Urgent Invasive Strategy Key for Out-of-Hospital Arrest Patients with ACS
Fast coronary angiography, and percutaneous coronary intervention (PCI) if necessary, improves outcomes in patients with out-of-hospital arrest, whether ST-segment elevation is present or not. The findings were presented October 20, 2012, at the Acute Cardiac Care Congress in Istanbul, Turkey.
Researchers led by Annamaria Nicolino, MD, of Santa Corona General Hospital (Pietra Ligure, Italy), looked at 70 patients with return of spontaneous circulation after out-of-hospital cardiac arrest treated at their institution from 2006 through 2009. In the 41% of patients found to have acute coronary syndromes (ACS) based on ECG and cardiac enzymes, successful urgent angiography and PCI were associated with improved in-hospital survival in both STEMI (83% vs. 51%; P = 0.003) and NSTEMI (81% vs. 55%; P = 0.004) patients.
In over half of the cohort (62%), the first rhythm after return of spontaneous circulation was ventricular tachycardia/ventricular fibrillation (VT/VF), which was the most frequent presentation rhythm in ACS patients (89% vs. 40%; P < 0.01). In patients with VT/VF as the first rhythm, successful urgent angiography and PCI also were associated with improved in-hospital survival (90% vs. 38%; P < 0.001).
Overall in-hospital survival was 48.5%, with a 1-year survival rate of 76% among those who survived to discharge. Postresuscitation neurologic injury occurred in one-third of patients (32.8%). The complication was associated with underuse of urgent coronary angiography and PCI and worse prognosis.
Clearing Up Controversy
While urgent coronary angiography and PCI are recommended in the presence of STEMI, “[t]here is controversy about what to do when a patient with out-of-hospital cardiac arrest has a normal ECG that does not show ST elevation,” Dr. Nicolino said in a press release. “[European Society of Cardiology] clinical practice guidelines are inconclusive—they say to consider performing coronary angiography, but they don’t say ‘do it’ or ‘don’t do it.’”
The current study, she notes, shows that successful urgent PCI improves survival whether ST elevation is present or not. “All patients with out-of-hospital cardiac arrest, if there is no non-cardiac cause, must have an urgent coronary angiography followed by coronary angioplasty if there is coronary disease,” Dr. Nicolino said.
ECG results can be misleading, she added. For instance, “we found that ECG detected just one-third of [ACS] in NSTEMI patients,” Dr. Nicolino said. “This means that even if the ECG is not showing ST elevation, you cannot rule out an acute coronary syndrome. Coronary angiography should be performed urgently to see if there is any acute coronary disease which needs treatment with PCI.”
Another interesting finding was that the incidence of VT/VF was the same in STEMI and NSTEMI patients. Previously, Dr. Nicolino explained, it was thought that STEMI patients had a greater arrhythmic risk than NSTEMI patients. “But we found that both STEMI and NSTEMI patients are at high risk of arrhythmias,” she said. “If the first recorded rhythm is a VF or a VT, an [ACS] is highly probable and it’s important to perform a coronary angiography immediately without waiting for a diagnosis of infarction (using an enzyme test).”
Mean patient age was 69.5 years, with males accounting for 63% of the cohort. Previous CAD was present in 11% of patients.
Nicolino A. Urgent invasive strategy for out-of-hospital cardiac arrest survivors is associated with better survival. Presented at: Acute Cardiac Care Congress; October 20, 2012; Istanbul, Turkey.
- The paper contains no information regarding conflicts of interest.