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Resuscitation

 

83 (2012) 1427–

 

1433

Contents

 

lists

 

available

 

at

 

SciVerse

 

ScienceDirect

Resuscitation

j o

 

u

 

r n

 

a l

 

h o m

 

e p a g e

 

:

 

w w w . e l s e v i e r . c o m / l o c a t e / r e s u s c i t a t i o n

Clinical

 

paper

Acute

 

coronary

 

angiography

 

in

 

patients

 

resuscitated

 

from

 

out-of-hospital

 

cardiac

arrest—A

 

systematic

 

review

 

and

 

meta-analysis

夽

Jacob

 

Moesgaard

 

Larsen

∗

,

 

Jan

 

Ravkilde

Department

 

of

 

Cardiology

 

and

 

Centre

 

for

 

Cardiovascular

 

Research,

 

Aalborg

 

University

 

Hospital,

 

Hobrovej

 

18-22,

 

9000

 

Aalborg,

 

Denmark

a

 

r

 

t

 

i

 

c

 

l

 

e

 

i

 

n

 

f

 

o

Article

 

history:

Received

 

22

 

June

 

2012

Received

 

in

 

revised

 

form

 

30

 

August

 

2012

Accepted

 

30

 

August

 

2012

Keywords:
Coronary

 

angiography

Heart

 

arrest

Outcome

a

 

b

 

s

 

t

 

r

 

a

 

c

 

t

Introduction:

 

Out-of-hospital

 

cardiac

 

arrest

 

has

 

a

 

poor

 

prognosis.

 

The

 

main

 

aetiology

 

is

 

ischaemic

 

heart

disease.
Aim:

 

To

 

make

 

a

 

systematic

 

review

 

addressing

 

the

 

question:

 

“In

 

patients

 

with

 

return

 

of

 

spontaneous

circulation

 

following

 

out-of-hospital

 

cardiac

 

arrest,

 

does

 

acute

 

coronary

 

angiography

 

with

 

coronary

intervention

 

improve

 

survival

 

compared

 

to

 

conventional

 

treatment?”

Methods:

 

Peer

 

reviewed

 

articles

 

written

 

in

 

English

 

with

 

relevant

 

prognostic

 

data

 

were

 

included.

 

Compar-

ison

 

studies

 

on

 

patients

 

with

 

and

 

without

 

acute

 

coronary

 

angiography

 

were

 

pooled

 

in

 

a

 

meta-analysis.

Results:

 

Thirty-two

 

non-randomised

 

studies

 

were

 

included

 

of

 

which

 

22

 

were

 

case-series

 

without

 

patients

with

 

conservative

 

treatment.

 

Seven

 

studies

 

with

 

specific

 

efforts

 

to

 

control

 

confounding

 

had

 

statistical

evidence

 

to

 

support

 

the

 

use

 

of

 

acute

 

coronary

 

angiography

 

following

 

resuscitation

 

from

 

out-of-hospital

cardiac

 

arrest.

 

The

 

remaining

 

25

 

studies

 

were

 

considered

 

neutral.

 

Following

 

acute

 

coronary

 

angiography,

the

 

survival

 

to

 

hospital

 

discharge,

 

30

 

days

 

or

 

six

 

months

 

ranged

 

from

 

23%

 

to

 

86%.

 

In

 

patients

 

without

 

an

obvious

 

non-cardiac

 

aetiology,

 

the

 

prevalence

 

of

 

significant

 

coronary

 

artery

 

disease

 

ranged

 

from

 

59%

 

to

71%.

 

Electrocardiographic

 

findings

 

were

 

unreliable

 

for

 

identifying

 

angiographic

 

findings

 

of

 

acute

 

coronary

syndrome.

 

Ten

 

comparison

 

studies

 

demonstrated

 

a

 

pooled

 

unadjusted

 

odds

 

ratio

 

for

 

survival

 

of

 

2.78

 

(1.89;

4.10)

 

favouring

 

acute

 

coronary

 

angiography.

Conclusion:

 

No

 

randomised

 

studies

 

exist

 

on

 

acute

 

coronary

 

angiography

 

following

 

out-of-hospital

 

cardiac

arrest.

 

An

 

increasing

 

number

 

of

 

observational

 

studies

 

support

 

feasibility

 

and

 

a

 

possible

 

survival

 

benefit

of

 

an

 

early

 

invasive

 

approach.

 

In

 

patients

 

without

 

an

 

obvious

 

non-cardiac

 

aetiology,

 

acute

 

coronary

angiography

 

should

 

be

 

strongly

 

considered

 

irrespective

 

of

 

electrocardiographic

 

findings

 

due

 

to

 

a

 

high

prevalence

 

of

 

coronary

 

artery

 

disease.

© 2012 Elsevier Ireland Ltd. All rights reserved.

1.

 

Introduction

Out-of-hospital

 

cardiac

 

arrest

 

(OHCA)

 

has

 

a

 

poor

 

prognosis

 

and

is

 

a

 

leading

 

cause

 

of

 

death.

 

The

 

incidence

 

of

 

OHCA

 

treated

 

by

 

the

emergency

 

medical

 

service

 

in

 

Europe

 

has

 

been

 

estimated

 

to

 

be

approximately

 

275,000

 

persons

 

per

 

year

 

with

 

a

 

survival

 

of

 

10.7%

 

for

all

 

rhythms

 

and

 

21.2%

 

for

 

ventricular

 

fibrillation

 

arrest.

1

The

 

most

frequent

 

cause

 

of

 

OHCA

 

is

 

ischaemic

 

heart

 

disease.

2

Acute

 

coro-

nary

 

angiography

 

(CAG)

 

with

 

percutaneous

 

coronary

 

intervention

(PCI)

 

is

 

the

 

treatment

 

of

 

choice

 

in

 

patients

 

with

 

acute

 

coronary

 

syn-

drome

 

(ACS)

 

with

 

ST-segment

 

elevation

 

(STEMI)

 

or

 

new

 

left

 

bundle

branch

 

block

 

(LBBB)

 

in

 

the

 

electrocardiogram

 

(ECG)

 

without

 

pre-

ceding

 

cardiac

 

arrest.

3

The

 

prognostic

 

value

 

of

 

acute

 

CAG

 

following

夽 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.2012.08.337

.

∗ Corresponding

 

author.

E-mail

 

address:

 

jaml@rn.dk

(J.M.

 

Larsen).

return

 

of

 

spontaneous

 

circulation

 

(ROSC)

 

after

 

OHCA

 

is

 

less

 

clear,

especially

 

in

 

comatose

 

survivors.

 

The

 

topic

 

was

 

evaluated

 

in

 

the

2010

 

International

 

Consensus

 

on

 

Cardiopulmonary

 

Resuscitation

and

 

Emergency

 

Cardiovascular

 

Care

 

Science

 

with

 

Treatment

 

Rec-

ommendations

 

(2010

 

CoSTR).

4

The

 

recommendation

 

was:

 

acute

CAG

 

should

 

be

 

considered

 

in

 

STEMI

 

or

 

clinical

 

suspicion

 

of

 

coro-

nary

 

ischaemia

 

as

 

a

 

likely

 

cause

 

of

 

the

 

arrest,

 

and

 

that

 

it

 

may

 

be

reasonable

 

to

 

be

 

included

 

in

 

a

 

systematic

 

standardised

 

post

 

cardiac

arrest

 

protocol.

 

Several

 

new

 

studies

 

have

 

emerged.

 

The

 

aim

 

of

 

this

study

 

was

 

to

 

make

 

an

 

updated

 

systematic

 

review

 

of

 

the

 

evidence

on

 

performing

 

acute

 

CAG

 

following

 

ROSC

 

after

 

OHCA.

2.

 

Methods

The

 

study

 

was

 

conducted

 

in

 

accordance

 

with

 

the

 

principles

stated

 

by

 

the

 

Meta-analysis

 

Of

 

Observational

 

Studies

 

in

 

Epi-

demiology

 

(MOOSE)

 

group

 

and

 

the

 

Preferred

 

Reporting

 

Items

for

 

Systematic

 

Reviews

 

and

 

Meta-analysis

 

(PRISMA)

 

group.

5,6

In

short,

 

we

 

defined

 

a

 

structured

 

question

 

describing

 

the

 

Population,

0300-9572/$

 

–

 

see

 

front

 

matter ©

 

 2012 Elsevier Ireland Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.resuscitation.2012.08.337

background image

1428

J.M.

 

Larsen,

 

J.

