Coronary angiogram for all post cardiac arrest patients?

Courtesy of Dr. Agustín Vecchia.

There is no doubt cases of post out of hospital cardiac arrest (OHCA) secondary to an ST elevation acute coronary syndrome (STEMI) should be submitted to a coronary angiogram and eventually an angioplasty (PCI). However, in patients with non ST elevation MI, the use of a similar invasive strategy is still under discussion.

Many centers use emergent coronary angiogram (and eventual PCI, if needed) as standard care for OHCA patients with no clear extra cardiac cause.

This analyzis used the PROCAT registry (Parisian Registry Out-of-Hospital Cardiac Arrest). Researchers located patients with non ST elevation MI were localized and, using logistic regression, explored the association between the use of coronary angiogram and a favorable outcome (brain performance category 1 or 2), and evaluated PCI predictors.

From 2004 to 2013, 958 OHCA patients undergoing coronary angiogram were registered. From this total, 695 (73%), mostly men (76%) average 60 years of age, had no evidence of STE in post resuscitation ECG. 199 out of 695 (29%) required PCI. A favorable outcome was observed in 87/200 (43%) of patients submitted to a PCI vs. 164/495 (33%) of those without PCI (p=0.02). After adjusting, PCI was associated to better outcomes (adjusted odds ratio: 1.80 [95% CI: 1.09 to 2.97]; p=0.02). The rest of factors that predicted favorable outcomes were: short resuscitation time (<20 min), initial shockable rhythm and the use of a lower dose of epinephrine during resuscitation (p=0.001). An initial shockable rhythm (adjusted odds ratio: 2.83 [95% CI: 1.84 to 4.36]; p<0.001) was the only predictor of PCI.

The authors concluded that one third of patients studied presented a lesion requiring PCI and in this group, emergency PCI was associated with a 2 fold increase of favorable outcomes. Findings support the use of routine invasive strategy in this group of patients, especially in those post OHCA with initial shockable rhythm.

Editorial Comment

ACLS Guidelines recommend emergent coronary angiogram in post out of hospital cardiac arrest patients in case of STEMI or in electric or hemodynamically unstable patients. For the rest of patients, it is still under discussion. In this study, a wider group of patients currently not included in such recommendations seems to benefit from this invasive strategy. Those who saw more benefits where men older than 50 with initial shockable rhythm. As negative points, despite this analyzis was fairly strict, we should not forget its observational nature and a possible omission of confounders, such as clinical stability at the moment of angiogram and functional assessment of lesions, among others.

Courtesy of Dr. Agustín Vecchia. German Hospital, Buenos Aires, Argentina.

Original Title: Emergency PCI in Post–Cardiac Arrest Patients Without ST-Segment Elevation Pattern Insights From the PROCAT II Registry

Reference: J Am Coll Cardiol Intv. 2016; DOI:10.1016/j.jcin.2016.02.001.

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