Abstract
Myocardial infarction is the most frequent cause for out-of-hospital cardiac arrest (OHCA) in adults. Patients with ST-segment elevations (STE) following return of spontaneous circulation (ROSC) are regularly admitted to the catheterisation laboratory for urgent coronary angiography. Whether patients without obvious STE (NSTE) should receive coronary angiography as part of a standardised diagnostic work-up following OHCA is still debated. We analysed a cohort of 517 subsequent OHCA patients admitted at our institution who received a standardised diagnostic work-up including coronary angiography and therapeutic hypothermia. Patients were 63±14 years old, 76% were male. Overall, 180 (35%) had ST-elevation in the post-ROSC ECG, 317 (61%) had shockable rhythm (ventricular fibrillation or tachycardia) at first ECG. ROSC was achieved after 26±21 minutes. Critical coronary stenosis requiring PCI was present in 83% of shockable and 87% of non-shockable STE-OHCA and in 48% of shockable and 22% of non-shockable NSTE-OHCA patients. In-hospital survival was 61% in shockable and 55% in non-shockable STE-OHCA and 60% in shockable and 28% in non-shockable NSTE-OHCA. Standardised admission diagnostics in OHCA patients undergoing therapeutic hypothermia with a strict admission protocol incorporating ECG and coronary catheterisation shows a high rate of relevant coronary stenosis in STE-OHCA irrespective of the initial rhythm and in NSTE-OHCA with initial shockable rhythm. Based on the unfavourable outcome and low PCI rate observed in NSTE-OHCA patients with a primary non-shockable ECG rhythm it might be reasonable to restrict routine early coronary angiography to patients with primary shockable rhythms and/or ST-segment elevations after ROSC.
Highlights
After out-of-hospital cardiac arrest (OHCA) cardio-pulmonary resuscitation (CPR) is provided to get return of spontaneous circulation (ROSC) as quickly as possible [1] and to prevent cerebral reperfusion injury [2]
Critical coronary stenosis requiring percutaneous coronary intervention (PCI) was present in 83% of shockable and 87% of nonshockable segment elevations (STE)-OHCA and in 48% of shockable and 22% of non-shockable NSTE-OHCA patients
Urgent coronary angiography is well recommended for patients with ST-segment elevations in their post-ROSC electrocardiogram (ECG), but there is no clear evidence for OHCA patients without ST-segment elevation [1]
Summary
After out-of-hospital cardiac arrest (OHCA) cardio-pulmonary resuscitation (CPR) is provided to get return of spontaneous circulation (ROSC) as quickly as possible [1] and to prevent cerebral reperfusion injury [2]. While urgent coronary angiography is highly recommended for NSTE-myocardial infarction patients with subsequent cardiac arrest [4,5], it is difficult to diagnose NSTE-myocardial infarction in patients with a primary presentation as OHCA, because elevated biomarkers such as troponin following CPR are not specific to proof myocardial infarction as the cause of cardiac arrest. It remains unclear whether all NSTE-OHCA patients with a presumed cardiac cause for arrest should undergo routine coronary angiography as part of a standardised diagnostic work-up. Whether patients without obvious STE (NSTE) should receive coronary angiography as part of a standardised diagnostic work-up following OHCA is still debated
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