
53 14
DC DC
Hollenbeck [7] Mooney [61] Nanjayya [62] Werling [63] Zanuttini [64] Waldo [65] Strote [66] Reynolds [67] Tomte [68] Bro-Jeppesen [69] Cronier [70] Grasner [71] Nielsen [72]
2013 2011 2012 2007 2012 2013 2012 2009 2011 2012 2011 2011 2009
2005–2011 2006–2009 2003–2008 2003–2005 2008–2011 2008–2012 1999–2002 2005–2007 2003–2009 2004–2010 2003–2008 2004–2010 2004–2008
Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Prospective Prospective Prospective Prospective
France The Netherlands USA USA Australia Sweden Italy USA USA USA Norway Denmark France Germany Multinational Mean
100 100 100 100 100 78.2 100 56 100 100 100 100 100 95.3
85.1 82 88.6 ND 84 ND 83.3 ND 93.1 86 100 75.3 86 84.7
100 76 100 50 65 57.3 98 39 89.7 80 100 41 70 71.1
100 100 ND ND 100 ND ND ND 100 100 100 ND 100 95.1
100 100 65.7 32 ND 29.1 0 33 86.8 90 100 31 100 64
0 49 ND ND 42 76.4 34.2 20 ND 32.2 51 ND ND 37
0 ND ND ND 64.6 82 75 44 ND 59
0 ND ND ND 17.8 64 20 3 ND 0 ND ND ND 15.5
269 140 70 85 93 110 240 96 174 360 111 584 986
122 101 35 28 48 84 61 63 145 198 91 154 479
147 39 35 57 45 26 179 33 29 162 20 430 507
40 56 21 ND 25 ND 38 ND 80 ND 46 ND 299
14.9 40 60 ND 52 ND 15.8 ND 46 ND 41.1 ND 30.1 36.7
DC DC DC DC DC DC DC DC DC 30D DC DC DC
ND ND 55.4
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outcome of the subset of OHCA patients with STEMI, it is unlikely that a randomized controlled trial will ever be performed in this population. It is reassuring however that a recent randomized animal model demonstrated clearly superior outcomes with prompt reperfusion.12 The short-term survival (mostly in-hospital) for STEMI patients post-ROSC from an OHCA in the current study was 64.8% and is far lower than that seen in the standard STEMI population without OHCA.13 As with the other cohorts analyzed in the current study, the vast majority of patients who did survive had a satisfactory neurological outcome. Some investigators have raised concerns about the institution of hypothermia around the time of percutaneous intervention but these would seem largely unfounded.14 The study by Koester et al. assessed the outcomes of patients who had MTH instituted prior to and during cardiac catheterization.15 With regard to vasospasm, arrhythmia, and bleeding the investigators did not identify any significant barriers to MTH. They suggested MTH is safe and feasible in the setting of immediate angiography and PCI. However, the study did not evaluate the lingering potential issue of an association between MTH and potentially elevated rates of acute and sub-acute stent thrombosis.16 In relation to the published data on cohorts not restricted to STEMI patients, the data overall are supportive for a low threshold for invasive cardiac assessment in survivors of OHCA, including those who are comatose. There is obvious patient selection bias in observational studies conducted in this setting. None of the studies were randomized, most are retrospective analyses, and even the prospective evaluations included only carefully selected patients. Hence, the level of evidence for a routine acute invasive strategy for patients with OHCA (similar to that for STEMI) is relatively low and would be consistent with AHA Level B to C. Given the evidence of a lack of harm and potential significant benefit, clinicians can justify acute invasive assessment where non-cardiac causes for arrest are not obvious. The integration of systems of care around the concept of cardiac arrest centers also seems to be an important part of the progress toward better outcomes for survivors of OHCA.17 The implementation post cardiac arrest care bundles allow for the systemization of evidence based post arrest therapies in a coordinated manor. This is likely to result in more survivors of OHCA achieving better outcomes with evidenced based therapies (including TH and coronary reperfusion) being applied more consistently with less time delay.18,19 Improving survival to hospital discharge (with a good neurological outcome) is important in this patient group because long-term outcomes can be quite favorable if this initial hurdle is met. Investigators analyzing five-year follow-up data from Paris, France reported an 81.7% five-year survival rate for OHCA patients alive at hospital discharge (92.2% if the cause of the OHCA was ACS) in a system where resuscitated OHCA patients receive immediate coronary angiography and TH in a well organized post cardiac arrest system of care setting.20 The relatively poor sensitivity of the 12 lead ECG in this patient population for identifying acute arterial occlusion means that the ECG should not be the sole factor in deciding upon an invasive strategy.6,7,21,22 Acute culprit lesions can be present in the absence of ST elevation especially if the occlusion involves the left circumflex territory.21,23,24 Among a group of 122 OHCA patients with ROSC but without STEMI who underwent early angiography, 16.4% had a culprit lesion with TIMI 2 flow or less and 32% had a culprit lesion of 70% stenosis or more. Importantly, 1 in 10 patients had an acute lesion with TIMI 0 flow. Almost all of these patients underwent successful revascularization.7 In an analysis to correlate ECG findings with angiographic characteristics post OHCA Zantunni et al. report that 33% of OHCA without STEMI on the post ROSC ECG had an acute presumed recent coronary lesion.6
5. Conclusions Current data suggest an association between acute coronary angiography and improved outcomes, including survival, following OHCA. Data quality is limited by the fact that no randomized studies assessing the role of acute angiography in patients with OHCA have been performed. Based on available data, a routine early acute invasive strategy in this patient population (especially for patients with STEMI) is reasonable where ACS is the suspected cause of the arrest. Randomized studies, particularly for patients with no specific ischemic ECG changes post ROSC, are needed to guide further stratification and resource allocation for the treatment of survivors of OHCA. The 12 lead ECG should not be solely relied upon to exclude acute epicardial coronary artery thrombosis because of its relatively low sensitivity for detecting acute arterial occlusion in this patient population. The introduction of an early and routine coronary angiography strategy for resuscitated OHCA patients should ideally occur within an integrated system incorporating cardiac arrest centers and the implementation of post cardiac arrest care bundles. Conflict of interst statement Relevant disclosures or conflicts of interest: Nil. Disclosures None relevant. References 1. Rubart M, Zipes DP. Mechanisms of sudden cardiac death. J Clin Invest 2005;115:2305–15. 2. Fox KA, Clayton TC, Damman P, et al. Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data. J Am Coll Cardiol 2010;55:2435–45. 3. Kern KB. Optimal treatment of patients surviving out-of-hospital cardiac arrest. JACC: Cardiovasc Intervent 2012;5:597–605. 4. Larsen JM, Ravkilde J. Acute coronary angiography in patients resuscitated from out-of-hospital cardiac arrest-a systematic review and meta-analysis. Resuscitation 2012;83:1427–33. 5. Arrich J, Holzer M, Havel C, Müllner M, Herkner H. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database Syst Rev 2012;4:9. 6. Zanuttini D, Armellini I, Nucifora G, et al. Predictive value of electrocardiogram in diagnosing acute coronary artery lesions among patients with out-of-hospitalcardiac-arrest. Resuscitation 2013;84:1250–4. 7. Hollenbeck RD, McPherson JA, Mooney MR, et al. Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI. Resuscitation 2013;85:88–95. 8. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151:264–9. 9. Jacobs I, Nadkarni V, Bahr J, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa). Resuscitation 2004;63:233–49. 10. Stub D, Hengel C, Chan W, et al. Usefulness of cooling and coronary catheterization to improve survival in out-of-hospital cardiac arrest. Am J Cardiol 2011;107:522–7. 11. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e362–425. 12. Sideris G, Magkoutis N, Sharma A, et al. Early coronary revascularization improves 24h survival and neurological function after ischemic cardiac arrest. A randomized animal study. Resuscitation 2014;85:292–8. 13. Camuglia AC, Luis SA, Sengupta A, Bett JHN, Walters DL. Pre-hospital fibrinolysis in the management of patients with ST elevation acute coronary syndrome: review of the evidence, implementation and future directions. Cardiovasc Hematol Disord Drug Targets 2013;13:243–55.