 

Ravkilde

 

/

 

Resuscitation

 

83 (2012) 1427–

 

1433

Intervention,

 

Comparison

 

and

 

Outcome

 

(PICO).

 

This

 

was

 

followed

by

 

literature

 

search

 

and

 

critical

 

appraisal

 

of

 

the

 

evidence.

 

The

 

eli-

gible

 

studies

 

were

 

summarised

 

in

 

tables,

 

and

 

the

 

outcome

 

was

evaluated

 

in

 

a

 

meta-analysis.

2.1.

 

PICO

 

question

“In

 

patients

 

with

 

ROSC

 

following

 

OHCA

 

(P),

 

does

 

acute

 

CAG

 

with

coronary

 

intervention

 

(I),

 

compared

 

to

 

conventional

 

treatment

 

(C),

improve

 

survival

 

(O)?

2.2.

 

Literature

 

search

The

 

literature

 

search

 

was

 

performed

 

on

 

May

 

1st,

 

2012,

 

in

 

collab-

oration

 

with

 

experienced

 

research

 

librarians.

 

PubMed

 

search

 

terms

were:

 

“Heart

 

arrest”

 

[Mesh]

 

AND

 

(“Coronary

 

Angiography”

 

[Mesh]

OR

 

“Angioplasty,

 

Balloon,

 

Coronary”

 

[Mesh]).

 

Embase

 

search

 

terms

were:

 

“exp

 

heart

 

arrest”

 

AND

 

(“exp

 

angiocardiography”

 

OR

 

“exp

transluminal

 

coronary

 

angioplasty”).

 

SveMed+

 

search

 

terms

 

were:

“exp

 

Heart-Arrest”

 

AND

 

(“exp

 

Coronary-Angiography”

 

OR

 

“exp

Angioplasty,-Transluminal,

 

Percutaneous

 

Coronary”).

 

The

 

identi-

fied

 

records

 

were

 

managed

 

using

 

reference

 

management

 

software

(RefWorks

 

2.0,

 

ProQuest

 

LLC,

 

USA).

 

Duplicates

 

were

 

identified

 

and

deleted.

 

Screening

 

of

 

the

 

records

 

was

 

done

 

by

 

one

 

author

 

(Larsen

JM).

 

Reviews,

 

case

 

reports,

 

editorials,

 

letters,

 

comments,

 

conference

abstracts,

 

records

 

with

 

clearly

 

no

 

relevance

 

to

 

the

 

PICO

 

question,

and

 

articles

 

not

 

written

 

in

 

English

 

were

 

excluded.

 

Full

 

text

 

arti-

cles

 

were

 

evaluated

 

for

 

eligibility

 

by

 

both

 

authors.

 

Articles

 

without

prognostic

 

data

 

at

 

hospital

 

discharge,

 

30

 

days

 

or

 

six

 

months

 

for

patients

 

with

 

acute

 

CAG

 

or

 

with

 

double

 

publication

 

of

 

prognostic

data

 

were

 

excluded.

 

Other

 

literature

 

sources

 

were

 

screening

 

of

 

the

reference

 

lists

 

of

 

the

 

included

 

articles

 

and

 

2010

 

CoSTR

 

and

 

the

 

peer

review

 

process.

2.3.

 

Evidence

 

appraisal

The

 

level

 

of

 

evidence

 

(LOE)

 

was

 

evaluated

 

by

 

both

 

authors:

 

LOE

1—randomised

 

controlled

 

trials

 

or

 

meta-analyses

 

of

 

randomised

controlled

 

trials;

 

LOE

 

2—studies

 

using

 

concurrent

 

controls

 

without

randomisation

 

for

 

comparison;

 

LOE

 

3—studies

 

using

 

retrospective

controls

 

for

 

comparison;

 

LOE

 

4—studies

 

without

 

a

 

control

 

group

for

 

comparison;

 

and

 

LOE

 

5—studies

 

not

 

directly

 

related

 

to

 

the

 

spe-

cific

 

population.

7

Comparison

 

studies

 

without

 

matched

 

concurrent

controls

 

were

 

classified

 

as

 

LOE

 

4.

 

The

 

studies

 

were

 

categorised

 

as

prospective

 

or

 

retrospective

 

as

 

a

 

simple

 

evaluation

 

of

 

quality.

 

Stud-

ies

 

favouring

 

acute

 

CAG

 

in

 

a

 

propensity

 

score

 

analysis

 

or

 

reporting

a

 

significant

 

adjusted

 

odds

 

ratio

 

in

 

favour

 

of

 

acute

 

CAG

 

or

 

acute

 

PCI

were

 

classified

 

as

 

“supporting”

 

PICO.

 

Studies

 

with

 

non-significant

adjusted

 

results

 

were

 

classified

 

as

 

“neutral”

 

to

 

PICO.

 

Studies

 

with

significant

 

adjusted

 

results

 

favouring

 

conservative

 

treatment

 

were

classified

 

as

 

“opposing”.

 

To

 

be

 

conservative,

 

case-series

 

without

comparison

 

groups

 

were

 

classified

 

as

 

“neutral”

 

despite

 

high

 

sur-

vival

 

rates

 

due

 

to

 

possible

 

selection

 

bias.

2.4.

 

Statistics

The

 

statistical

 

analysis

 

was

 

performed

 

with

 

a

 

significance

 

level

of

 

p

 

<

 

0.05

 

(Stata

 

11,

 

StataCorp

 

LP,

 

USA).

 

Data

 

was

 

collected

 

from

 

the

result

 

sections

 

of

 

the

 

included

 

articles.

 

Comparison

 

studies

 

were

included

 

in

 

a

 

meta-analysis

 

estimating

 

an

 

unadjusted

 

pooled

 

OR

for

 

survival

 

using

 

a

 

random-effect

 

model.

 

The

 

heterogeneity

 

of

 

the

studies

 

was

 

evaluated

 

by

 

the

 

I-squared

 

measure,

 

which

 

describes

the

 

percentage

 

of

 

variation

 

across

 

the

 

studies

 

due

 

to

 

heterogeneity

rather

 

than

 

chance.

3.

 

Results

3.1.

 

Eligible

 

studies

The

 

literature

 

search

 

is

 

illustrated

 

in

 

the

 

flow

 

diagram

 

in

 

Fig.

 

1

.

Thirty-two

 

studies

 

met

 

the

 

criteria

 

for

 

inclusion

 

in

 

the

 

review.

Ten

 

were

 

included

 

in

 

the

 

meta-analysis.

 

Seven

 

studies

 

were

 

clas-

sified

 

as

 

supporting

 

acute

 

CAG

 

following

 

ROSC

 

after

 

OHCA,

 

and

the

 

remaining

 

25

 

studies

 

were

 

neutral.

 

Twelve

 

studies

 

were

 

not

considered

 

in

 

the

 

2010

 

CoSTR,

 

primarily

 

due

 

to

 

publication

 

after

completion

 

of

 

the

 

2010

 

CoSTR

 

evaluation

 

process.

 

Table

 

1

 

sum-

marises

 

the

 

LOE

 

and

 

design

 

of

 

the

 

included

 

studies:

 

LOE

 

2

 

(one

study),

 

LOE

 

4

 

(22

 

studies)

 

and

 

LOE

 

5

 

(nine

 

studies).

 

In

 

all

 

cases,

 

LOE

5

 

was

 

due

 

to

 

inclusion

 

of

 

patients

 

with

 

in-hospital

 

cardiac

 

arrest

 

or

cardiac

 

arrest

 

without

 

specification

 

of

 

location.

 

Seventeen

 

studies

were

 

retrospective.

3.2.

 

Studies

 

on

 

acute

 

coronary

 

angiography

 

in

 

ST-segment

elevation

 

myocardial

 

infarction

Table

 

2

 

summarises

 

the

 

characteristics

 

of

 

the

 

15

 

studies

 

on

acute

 

CAG

 

in

 

patients

 

with

 

STEMI

 

following

 

ROSC.

8–22

The

 

survival

ranged

 

from

 

41%

 

to

 

92%.

 

Common

 

characteristics

 

were

 

male

 

sex,

witnessed

 

cardiac

 

arrest,

 

OHCA

 

and

 

shockable

 

rhythm.

 

The

 

inclu-

sion

 

periods

 

were

 

generally

 

before

 

or

 

in

 

the

 

early

 

era

 

of

 

therapeutic

hypothermia

 

(TH),

 

and

 

the

 

use

 

of

 

TH

 

was

 

therefore

 

low

 

despite

a

 

high

 

prevalence

 

of

 

comatose

 

survivors

 

on

 

arrival

 

to

 

hospital.

