A Routine Invasive Strategy for Out-of-Hospital Cardiac Arrest Survivors
2010; Lippincott Williams & Wilkins; Volume: 3; Issue: 3 Linguagem: Inglês
10.1161/circinterventions.110.957241
ISSN1941-7632
AutoresSripal Bangalore, Judith S. Hochman,
Tópico(s)Mechanical Circulatory Support Devices
ResumoHomeCirculation: Cardiovascular InterventionsVol. 3, No. 3A Routine Invasive Strategy for Out-of-Hospital Cardiac Arrest Survivors Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBA Routine Invasive Strategy for Out-of-Hospital Cardiac Arrest SurvivorsAre We There Yet? Sripal Bangalore, MD, MHA and Judith S. Hochman, MA, MD Sripal BangaloreSripal Bangalore From the Brigham and Women's Hospital (S.B.), Boston, Mass; Harvard Clinical Research Institute (S.B.), Boston, Mass; and New York University School of Medicine (J.S.H.), Cardiovascular Clinical Research Center, New York, NY. and Judith S. HochmanJudith S. Hochman From the Brigham and Women's Hospital (S.B.), Boston, Mass; Harvard Clinical Research Institute (S.B.), Boston, Mass; and New York University School of Medicine (J.S.H.), Cardiovascular Clinical Research Center, New York, NY. Originally published1 Jun 2010https://doi.org/10.1161/CIRCINTERVENTIONS.110.957241Circulation: Cardiovascular Interventions. 2010;3:197–199Out-of-hospital cardiac arrest (OHCA) is estimated to afflict approximately 236 000 to 325 000 people in the United States annually,1 with wide regional1 and interhospital2 variation in the survival to discharge rates. The prospective, multicenter registry of OHCA in 8 US and 3 Canadian emergency medical service (EMS) agencies and receiving institutions (ROC Epistry–Cardiac Arrest) serving an area of 21.4 million people reported a survival to discharge rate of a mere 1.1% to 8.1% for all EMS-assessed OHCAs, 3.0% to 16.3% for EMS-treated, and 7.7% to 39.9% for patients who presented with ventricular fibrillation.1 Of note, these reported rates are for all EMS-assessed or EMS-treated OHCA regardless of whether there was return of spontaneous circulation (ROSC) before hospital entry. In patients with ROSC at hospital entry, the survival to discharge rate ranges from 10% to 42%.2–7 With the initiation of a community-wide early defibrillation program, White et al8 reported that in patients with ventricular fibrillation and sustained ROSC after defibrillation (only in the field), the survival to discharge rate was a remarkable 87%. Thus, there is wide variation in reported rates of survival depending on the cohort reported and the regional systems of care. There are great opportunities to further improve outcomes in OHCA. In this setting, the role of urgent cardiac catheterization and percutaneous coronary intervention (PCI) is of great interest.Article see p 200In patients with cardiac arrest (predominantly due to ventricular fibrillation) up to 71% have coronary artery disease and 50% have acute coronary artery occlusion.9,10 Prior studies have shown that in postcardiac arrest patients with ST elevation on ECG, PCI was associated with angiographic success rates of 78% to 95% and overall survival to discharge rates of 44% to 75%.11–13 The 2008 consensus statement on post–cardiac arrest syndrome therefore recommends immediate angiography and subsequent PCI (or thrombolytic therapy if PCI is unavailable), if indicated, in patients resuscitated from cardiac arrest who have ECG criteria for ST-segment elevation myocardial infarction.14 This recommendation is not intended for patients with ongoing cardiopulmonary resuscitation (CPR). Recently concluded randomized trials of fibrinolytic therapy in patients with ongoing CPR have not demonstrated improved outcomes compared with the usual care group.15,16 Because chest pain after cardiac arrest and absence of ST-segment elevation are poorly correlated with the presence or absence of acute coronary occlusion in post–cardiac arrest patients,9 the consensus statement states that "it is appropriate to consider immediate coronary angiography in all postcardiac arrest patients in whom acute coronary syndrome is suspected," a recommendation that is not as strong as that for the ST-segment elevation cohort.In this issue of the Journal, Duman et al17 make an important contribution to this literature with a report of encouraging data from the Paris PROCAT registry that suggest improved hospital survival with a routine invasive strategy, regardless of the ECG pattern, in 435 survivors with OHCA (with no obvious extracardiac cause) and ROSC in the field. Coronary angiography revealed at least 1 significant coronary artery lesion in 70% of patients: 96% in those with ST-segment elevation on ECG performed after ROSC and 58% in those without ST-segment elevation. The hospital survival rate was relatively high (40%), and successful coronary angioplasty compared with failed PCI or no PCI was independently associated with survival regardless of whether the postresuscitation ECG showed ST elevation or another pattern (no ST elevation). They recommend the use of immediate coronary angiography in survivors of OHCA with no obvious noncardiac cause of arrest regardless of the ECG pattern. Are we there yet?For perspective, the variation in regional systems of care and the cohort studied is worth highlighting. In