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41. Maze R, Le May MR, Hibbert B, et al. The impact of therapeutic hypothermia as adjunctive therapy in a regional primary PCI program. Resuscitation 2013;84:460–4. 42. McCullough PA, Prakash R, Tobin KJ, O’Neill WW, Thompson RJ. Application of a cardiac arrest score in patients with sudden death and ST segment elevation for triage to angiography and intervention. J Interv Cardiol 2002;15:257–61. 43. Mylotte D, Morice MC, Eltchaninoff H, et al. Primary percutaneous coronary intervention in patients with acute myocardial infarction, resuscitated cardiac arrest, and cardiogenic shock: the role of primary multivessel revascularization. JACC: Cardiovasc Interv 2013;6:115–25. 44. Peels HO, Jessurun GAJ, Van Der Horst ICC, Arnold AER, Piers LH, Zijlstra F. Outcome in transferred and nontransferred patients after primary percutaneous coronary intervention for ischaemic out-of-hospital cardiac arrest. Catheter Cardiovasc Interv 2008;71:147–51. 45. Quintero-Moran B, Moreno R, Villarreal S, et al. Percutaneous coronary intervention for cardiac arrest secondary to ST-elevation acute myocardial infarction influence of immediate paramedical/medical assistance on clinical outcome. J Invasive Cardiol 2006;18:269–72. 46. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W. Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac arrest due to acute ST-segment elevation myocardial infarction and its effect on outcome. Am J Emerg Med 2007;25:545–50. 47. Siudak Z, Birkemeyer R, Dziewierz A, et al. Out-of-hospital cardiac arrest in patients treated with primary PCI for STEMI Long-term follow up data from EUROTRANSFER registry. Resuscitation 2012;83:303–6. 48. Valente S, Lazzeri C, Saletti E, Chiostri M, Gensini GF. Primary percutaneous coronary intervention in comatose survivors of cardiac arrest with ST-elevation acute myocardial infarction: a single-center experience in florence. J Cardiovasc Med 2008;9:1083–7. 49. Velders MA, van Boven N, Boden H, et al. Association between angiographic culprit lesion and out-of-hospital cardiac arrest in ST-elevation myocardial infarction patients. Resuscitation 2013;84:1530–5. 50. Wolfrum S, Pierau C, Radke PW, Schunkert H, Kurowski V. Mild therapeutic hypothermia in patients after out-of-hospital cardiac arrest due to acute STsegment elevation myocardial infarction undergoing immediate percutaneous coronary intervention. Crit Care Med 2008;36:1780–6. 51. Zimmermann S, Flachskampf FA, Alff A, et al. Out-of-hospital cardiac arrest and percutaneous coronary intervention for ST-elevation myocardial infarction: long-term survival and neurological outcome. Int J Cardiol 2013;166:236–41. 52. Anyfantakis ZA, Baron G, Aubry P, et al. Acute coronary angiographic findings in survivors of out-of-hospital cardiac arrest. Am Heart J 2009;157:312–8. 53. Chelly J, Mongardon N, Dumas F, et al. Benefit of an early and systematic imaging procedure after cardiac arrest: insights from the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) registry. Resuscitation 2012;83:1444–50. 54. Dumas F, Cariou A, Manzo-Silberman S, et al. 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: Cardiovasc Interv 2010;3:200–7. 55. Gonzalez MR, Esposito EC, Leary M, et al. Initial clinical predictors of significant coronary lesions after resuscitation from cardiac arrest. Ther Hypothermia Temperature Manag 2012;2:73–7. 56. Mollmann H, Szardien S, Liebetrau C, et al. Clinical outcome of patients treated with an early invasive strategy after out-of-hospital cardiac arrest. J Int Med Res 2011;39:2169–77. 57. Sideris G, Voicu S, Dillinger JG, et al. Value of post-resuscitation electrocardiogram in the diagnosis of acute myocardial infarction in out-of-hospital cardiac arrest patients. Resuscitation 2011;82:1148–53. 58. Spaulding CM, Joly LM, Rosenberg A, et al. Immediate coronary angiography in survivors of out-of-hospital cardiac arrest. N Engl J Med 1997;336:1629–33. 59. Aurore A, Jabre P, Liot P, Margenet A, Lecarpentier E, Combes X. Predictive factors for positive coronary angiography in out-of-hospital cardiac arrest patients. Eur J Emerg Med 2011;18:73–6. 60. Bulut S, Aengevaeren WR, Luijten HJ, Verheugt FW. Successful out-of-hospital cardiopulmonary resuscitation: what is the optimal in-hospital treatment strategy? Resuscitation 2000;47:155–61. 61. Mooney MR, Unger BT, Boland LL, et al. Therapeutic hypothermia after out-ofhospital cardiac arrest: evaluation of a regional system to increase access to cooling. Circulation 2011;124:206–14. 62. Nanjayya VB, Nayyar V. Immediate coronary angiogram in comatose survivors of out-of-hospital cardiac arrest-an Australian study. Resuscitation 2012;83:699–704. 63. Werling M, Thoren AB, Axelsson C, Herlitz J. Treatment and outcome in post-resuscitation care after out-of-hospital cardiac arrest when a modern therapeutic approach was introduced. Resuscitation 2007;73:40–5. 64. Zanuttini D, Armellini I, Nucifora G, et al. Impact of emergency coronary angiography on in-hospital outcome of unconscious survivors after out-of-hospital cardiac arrest. Am J Cardiol 2012;110:1723–8. 65. Waldo SW, Armstrong EJ, Kulkarni A, et al. Comparison of clinical characteristics and outcomes of cardiac arrest survivors having versus not having coronary angiography. Am J Cardiol 2013;111:1253–8. 66. Strote JA, Maynard C, Olsufka M, et al. Comparison of role of early (less than six hours) to later (more than six hours) or no cardiac catheterization after resuscitation from out-of-hospital cardiac arrest. Am J Cardiol 2012;109:451–4. 67. Reynolds JC, Callaway CW, El Khoudary SR, Moore CG, Alvarez RJ, Rittenberger JC. Coronary angiography predicts improved outcome following cardiac arrest: propensity-adjusted analysis. J Intensive Care Med 2009;24:179–86.
