Clinical paperAssociation between coronary angiography with or without percutaneous coronary intervention and outcomes after out-of-hospital cardiac arrest☆
Introduction
Out-of-hospital cardiac arrest (OHCA) remains a major public health problem in the United States [1]. Successful resuscitation requires a synchronized set of interdependent actions (the “chain of survival”) which in the latest 2015 American Heart Association (AHA) Guidelines includes targeted temperature management (TTM) and coronary angiography (CAG) after return of circulation [2]. Early revascularization is thought to be the primary benefit of emergent CAG after cardiac arrest [3].
Numerous (>15) studies have reported improved rates of survival to hospital discharge with emergent CAG in patients with ST-segment elevation (STE) [2]. As such, the AHA endorses emergent CAG for OHCA patients with suspected cardiac etiology and STE regardless of whether they are comatose or awake [2]. Several studies have reported lesions amenable to percutaneous coronary intervention (PCI) in a significant minority of patients without STE on their initial post-cardiac arrest electrocardiogram (EKG) [[4], [5], [6], [7]]. While studies have associated emergent CAG in patients without STE after cardiac arrest with improved survival, PCI has not always been shown to provide added benefit [6,8].
The purpose of this study was to assess the association between CAG alone and CAG plus PCI on outcomes after OHCA without initial STE.
Section snippets
Setting
Arizona had 6.7 million residents in 2014 [9]. The Arizona Department of Health Services (ADHS) establishes the EMS scope of practice and provider certification. EMS protocols are implemented on regional level. Crew configuration, vehicle deployment, dispatch, and response intervals vary widely across the state and some local OHCA bypass protocols are in place. About 100 EMS agencies and 40 Cardiac Receiving Centers (CRCs) responding to approximately 80% of the Arizona’s population voluntarily
Results
There were 11,976 OHCA cases during the study period. After exclusions, the study population was 1881 (Fig. 1), 1007 (54%) of which underwent CAG. Of those undergoing CAG 482 (48%) had PCI (Table 1). Overall, 63% of cases survived to hospital discharge and 81% of survivors had a CPC 1/2. Ninety percent of (450/499) STE cases underwent CAG, 70% of which had PCI. Of the 1230 cases without initial STE 43% underwent CAG, 157 (30%) of which had PCI performed (Table 2). Fig. 2 presents a histogram
Discussion
The AHA Guidelines recommend that OHCA with initial STE undergo emergent CAG whether or not they are comatose [2]. It remains less clear whether OHCA patients without initial STE should be taken for early CAG. While observational data regularly show associations between CAG and improved outcomes even without STE, authors have suggested that indication bias has impacted these findings [2,5,6,20]. The fact that CAG with PCI has not consistently been associated with better outcomes when compared
Limitations
As with any observational study, this analysis has several limitations. Despite the large size of this study and the use of propensity matching, unaccounted for bias still remains a possibility. We also selected specific inclusion criteria which could potentially impact the findings. For example, we chose to include all cases whether or not they remained comatose and we controlled for GCS. The vast majority of cases, however, were comatose and, as such, when we ran the analysis on only the
Conclusions
In conclusion, we found that coronary angiography was widely utilized after out-of-hospital cardiac arrest in this statewide cardiac receiving system. In cases without initial ST-elevation, a significant minority of cases had a lesion amenable to percutaneous coronary intervention and coronary angiography was associated with improved outcomes with or without PCI. After propensity matching, coronary angiography remained significantly associated with higher survival to hospital discharge and
Role of funding
None.
Conflicts of interest
None.
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Cited by (19)
Impact of emergent coronary angiography after out-of-the-hospital cardiac arrest without ST-segment elevation – A systematic review and meta-analysis
2022, International Journal of CardiologyCitation Excerpt :Although its prognosis has improved along with the improvement in pre-hospital management and post-OHCA care, including the advent of early reperfusion and target temperature management (TTM) protocols, survival and neurological outcomes are still unfavourable [2]. In line with this perspective, observational studies have shown that coronary artery disease (CAD) is one of the leading causes of non-traumatic OHCA, even in the absence of ST-segment elevation (STE) and that OHCA patients undergoing coronary angiography (CAG) had a better prognosis [3,4]. Due to the critical nature of the condition, there was a perception, supported by observational data, that CAG should be performed within the first few hours after OHCA, regardless of STE [5–9].
Race and ethnicity disparities in post-arrest care in Texas
2022, ResuscitationCitation Excerpt :While bystander CPR and AED use represent important links in the chain of survival, post-arrest care in the hospital is also crucial for improving outcomes.8 Post-arrest procedures, particularly targeted temperature management (TTM),9–12 and percutaneous coronary intervention (PCI),13–15 are linked to improved OHCA outcomes. Additionally, the American Heart Association (AHA) recommends delaying neuroprognostication until 72 hours to improve outcomes,8 as physical exam can misclassify possible survivors if performed within 72 hours16–18 and early withdrawal of life-sustaining therapy (WLST) is associated with worse outcomes.19,20
European Resuscitation Council Guidelines 2021: Epidemiology of cardiac arrest in Europe
2021, ResuscitationCitation Excerpt :Currently there is no unique definition of a CAC, but the usual understanding is that this is an acute care facility capable of providing early emergency coronary angiography (CAG) and intervention, target temperature management (TTM) and critical care facilities on a 24/7 basis.27 Two post-resuscitation interventions are most closely associated with improved outcomes post-cardiac arrest: early CAG and TTM, particularly for patients with an initial shockable rhythm and a presumed cardiac cause of the arrest.28–37 The rationale behind these interventions is discussed elsewhere.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at https://doi.org/10.1016/j.resuscitation.2018.03.023.
- 1
Bureau of Emergency Medical Services, Arizona Department of Health Services, 150 N. 18th Avenue, #540, Phoenix, AZ 85007, United States.
- 2
University of Arizona, PO Box 245057, 1501 N. Campbell, Tucson, AZ 85724-5057, United States.
- 3
Department of Emergency Medicine, University of Arizona, Box 245057, 1501 N. Campbell, Tucson, AZ 85724-5057, United States.
- 4
Address for reprints: Arizona Department of Health Services, 150 N 18th Avenue, Suite 540, Phoenix, AZ, United States.