Coronary Angiography after Cardiac Arrest without ST-Segment Elevation

Coronary angiography after cardiac arrest: Rationale and design of the COACT trial

Background The effect of immediate coronary angiography and percutaneous coronary intervention (PCI) in patients who are successfully resuscitated after cardiac arrest in the absence of ST-segment elevation myocardial infarction (STEMI) on left ventricular function is currently unknown. Purpose To evaluate whether immediate coronary angiography and PCI improves left ventricular function in patients who are successfully resuscitated from cardiac arrest without STEMI. Methods This prespecified sub-study of the multicentre COACT trial evaluated 552 patients, successfully resuscitated from out-of-hospital cardiac arrest without signs of STEMI. Patients were randomized to either undergo immediate coronary angiography or delayed coronary angiography, after neurologic recovery. All patients underwent PCI if indicated. The main outcomes of this analysis were left ventricular ejection fraction and end-diastolic and systolic volumes assessed by cardiac magnetic resonance imaging or echocardiography. Results Data on left ventricular function was available for 397 patients. The mean (± standard deviation) left ventricular ejection fraction was 45.2% (±12.8) in the immediate angiography group and 48.4% (±13.2) in the delayed angiography group (mean difference: −3.19; 95% confidence interval [CI], −6.75 to 0.37). Median left ventricular end-diastolic volume was 177 ml in the immediate angiography group compared to 169 ml in the delayed angiography group (ratio of geometric means: 1.06; 95% CI, 0.95 to 1.19). In addition, mean left ventricular end-systolic volume was 90 ml in the immediate angiography group compared to 78 ml in the delayed angiography group (ratio of geometric means: 1.13; 95% CI 0.97 to 1.32). Conclusion In patients successfully resuscitated after out-of-hospital cardiac arrest and without signs of STEMI, immediate coronary angiography was not found to improve left ventricular dimensions or function compared with a delayed angiography strategy. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Netherlands Heart InstituteBiotronikAstraZeneca

Despite advances in the fields of resuscitation and intensive care management, the outcome of out-of-hospital cardiac arrest remains poor.Optimal care after out-of-hospital cardiac arrest and successful resuscitation includes targeted temperature management, vital organ support, and treatment of the underlying cause of the arrest.The cause of the arrest is often unclear immediately after the event, in particular in the absence of ST-segment elevation (STE) on ECG.This lack of a definitive diagnosis can lead to uncertainty about the appropriate treatment.Patients who survive cardiac arrest have a high prevalence of coronary artery disease and if myocardial infarction is the cause of the arrest, immediate coronary angiography and percutaneous coronary intervention might improve outcome.Previous observation studies reported a survival benefit of an immediate invasive strategy in patients who were resuscitated from cardiac arrest even in the absence of STE myocardial infarction compared with historical controls. 1,2However, these outcomes might have been an effect of the observational nature of these studies, which may have resulted in selection bias that favored selecting patients who had a presumed better prognosis for immediate angiography.The first large randomized, controlled trial addressing the effect of immediate coronary angiography in patients without STE after cardiac arrest was the COACT study (Coronary Angiography After Cardiac Arrest).The COACT study randomly assigned 552 patients after cardiac arrest to either immediate coronary angiography or delayed coronary angiography after neurologic recovery and found no difference in 90-day survival. 3It has been advocated that these results should be confirmed by additional randomized studies.The international, multicentered, randomized PEARL trial (Early Coronary Angiography Versus Delayed Coronary Angiography), 4 reported in this issue, is a pilot study comparing early (<2 hours) coronary angiography versus no early coronary angiography in comatose patients resuscitated from out-of-hospital cardiac arrest without STE.The trial had slow recruitment and inclusion was terminated when 99 of the planned 226 patients were randomized.The study should therefore be considered underpowered.PEARL found no difference in the primary end point (a composite of efficacy and safety measures, including efficacy measures of survival to discharge, favorable neurologic status at discharge, echocardiographic measures of left ventricular ejection fraction >50%, and a normal wall motion score of 16 within 24 hours of admission).Adverse events including rearrest, pulmonary edema on chest x-ray, acute renal dysfunction, bleeding requiring transfusion or intervention, hypotension, and pneumonia were compared between the 2 groups (55.1% versus 46.0%; P=0.64).The trial found no difference in individual efficacy