The

 

largest

 

study

 

is

 

a

 

retrospective

 

case

 

series

 

of

 

186

 

consecutive

patients

 

undergoing

 

acute

 

CAG

 

due

 

to

 

ST-segment

 

elevation

 

or

Table

 

1

Evidence

 

level

 

and

 

design

 

of

 

the

 

studies

 

included

 

in

 

the

 

systematic

 

review.

Study

 

design

 

LOE

 

1

 

LOE

 

2

 

LOE

 

3

 

LOE

 

4

 

LOE

 

5

Studies

 

supporting

 

acute

 

CAG

 

following

 

OHCA

Prospective

 

–

 

–

 

–

 

Cronier

a

–

Dumas
Gräsner

a

Tömte

a

Spaulding

Retrospective

 

–

 

Strote

a

–

 

–

 

Merchant

Studies

 

neutral

 

to

 

acute

 

CAG

 

following

 

OHCA

Prospective

 

–

 

–

 

–

 

Bendz

 

Quintero-Moran

Kahn

 

Szymanski

a

Lettieri
Mooney

a

Möllmann

a

Nielsen
Peels
Pleskot

Retrospective

 

–

 

–

 

–

 

Anyfantakis

 

Garot

Aurore

a

Hosmane

Bulut

a

Knafelj

Hovdenes

a

Mager

Keelan

a

Reynolds

Markusohn

 

Richling

McCullough
Sideris

a

Wolfrum

Studies

 

opposing

 

acute

 

CAG

 

following

 

OHCA

Prospective

 

–

 

–

 

–

 

–

 

–

Retrospective

 

–

 

–

 

–

 

–

 

–

LOE

 

=

 

level

 

of

 

evidence

 

(1

 

– randomised

 

controlled

 

trials

 

or

 

meta-analyses

 

of

randomised

 

controlled

 

trials;

 

2

 

–

 

studies

 

using

 

concurrent

 

controls

 

without

 

ran-

domisation

 

for

 

comparison;

 

3

 

–

 

studies

 

using

 

retrospective

 

controls

 

for

 

comparison;

4

 

–

 

studies

 

without

 

a

 

control

 

group

 

for

 

comparison;

 

and

 

5

 

–

 

studies

 

not

 

directly

related

 

to

 

the

 

specific

 

population;

 

CAG

 

=

 

coronary

 

angiography;

 

OHCA

 

=

 

out-of-

hospital

 

cardiac

 

arrest.

a

Studies

 

not

 

evaluated

 

in

 

the

 

2010

 

International

 

Consensus

 

on

 

Cardiopulmonary

Resuscitation

 

and

 

Emergency

 

Cardiovascular

 

CareScience

 

with

 

Treatment

 

Recom-

mendations

 

document.

background image

J.M.

 

Larsen,

 

J.

 

Ravkilde

 

/

 

Resuscitation

 

83 (2012) 1427–

 

1433

1429

Records identified through 

database searching

(n = 1484) 

Screening

Included

Eligibility

Identification

Additional records identified 

through other sources

(n = 5) 

Records after duplicates removed 

(n = 1313) 

Records screened

(n = 1313) 

Records excluded 

(n = 1249) 

Reviews; case reports; 

editorials; letters; 

comments; conference 

abstracts; studies not 

relevant to PICO; non-

English writing. 

Full-text articles 

assessed for eligibility

(n = 64) 

Full-text articles 

excluded 

(n = 32) 

Necessary prognostic 

information not 

available; double-

publication of prognostic 

data; studies not 

relevant to PICO.

Studies included in 

the systematic review 

(n = 32) 

Studies included in 

the meta-analysis

(n = 10) 

Fig.

 

1.

 

Flow

 

chart

 

of

 

the

 

selection

 

of

 

articles

 

for

 

the

 

systematic

 

review

 

and

 

meta-analysis.

 

The

 

database

 

search

 

included

 

PubMed

 

(n

 

=

 

613

 

records),

 

Embase

 

(n

 

=

 

866

 

records)

 

and

SveMed+

 

(n

 

=

 

5).

 

The

 

records

 

from

 

other

 

sources

 

were

 

obtained

 

by

 

screening

 

reference

 

lists

 

of

 

the

 

included

 

studies

 

and

 

the

 

2010

 

International

 

Consensus

 

on

 

Cardiopulmonary

Resuscitation

 

and

 

Emergency

 

Cardiovascular

 

Care

 

Science

 

with

 

Treatment

 

Recommendations

 

document

 

and

 

the

 

peer

 

review

 

process.

 

PICO

 

=

 

patient,

 

intervention,

 

comparison,

outcome.

presumed

 

new

 

LBBB

 

after

 

ROSC,

 

mainly

 

after

 

OHCA.

13

Acute

coronary

 

occlusion

 

was

 

found

 

in

 

74%.

 

The

 

remaining

 

patients

 

had

severe

 

chronic

 

stenosis.

 

The

 

survival

 

to

 

hospital

 

discharge

 

was

 

55%.

The

 

survival

 

at

 

six

 

months

 

was

 

54%,

 

primarily

 

with

 

a

 

good

 

neuro-

logical

 

status.

 

A

 

comparably

 

good

 

long-term

 

prognosis

 

was

 

seen

in

 

two

 

other

 

studies.

10,20

A

 

study,

 

comparing

 

direct

 

admittance

to

 

a

 

PCI

 

centre

 

and

 

transfer

 

from

 

a

 

referral

 

hospital,

 

demon-

strated

 

no

 

significant

 

difference

 

in

 

survival,

 

but

 

the

 

proportion

 

of

non-transferred

 

patients

 

with

 

preserved

 

left

 

ventricular

 

ejection

fraction

 

was

 

higher

 

(61%

 

vs

 

25%,

 

p

 

=

 

0.02).

17

A

 

comparison

 

of

Table

 

2

Characteristics

 

of

 

studies

 

on

 

acute

 

coronary

 

angiography

 

in

 

patients

 

with

 

ST-segment

 

elevation

 

myocardial

 

infarction.

Study

 

Inclusion

 

of

 

patients

 

N

 

OHCA

 

(%)

 

Witnessed

 

(%)

 

VF/VT

 

(%)

 

Unconscious

 

(%)

 

TH

 

(%)

 

Survival

a

(%)

Kahn

 

et

 

al.,

8

USA

 

1989–1994

 

11

 

100

 

NA

 

100

 

64

 

0

 

51

McCullough

 

et

 

al.,

9

USA

 

1989–1996

 

22

 

100

 

100

 

91

 

NA

 

0

 

41

Bendz

 

et

 

al.,

10

Norway

 

1998–2001

 

40

b

100

 

100

 

90

 

90

 

0

 

73

Quintero-Moran

 

et

 

al.,

11

Spain

 

2000–2003

 

63

 

43

 

100

 

81

 

NA

 

NA

 

68

 

(30

 

days)

Markusohn

 

et

 

al.,

12

Israel

 

1998–2006

 

25

 

100

 

92

 

84

 

72

 

8

 

76

Garot

 

et

 

al.,

13

France

 

1995–2005

 

186

 

84

 

67

 

NA

 

NA

 

18

 

55

Knafelj

 

et

 

al.,

14

Slovenea

 

2000–2005

 

72

 

NA

 

100

 

100

 

100

 

56

 

61

Richling

 

et

 

al.,

15

Austria

 

1991–2003

 

46

b

98

 

98

 

100

 

NA

 

37

 

55

 

(6

 

months)

Pleskot

 

et

 

al.,

16

Czech

 

Republic

 

2002–2004

 

20

b

100

 

NA

 

100

 

90

 

NA

 

70

Peels

 

et

 

al.,

17

The

 

Netherlands

 

2004–2005

 

44

 

100

 

NA

 

NA

 

NA

 

NA

 

50

Mager

 

et

 

al.,

18

Israel

 

2001–2006

 

21

 

NA

 

NA

 

NA

 

43

 

5

 

86

 

(30

 

days)

Wolfrum

 

et

 

al.,

19

Germany

 

2003–2006

 

33

 

100

 

NA

 

100

 

100

 

48

 

70

 

(6

 

months)

Lettieri

 

et

 

al.,

20

Italy

 

2005

 

99

b

100

 

70

 

90

 

NA

 

12

 

78

Szymanski

 

et

 

al.,

21

Poland

 

NA

 

12

b

NA

 

NA

 

100

 

NA

 

NA

 

92

 

(30

 

days)

Hosmane

 

et

 

al.,

22

USA

 

2002–2006

 

98

 

68

 

90

 

NA

 

75

 

NA

 

64

Total

NA

 

792

 

NA

 

NA

 

NA

 

NA

 

NA

 

64

 

(mean)

N

 

=

 

number

 

of

 

patients;

 

OHCA

 

=

 

out-of-hospital

 

cardiac

 

arrest;

 

VF/VT

 

=

 

ventricular

 

fibrillation

 

or

 

tachycardia;

 

TH

 

=

 

therapeutic

 

hypothermia;

 

NA

 

=

 

not

 

available.

a

Survival

 

to

 

hospital

 

discharge

 

unless

 

otherwise

 

stated.

b

Only

 

data

 

on

 

patients

 

with

 

acute

 

coronary

 

angiography

 

following

 

cardiac

 

arrest

 

is

 

reported

 

from

 

the

 

study.

background image

1430

J.M.

