"All patients with return of spontaneous circulation after out of hospital cardiac arrest should have an urgent cardiac catheterisation, including patients with normal post resuscitation ECGs."
What are the pros and cons of this approach?
a. In the presence of ST elevation post OHCA (Out of Hospital Cardiac Arrest) all patients without absolute contra-indications should go to cath lab
b. Patients without clear symptoms or signs of ischaemia may still have had an ischaemic cause for arrest. Case series and registries of OHCA have suggested that 1/4 cases taken to cab lab with no ECG evidence of ischemia will have lesions requiring treatment. Treatment in these patients will lead to a 60% survival improvement with a 90% chance of good neurological recovery. Most studies have published a number needed to treat of 4 to prevent one death with a 90% chance of good neurological recovery.
c. Current recommendations from the American Heart Association suggest that any OHCA with
ROSC should go to cath lab if ischemia is suspected
d. Transfer to cath lab with treatment may prevent further cardiac arrests
e. Professional (American Heart Association and European Resuscitation council) bodies who have made recommendations say there is no role in waiting to assess neurological recovery
a. These may be unstable patients
b. The cath lab maybe isolated from other emergency services and take staff away from ED or ICU
c. Transfer to another centre may be required
d. Experienced staff are required to anaesthetize a patient undergoing coronary angioplasty or stenting.
e. Taking all comers to cath lab may lead to many poor outcomes due to high pre OHCA morbidities.
f. Many patients may be taken after prolonged cardiac arrest who may go onto survive with poor neurological recovery
g. There are financial consequences to running a 24-hour cath lab service
h. If there is another explanation for the cardiac arrest the time in the catheter lab maybe detrimental to the patient
i. Anti-coagulation and anti-platelet medications may increase the risk of haemorrhage
j. Difficulty with targeted temperature management in cath lab environment
Overall reasonable answers. Not a great deal of reference to guidelines, and the “pro” side was not as well answered as the “con”.
The excellent powerpoint presentation by Georg Furnau Luebeck for the European Society of Cardiology is a good starting point to look for references. Some of the best review of the most important arguments for and against angiography in unselected cardiac arrest patients can be found in the paper on the study design of the COACT trial by Lemkes et al (2016).
What's happened since the last time this appeared in 2018?
Lemkes, Jorrit S., et al. "Coronary angiography after cardiac arrest: Rationale and design of the COACT trial." American heart journal 180 (2016): 39-45.
Spaulding, Christian M., et al. "Immediate coronary angiography in survivors of out-of-hospital cardiac arrest." New England Journal of Medicine 336.23 (1997): 1629-1633.
Hollenbeck, Ryan D., et al. "Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI." Resuscitation 85.1 (2014): 88-95.
Dumas, Florence, et al. "Immediate Percutaneous Coronary Intervention Is Associated With Better Survival After Out-of-Hospital Cardiac ArrestClinical Perspective: Insights From the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) Registry." Circulation: Cardiovascular Interventions 3.3 (2010): 200-207.
Geri, Guillaume, et al. "Immediate percutaneous coronary intervention is associated with improved short-and long-term survival after out-of-hospital cardiac arrest." Circulation: Cardiovascular Interventions 8.10 (2015): e002303.
Callaway, Clifton W., et al. "Part 8: post–cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care." Circulation 132.18 suppl 2 (2015): S465-S482.
Nolan, Jerry P., et al. "European resuscitation council and european society of intensive care medicine guidelines for post-resuscitation care 2015: section 5 of the european resuscitation council guidelines for resuscitation 2015." Resuscitation 95 (2015): 202-222.
Wester, Axel, et al. "Coronary angiographic findings and outcomes in patients with sudden cardiac arrest without ST-elevation myocardial infarction: A SWEDEHEART study." Resuscitation 126 (2018): 172-178.
Jentzer, Jacob C., et al. "Early coronary angiography and percutaneous coronary intervention are associated with improved outcomes after out of hospital cardiac arrest." Resuscitation 123 (2018): 15-21.
Verma, Beni R., et al. "Coronary angiography in patients with out-of-hospital cardiac arrest without ST-segment elevation: a systematic review and meta-analysis." Cardiovascular Interventions 13.19 (2020): 2193-2205.
Song, Hwan, et al. "Which Out-of-Hospital Cardiac Arrest Patients without ST-Segment Elevation Benefit from Early Coronary Angiography? Results from the Korean Hypothermia Network Prospective Registry." Journal of Clinical Medicine 10.3 (2021): 439.
Desch, Steffen, et al. "Angiography after out-of-hospital cardiac arrest without ST-segment elevation." New England Journal of Medicine 385.27 (2021): 2544-2553.