Incidence of coronary intervention in cardiac arrest survivors with non-shockable initial rhythms and no evidence of ST-elevation MI (STEMI)

Abstract

Objective

With the demonstrated benefit of an early-invasive strategy for STEMI and VF/VT arrest patients, there is interest in assessing the potential benefit of early angiography for non-shockable (PEA/Asystole) arrest patients. We hypothesized that in cardiac arrest patients who obtain return of spontaneous circulation (ROSC) after a non-shockable initial rhythm and do not have STEMI the incidence of coronary intervention would be clinically insignificant (<5%).

Methods

Retrospective multicenter US clinical registry study of post-cardiac arrest patients at 18 hospitals between 1/00 and 5/14. The incidence of significant coronary artery disease (CAD) as defined by documented coronary intervention (i.e. PCI, angioplasty, stent or CABG) was assessed.

Results

There were 1396 arrest patients with ROSC and known initial rhythms (517/1396 = 37% shockable; 879/1396 = 63% nonshockable). 440 (299/440 = 58% shockable; 141/440 = 32% nonshockable) of these patients received angiography. In the 141 non-shockable patients that received angiography, 97 patients did not have STEMI listed as an indication for catheterization and 24 (25%) of those had a coronary intervention documented yielding an observed incidence of coronary intervention in non-shockable post-arrest patients without STEMI who received angiography of 24.7% (24/97). Of note, the overall incidence of coronary intervention in all ROSC patients with non-shockable initial rhythms was 5.5% (48/879).

Conclusions

In this large multi-center retrospective analysis there is a high incidence of coronary intervention in post-arrest patients with initially non-shockable rhythms and without STEMI on ECG who are taken for angiography.

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%).