 

Larsen,

 

J.

 

Ravkilde

 

/

 

Resuscitation

 

83 (2012) 1427–

 

1433

Table

 

3

Characteristics

 

of

 

studies

 

on

 

patients

 

with

 

systematic

 

acute

 

coronary

 

angiography

 

following

 

out-of-hospital

 

cardiac

 

arrest

 

without

 

an

 

obvious

 

non-cardiac

 

aetiology.

Study

 

Inclusion

 

of

patients

n

 

ST-segment
elevation

 

or

LBBB

 

(%)

Significant
CAD

 

(%)

Angiographic
ACS

 

(%)

PCI

 

(%)

 

VF/VT

 

(%)

 

Unconscious

 

(%)

 

TH

 

(%)

 

Survival

a

(%)

Spaulding

 

et

 

al.,

23

France

 

1994–1996

 

84

 

63

 

71

 

69

 

33

 

93

 

NA

 

0

 

38

Anyfantakis

 

et

 

al.,

24

France

 

2001–2006

 

72

 

49

 

64

 

45

 

33

 

50

 

94

c

NA

 

49

Dumas

 

et

 

al.,

25

France

 

2003–2008

 

435

 

31

d

70

 

46

 

41

 

68

 

NA

 

86

 

39

Sideris

 

et

 

al.,

26

France

 

2002–2008

 

165

 

50

 

59

 

36

 

30

 

51

 

99

c

76

 

31

Möllmann

 

et

 

al.,

27

Germany

 

2003–2005

 

65

b

55

d

NA

 

NA

 

58

 

NA

 

NA

 

NA

 

81

 

(6

 

months)

Total

 

1994–2008

 

821

 

42

 

NA

 

NA

 

39

 

NA

 

NA

 

NA

 

41

 

(mean)

N

 

=

 

number

 

of

 

patients;

 

LBBB

 

=

 

left

 

bundle

 

branch

 

block;

 

CAD

 

=

 

coronary

 

artery

 

disease;

 

angiographic

 

ACS

 

=

 

recent

 

occlusion

 

or

 

irregular

 

lesion

 

at

 

angiography

 

in

 

resuscitated

patients;

 

PCI

 

=

 

percutaneous

 

coronary

 

intervention;

 

VF/VT

 

=

 

ventricular

 

fibrillation

 

or

 

tachycardia;

 

TH

 

=

 

therapeutic

 

hypothermia;

 

NA

 

=

 

not

 

available.

a

Survival

 

to

 

hospital

 

discharge

 

unless

 

otherwise

 

stated.

b

Only

 

data

 

on

 

patients

 

with

 

acute

 

coronary

 

angiography

 

following

 

cardiac

 

arrest

 

is

 

reported

 

from

 

the

 

study.

c

Unconscious

 

and

 

intubated.

d

ST-segment

 

elevation

 

but

 

not

 

left

 

LBBB

 

was

 

reported

 

in

 

study.

thrombolysis

 

and

 

acute

 

CAG

 

demonstrated

 

no

 

significant

difference

 

in

 

survival

 

at

 

six

 

months

 

(68%

 

vs

 

55%,

 

p

 

=

 

0.13).

15

Two

 

studies

 

indicated

 

TH

 

to

 

be

 

feasible

 

in

 

STEMI

 

patients

 

undergo-

ing

 

acute

 

CAG

 

with

 

a

 

probable

 

positive

 

effect

 

on

 

good

 

neurological

survival.

14,19

3.3.

 

Studies

 

on

 

systematic

 

acute

 

coronary

 

angiography

 

in

 

selected

patients

 

with

 

out-of-hospital

 

cardiac

 

arrest

 

of

 

mixed

 

aetiology

Table

 

3

 

illustrates

 

five

 

studies

 

on

 

systematic

 

acute

 

CAG

 

in

patients

 

following

 

ROSC

 

after

 

OHCA

 

without

 

an

 

obvious

 

non-

cardiac

 

aetiology.

23–27

The

 

reported

 

survival

 

ranged

 

from

 

31%

 

to

81%.

 

The

 

patient

 

characteristics

 

were

 

more

 

varied

 

compared

 

to

 

the

pure

 

STEMI

 

studies.

 

TH

 

was

 

used

 

in

 

the

 

majority

 

of

 

the

 

patients

in

 

the

 

two

 

largest

 

studies.

25,26

The

 

prevalence

 

of

 

significant

 

coro-

nary

 

artery

 

disease

 

(CAD)

 

was

 

high

 

ranging

 

from

 

59%

 

to

 

71%.

Angiographic

 

signs

 

comparable

 

to

 

acute

 

myocardial

 

infarction

 

with

recent

 

occlusion

 

or

 

irregular

 

lesions

 

varied

 

from

 

36%

 

to

 

69%.

 

ST-

segment

 

elevation

 

or

 

LBBB

 

was

 

seen

 

in

 

31–63%.

 

Shockable

 

rhythms

ranged

 

from

 

50%

 

to

 

93%.

The

 

pioneering

 

prospective

 

study

 

by

 

Spaulding

 

et

 

al.

 

included

84

 

patients

 

with

 

systematic

 

acute

 

CAG

 

following

 

OHCA

 

without

obvious

 

non-cardiac

 

aetiology.

23

The

 

positive

 

and

 

negative

 

pre-

dictive

 

values

 

for

 

recent

 

coronary

 

occlusion

 

on

 

angiography

 

of

chest

 

pain

 

and/or

 

ST-segment

 

elevation

 

were

 

63%

 

and

 

74%,

 

respec-

tively.

 

Survival

 

to

 

hospital

 

discharge

 

was

 

38%.

 

Successful

 

PCI

 

was

an

 

independent

 

predictor

 

of

 

survival

 

(adjusted

 

OR

 

5.2,

 

p

 

=

 

0.04).

The

 

largest

 

study

 

including

 

435

 

patients

 

from

 

a

 

prospective

 

reg-

istry

 

also

 

demonstrated

 

suboptimal

 

but

 

slightly

 

better

 

diagnostic

predictive

 

values

 

of

 

ST-segment

 

elevation,

 

and

 

successful

 

PCI

 

was

an

 

independent

 

predictor

 

of

 

survival

 

(adjusted

 

OR

 

2.1,

 

p

 

=

 

0.01).

25

Similar

 

suboptimal

 

diagnostic

 

values

 

of

 

ST-segment

 

elevation

 

for

identifying

 

angiographic

 

lesions

 

comparable

 

to

 

ACS

 

were

 

also

seen

 

in

 

two

 

retrospective

 

studies.

24,26

The

 

newest

 

of

 

these

 

stud-

ies

 

suggested

 

an

 

extended

 

ECG

 

criterion

 

of

 

ST-segment

 

elevation

and/or

 

depression

 

and/or

 

LBBB

 

and/or

 

unspecific

 

wide

 

QRS

 

and/or

right

 

bundle

 

branch

 

block.

26

The

 

extended

 

criterion

 

demonstrated

a

 

lower

 

positive

 

predictive

 

value

 

of

 

48%

 

but

 

a

 

negative

 

predic-

tive

 

value

 

of

 

100%

 

with

 

a

 

potential

 

to

 

reduce

 

the

 

needed

 

acute

procedures.

Table

 

4

Studies

 

including

 

patients

 

with

 

and

 

without

 

acute

 

coronary

 

angiography

 

following

 

cardiac

 

arrest.