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68. Tomte O, Andersen GO, Jacobsen D, Draegni T, Auestad B, Sunde K. Strong and weak aspects of an established post-resuscitation treatment protocol—a fiveyear observational study. Resuscitation 2011;82:1186–93. 69. Bro-Jeppesen J, Kjaergaard J, Wanscher M, et al. Emergency coronary angiography in comatose cardiac arrest patients: do real-life experiences support the guidelines? Eur Heart J: Acute Cardiovasc Care 2012;1:291–301. 70. Cronier P, Vignon P, Bouferrache K, et al. Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to ventricular fibrillation. Crit Care 2011:15.
71. Grasner JT, Meybohm P, Caliebe A, et al. Postresuscitation care with mild therapeutic hypothermia and coronary intervention after out-of-hospital cardiopulmonary resuscitation: a prospective registry analysis. Crit Care 2011: 15. 72. Nielsen N, Hovdenes J, Nilsson F, et al. Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest. Acta Anaesthesiol Scand 2009;53:926–34.
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Clinical paper
Cardiac catheterization is associated with superior outcomes for survivors of out of hospital cardiac arrest: Review and meta-analysis夽 Anthony C. Camuglia a,b,c,∗ , Varinder K. Randhawa d , Shahar Lavi d , Darren L. Walters c,e a
Mater Health Cardiovascular Unit, South Brisbane, QLD, Australia Princess Alexandra Hospital, Department of Cardiology, Brisbane, QLD, Australia University of Queensland, Brisbane, QLD, Australia d London Health Sciences Centre, University of Western Ontario, London, ON, Canada e The Prince Charles Hospital, Chermside, Brisbane, QLD, Australia b c
a r t i c l e
i n f o
Article history: Received 2 May 2014 Received in revised form 3 August 2014 Accepted 16 August 2014 Keywords: Out-of-hospital cardiac arrest Coronary angiography Cardiac catheterization
a b s t r a c t Aims: Survivors of out-of-hospital cardiac arrest (OHCA) have a high rate of morbidity and mortality. Invasive cardiac assessment with coronary angiography offers the potential for improving outcomes by facilitating early revascularization. The aim of the present study was to review the published data on early coronary angiography for survivors of OHCA, and its impact on survival and neurological outcomes. Methods: Medline, Embase and PubMed were searched with a structured search query. The primary outcome was in-hospital (or if not available, 30 day or 6 month) survival. Rates of survival with good neurological outcome were a secondary endpoint. The time period of the search was from 1 January 1980 to 1 January 2014. Data was pooled with means and 95% CI interval calculated. Meta-analysis of the main outcomes was performed using a weighted random effects model. Results: Following review of all identified records, 105 relevant full text articles were retrieved. Fifty had adequate outcome information stratified by the use of coronary angiography for analysis. In studies where a control group was available for comparison, the overall survival in the acute angiography group was 58.8% versus 30.9% in the control group (Odds ratio 2.77, 95% CI 2.06–3.72). Survival with good neurological outcome (as per the Utstein framework) in the early angiography group was 58% versus 35.8% in the control group (Odds ratio 2.20, 95% CI 1.46–3.32). Conclusions: Early coronary angiography in patients following OHCA is associated with improved outcome and better survival. Crown Copyright © 2014 Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Out-of-hospital cardiac arrest (OHCA) is an important source of death and disability; and ischemic heart disease is recognized as the most frequent cause of OHCA.1 In patients with acute coronary syndrome who do not experience OHCA, a routine early invasive strategy has been shown to improve patient outcomes.2 Survivors of OHCA represent a group with high rates of morbidity and mortality.3 However, owing to a lack of randomized clinical trial
夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.08.025. ∗ Corresponding author at: Mater Health, Cardiovascular Unit, 301 Vulture Street, South Brisbane, QLD 4101, Australia. Fax: +64 7 3217 2550. E-mail address: [email protected] (A.C. Camuglia).
evidence uncertainty remains concerning the role of early invasive cardiac assessment. An analysis of non-randomized studies showed that significant coronary artery disease is highly prevalent among OHCA patients who did not have an obvious non-cardiac etiology. Early angiography in these patients is feasible and may improve outcomes.4 There has been considerable work published in the area since this analysis, as well as the continued adoption of mild therapeutic hypothermia (MTH) in comatose patients in conjunction with invasive assessment and management pathways.5 Part of the rationale for a benefit of routine acute angiography is the identification and appropriate revascularization of patients with acute coronary occlusions that occur without attendant significant ischemic changes on ECG.6,7 On this basis, the current study is a systematic review and meta-analysis of the potential role of acute coronary angiography in the management pathway of patients who are survivors of OHCA.
http://dx.doi.org/10.1016/j.resuscitation.2014.08.025 0300-9572/Crown Copyright © 2014 Published by Elsevier Ireland Ltd. All rights reserved.