BackgroundThe effect of immediate coronary angiography and percutaneous coronary intervention (PCI) in patients who are successfully resuscitated after cardiac arrest in the absence of ST-segment elevation myocardial infarction (STEMI) on left ventricular function is currently unknown. MethodsThis prespecified sub-study of a multicentre trial evaluated 552 patients, successfully resuscitated from out-of-hospital cardiac arrest without signs of STEMI. Patients were randomized to either undergo immediate coronary angiography or delayed coronary angiography, after neurologic recovery. All patients underwent PCI if indicated. The main outcomes of this analysis were left ventricular ejection fraction and end-diastolic and systolic volumes assessed by cardiac magnetic resonance imaging or echocardiography. ResultsData on left ventricular function was available for 397 patients. The mean (± standard deviation) left ventricular ejection fraction was 45.2% (±12.8) in the immediate angiography group and 48.4% (±13.2) in the delayed angiography group (mean difference: −3.19; 95% confidence interval [CI], −6.75 to 0.37). Median left ventricular end-diastolic volume was 177 ml in the immediate angiography group compared to 169 ml in the delayed angiography group (ratio of geometric means: 1.06; 95% CI, 0.95–1.19). In addition, mean left ventricular end-systolic volume was 90 ml in the immediate angiography group compared to 78 ml in the delayed angiography group (ratio of geometric means: 1.13; 95% CI 0.97–1.32). ConclusionIn patients successfully resuscitated after out-of-hospital cardiac arrest and without signs of STEMI, immediate coronary angiography was not found to improve left ventricular dimensions or function compared with a delayed angiography strategy.Clinical Trial Registration: Netherlands Trial Register number, NTR4973

Background: Ischemic heart disease is a leading reason of cardiac arrest outside the hospital. However, the best approach for treating successfully resuscitated cardiac arrest patients without ST-segment elevation myocardial infarction (STEMI) remains uncertain. Methods: The primary endpoint of this multicenter study was survival at 90 days; secondary endpoints included duration of catecholamine support, myocardial injury, indicators of shock, length of time on mechanical breathing, ventricular tachycardia recurrence, significant bleeding, need for renal replacement therapy, acute kidney injury, neurologic status at ICU discharge, and time to reach the target temperature. Following neurological recovery, 152 patients who had suffered cardiac arrest but had not had STEMI were randomized to either quick coronary angiography or delayed coronary angiography, with PCI administered as needed. Results: The immediate angiography category had 63.5% survival at 90 days (56 out of 123 participants), while the delayed angiography category had 66.2% survival (68 out of 95 patients). In the immediate angiography category, the median time to reach the goal temp. was 5.3 hours, while in the delayed angiography category, it took 4.6 hours. The remaining secondary endpoints showed no discernible differences between the categories. Conclusions: Within the category of patients who underwent successful resuscitation following an out-of-hospital cardiac arrest and did not exhibit indications of STEMI, the overall survival at 90 days did not demonstrate a superiority between an urgent angiography method and a delayed angiography strategy. Recommendation: Based on the findings of this study, there is no clear superiority between an urgent angiography approach and a delayed angiography strategy for patients who have been successfully resuscitated following an out-of-hospital cardiac arrest without indications of ST-segment elevation myocardial infarction (STEMI). Further research and clinical guidelines may be necessary to determine the most effective treatment approach for this patient population.