Study

 

Inclusion

 

of

patients

N

 

OHCA

 

(%)

 

ST-segment
elevation

 

or

LBBB

 

(%)

Acute
CAG

 

(%)

PCI

 

(%)

 

VF/VT

 

(%)

 

Unconscious

 

(%)

 

TH

 

(%)

 

Survival

 

with

and

 

without

acute

 

CAG

 

(%)

a

Bulut

 

et

 

al.,

30

The

 

Netherlands

 

NA

 

72

 

100

 

NA

 

14

 

11

 

69

 

69

 

0

 

40

 

vs

 

37

p

 

=

 

1.00

Merchant

 

et

 

al.,

31

USA

 

2000–2005

 

110

 

0

 

12

 

27

 

15

 

100

 

NA

 

NA

 

80

 

vs

 

54

p

 

=

 

0.02

Nielsen

 

et

 

al.,

32

Multinational

 

2004–2008

 

986

 

100

 

NA

 

49

 

30

 

70

 

100

 

100

 

63

 

vs

 

50

p

 

<

 

0.001

Reynolds

 

et

 

al.,

33

USA

 

2005–2007

 

241

 

56

 

19

 

26

 

NA

 

39

 

NA

 

33

 

52

 

vs

 

31

b

p

 

=

 

0.004

Aurore

 

et

 

al.,

34

France

 

2000–2006

 

445

 

100

 

28

 

30

 

16

 

42

 

NA

 

NA

 

23

 

vs

 

10

p

 

<

 

0.001

Cronier

 

et

 

al.,

35

France

 

2003–2008

 

111

 

100

 

54

 

82

 

42

 

100

 

NA

 

70

 

59

 

vs

 

30

p

 

=

 

0.02

Gräsner

 

et

 

al.,

36

Germany

 

2004–2010

 

584

 

100

 

NA

 

26

 

NA

 

42

 

NA

 

31

 

52

 

vs

 

13

b

p

 

<

 

0.001

Mooney

 

et

 

al.,

37

USA

 

2006–2009

 

140

 

100

 

49

 

72

 

40

 

76

 

100

 

100

 

62

 

vs

 

38

p

 

=

 

0.01

Tömte

 

et

 

al.,

38

Norway

 

2003–2009

 

174

 

100

 

NA

 

83

 

45

 

49

 

78

 

NA

 

52

 

vs

 

31

b

p

 

=

 

0.04

Strote

 

et

 

al.,

39

USA

 

1999–2002

 

240

 

100

 

34

 

25

 

16

 

98

 

NA

 

0

 

72

 

vs

 

49

p

 

=

 

0.003

Total

 

NA

 

3103

 

92

 

NA

 

41

 

NA

 

62

 

NA

 

NA

 

56

 

vs

 

32

 

(means)

p

 

<

 

0.001

N

 

=

 

number

 

of

 

patients;

 

OHCA

 

=

 

out-of-hospital

 

cardiac

 

arrest;

 

LBBB

 

=

 

left

 

bundle

 

branch

 

block;

 

CAG

 

=

 

coronary

 

angiography;

 

PCI

 

=

 

percutaneous

 

coronary

 

intervention;

VF/VT

 

=

 

ventricular

 

fibrillation

 

or

 

tachycardia;

 

TH

 

=

 

therapeutic

 

hypothermia;

 

NA

 

=

 

not

 

available.

a

Survival

 

to

 

hospital

 

discharge

 

unless

 

otherwise

 

stated

 

with

 

calculated

 

p-values

 

by

 

Fischer’s

 

exact

 

test

 

or

 

Chi-square

 

test.

b

Survival

 

to

 

hospital

 

discharge

 

with

 

good

 

neurology.

background image

J.M.

 

Larsen,

 

J.

 

Ravkilde

 

/

 

Resuscitation

 

83 (2012) 1427–

 

1433

1431

Fig.

 

2.

 

Forest

 

plot

 

from

 

a

 

meta-analysis

 

of

 

studies

 

including

 

patients

 

with

 

and

 

without

 

acute

 

coronary

 

angiography.

 

The

 

odds

 

ratios

 

are

 

unadjusted

 

for

 

possible

 

selection

bias

 

and

 

should

 

be

 

interpreted

 

with

 

caution.

 

The

 

grey

 

boxes

 

covering

 

the

 

point

 

estimate

 

of

 

the

 

odds

 

ratio

 

illustrate

 

the

 

weight

 

of

 

the

 

individual

 

study

 

in

 

the

 

pooled

 

odds

ratio.

 

These

 

weights

 

were

 

defined

 

by

 

a

 

random

 

effect

 

model

 

due

 

to

 

heterogeneity

 

of

 

the

 

studies

 

as

 

illustrated

 

by

 

a

 

high

 

I-squared.

 

N

 

=

 

number

 

of

 

patients;

 

OR

 

=

 

odds

 

ratio;

CI

 

=

 

confidence

 

interval;

 

CAG

 

=

 

coronary

 

angiography.

Two

 

small

 

studies

 

with

 

systematic

 

acute

 

CAG

 

following

 

OHCA

with

 

ventricular

 

fibrillation

 

were

 

not

 

included

 

in

 

Table

 

3

 

due

 

to

more

 

selective

 

inclusion

 

criteria.

 

One

 

of

 

the

 

studies

 

included

 

15

patients

 

with

 

a

 

survival

 

to

 

hospital

 

discharge

 

of

 

73%.

28

The

 

other

study

 

included

 

50

 

comatose

 

haemodynamic

 

unstable

 

patients

 

and

demonstrated

 

an

 

impressive

 

six-month

 

survival

 

of

 

82%.

29

3.4.

 

Comparison

 

studies

 

including

 

patients

 

with

 

and

 

without

acute

 

coronary

 

angiography

Table

 

4

 

illustrates

 

10

 

studies

 

on

 

patients

 

resuscitated

 

from

 

car-

diac

 

arrest

 

of

 

mixed

 

aetiology

 

with

 

acute

 

CAG

 

only

 

performed

 

in

selected

 

patients.

30–39

The

 

indication

 

for

 

performing

 

acute

 

CAG

 

was

not

 

specified

 

in

 

most

 

of

 

the

 

studies.

 

The

 

use

 

of

 

acute

 

CAG

 

was

 

very

heterogeneous

 

in

 

the

 

studies

 

ranging

 

from

 

14%

 

to

 

83%.

 

Overall,

 

the

patients

 

undergoing

 

acute

 

CAG

 

had

 

a

 

better

 

survival.

 

The

 

character-

istics

 

of

 

patients

 

in

 

the

 

studies

 

were

 

heterogeneous,

 

e.g.

 

shockable

rhythms

 

ranged

 

from

 

39%

 

to

 

100%.

 

The

 

prevalence

 

of

 

comatose

 

sur-

vivors

 

was

 

only

 

sparsely

 

reported,

 

but

 

TH

 

was

 

generally

 

used

 

more

common

 

than

 

in

 

the

 

pure

 

STEMI-studies.

The

 

largest

 

study

 

prospectively

 

included

 

986

 

patients

 

resus-

citated

 

from

 

OHCA

 

at

 

38

 

centres

 

in

 

seven

 

countries

 

admitted

 

to

intensive

 

care

 

units

 

treated

 

with

 

TH.

32

Sixty-three

 

percent

 

of

 

the

patients

 

presented

 

with

 

acute

 

myocardial

 

infarction,

 

but

 

only

 

49%

underwent

 

acute

 

CAG,

 

30%

 

PCI,

 

5%

 

thrombolytic

 

treatment

 

and

1%

 

coronary

 

artery

 

bypass

 

grafting.

 

Initial

 

shockable

 

rhythm

 

was

predictive

 

of

 

a

 

favourable

 

outcome

 

if

 

acute

 

CAG

 

was

 

performed

(p

 

<

 

0.001),

 

whereas

 

asystole

 

was

 

only

 

predictive

 

of

 

a

 

bad

 

outcome

 

if

acute

 

CAG

 

was

 

not

 

performed

 

(p

 

<

 

0.001).

 

Bleeding

 

requiring

 

trans-

fusion

 

was

 

more

 

common

 

in

 

patients

 

with

 

acute

 

CAG

 

(6.2%

 

vs

 

2.8%,

p

 

=

 

0.02).

 

In

 

three

 

other

 

studies,

 

acute

 

CAG

 

was

 

found

 

to

 

be

 

an

 

inde-

pendent

 

predictor

 

of

 

survival

 

with

 

adjusted

 

OR

 

of

 

3.8

 

(p

 

<

 

0.05),

 

5.7

(p

 

<

 

0.001)

 

and

 

11.2

 

(p

 

<

 

0.001),

 

respectively.