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Table 1 STEMI complicated by out of hospital cardiac arrest. Published
Period
Study type
Country
OHCA (%)
Witnessed (%)
Bendz [25] Fothergill [26] Garot [27] Gorjup [28] Hosmane [29] Hovdenes [30] Kahn [31] Keelan [32] Knafelj [33] Koeth [34] Lee [35] Lettieri [36] Lim [37] Liu [38] Mager [39] Markusohn [40] Maze [41] McCullough [42] Mylotte [43] Peels [44] Quintero-Moran [45] Richling[46] Siudak [47] Valente [48] Velders [49] Wolfrum [50] Zimmerman [51]
2004 2013 2007 2007 2009 2007 1995 2003 2007 2012 2005 2012 2013 2013 2008 2007 2013 2002 2013 2008 2006 2007 2012 2008 2013 2008 2013
1998–2001 2011–2012 1995–2005 2000–2004 2002–2006 2003–2005 1989–1994 1991–2000 2003–2005 2003–2004 2000–2002 2005 2004–2009 2004–2008 2001–2006 1998–2006 2004–2011 1989–1996 1998–2010 2004–2005 2000–2003 1997–2003 2005–2007 2005–2006 2006–2009 2003–2008 2001–2008
Prospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Prospective Retrospective Prospective Prospective Prospective Prospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective
Norway United Kingdom France Slovenia USA Norway USA USA Slovenia Germany The Netherlands Italy Australia China Israel Israel Canada USA France The Netherlands Spain Austria Multinational Italy The Netherlands Germany Germany
100 100 84 77 68 100 100 100 ND 100 100 100 100 100 100 100 100 100 100 100 100 98 100 100 100 100 100
85 86.4 67 100 90 94 ND ND 100 ND ND 69 ND ND ND 92 84 100 22 ND 100 98 ND ND 93.8 91 100
VF/VT (%)
90 85.4 ND 83 ND 100 100 100 100 ND 100 88 83 ND ND 84 96 91 70 ND 77.8 100 83 73.9 93.8 100 ND
Comatose (%) 90 ND ND 64 ND 100 64 86.7 100 ND ND ND ND 28.6 42.9 72 100 ND ND ND ND ND ND 100 71 100 ND
HT (%)
ST elevation or LBBB (%)
ND ND 18 22.2 ND 100 0 0 56 ND ND 12 ND
100 100 100 100 100 ND ND 80 100 100 100 100 90.9 100 100 100 100 ND 100 100 100 100 100 100 100 100 100
4.8 8 100 ND 22.2 ND ND 37 ND ND 71 48.5 26.4
Size (n)
40 206 186 135 98 50 11 15 72 52 22 99 88 49 21 25 50 22 266 44 27 46 42 31 224 33 72
PCI (%)
Survival (%)
Good neuro (%)
Survival type
100 ND 100 80 65.3 72 100 100 ND ND 100 ND ND ND 100 100 100 100 100 100 ND 100 100 100 100 100 100 Mean 95% CI
72.5 66 55 68.9 60 82 51 73.3 61 69.2 77.3 78 62.5 63.3 85.7 76 68 59 34.6 50 66.7 55 92.9 65.3 83.5 69.7 73.6 67.4 62.5–72.3
ND ND 69.7 ND ND 85.7 54.8 ND 96.1 92 68 100 81.8 37.5 81.8 68 60 63.6 32 ND 77.1 58.3 ND 57.6 ND 47.8 ND 68.4 59.5–77.3
DC DC DC DC DC 30D DC DC DC DC 6M DC DC DC DC DC DC DC 6M DC DC 30D 30D 6M DC 6M DC
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Author
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Fig. 1. Flow chart of paper identification for inclusion in review and meta-analysis.
2. Methods
collected from the appropriately selected studies were generated with reference to the Utstein style reporting template.9
2.1. Inclusion criteria Data collection was performed using the method outlined in the preferred reporting items for systematic reviews and metaanalyses (PRISMA) statement.8 The focus of the systematic review and meta-analysis was to quantitatively describe the outcomes associated with early coronary angiography in the setting of OHCA, and where possible to compare these outcomes to contemporaneously reported controls. The primary outcome measure was the pooled outcome data of survival (to hospital discharge), and thus only studies allowing for calculation of outcomes stratified by coronary angiography were included.