EP News: Clinical

Out-of-hospital cardiac arrest (OHCA) is a common initial presentation of cardiovascular disease, affecting up to 325 000 people in the United States each year.1 In a recent meta-analysis of >140 000 patients with OHCA, survival to hospital admission was 23.8%, and survival to hospital discharge was only 7.6%.2 In patients who initially achieve return of spontaneous circulation (ROSC) after OHCA, the significant subsequent morbidity and mortality are due largely to the cerebral and cardiac dysfunction that accompanies prolonged whole-body ischemia. This syndrome, called the post cardiac arrest syndrome, comprises anoxic brain injury, post cardiac arrest myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathology3,4 (Table 1). The contribution of each of these components in an individual patient depends on various factors, including prearrest comorbidities, duration of the ischemic insult, and cause of the cardiac arrest. This review focuses on therapeutic strategies and recent developments in managing patients who are initially resuscitated from cardiac arrest. View this table: Table 1. Post Cardiac Arrest Syndrome: Pathophysiology and Potential Treatment Strategies There are 3 major aspects that require consideration in the management of the post cardiac arrest patient. After resuscitation, a decision must be made in relation to the appropriate triage of the OHCA patient. The next phase of management concerns the in-hospital treatment, which must address each component of the postarrest syndrome as appropriate for the individual patient. Finally, there are issues relating to prognostication and the deployment of various secondary prevention measures. Our recommended treatment algorithm is summarized in the Figure. This ideally follows from the implementation of basic and advanced life support measures, including effective cardiopulmonary resuscitation and defibrillation when appropriate, which are major determinants of outcome.2 Such an approach to care may be further modified according to the presence of other comorbidities and precipitating factors, which should be assessed …

Ischemic heart disease is a common cause of cardiac arrest. However, randomized data on long-term clinical outcomes of immediate coronary angiography and percutaneous coronary intervention (PCI) in patients successfully resuscitated from cardiac arrest in the absence of ST segment elevation myocardial infarction (STEMI) are lacking. To determine whether immediate coronary angiography improves clinical outcomes at 1 year in patients after cardiac arrest without signs of STEMI, compared with a delayed coronary angiography strategy. A prespecified analysis of a multicenter, open-label, randomized clinical trial evaluated 552 patients who were enrolled in 19 Dutch centers between January 8, 2015, and July 17, 2018. The study included patients who experienced out-of-hospital cardiac arrest with a shockable rhythm who were successfully resuscitated without signs of STEMI. Follow-up was performed at 1 year. Data were analyzed, using the intention-to-treat principle, between August 29 and October 10, 2019. Immediate coronary angiography and PCI if indicated or coronary angiography and PCI if indicated, delayed until after neurologic recovery. Survival, myocardial infarction, revascularization, implantable cardiac defibrillator shock, quality of life, hospitalization for heart failure, and the composite of death or myocardial infarction or revascularization after 1 year. At 1 year, data on 522 of 552 patients (94.6%) were available for analysis. Of these patients, 413 were men (79.1%); mean (SD) age was 65.4 (12.3) years. A total of 162 of 264 patients (61.4%) in the immediate angiography group and 165 of 258 patients (64.0%) in the delayed angiography group were alive (odds ratio, 0.90; 95% CI, 0.63-1.28). The composite end point of death, myocardial infarction, or repeated revascularization since the index hospitalization was met in 112 patients (42.9%) in the immediate group and 104 patients (40.6%) in the delayed group (odds ratio, 1.10; 95% CI, 0.77-1.56). No significant differences between the groups were observed for the other outcomes at 1-year follow-up. For example, the rate of ICD shocks was 20.4% in the immediate group and 16.2% in the delayed group (odds ratio, 1.32; 95% CI, 0.66-2.64). In this trial of patients successfully resuscitated after out-of-hospital cardiac arrest and without signs of STEMI, a strategy of immediate angiography was not found to be superior to a strategy of delayed angiography with respect to clinical outcomes at 1 year. Coronary angiography in this patient group can therefore be delayed until after neurologic recovery without affecting outcomes. trialregister.nl Identifier: NTR4973.

Immediate Versus Delayed Cardiac Catheterization in Post-Arrest Patients Without ST Elevation Myocardial Infarction: Is Survivorship Bias an Important Influence?: March 2022 Annals of Emergency Medicine Journal Club

A Multidisciplinary Approach to Reducing Door-to-Balloon Time in a Community Hospital