31,36,38

One

 

study

 

only

demonstrated

 

a

 

significant

 

independent

 

predictive

 

value

 

on

 

sur-

vival

 

with

 

good

 

neurology

 

of

 

performing

 

CAG

 

before

 

discharge,

 

but

not

 

acute

 

CAG.

33

Another

 

study

 

found

 

a

 

significant

 

independent

predictive

 

value

 

of

 

acute

 

PCI,

 

but

 

not

 

acute

 

CAG.

35

The

 

newest

 

and

 

only

 

LOE2

 

study

 

by

 

Strote

 

et

 

al.

 

included

 

240

resuscitated

 

OHCA

 

patients

 

and

 

compared

 

acute

 

CAG

 

(

≤6

 

h)

 

to

 

later

CAG

 

(>6

 

h)

 

or

 

no

 

CAG

 

before

 

discharge.

39

PCI

 

was

 

performed

 

in

 

61%

with

 

acute

 

CAG,

 

which

 

more

 

often

 

had

 

ST-segment

 

elevation

 

and

pre-arrest

 

symptoms

 

indicating

 

ACS.

 

PCI

 

before

 

discharge

 

was

 

only

performed

 

in

 

7%

 

of

 

patients

 

without

 

acute

 

CAG.

 

The

 

crude

 

survival

to

 

hospital

 

discharge

 

was

 

better

 

in

 

patients

 

with

 

acute

 

CAG

 

(72%

 

vs

49%,

 

p

 

=

 

0.003).

 

To

 

address

 

possible

 

selection

 

bias,

 

matching

 

with

propensity

 

score

 

analysis

 

was

 

done

 

indicating

 

a

 

survival

 

benefit

 

of

acute

 

CAG

 

in

 

the

 

patients

 

with

 

propensity

 

scores

 

with

 

middle

 

to

high

 

likelihood

 

of

 

undergoing

 

acute

 

CAG.

 

No

 

multivariate

 

analysis

of

 

the

 

prognostic

 

effect

 

of

 

acute

 

CAG

 

including

 

the

 

propensity

 

score

was

 

reported

 

in

 

the

 

study.

The

 

crude

 

prognostic

 

information

 

from

 

the

 

ten

 

studies

 

was

 

com-

piled

 

in

 

a

 

meta-analysis

 

as

 

illustrated

 

in

 

the

 

forest

 

plot

 

in

 

Fig.

 

2

.

 

All

studies,

 

except

 

the

 

smallest

 

and

 

oldest,

 

had

 

a

 

significant

 

unadjusted

OR

 

for

 

survival

 

favouring

 

acute

 

CAG.

 

The

 

pooled

 

unadjusted

 

OR

was

 

2.78,

 

95%

 

confidence

 

interval

 

(1.89;

 

4.10).

 

The

 

high

 

I-squared

illustrates

 

heterogeneity

 

in

 

the

 

studies.

4.

 

Discussion

The

 

high

 

rate

 

of

 

mortality

 

associated

 

with

 

OHCA

 

calls

 

for

 

opti-

mised

 

treatment

 

both

 

before

 

and

 

after

 

ROSC.

 

No

 

randomised

 

trials

exist

 

evaluating

 

the

 

use

 

of

 

acute

 

CAG

 

following

 

successful

 

resusci-

tation

 

from

 

OHCA

 

(

Table

 

1

).

4.1.

 

Acute

 

coronary

 

angiography

 

in

 

ST-segment

 

elevation

myocardial

 

infarction

 

following

 

resuscitation

 

from

 

out-of-hospital

cardiac

 

arrest

Acute

 

CAG

 

with

 

subsequent

 

PCI

 

compared

 

to

 

fibrinolysis

 

in

STEMI

 

patients

 

without

 

preceding

 

cardiac

 

arrest

 

is

 

favourable

 

for

survival

 

and

 

morbidity,

 

when

 

the

 

transfer

 

time

 

to

 

a

 

PCI

 

cen-

tre

 

is

 

short.

3,40

Cardiac

 

arrest

 

survivors

 

are

 

frequently

 

excluded

from

 

randomised

 

studies

 

because

 

of

 

unconsciousness

 

and

 

unsta-

ble

 

circulation

 

due

 

to

 

post-cardiac

 

arrest

 

syndrome

 

and

 

potential

irreversible

 

brain

 

injury.

41

The

 

optimal

 

management

 

of

 

espe-

cially

 

the

 

comatose

 

survivors

 

of

 

OHCA

 

with

 

a

 

proper

 

balance

between

 

action

 

and

 

withdrawal

 

of

 

treatment

 

is

 

very

 

challenging

both

 

for

 

the

 

interventional

 

cardiologist

 

and

 

the

 

intensivist.

 

The

background image

1432

J.M.

 

Larsen,

 

J.

 

Ravkilde

 

/

 

Resuscitation

 

83 (2012) 1427–

 

1433

recommendation

 

in

 

the

 

2010

 

CoSTR

 

and

 

2010

 

European

 

guide-

lines

 

for

 

resuscitation

 

is

 

that

 

acute

 

CAG

 

should

 

be

 

considered

 

in

resuscitated

 

OHCA

 

patients

 

with

 

ST-segment

 

elevation

 

or

 

new

LBBB.

4,42

Several

 

case

 

series

 

on

 

selected

 

resuscitated

 

patients

 

with

ST-segment

 

elevation

 

or

 

new

 

LBBB

 

demonstrate

 

acute

 

CAG

 

to

 

be

feasible

 

and

 

with

 

a

 

relatively

 

good

 

survival

 

(

Table

 

2

).

 

The

 

studies

have

 

poor

 

evidence

 

levels

 

most

 

often

 

including

 

patients

 

with

 

wit-

nessed

 

arrests

 

and

 

shockable

 

rhythms.

 

This

 

selection

 

of

 

patients

probably

 

results

 

in

 

overoptimistic

 

survival

 

rates,

 

but

 

the

 

studies

 

do

demonstrate

 

that

 

acute

 

CAG

 

with

 

coronary

 

intervention

 

indeed

 

is

feasible

 

in

 

the

 

post

 

cardiac

 

arrest

 

setting.

A

 

small

 

retrospective

 

study

 

comparing

 

acute

 

fibrinolysis

 

and

acute

 

CAG

 

following

 

OHCA

 

demonstrated

 

no

 

significant

 

difference

in

 

survival,

 

but

 

actually

 

a

 

non-significant

 

trend

 

favouring

 

fibri-

nolysis

 

probably

 

due

 

to

 

time

 

delay

 

before

 

start

 

of

 

the

 

invasive

treatment.

15

Time

 

delay

 

can

 

also

 

explain

 

poorer

 

left

 

ventricu-

lar

 

ejection

 

fraction

 

in

 

patients

 

transfer

 

from

 

referral

 

hospital

compared

 

to

 

direct

 

admittance

 

to

 

a

 

PCI

 

centre

 

for

 

acute

 

CAG

 

fol-

lowing

 

OHCA.

17

This

 

emphasises

 

the

 

need

 

for

 

speed

 

in

 

treatment

 

of

patients

 

with

 

an

 

acute

 

coronary

 

occlusion.

 

If

 

transfer

 

to

 

a

 

PCI

 

centre

is

 

not

 

possible

 

in

 

a

 

reasonable

 

time,

 

an

 

alternative

 

reperfusion

 

strat-

egy

 

with

 

acute

 

fibrinolysis

 

should

 

still

 

be

 

considered

 

in

 

resuscitated

patients

 

with

 

STEMI

 

despite

 

preceding

 

chest

 

compressions.

4.2.

 

Acute

 

coronary

 

angiography

 

in

 

patients

 

following

resuscitation

 

from

 

out-of-hospital

 

cardiac

 

arrest

The

 

2010

 

CoSTR

 

and

 

European

 

guidelines

 

on

 

resuscitation

 

rec-

ommend

 

acute

 

CAG

 

to

 

be

 

considered

 

in

 

selected

 

resuscitated

 

OHCA

patients

 

irrespective

 

of

 

ECG

 

findings,

 

if

 

coronary

 

ischaemia

 

is

suspected

 

to

 

be

 

the

 

aetiology

 

for

 

cardiac

 

arrest,

 

and

 

it

 

may

 

be

 

rea-

sonable

 

to

 

include

 

acute

 

CAG

 

as

 

part

 

of

 

a

 

standardised

 

post-cardiac

arrest

 

protocol.

