Cooling, PCI Improves Long-term Outcomes for Cardiac Arrest Survivors
AMSTERDAM, The Netherlands—In comatose patients who undergo hypothermia therapy after resuscitation, emergency angiography and percutaneous coronary intervention (PCI) are feasible and safe, according to a study presented on September 4, 2013, at the European Society of Cardiology Congress.
Gianni Casella, MD, of Maggiore Hospital (Bologna, Italy), and colleagues treated 142 comatose patients, all of whom were resuscitated within 4 hours of out-of-hospital cardiac arrest, with hypothermia from March 2004 to December 2012. Two-thirds (69%) underwent coronary angiography, while 32% had PCI.
Long-term Prognosis Good with PCI
PCI patients were more likely to have multivessel disease and acute occlusion and to receive IABPs compared to those who had angiography alone. Only 9% of PCI patients were implanted with DES, and 36% were treated radially.
The target vessel was the LAD in 35% of patients and post-PCI TIMI 3 flow was achieved in 92%. All patients received unfractionated heparin (70 U/kg bolus), aspirin (300 mg), and clopidogrel (300 mg loading dose, with 12% receiving 600 mg loading dose). Less than half (43%) received abciximab, which resulted in 1 major nonfatal GI bleed. No stent thrombosis was reported.
Hemoglobin, hematocrit, and platelet counts were mildly reduced during cooling in all groups. Partial thromboplastin time increased.
Kaplan-Meier curves showed a good long-term prognosis out to 1 year for patients undergoing PCI, with a difference in mortality among the 3 groups favoring angiography (P = 0.0009). Differences in in-hospital mortality were not as pronounced among the no angiography (50%), angiography (25%), and PCI (31%) groups.
DES Limited by Cost Constraints
“Emergency coronary angiography and intervention in combination with therapeutic hypothermia are feasible in comatose patients resuscitated after out-of-hospital cardiac arrest,” Dr. Casella said. “The first electrocardiogram after resuscitation could help in triaging these triaging to emergent angiography.”
Although Dr. Casella said he feels confident that PCI and antithrombotics “could be associated with an acceptable rate of bleedings or ischemic complications,” he also stressed it is important to remember that “cooled patients undergoing angiography are a preselected population with favorable outcomes.”
With regard to antiplatelet agents, Dr. Casella reported that none of the patients were preloaded. “At the beginning we were very aggressive with abciximab until a severe bleeding incidence,” he said. “Now we are very conservative.”
Chair Pascal Vranckx, MD, of Cardiology and Critical Care Hartcentrum Hasselt (Hasselt, Belgium), questioned the limited use of DES.
Maggiore Hospital still mainly uses BMS for STEMI, Dr. Casella explained. “In this study we liberally used bare-metal stents because we didn’t know if the patients would survive. So for cost constraints, we prefer not to use DES unless there is left main [disease].”
Average age was 65, and 68% of patients were men. The majority (72%) had ventricular fibrillation/tachycardia, and 35% had STEMI in their first ECG. Most (80%) were treated within 20 minutes of resuscitation, with 30% treated in the field.
Casella G. Emergency coronary angiography and interventions in comatose patients resuscitated after out-of-hospital cardiac arrest treated with mild therapeutic hypothermia. Presented at: European Society of Cardiology Congress; September 4, 2013; Amsterdam, The Netherlands.
- Dr. Casella reports no relevant conflicts of interest.