Introduction. The prognosis of patients with out-of-hospital cardiac arrest (OHCA) is poor, with high mortality rates and poor neurological outcomes. Early coronary angiography (CAG) is recommended in patients with ST-segment elevation myocardial infarction (STEMI) associated with cardiac arrest; however, performing early or delayed CAG in patients with OHCA without STEMI is unclear. Therefore, we conducted a meta-analysis of randomized controlled trials (RCTs) to investigate the efficacy of early versus delayed CAG in patients with OHCA without STEMI. Methods. We searched Web of Science, SCOPUS, EMBASE, PubMed (MEDLINE), and CENTRAL from inception till June 2022. We included only RCTs that compared early versus delayed CAG in patients with OHCA. The main outcomes were percutaneous coronary intervention (PCI) rate, 30-day all-cause mortality, and neurological recovery (cerebral performance category (CPC) &lt; 3). We used the fixed-effect model to pool the risk ratio (RR) with a 95% confidence interval (CI). Results. We included seven RCTs with a total of 2104 patients. The overall risk ratio showed no difference between early and delayed CAG regarding PCI rate (RR: 1.06 with 95% [0.92, 1.23] p= 0.43), 30 days mortality (RR: 1.08 with 95% CI [0.97, 1.20] p= 0.15, and neurological recovery (RR: 1.04 with 95% CI [0.95, 1.13] p= 0.4). Conclusion. Among patients who experience an OHCA without STEMI, a strategy of performing early CAG provided no benefits in respect to the rate of PCI, 30 days mortality, and neurological recovery compared to delayed CAG.

Background: Despite advances in post-arrest management, cardiac arrest is frequently fatal and is often associated with high morbidity in survivors. Though there is evidence supporting the use of immediate coronary angiography (CA) and percutaneous coronary intervention among patients with ST elevation myocardial infarction (STEMI) complicated by cardiac arrest, the majority of patients that are successfully resuscitated from cardiac arrest do not have ST segment elevations on EKG. Among survivors of cardiac arrest without ST segment elevations on EKG, there are observational analyses that suggest benefit with early coronary angiography. Risk aversion has been previously demonstrated in patients with acute myocardial infarction complicated by cardiogenic shock in states with public reporting. Given concerns of risk aversion in high-risk patients, we utilized the Nationwide Inpatient Sample (NIS) to identify whether there was evidence of risk avoidant behavior in performing coronary angiography on patients with cardiac arrest in states that participate in public reporting. Methods: We performed a cross-sectional analysis of all adult patients (age≥18 years) with in-hospital and out-of-hospital cardiac arrest between 2005 and 2011 in states with public reporting (New York and Massachusetts) and surrounding states without public reporting (Delaware, Connecticut, Maine, Maryland, Rhode Island and Vermont) in the NIS. Adjusted logistical regression models were used to assess the relationship between public reporting and CA with clustering by hospital. The association between public reporting and in-hospital mortality was assessed using logistical regression models adjusted for the same set of demographic and clinical characteristics. An interaction term was used to assess whether the association between public reporting and in-hospital mortality differed based on the performance of CA. Results: We analyzed 75,080 patients with cardiac arrest between 2005 and 2011 in the selected states. There was a trend towards decreased utilization of CA in states with public reporting (adjusted OR 0.82, 95% CI 0.67-1.00, p=0.055), but significantly lower use of CA in those patients presenting with STEMI (adjusted OR 0.65, 95% CI 0.44-0.96, p=0.032). There was no association between public reporting and in-hospital mortality (adjusted OR 0.99, 95% CI 0.85-1.14, p=0.841) and no significant interaction of CA on the relationship between public reporting and in-hospital mortality (p=0.273). Conclusion: There is a trend towards risk-avoidant behavior in the performance of CA on patients with cardiac arrest, and patients with STEMI and cardiac arrest are less likely to undergo CA in states with public reporting. Overall, there is no difference in mortality for patients with cardiac arrest in states with and without public reporting, and there was no interaction with CA.

Association Between Intraprocedural Thrombotic Events and Adverse Outcomes After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction (a Harmonizing Outcomes With RevasculariZatiON and Stents in Acute Myocardial Infarction [HORIZONS-AMI] Substudy)

Clinical Summaries

BackgroundIn-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI.MethodsBaseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient.ResultsIn-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of >35 breaths/min, cardiogenic shock, oxygen saturation of <93%, age of >55 ​years, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χ2, P ​< ​.001), and the model demonstrated good discriminative power (c-statistic ​= ​0.81) and calibration (Hosmer-Lemeshow, P ​= ​.40). The increasing risk score was strongly associated with in-hospital mortality (3.6%-60% mortality for low-risk and very high–risk score categories, respectively).ConclusionsThe risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.