PROCAT, of the 714 patients with ROSC admitted to the intensive care unit, the majority, 435 (61%) patients, were considered to have no obvious extracardiac cause for the arrest and were taken for immediate angiography. In Paris, unlike the United States, the field emergency team includes at least 1 trained physician who reports to a central command center. This cohort, selected for immediate angiography, had exceptional prehospital care with time from collapse to basic life support (BLS) of <5 minutes and time from BLS to ROSC of <15 minutes in half the cohort; 68% had ventricular fibrillation. The reported rates of bystander CPR in the United States are low (19% to 31%), with a median time from call to first EMS rhythm analysis of over 9 minutes.1 However, with organized regional systems of care, such as that reported by White et al,8 the bystander CPR rate can be as high as 41% to 50% and the call-to-shock time just over 6 minutes. The majority of patients in PROCAT received therapeutic hypothermia, which was infrequently used in the United States during a comparable period.18In patients with ST-segment elevation (31% of this cohort), the study adds to the growing data on the importance of primary PCI in post–cardiac arrest patients with ROSC.11–13 The overwhelming majority (96%) with ST elevation in the PROCAT cohort had at least 1 significant coronary stenosis; PCI was attempted in 86% of patients with a significant lesion and was successful in 90% of those who underwent PCI. Thus, 74% of patients with ST elevation had a successful PCI, and this translated into a survival rate of 54%, compared with a survival rate of 31% (P<0.001) in ST-elevation patients with failed or no PCI.In contrast, interpretation of the findings in patients without ST-segment elevation is more challenging. The percentage of no ST-elevation patients with troponin <2.3 (minimal or no elevation) was 49% in this cohort. Making the diagnosis of an acute coronary event as the primary event leading to arrest when there is no ST elevation and only low-level troponin elevation in a cohort of patients who received CPR/defibrillation is very difficult in the absence of confirmation of an acute culprit. Only 58% of all no ST-elevation patients had at least 1 significant coronary stenosis, in contrast to 96% with ST elevation, and no information is provided regarding culprit lesions. PCI was attempted in only half of the no ST-elevation patients who had a significant lesion; it was successful in 85% of those in whom it was attempted. Therefore, among all patients without ST-segment elevation, only 26% had successful PCI, and this was associated with a 47% survival rate compared with 31% survival rate (P 15 minutes and 29% in those with arrest to BLS time of ≥5 minutes. Whether a routine invasive strategy should be adopted for all patients or be applied to select group of patients (those with ST-segment elevation, those with short times to ROSC) remains to be determined. There is a need for more robust data and, ideally, a randomized trial.Based on the current body of evidence, including this largest cohort of postarrest ROSC patients, it is prudent to adopt a routine invasive strategy for suitable OHCA survivors with ST-segment elevation. It is likely that a select group of patients without ST-segment elevation, such as those with acute circumflex occlusion (posterior myocardial infarction) or critical left main disease may benefit from emergent coronary angiography. Therefore, it is prudent to consider immediate coronary angiography where there is high index of suspicion of acute occlusion and emergency PCI in select patients if angiography suggests an acute culprit. Whether a routine emergent invasive strategy is beneficial in all postarrest patients with ROSC and no ST elevation on ECG is yet to be determined. More widespread use of PCI performed for postarrest patients who have not promptly regained consciousness by the time of cardiac catheterization and may have anoxic brain damage after prolonged arrest times has implications for both for the patients and publicly reported interventionalist mortality rates. Given the extremely poor prognosis in patients with longer delays to resuscitation, even with a routine invasive strategy, in most areas the greatest need is for regional systems of care to streamline the process and promote rapid initiation of bystander chest compression. "Time is survival" for cardiac arrest.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Judith S. 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Gersh B (2011) Immediate Percutaneous Coronary Intervention Is Associated With Better Survival After Out-of-Hospital Cardiac Arrest: Insights From the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) Registry, Yearbook of Cardiology, 10.1016/j.ycar.2011.01.051, 2011, (188-189), Online publication date: 1-Jan-2011. June 2010Vol 3, Issue 3 Advertisement Article InformationMetrics © 2010 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.110.957241PMID: 20551393 Originally publishedJune 1, 2010 Keywordsmyocardial infarctioncardiac arrestrevascularizationEditorialsPDF download Advertisement SubjectsAcute Coronary SyndromesAngiographyStent
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