Clinical paperIncidence of coronary intervention in cardiac arrest survivors with non-shockable initial rhythms and no evidence of ST-elevation MI (STEMI)☆
Introduction
The 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care include a class IIa recommendation that emergency coronary angiography is reasonable for select adult patients after out-of-hospital cardiac arrest (OHCA) of suspected cardiac origin but without ST elevation on electrocariography (ECG).1 This updated guideline reflects the work of several investigations in demonstrating that electrocardiographic findings in cardiac arrest victims can be poorly predictive of acute coronary-artery occlusion.2, 3 Given that an early invasive strategy for ST-Elevation Myocardial Infarction (STEMI) patients and for Ventricular Fibrillation(VF)/Ventricular Tachycardia(VT) arrest patients has been previously associated with improved outcomes, there is ongoing interest in utilizing early angiography in those who suffer cardiac arrest with an initial non-shockable rhythm (Pulseless Electrical Activity(PEA)/Asystole).4, 5
A recent meta-analysis explored the benefits of an early invasive approach, concluding that coronary angiography should be considered for all post-arrest patients given the 59–71% incidence of coronary artery disease (CAD) found.6 However, their source data have a high rate of patients with STEMI and patients with VF/VT limiting their ability to draw applicable conclusions with regard to patients with non-shockable initial rhythms. Despite the high incidence of CAD in OHCA survivors it is often suggested that non-shockable initial rhythms are frequently the result of non-cardiac causes and non-shockable rhythms have also been associated with a higher mortality.3, 7, 8, 9, 10 Previously published data from our institution confirmed a lower survival rate for our patients with non-shockable initial rhythms and led us to question the frequency of significant coronary angiography findings in patients with return of spontaneous circulation (ROSC) after a non-shockable arrest.11 We hypothesized that in cardiac arrest patients with a non-shockable initial rhythm who obtain ROSC and do not have evidence of STEMI the incidence of coronary intervention would be uncommon (<5%).
Section snippets
Methods
A retrospective analysis was performed using data from the Penn Alliance for Therapeutic Hypothermia (PATH) registry. PATH is a multi-center, Utstein style, U.S-based registry hosted by the University of Pennsylvania, to serve as a clinical data repository for cardiac arrest and post-arrest care. Details of the database have been previously described.12 At the time of data analysis, there were 18 participating institutions. All PATH member institutions received Institutional Review Board (IRB)
Results
Out of 1497 arrest patents with ROSC there were 1396 arrest patients with known initial rhythms recorded at the time of the study. Of these, 865 (62%) were OHCA and 531 (38%) were IHCA; sex and race demographics are described in Table 1. Of these 1396 cases [517 (37%) shockable; 879 (63%) nonshockable], 440 received angiography (32%).
Fig. 1 presents the subgroup analysis of the 1396 arrest patients with ROSC. Specifically, of the 440 who received angiography 299 (68%) had a shockable rhythm and
Discussion
In this retrospective analysis of cardiac arrest patients with nonshockable initial rhythms and no STEMI there is an unexpectedly high incidence of coronary intervention (24.7%) in patients taken for angiography. These findings are similar to the recent study by Bro-Jeppesen et al. in which 15/82 arrest patients without STEMI underwent coronary intervention.14 The significance of these lesions which ultimately merited intervention remains unclear as it is felt that a culprit lesion that causes
Conflict of interest statement
We have no conflicts of interest to report for this publication.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2016.10.025.