Patients with Cardiac Arrest Fare Poorly After PCI

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Patients who undergo percutaneous coronary intervention (PCI) after cardiac arrest are more likely to have cardiogenic shock and complex anatomy. They also face more than double the mortality risk of PCI patients without cardiac arrest regardless of whether or not they presented with ST-segment elevation myocardial infarction (STEMI), according to a study published in the March 1, 2014, issue of the American Journal of Cardiology.

Navdeep Gupta, MBBS, of the Medical College of Wisconsin (Milwaukee, WI), and colleagues analyzed data from the National Cardiovascular Data Registry (NCDR) CathPCI Registry on 594,734 patients who underwent PCI from August 2009 through July 2010. Of this cohort, 114,768 patients had STEMI, including 9,375 (8.2%) with cardiac arrest, while 479,966 patients had other indications for PCI (59% NSTEMI, 22%, unstable angina, and 5.8% stable angina) including 2,775 (0.6%) with cardiac arrest.

Compared with non-arrest patients, those with cardiac arrest in the STEMI and without-STEMI groups had higher rates of in-hospital mortality and complications (table 1).

Table 1. In-Hospital Outcomesa

 

Cardiac Arrest

No Cardiac Arrest

Death
STEMI
Without STEMI

 
24.9%
18.7%

 
3.1%
0.4%

Cerebrovascular Accident/Stroke
STEMI
Without STEMI

 
1.2%
0.9%

 
0.5%
0.1%

Renal Failure
STEMI
Without STEMI

 
1.6%
1.8%

 
0.4%
0.1%

Bleeding ≤ 72 Hrs
STEMI
Without STEMI

 
7.8%
5.2%

 
3.8%
1.3%

RBC/Whole Blood Transfusion
STEMI
Without STEMI

 
12.6%
10.6%

 
5.0%
1.4%

aP < 0.001 for all.

Patients with cardiogenic shock and cardiac arrest accounted for 82% and 78% of deaths in the STEMI and without-STEMI groups, respectively. Subjects with shock but not cardiac arrest comprised 49% and 29% of the deaths in the STEMI and without-STEMI groups, respectively.

At baseline, cardiac arrest patients were less likely to have known CAD or risk factors such as diabetes, hypertension, and dyslipidemia or to have undergone previous revascularization compared with non-arrest patients. Cardiogenic shock within 24 hours of PCI was far more common in cardiac arrest patients both in those with STEMI or other indications (both P < 0.0001).

In addition, patients with cardiac arrest were more likely to have complex anatomy and an LVEF < 40% and to be treated using an intra-aortic balloon pump. They also more commonly had a completely occlusive lesion (TIMI flow 0) before PCI and no, slow, or partial flow afterward. Moreover, cardiac arrest patients without STEMI were more likely to have an acute lesion or thrombus.

An Important Patient Subset

“We found that patients with [cardiac arrest] who underwent PCI had a twofold to threefold higher mortality than corresponding patients without [cardiac arrest], a finding present in patients with and without STEMI,” the study authors say, adding, “Cardiogenic shock was significantly more common in patients with cardiac arrest and accounted for a substantial proportion of the mortality in both cardiac arrest groups.”

The paper looks at an important subset of cardiac arrest survivors: those who had significant coronary disease but were stable enough to undergo PCI, Dr. Gupta told TCTMD in an email. “The treating physicians felt that performance of PCI might make a positive impact,” he said.

While acknowledging the study’s interest, Dimitrios Karmpaliotis, MD, PhD, of Columbia University Medical Center (New York, NY), observed in a telephone interview with TCTMD that key details are lacking, such as the initial heart rhythm in the field, how long patients went without a pulse, and how much time passed before they underwent PCI.

Also of note, cardiac arrest was the first presentation of CAD in a large number of patients who had no known risk factors or history of the disease, said Dr. Karmpaliotis. This finding—indicating that the first sign of CAD can be sudden death—confirms prior data and underlines the need “to continue our efforts to discover and apply effective and efficient ways to diagnose CAD at an early stage and treat it appropriately,” he emphasized.

In a telephone interview with TCTMD, Morton J. Kern, MD, of the University of California, Irvine (Irvine, CA), noted that outcomes are generally poor no matter what approach is taken in these patients. However, urgent catheterization and resuscitation at least give interventionalists a chance to save a few people, he said.

Multiple Strategies Needed

In addition to early and high-quality cardiopulmonary resuscitation, Dr. Gupta advised, a multipronged approach to remove and limit ongoing injury from the initial insult is important. Also, multisystem ischemic injury caused by cardiac arrest itself has to be minimized, for example, by utilizing therapeutic hypothermia, he said.

With regard to PCI, certain patients with or without STEMI may benefit, said Dr. Gupta. He noted that identifying patients for whom a coronary event was the inciting cause of cardiac arrest and for whom PCI will make a difference in outcome is key.

In this select subset, a ‘cool and cath’ strategy might be valuable, Dr. Gupta proposed.

The paper suggests that cardiac arrest and shock patients should be treated at high-volume centers with state-of-the-art capabilities. While praising the idea, Dr. Karmpaliotis questioned whether it is realistic. “How many of these centers are we going to have in every region?” he asked.

Dr. Karmpaliotis countered that, based on current knowledge, these patients should be taken to the closest facility with primary PCI capabilities, receive treatment for the culprit artery, and undergo hemodynamic support and hypothermia therapy. They could then be transferred to a center with experienced shock teams that have established protocols and expertise in advanced extracorporeal hemodynamic support.

Unfortunately, one obstacle to good care is public reporting of PCI mortality, which makes physicians reluctant to treat or take care of very ill patients, noted Dr. Karmpaliotis. For this reason, a nationwide consensus on using different metrics to report PCI outcomes in cardiac arrest and shock patients is needed, he said, adding, “These patients should not be reported in the same category as elective PCI in hemodynamically stable patients.”

 


Source:
Gupta N, Kontos MC, Gupta A, et al. Characteristics and outcomes in patients undergoing percutaneous coronary intervention following cardiac arrest (from the NCDR). Am J Cardiol. 2014;113:1087-1092.

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Patients with Cardiac Arrest Fare Poorly After PCI

Patients who undergo percutaneous coronary intervention (PCI) after cardiac arrest are more likely to have cardiogenic shock and complex anatomy. They also face more than double the mortality risk of PCI patients without cardiac arrest regardless
Disclosures
  • Drs. Gupta, Karmpaliotis, and Kern report no relevant conflicts of interest.

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