2.3. Statistics Analysis was performed using SAS JMP 10.0.2 and RevMan 5.2.7. Pooled data for the comparison between OHCA survivors having early coronary angiography compared to controls was analyzed using a weighted random effects model and study heterogeneity assessed with the I2 statistic. Where there was single group data only (no control or comparison group), outcomes were expressed as mean and 95% confidence interval (CI). 3. Results
2.2. Database search
3.1. Studies included
Embase, Medline and PubMed were interrogated using the search term [(‘coronary angiography’ OR ‘coronary angiogram’ OR ‘coronary angioplasty’ OR ‘percutaneous coronary intervention’ OR ‘cardiac catheterization’) AND (‘out of hospital cardiac arrest’ OR ‘cardiac arrest’ OR ‘heart arrest’)]. The time period of the search was from 1 January 1980 to 1 January 2014. Data points to be
After removing duplicates, 2361 articles were identified. Following filtering to exclude letters to the editor, meeting abstracts, reviews and non-human studies, 1317 articles were then screened (title and abstract), resulting in a list of 105 full manuscripts that were then retrieved. These manuscripts were assessed in full, resulting in 50 articles that were included
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Fig. 2. Weighted hazard effects model of the relationship between acute coronary angiography and survival after OHCA.
in the systematic review and meta-analysis. This is shown in Fig. 1. 3.2. Patients with STEMI and OHCA Patients with STEMI and OHCA with ongoing coma represent a high-risk subgroup of ACS patients and are frequently excluded from mainstream randomized controlled trials. There are no dedicated randomized controlled trials assessing the role of angiography with a view to primary percutaneous coronary intervention (PCI) in this subgroup. Table 1 highlights the 27 identified studies that report survival data for patients with STEMI admitted following OHCA that allowed calculation of survival in patients undergoing invasive assessment. Most studies reported survival to hospital discharge, with others reporting 30 day and 6 month data. TH was employed variably in these studies, and largely in those studies from the latter part of the last decade onward. Mean survival was 67.4% (95% CI 62.5–72.3%). Neurological outcomes were not reported to allow analysis in 9 studies. From the studies that did report neurological outcomes the mean survival with good neurological outcome was 68.4% (95% CI 59.5–77.3%). The study by Stub et al. was of satisfactory quality for analysis but was unable to be included because outcome data stratified by angiography was not published in a raw format.10 3.3. Patients with OHCA not restricted to STEMI with no control group Seven studies (Table 2) reported outcome data for heterogeneous patient groups with OHCA with and without STEMI. Among these patients STEMI was a frequent finding on the post
arrest ECG (mean = 52%) and a significant proportion of patients underwent PCI (mean = 47.9%). Overall mean survival was 47.5% (95% CI 35.5–59.5%) and survival with a good neurological outcome (reported in four studies) with reference to the Utstein definitions was 50.4% (95% CI 20.8–79.6%). 3.4. Studies of OHCA with data on patients undergoing and not undergoing angiography Fifteen studies were identified that compared OHCA patients who underwent angiography against those who did not. None of these studies were randomized. Eleven of the studies were retrospective in nature. Table 3 shows the characteristics of the included studies. Most of the patients were comatose and 71% had VF or VT on the ECG. Not surprisingly, more patients in the angiography group had a STEMI pattern on ECG. Overall survival in the early angiography group was 58.8% versus 30.9% in the conservative management group (Odds ratio 2.77, 95% CI 2.06–3.72), shown in Fig. 1. Survival with good neurological outcome in the acute angiography group was 58% versus 35.8% in the conservative management group (Odds ratio 2.20, 95% CI 1.46–3.32), shown in Figs. 2 and 3 4. Discussion The results of the current analysis support the current American Heart Association (AHA) class I guideline recommendation that in the setting of resuscitated OHCA with an initial ECG showing STEMI, immediate coronary angiography and PCI is the appropriate management strategy.11 Given the body of evidence around STEMI and reperfusion therapies and the relatively good neurological
Fig. 3. Weighted hazard effects model of the relationship between acute coronary angiography and good neurological outcome after OHCA.
