Cardiac Arrest: Cardiovert, Compress, Cool, ... and Cath?
Cardiac Arrest: Cardiovert, Compress, Cool, ... and Cath?
In recent decades, numerous therapies have been promoted as great advances in the treatment of primary cardiac arrest: epinephrine, high-dose epinephrine, vasopressin, lidocaine, amiodarone, electrical defibrillation, biphasic defibrillation, induced hypothermia, and so on. The initial literature on these "miracle cures" has always looked promising. However, when attempts at validating these early studies were made or when meaningful outcomes (eg, hospital discharge with good neurologic function) were evaluated, most of these therapies fell short and eventually lost favor in the literature. Currently, only 3 therapies have emerged as truly beneficial in terms of meaningful outcomes: rapid defibrillation of ventricular fibrillation/pulseless ventricular tachycardia, good chest compressions (with less emphasis on early airway interventions and minimizing interruptions), and induced hypothermia.
Given that the majority of cases of primary cardiac arrest are associated with acute coronary syndromes, it seems reasonable to assume that urgent coronary angiography and percutaneous coronary intervention (PCI) would be associated with improved outcomes in patients with return of spontaneous circulation (ROSC) after cardiac arrest. Recent studies have demonstrated this to be true for patients with electrocardiogram (ECG) evidence of ST-segment elevation myocardial infarction (STEMI) either before or after resuscitation. However, it is well-known that the ECG is far from perfect at demonstrating evidence of acute MI. Therefore, use of the ECG to determine which patients should undergo urgent PCI might potentially lead to many patients missing out on beneficial therapy. Can coronary angiography and PCI improve the outcomes of resuscitated patients without definite evidence of STEMI? Reynolds and colleagues attempted to answer this question.
Reynolds JC, Callaway CW, El Khoudary SR, Moore CG, Alvarez RJ, Rittenberger JC
J Intensive Care Med. 2009;24:179-186
The authors performed a chart review of resuscitated patients in cardiac arrest between 2005 and 2007. They evaluated an assortment of parameters including acute ischemic ECG changes (new left bundle branch block or STEMI), presenting rhythm, neurologic status, and outcome. A good outcome was defined as discharge home or to an acute rehabilitation facility. Of the 241 patients they reviewed, 40% received coronary angiography. Significant disease (defined as ≥ 70% stenosis in at least 1 coronary artery) was identified in 69% of patients, including 57% of patients without any ischemic changes on ECG. Of the patients who received coronary angiography and PCI, 54% experienced a good clinical outcome compared with 25% of patients not receiving coronary angiography. A propensity-adjusted analysis was used to account for the nonrandomized nature of the study. The authors determined that improved survival and good outcome were associated with coronary angiography regardless of the presence of new left bundle branch block or STEMI, and also regardless of presenting rhythm or neurologic status immediately after resuscitation.
Reynolds' study further supports previously published reports encouraging urgent catheterization for survivors of cardiac arrest regardless of ECG evidence of STEMI. Recent publications also show that therapeutic hypothermia can be used safely in these patients during and after PCI without producing delays in time to balloon inflation.
The significance of this new literature cannot be overstated. If further studies confirm these findings, it would strongly argue for enormous changes in prehospital systems of care. All survivors of primary cardiac arrest would be recommended for immediate transport to hospitals that have the capability of performing urgent PCI in conjunction with therapeutic hypothermia. Based on the current literature, it certainly seems advisable that emergency healthcare practitioners who care for resuscitated victims of primary cardiac arrest should engage in conversations with cardiology consultants and urge them to take an aggressive approach to PCI in these patients.
Abstract
Introduction
In recent decades, numerous therapies have been promoted as great advances in the treatment of primary cardiac arrest: epinephrine, high-dose epinephrine, vasopressin, lidocaine, amiodarone, electrical defibrillation, biphasic defibrillation, induced hypothermia, and so on. The initial literature on these "miracle cures" has always looked promising. However, when attempts at validating these early studies were made or when meaningful outcomes (eg, hospital discharge with good neurologic function) were evaluated, most of these therapies fell short and eventually lost favor in the literature. Currently, only 3 therapies have emerged as truly beneficial in terms of meaningful outcomes: rapid defibrillation of ventricular fibrillation/pulseless ventricular tachycardia, good chest compressions (with less emphasis on early airway interventions and minimizing interruptions), and induced hypothermia.
Given that the majority of cases of primary cardiac arrest are associated with acute coronary syndromes, it seems reasonable to assume that urgent coronary angiography and percutaneous coronary intervention (PCI) would be associated with improved outcomes in patients with return of spontaneous circulation (ROSC) after cardiac arrest. Recent studies have demonstrated this to be true for patients with electrocardiogram (ECG) evidence of ST-segment elevation myocardial infarction (STEMI) either before or after resuscitation. However, it is well-known that the ECG is far from perfect at demonstrating evidence of acute MI. Therefore, use of the ECG to determine which patients should undergo urgent PCI might potentially lead to many patients missing out on beneficial therapy. Can coronary angiography and PCI improve the outcomes of resuscitated patients without definite evidence of STEMI? Reynolds and colleagues attempted to answer this question.
Coronary Angiography Predicts Improved Outcome Following Cardiac Arrest: Propensity-adjusted Analysis
Reynolds JC, Callaway CW, El Khoudary SR, Moore CG, Alvarez RJ, Rittenberger JC
J Intensive Care Med. 2009;24:179-186
Summary
The authors performed a chart review of resuscitated patients in cardiac arrest between 2005 and 2007. They evaluated an assortment of parameters including acute ischemic ECG changes (new left bundle branch block or STEMI), presenting rhythm, neurologic status, and outcome. A good outcome was defined as discharge home or to an acute rehabilitation facility. Of the 241 patients they reviewed, 40% received coronary angiography. Significant disease (defined as ≥ 70% stenosis in at least 1 coronary artery) was identified in 69% of patients, including 57% of patients without any ischemic changes on ECG. Of the patients who received coronary angiography and PCI, 54% experienced a good clinical outcome compared with 25% of patients not receiving coronary angiography. A propensity-adjusted analysis was used to account for the nonrandomized nature of the study. The authors determined that improved survival and good outcome were associated with coronary angiography regardless of the presence of new left bundle branch block or STEMI, and also regardless of presenting rhythm or neurologic status immediately after resuscitation.
Viewpoint
Reynolds' study further supports previously published reports encouraging urgent catheterization for survivors of cardiac arrest regardless of ECG evidence of STEMI. Recent publications also show that therapeutic hypothermia can be used safely in these patients during and after PCI without producing delays in time to balloon inflation.
The significance of this new literature cannot be overstated. If further studies confirm these findings, it would strongly argue for enormous changes in prehospital systems of care. All survivors of primary cardiac arrest would be recommended for immediate transport to hospitals that have the capability of performing urgent PCI in conjunction with therapeutic hypothermia. Based on the current literature, it certainly seems advisable that emergency healthcare practitioners who care for resuscitated victims of primary cardiac arrest should engage in conversations with cardiology consultants and urge them to take an aggressive approach to PCI in these patients.
Abstract
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