Elsevier

Resuscitation

Volume 175, June 2022, Pages 133-141
Resuscitation

Clinical paper
Coronary angiography and percutaneous coronary intervention in cardiac arrest patients without return of spontaneous circulation

https://doi.org/10.1016/j.resuscitation.2022.03.027Get rights and content

Abstract

Objectives

This study aimed to examine coronary angiography (CAG) findings, percutaneous coronary intervention (PCI) results and outcomes in out-of-hospital cardiac arrest patients (OHCA) without return of spontaneous circulation (ROSC) on admission to hospital.

Methods

We analyzed the OHCA register and compared CAG, PCI, and outcome data in patients with and without ROSC on admission to hospital.

Results

Between January 2012 and December 2020, 697 OHCA patients were analyzed. Of these, 163 (23%) did not have ROSC at admission. Patients without ROSC were younger (59 vs. 61 years, p = 0.001) and had a longer resuscitation time (62 vs. 18 minutes, p < 0.001) than patients with ROSC. Significant coronary artery disease was highly prevalent in both groups (65% vs. 68%, p = 0.48). Patients without ROSC had higher rates of acute coronary occlusions (42% vs. 33%, p = 0.046), specifically affecting the left main stem (16% vs. 1%, p < 0.001). PCI was performed in 81 patients (50%) without ROSC and in 295 (55%) with ROSC (p = 0.21). The success rate was 86% in patients without ROSC and 90% in patients with ROSC (p = 0.33). Thirty-day survival was 24% in patients without ROSC and 70% in patients with ROSC.

Conclusions

OHCA patients without ROSC on admission to hospital had higher acute coronary occlusion rates than patients with prehospital ROSC. PCI is feasible with a high success rate in patients without ROSC. Despite prolonged resuscitation times, meaningful survival in patients admitted without ROSC is achievable.

Introduction

Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death in Western countries and acute coronary syndromes (ACS) are the most common cause of OHCA.1 Patients without prehospital return of spontaneous circulation (ROSC) bear a grave prognosis with survival rates as low as 4%.2., 3., 4. However, an increasing number of cardiac arrest centers worldwide have established a collaboration with emergency medical services using early transport from the field and extracorporeal life support (ECLS) implantation during ongoing cardiopulmonary resuscitation (CPR), a method called extracorporeal cardiopulmonary resuscitation (ECPR). This method is frequently followed by coronary angiography (CAG) and percutaneous coronary intervention (PCI).5., 6., 7.

CAG is recommended by the current European Resuscitation Guidelines, the European Society of Cardiology, and the American College of Cardiology/American Heart Association guidelines for OHCA patients with a presumed cardiac cause of arrest after ROSC.8., 9., 10. However, current European guidelines also state that unfavorable prehospital settings indicating a remote likelihood for neurological recovery, including more than 20 minutes of advanced life support without ROSC, should be an argument against a primary invasive coronary strategy.9 In addition, none of these guidelines include recommendations for CAG in patients without prehospital ROSC. However, there is growing evidence that ECLS–facilitated CAG and PCI is a promising strategy for patients with OHCA without prehospital ROSC.11., 12.

Current evidence on CAG and PCI in OHCA has mainly been reported in patients with early ROSC (e.g., a median time to ROSC of 15 minutes).13., 14. To date, only a few small studies have described CAG findings and PCI results in refractory OHCA, showing that complex but treatable coronary artery disease is the leading cause of OHCA in most patients.15., 16. These studies are limited to highly selected patient populations with initial shockable rhythms. Therefore, we decided to analyze our prospective OHCA register data to compare baseline demographics, cardiac arrest characteristics, CAG findings, PCI results and outcomes between patients with and without ROSC on hospital admission.

Section snippets

Study setting and population

The prehospital CPR system and its results in Prague, the Czech Republic have been described previously.17 Since 2012, close cooperation has been established between the Prague Emergency Medical Service and the cardiac arrest center at the General University Hospital in Prague, consisting of timely transport from the field in patients without ROSC to eventually implement the ECPR approach.7 The General University Hospital is a tertiary cardiac arrest center that accepts all OHCA patients,

Baseline and resuscitation characteristics

From January 2012 to December 2020, 960 adult patients with OHCA were admitted to our hospital. Of these 960 patients, 726 (76%) received CAG and 697 (73%) were included in the analysis (Fig. 1). Baseline characteristics of patients by ROSC status on admission are presented in Table 1. Patients admitted without ROSC were younger (59 vs. 61 years, p = 0.001) and had less history of arterial hypertension, coronary artery disease, myocardial infarction and dyslipidemia than patients with

Discussion

This register study shows several important findings. First, patients without ROSC on admission to hospital had a higher incidence of acute coronary occlusions, specifically affecting the left main stem, than patients with prehospital ROSC. Our analysis also shows a different distribution of coronary culprit lesions, with higher rates of the left main disease in patients without ROSC on admission. These findings might be expected in refractory OHCA and support the hypothesis that the severity

Conclusions

OHCA patients admitted to hospital without ROSC have higher rates of acute coronary occlusions with more frequent left main stem disease involvement than patients with prehospital ROSC. It is possible to achieve high PCI success rates in patients without ROSC on hospital admission. Our results also suggest that PCI during ongoing CPR with a mechanical chest compression device is inferior to ECLS-facilitated PCI. Despite prolonged resuscitation times, meaningful survival in patients admitted

CRediT authorship contribution statement

Daniel Rob: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Validation, Visualization, Writing – original draft, Writing – review & editing. Petra Kavalkova: Data curation, Formal analysis, Methodology, Project administration, Validation, Visualization, Writing – review & editing. Jana Smalcova: Conceptualization, Investigation, Project administration, Validation, Visualization, Writing – review & editing. Ales Kral:

Declaration of Competing Interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [This work was supported by a research grant from the Ministry of Health, Czech Republic – conceptual development of research organization, General University Hospital in Prague, 00064165. There is no other relevant conflict of interest.]

Acknowledgments

The authors express their gratitude to the Emergency Medical Service teams and the coronary care unit and catheterization laboratory teams of the 2nd Department of Internal Medicine, Cardiovascular Medicine, General University Hospital in Prague for their high-quality care. Thanks to Leslie Shaps for proofreading the article.

Data statement

Data are available upon reasonable request.

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