Table 2 Out of hospital cardiac arrest not stratified by STEMI. Year
Period
Type
Country
OHCA (%)
Witnessed (%)
VF/VT (%)
Comatose (%)
HT (%)
ST elevation or LBBB (%)
Anyfantakis [52] Chelly [53] Dumas [54] Gonzalez [55] Mollman [56] Sideris [57] Spaulding [58]
2009 2012 2010 2012 2011 2011 1997
2001–2006 2000–2010 2003–2008 2007–2012 2003–2005 2002–2008 1994–1996
Retrospective Prospective Prospective Retrospective Prospective Retrospective Prospective
France France France USA Germany France France
100 100 100 100 100 100 100
84.7 ND ND ND ND ND ND
50 66.6 68 73 ND 50.9 93
ND ND ND ND ND 99 ND
ND 72.5 86 75 ND 76 0 MEAN 95% CI
55.6 ND 31 ND 55.4 55 63 52 41.3–62.7
Size (n) 72 896 435 103 65 165 84
PCI (n) 49 344 201 43 38 52 37
PCI (%)
Survival (%)
Good neuro (%)
Survival type
68 46.2 46.4 40.6 58.5 31.6 44 47.9 39.1–56.8
48.6 36 39 69 71 31 38.1 47.5 35.5–59.5
45.8 ND 94 ND ND 26.1 35.7 50.4 20.8–79.6
DC DC DC DC 6M DC DC
Table 3 Studies of OHCA with data on patients undergoing and not undergoing angiography. Author
Year
Period
Type
Country
OHCA (%)
Witnessed (%)
VF/VT (%)
Comatose (%)
HT (%)
STEMI or LBBB all (%)
STEMI or LBBB in angio group
STEMI or LBBB in control
Size total
Angio group size
Control size
PCI size (n)
PCI % (of total cohort)
Survival type
Aurore [59] Bulut [60]
2011 1999
2000–2006 ND
Retrospective Retrospective
100 ND
ND 68
31.7 69
ND 61
ND ND
28.3 ND
63 ND
4 ND
445 37
133 10
312 27
71 10
53 14
DC DC
Hollenbeck [7] Mooney [61] Nanjayya [62] Werling [63] Zanuttini [64] Waldo [65] Strote [66] Reynolds [67] Tomte [68] Bro-Jeppesen [69] Cronier [70] Grasner [71] Nielsen [72]
2013 2011 2012 2007 2012 2013 2012 2009 2011 2012 2011 2011 2009
2005–2011 2006–2009 2003–2008 2003–2005 2008–2011 2008–2012 1999–2002 2005–2007 2003–2009 2004–2010 2003–2008 2004–2010 2004–2008
Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Prospective Prospective Prospective Prospective
France The Netherlands USA USA Australia Sweden Italy USA USA USA Norway Denmark France Germany Multinational Mean
100 100 100 100 100 78.2 100 56 100 100 100 100 100 95.3
85.1 82 88.6 ND 84 ND 83.3 ND 93.1 86 100 75.3 86 84.7
100 76 100 50 65 57.3 98 39 89.7 80 100 41 70 71.1
100 100 ND ND 100 ND ND ND 100 100 100 ND 100 95.1
100 100 65.7 32 ND 29.1 0 33 86.8 90 100 31 100 64
0 49 ND ND 42 76.4 34.2 20 ND 32.2 51 ND ND 37
0 ND ND ND 64.6 82 75 44 ND 59
0 ND ND ND 17.8 64 20 3 ND 0 ND ND ND 15.5
269 140 70 85 93 110 240 96 174 360 111 584 986
122 101 35 28 48 84 61 63 145 198 91 154 479
147 39 35 57 45 26 179 33 29 162 20 430 507
40 56 21 ND 25 ND 38 ND 80 ND 46 ND 299
14.9 40 60 ND 52 ND 15.8 ND 46 ND 41.1 ND 30.1 36.7
DC DC DC DC DC DC DC DC DC 30D DC DC DC
ND ND 55.4
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outcome of the subset of OHCA patients with STEMI, it is unlikely that a randomized controlled trial will ever be performed in this population. It is reassuring however that a recent randomized animal model demonstrated clearly superior outcomes with prompt reperfusion.12 The short-term survival (mostly in-hospital) for STEMI patients post-ROSC from an OHCA in the current study was 64.8% and is far lower than that seen in the standard STEMI population without OHCA.13 As with the other cohorts analyzed in the current study, the vast majority of patients who did survive had a satisfactory neurological outcome. Some investigators have raised concerns about the institution of hypothermia around the time of percutaneous intervention but these would seem largely unfounded.14 The study by Koester et al. assessed the outcomes of patients who had MTH instituted prior to and during cardiac catheterization.15 With regard to vasospasm, arrhythmia, and bleeding the investigators did not identify any significant barriers to MTH. They suggested MTH is safe and feasible in the setting of immediate angiography and PCI. However, the study did not evaluate the lingering potential issue of an association between MTH and potentially elevated rates of acute and sub-acute stent thrombosis.16 In relation to the published data on cohorts not restricted to STEMI patients, the data overall are supportive for a low threshold for invasive cardiac assessment in survivors of OHCA, including those who are comatose. There is obvious patient selection bias in observational studies conducted in this setting. None of the studies were randomized, most are retrospective analyses, and even the prospective evaluations included only carefully selected patients. Hence, the level of evidence for a routine acute invasive strategy for patients with OHCA (similar to that for STEMI) is relatively low and would be consistent with AHA Level B to C. Given the evidence of a lack of harm and potential significant benefit, clinicians can justify acute invasive assessment where non-cardiac causes for arrest are not obvious. The integration of systems of care around the concept of cardiac arrest centers also seems to be an important part of the progress toward better outcomes for survivors of OHCA.17 The