4,42

This

 

recommendation

 

is

 

based

 

on

 

observational

studies

 

with

 

poor

 

evidence

 

levels.

 

In

 

our

 

review,

 

we

 

identified

 

sev-

eral

 

mainly

 

newer

 

but

 

still

 

low

 

evidence

 

level

 

studies

 

on

 

patients

with

 

cardiac

 

arrest

 

of

 

mixed

 

aetiology

 

not

 

evaluated

 

in

 

the

 

2010

CoSTR,

 

adding

 

further

 

evidence

 

on

 

the

 

topic.

21,26–30,34–39

Systematic

 

acute

 

CAG

 

in

 

patient

 

without

 

an

 

obvious

 

non-cardiac

aetiology

 

has

 

demonstrated

 

a

 

high

 

prevalence

 

of

 

significant

 

CAD

and

 

a

 

favourable

 

survival

 

(

Table

 

3

).

 

Studies

 

with

 

systematic

 

acute

CAG

 

in

 

patients

 

resuscitated

 

from

 

OHCA

 

with

 

shockable

 

rhythms

also

 

demonstrate

 

very

 

high

 

survival

 

rates.

28,29

Several

 

studies

 

have

examined

 

the

 

diagnostic

 

properties

 

of

 

ST-segment

 

elevation

 

fol-

lowing

 

OHCA

 

compared

 

to

 

angiographic

 

findings

 

with

 

variable

results.

 

In

 

general,

 

the

 

diagnostic

 

values

 

were

 

suboptimal,

 

espe-

cially

 

the

 

negative

 

predictive

 

value.

23–26

In

 

one

 

study,

 

the

 

negative

predictive

 

value

 

was

 

increased

 

to

 

100%

 

on

 

behalf

 

of

 

a

 

much

 

poorer

positive

 

predictive

 

value

 

by

 

using

 

an

 

extended

 

ECG

 

criterion

 

for

triage

 

with

 

ST-segment

 

elevation

 

and/or

 

depression

 

and/or

 

LBBB

and/or

 

unspecific

 

wide

 

QRS

 

and/or

 

right

 

bundle

 

branch

 

block.

26

However,

 

the

 

author

 

is

 

cautious

 

to

 

recommend

 

implementation

 

of

this

 

strategy

 

for

 

triage

 

before

 

completion

 

of

 

prospective

 

studies,

 

as

it

 

is

 

well

 

known

 

that

 

the

 

ECG

 

can

 

be

 

without

 

ischaemic

 

findings

despite

 

an

 

acute

 

occlusion

 

in

 

patients

 

without

 

preceding

 

cardiac

arrest.

Our

 

meta-analysis

 

comparing

 

patients

 

with

 

and

 

without

 

acute

CAG

 

in

 

populations

 

with

 

mixed

 

aetiology

 

to

 

the

 

cardiac

 

arrest

demonstrated

 

a

 

significant

 

crude

 

positive

 

association

 

between

acute

 

CAG

 

and

 

survival.

 

Unfortunately,

 

no

 

data

 

is

 

available

 

for

 

an

adjusted

 

analysis

 

to

 

control

 

for

 

selection

 

bias

 

(

Table

 

4

 

and

 

Fig.

 

2

).

Therefore,

 

the

 

pooled

 

OR

 

in

 

the

 

meta-analysis

 

should

 

be

 

inter-

preted

 

with

 

caution.

 

The

 

risk

 

of

 

selection

 

bias

 

is

 

emphasised

 

by

 

the

only

 

LOE2

 

study

 

in

 

which

 

age,

 

bystander

 

cardiopulmonary

 

resus-

citation,

 

daytime

 

presentation,

 

history

 

of

 

PCI

 

or

 

stroke

 

and

 

acute

ST-segment

 

elevation

 

in

 

ECG

 

were

 

positively

 

associated

 

to

 

receiv-

ing

 

an

 

acute

 

CAG.

39

The

 

study

 

did

 

however

 

indicate

 

a

 

survival

benefit

 

of

 

acute

 

CAG

 

when

 

adjusting

 

for

 

selection

 

bias

 

by

 

propensity

score

 

analysis.

 

Six

 

other

 

studies

 

of

 

our

 

review

 

also

 

demonstrated

significant

 

adjusted

 

odds

 

ratios

 

in

 

favour

 

of

 

either

 

acute

 

CAG

 

or

acute

 

PCI.

23,25,31,35,36,38

The

 

poor

 

diagnostic

 

properties

 

of

 

the

 

ECG

 

in

 

resuscitated

 

OHCA

patients

 

with

 

a

 

high

 

prevalence

 

of

 

CAD

 

emphasises

 

the

 

routine

 

use

of

 

systematic

 

acute

 

CAG

 

as

 

part

 

of

 

a

 

standard

 

post-cardiac-arrest

protocol.

 

The

 

use

 

of

 

routine

 

acute

 

CAG

 

in

 

conscious

 

survivors

 

is

 

not

very

 

controversial

 

as

 

most

 

interventional

 

cardiologists

 

will

 

con-

sider

 

this

 

as

 

high

 

risk

 

acute

 

coronary

 

syndrome.

 

Routine

 

acute

 

CAG

in

 

comatose

 

survivors

 

is

 

more

 

debatable

 

due

 

to

 

the

 

poor

 

evidence,

possible

 

irreversible

 

brain

 

injury

 

and

 

an

 

inherent

 

slightly

 

higher

risk

 

of

 

bleeding

 

complications

 

with

 

concurrent

 

TH.

19,32

However,

the

 

studies

 

in

 

our

 

review

 

exclusively

 

including

 

comatose

 

survivors

mainly

 

treated

 

with

 

TH

 

and

 

acute

 

CAG

 

with

 

coronary

 

intervention

did

 

show

 

relatively

 

good

 

survival

 

rates.

14,19,29,32,37

We

 

recommend

future

 

randomised

 

studies

 

including

 

comatose

 

survivors

 

of

 

OHCA

without

 

STEMI

 

or

 

new

 

LBBB

 

undergoing

 

TH.

 

This

 

will

 

be

 

clinical

feasible

 

and

 

of

 

importance

 

both

 

for

 

the

 

intensive

 

care

 

and

 

inter-

ventional

 

cardiology

 

communities.

5.

 

Limitations

The

 

search

 

strategy

 

only

 

included

 

three

 

databases.

 

Non-English

articles

 

were

 

excluded.

 

Relevant

 

articles

 

could

 

be

 

missing

 

in

 

the

review,

 

but

 

this

 

is

 

less

 

likely

 

as

 

the

 

reference

 

lists

 

of

 

the

 

included

articles

 

and

 

the

 

2010

 

CoSTR

 

were

 

screened.

 

The

 

classification

 

of

the

 

studies

 

as

 

supporting,

 

neutral

 

and

 

opposing

 

PICO

 

is

 

debat-

able.

 

We

 

have

 

used

 

a

 

more

 

conservative

 

approach

 

than

 

in

 

the

 

2010

CoSTR

 

evaluation

 

process

 

by

 

only

 

allowing

 

studies

 

to

 

be

 

classified

as

 

supporting

 

if

 

adjusted

 

statistical

 

evidence

 

was

 

present

 

in

 

order

 

to

reduce

 

confounding.

 

The

 

definition

 

of

 

acute

 

CAG

 

differed

 

between

the

 

studies

 

from

 

less

 

than

 

6

 

h

 

up

 

to

 

less

 

than

 

24

 

h.

 

This

 

contributes

 

to

the

 

heterogeneity

 

of

 

the

 

reported

 

prognosis

 

in

 

the

 

studies.

 

It

 

would

have

 

been

 

clinically

 

relevant

 

to

 

make

 

a

 

separate

 

more

 

thorough

prognostic

 

analysis

 

of

 

conscious

 

and

 

comatose

 

survivors,

 

as

 

their

prognosis

 

differ.

 

This

 

was

 

not

 

feasible

 

with

 

the

 

available

 

data.

 

The

meta-analysis

 

was

 

based

 

on

 

prognostic

 

data

 

from

 

heterogeneous

studies.

 

This

 

was

 

evident

 

by

 

the

 

high

 

I-squared

 

value.

 

A

 

pooled

 

OR

seemed

 

fair

 

as

 

the

 

individual

 

odds

 

ratios

 

all

 

were

 

pointing

 

in

 

the

same

 

direction.

