Early Angiography in Cardiac Arrest Patients Beneficial Even in Those Lacking ST-Segment Elevation


Routine use of early angiography and, if needed, reperfusion in patients resuscitated after out-of-hospital cardiac arrest is standard of care for those with ST-segment elevation. But whether the same approach benefits patients without this ECG abnormality is still debated, according to the authors of a French observational study.

Take Home. Early Angiography in Cardiac Arrest Patients Beneficial Even in Those Lacking ST-Segment Elevation

In fact, in their analysis of data from the PROCAT II registry, angiography was able to pinpoint a culprit lesion responsible for the arrest in nearly one-third of patients with no evidence of ST-segment elevation on post-resuscitation ECG. When such patients had a successful PCI, they were almost twice as likely to have a favorable neurologic outcome as those who did not undergo PCI at all.

“On the whole, the poor predictive value of ECG for acute coronary lesions in resuscitated [out-of-hospital cardiac arrest] patients with a high prevalence of coronary artery disease emphasizes the use of systematic acute coronary angiography as part of a standard post-cardiac arrest protocol,” urge Florence Dumas, MD, PhD (Parisian Cardiovascular Research Center, Paris Descartes University, France), and colleagues.

In Paris, where the study took place, management of sudden cardiac arrest involves out-of-hospital resuscitation delivered by an on-site team including at least one emergency medicine physician, they report. Resuscitated patients are referred to a cardiac arrest center with round-the-clock PCI availability. When there is no obvious extra-cardiac cause, such patients are admitted directly to the cath lab for immediate angiography and PCI if indicated.

The findings were published online April 27, 2016, ahead of print in the JACC: Cardiovascular Interventions.

Neurologic Outcome Better With Successful PCI

Dumas et al analyzed data from the prospective PROCAT II registry on 958 patients with out-of-hospital cardiac arrest who had an emergent coronary angiogram between 2004 and 2013.

Within this group, the 695 patients with no signs of ST-segment elevation on ECG—73% of the overall cohort—were the main focus of the current study. Among them, 58% had at least one significant lesion identified by emergent angiography and 29% had PCI in a culprit lesion deemed responsible for the cardiac arrest.

At discharge, 36% had a favorable outcome (defined as Cerebral Performance Category 1-2). Favorable outcome was more likely for patients who had successful PCI of a culprit lesion than it was for those who did not undergo intervention because no such lesion was found (43% vs 33%; P= 0.02), a relationship that persisted after adjustment for potential confounders. Other predictors of favorable outcome were shorter resuscitation length and initial shockable rhythm, whereas a higher epinephrine dose predicted poorer outcome.

Table. Early Angiography in Cardiac Arrest Patients Beneficial Even in Those Lacking ST-Segment Elevation

Men older than 50 years who had an initial shockable rhythm seemed particularly apt to benefit from early angiography, which uncovered a culprit coronary lesion rate of 40%. When PCI was performed in this subgroup, 48.1% had a favorable outcome.

Their study “is obviously limited by its nonrandomized and retrospective design,” the authors acknowledge, noting that data from ongoing randomized trials, including DISCO, will help clarify the role and timing of PCI in cardiac arrest patients.

Implications for Public Reporting

Joaquin E. Cigarroa, MD (Oregon Health Sciences University, Portland, OR), in an accompanying editorial, questions “how the interventional cardiologists assessing patients in the PROCAT registry determined the presence of an intervenable ‘culprit lesion’ in the absence of ischemia, infarction, or new regional wall motion abnormalities.”

Lesions deemed culprit may well have been a “true cause” of the event, or they could have been an “innocent bystander” or a marker of patients whose cardiac arrest etiology made them more likely to do well whether or not they underwent PCI, he suggests. Other clinically relevant factors in decision making also were unreported, he adds.

Yet the systematic approach to out-of-hospital arrest employed in Paris still offers lessons for healthcare providers elsewhere, notes Cigarroa, who along with others published an algorithm last year in JACC to aid first responders, emergency department physicians, and intensivists treating these complex patients.

“We recommend early angiography in all patients without extra-cardiac causes” who have return of spontaneous circulation after arrest but “do not have multiple risk factors which portend a poor prognosis,” he writes. “This approach, however, has substantial implications for the individual operator and institution as these results are included in publicly reported measures.”


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Sources
  • Dumas F, Bougouin W, Geri G, et al. Emergency PCI in post-cardiac arrest patients without ST-segment elevation pattern: insights from the PROCAT II registry. J Am Coll Cardiol Interv. 2016;Epub ahead of print.

  • Cigarroa JE. Out-of-hospital cardiac arrest survivors in patients without ST-segment elevation infarction: is routine coronary angiography reasonable? J Am Coll Cardiol Interv. 2016;Epub ahead of print.

Disclosures
  • Dumas and Cigarroa report no relevant conflicts of interest.

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