implementation post cardiac arrest care bundles allow for the systemization of evidence based post arrest therapies in a coordinated manor. This is likely to result in more survivors of OHCA achieving better outcomes with evidenced based therapies (including TH and coronary reperfusion) being applied more consistently with less time delay.18,19 Improving survival to hospital discharge (with a good neurological outcome) is important in this patient group because long-term outcomes can be quite favorable if this initial hurdle is met. Investigators analyzing five-year follow-up data from Paris, France reported an 81.7% five-year survival rate for OHCA patients alive at hospital discharge (92.2% if the cause of the OHCA was ACS) in a system where resuscitated OHCA patients receive immediate coronary angiography and TH in a well organized post cardiac arrest system of care setting.20 The relatively poor sensitivity of the 12 lead ECG in this patient population for identifying acute arterial occlusion means that the ECG should not be the sole factor in deciding upon an invasive strategy.6,7,21,22 Acute culprit lesions can be present in the absence of ST elevation especially if the occlusion involves the left circumflex territory.21,23,24 Among a group of 122 OHCA patients with ROSC but without STEMI who underwent early angiography, 16.4% had a culprit lesion with TIMI 2 flow or less and 32% had a culprit lesion of 70% stenosis or more. Importantly, 1 in 10 patients had an acute lesion with TIMI 0 flow. Almost all of these patients underwent successful revascularization.7 In an analysis to correlate ECG findings with angiographic characteristics post OHCA Zantunni et al. report that 33% of OHCA without STEMI on the post ROSC ECG had an acute presumed recent coronary lesion.6
5. Conclusions Current data suggest an association between acute coronary angiography and improved outcomes, including survival, following OHCA. Data quality is limited by the fact that no randomized studies assessing the role of acute angiography in patients with OHCA have been performed. Based on available data, a routine early acute invasive strategy in this patient population (especially for patients with STEMI) is reasonable where ACS is the suspected cause of the arrest. Randomized studies, particularly for patients with no specific ischemic ECG changes post ROSC, are needed to guide further stratification and resource allocation for the treatment of survivors of OHCA. The 12 lead ECG should not be solely relied upon to exclude acute epicardial coronary artery thrombosis because of its relatively low sensitivity for detecting acute arterial occlusion in this patient population. The introduction of an early and routine coronary angiography strategy for resuscitated OHCA patients should ideally occur within an integrated system incorporating cardiac arrest centers and the implementation of post cardiac arrest care bundles. Conflict of interst statement Relevant disclosures or conflicts of interest: Nil. Disclosures None relevant. References 1. Rubart M, Zipes DP. Mechanisms of sudden cardiac death. J Clin Invest 2005;115:2305–15. 2. Fox KA, Clayton TC, Damman P, et al. Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data. J Am Coll Cardiol 2010;55:2435–45. 3. Kern KB. Optimal treatment of patients surviving out-of-hospital cardiac arrest. JACC: Cardiovasc Intervent 2012;5:597–605. 4. Larsen JM, Ravkilde J. Acute coronary angiography in patients resuscitated from out-of-hospital cardiac arrest-a systematic review and meta-analysis. Resuscitation 2012;83:1427–33. 5. Arrich J, Holzer M, Havel C, Müllner M, Herkner H. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database Syst Rev 2012;4:9. 6. Zanuttini D, Armellini I, Nucifora G, et al. Predictive value of electrocardiogram in diagnosing acute coronary artery lesions among patients with out-of-hospitalcardiac-arrest. Resuscitation 2013;84:1250–4. 7. Hollenbeck RD, McPherson JA, Mooney MR, et al. Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI. Resuscitation 2013;85:88–95. 8. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151:264–9. 9. Jacobs I, Nadkarni V, Bahr J, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa). Resuscitation 2004;63:233–49. 10. Stub D, Hengel C, Chan W, et al. Usefulness of cooling and coronary catheterization to improve survival in out-of-hospital cardiac arrest. Am J Cardiol 2011;107:522–7. 11. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e362–425. 12. Sideris G, Magkoutis N, Sharma A, et al. Early coronary revascularization improves 24h survival and neurological function after ischemic cardiac arrest. A randomized animal study. Resuscitation 2014;85:292–8. 13. Camuglia AC, Luis SA, Sengupta A, Bett JHN, Walters DL. Pre-hospital fibrinolysis in the management of patients with ST elevation acute coronary syndrome: review of the evidence, implementation and future directions. Cardiovasc Hematol Disord Drug Targets 2013;13:243–55.
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