 

A

 

random

 

effect

 

model

 

was

 

used

 

due

 

to

 

the

 

hetero-

geneity.

 

The

 

meta-analysis

 

was

 

not

 

adjusted

 

for

 

possible

 

selection

bias

 

as

 

the

 

necessary

 

data

 

was

 

not

 

available.

 

Therefore,

 

the

 

meta-

analysis

 

should

 

be

 

interpreted

 

with

 

caution,

 

but

 

several

 

individual

studies

 

with

 

adjusted

 

analysis

 

do

 

support

 

the

 

use

 

of

 

acute

 

CAG

 

in

the

 

post

 

cardiac

 

arrest

 

setting.

6.

 

Conclusions

No

 

randomised

 

studies

 

exist

 

on

 

acute

 

CAG

 

following

 

OHCA.

 

An

increasing

 

number

 

of

 

observational

 

studies

 

support

 

feasibility

 

and

a

 

possible

 

survival

 

benefit

 

of

 

an

 

early

 

invasive

 

approach.

 

Acute

 

CAG

is

 

associated

 

to

 

a

 

better

 

survival

 

in

 

studies

 

on

 

resuscitated

 

patients

with

 

heterogeneous

 

aetiology

 

to

 

OHCA.

 

Systematic

 

acute

 

CAG

 

fol-

lowing

 

OHCA

 

without

 

an

 

obvious

 

non-cardiac

 

aetiology

 

should

 

be

strongly

 

considered

 

irrespective

 

of

 

electrocardiographic

 

findings

due

 

to

 

a

 

high

 

prevalence

 

of

 

CAD

 

and

 

unreliable

 

diagnostic

 

proper-

ties

 

of

 

the

 

electrocardiographic

 

findings.

 

Randomised

 

multicentre

studies

 

with

 

acute

 

CAG

 

following

 

OHCA

 

are

 

warranted

 

especially

 

in

comatose

 

survivors

 

for

 

optimising

 

the

 

diagnostic

 

and

 

therapeutic

strategy.

Conflict

 

of

 

interest

 

statement

None.

background image

J.M.

 

Larsen,

 

J.

 

Ravkilde

 

/

 

Resuscitation

 

83 (2012) 1427–

 

1433

1433

Acknowledgements

The

 

authors

 

thank

 

chief

 

librarian

 

Conni

 

Skrubbeltrang

 

and

librarian

 

assistant

 

Jacob

 

Borg

 

Andersen

 

from

 

the

 

Medical

 

Library

at

 

Aalborg

 

University

 

Hospital

 

for

 

valuable

 

help

 

on

 

performing

 

the

database

 

search.

 

We

 

thank

 

research

 

secretary

 

Hanne

 

Madsen

 

from

the

 

Department

 

of

 

Cardiology

 

at

 

Aalborg

 

University

 

Hospital

 

for

assisting

 

in

 

the

 

final

 

preparation

 

of

 

the

 

manuscript.

Funding:

 

No

 

external

 

funding

 

was

 

used

 

in

 

the

 

preparation

 

of

 

the

manuscript.

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H,

 

et

 

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outcome

 

of

 

emer-

gency

 

percutaneous

 

coronary

 

intervention

 

in

 

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after

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Primary

 

percutaneous

 

coronary

 

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mild

 

induced

 

hypothermia

 

in

 

comatose

 

survivors

 

of

 

ventricular

 

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acute

 

myocardial

 

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W.

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primary

 

percutaneous

 

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after

 

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cardiac

 

arrest

 

due

 

to

 

acute

 

ST-segment

 

elevation

 

myocardial

 

infarc-

tion

 

and

 

its

 

effect

 

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et

 

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arrests

 

in

 

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acute

 

ST

 

elevation

 

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infarctions

 

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East

 

Bohemian

 

region

 

over

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period

 

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HO,

 

Jessurun

 

GA,

 

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der

 

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IC,

 

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AE,

 

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LH,

 

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and

 

nontransferred

 

patients

 

after

 

primary

 

percutaneous

 

coronary

intervention

 

for

 

ischaemic

 

out-of-hospital

 

cardiac

 

arrest.

 

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A,

 

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R,

 

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D,

 

et

 

al.

 

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of

 

emergency

 

percutaneous

coronary

 

intervention

 

for

 

acute

 

ST-elevation

 

myocardial

 

infarction

 

complicated

by

 

cardiac

 

arrest.

 

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Dis

 

2008;19:615–8.

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S,

 

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C,

 

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PW,

 

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H,

 

Kurowski

 

V.

 

Mild

 

therapeutic

hypothermia

 

in

 

patients

 

after

 

out-of-hospital

 

cardiac

 

arrest

 

due

 

to

 

acute

 

ST-

segment

 

elevation

 

myocardial

 

infarction

 

undergoing

 

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et

 

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percutaneous

 

coronary

 

inter-

vention

 

in

 

patients

 

with

 

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complicated

 

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G.

 

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et

 

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F,

 

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A,

 

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S,

 

et

 

al.

 

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percutaneous

 

coro-

nary

 

intervention

 

is

 

associated

 

with

 

better

 

survival

 

after

 

out-of-hospital

 

cardiac

arrest:

 

insights

 

from

 

the

 

PROCAT

 

(Parisian

 

Region

 

Out

 

of

 

Hospital

 

Cardiac

 

Arrest)

registry.

 

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G,

 

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S,

 

Dillinger

 

JG,

 

et

 

al.

 

Value

 

of

 

post-resuscitation

 

electrocardio-

gram

 

in

 

the

 

diagnosis

 

of

 

acute

 

myocardial

 

infarction

 

in

 

out-of-hospital

 

cardiac

arrest

 

patients.

 

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2011;82:1148–53.

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Mollmann

 

H,

 

Szardien

 

S,

 

Liebetrau

 

C,

 

et

 

al.

 

Clinical

 

outcome

 

of

 

patients

 

treated

with

 

an

 

early

 

invasive

 

strategy

 

after

 

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cardiac

 

arrest.

 

J

 

Int

 

Med

 

Res

2011;39:2169–77.

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Keelan

 

PC,

 

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TJ,

 

White

 

RD,

 

Packer

 

DL,

 

Holmes

 

DR.

 

Early

 

direct

 

coro-

nary

 

angioplasty

 

in

 

survivors

 

of

 

out-of-hospital

 

cardiac

 

arrest.

 

Am

 

J

 

Cardiol

2003;91:1461–3.

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J,

 

Laake

 

JH,

 

Aaberge

 

L,

 

Haugaa

 

H,

 

Bugge

 

JF.

 

Therapeutic

 

hypother-

mia

 

after

 

out-of-hospital

 

cardiac

 

arrest:

 

experiences

 

with

 

patients

 

treated

 

with

percutaneous

 

coronary

 

intervention

 

and

 

cardiogenic

 

shock.

 

Acta

 

Anaesthesiol

Scand

 

2007;51:137–42.

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S,

 

Aengevaeren

 

WRM,

 

Luijten

 

HJE,

 

Verheugt

 

FWA.

 

Successful

 

out-

of-hospital

 

cardiopulmonary

 

resuscitation:

 

What

 

is

 

the

 

optimal

 

in-hospital

treatment

 

strategy?

 

Resuscitation

 

2000;47:155–61.

31.

 

Merchant

 

RM,

 

Abella

 

BS,

 

Khan

 

M,

 

et

 

al.

 

Cardiac

 

catheterization

 

is

 

underutilized

after

 

in-hospital

 

cardiac

 

arrest.

 

Resuscitation

 

2008;79:398–403.

32.

 

Nielsen

 

N,

 

Hovdenes

 

J,

 

Nilsson

 

F,

 

et

 

al.

 

Outcome,

 

timing

 

and

 

adverse

 

events

 

in

therapeutic

 

hypothermia

 

after

 

out-of-hospital

 

cardiac

 

arrest.

 

Acta

 

Anaesthesiol

Scand

 

2009;53:926–34.

33. Reynolds

 

JC,

 

Callaway

 

CW,

 

El

 

Khoudary

 

SR,

 

Moore

 

CG,

 

Alvarez

 

RJ,

 

Rittenberger

JC.

 

Coronary

 

angiography

 

predicts

 

improved

 

outcome

 

following

 

cardiac

 

arrest:

propensity-adjusted

 

analysis.

 

J

 

Intensive

 

Care

 

Med

 

2009;24:179–86.

34.

 

Aurore

 

A,

 

Jabre

 

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