Clinical paperDiagnostic test accuracy of life-threatening electrocardiographic findings (ST-elevation myocardial infarction equivalents) for acute coronary syndrome after out-of-hospital cardiac arrest without ST-segment elevation
Introduction
Approximately 30% of out-of-hospital cardiac arrests (OHCAs) are related to coronary artery disease, including acute coronary syndrome (ACS), which is the most common cause of OHCA.1 In patients with ACS, early reperfusion therapy effectively improves outcomes after cardiac arrest.2, 3 Patients with ST-segment elevation myocardial infarction (STEMI), identified by 12-lead monitoring, are recommended to undergo coronary angiography (CAG) for possible percutaneous coronary intervention.2, 3 However, several studies have reported that the absence of ST-segment elevation cannot rule out an intervenable coronary lesion.4, 5 International guidelines recommend against routine CAG in patients with OHCA after return of spontaneous circulation (ROSC) without ST-segment elevation and recommend individualised decisions with respect to urgent CAG and percutaneous coronary angioplasty when ACS is suspected.2, 3
In non-STEMI, electrocardiographic (ECG) findings suggestive of ACS have been reported, including left main coronary artery, proximal left anterior descending coronary artery, and severe three-vessel disease.6, 7
International guidelines also proposed that STEMI equivalents, such as De Winter ST-T, hyper-acute T-wave, isolated T-wave inversion, ST-segment depression, resting U-wave inversion, low QRS voltage, Wellens’ signs, and ST-segment elevation in lead aVR, are risk factors for acute coronary ischaemia or occlusion requiring immediate cardiac catheterisation.6, 7, 8, 9 However, after ROSC, ECG changes may be secondary to cardiac arrest or drugs used during cardiopulmonary resuscitation rather than ischaemic changes due to coronary events.10 Therefore, it is unknown whether the findings of STEMI equivalents are effective in screening for ACS in patients with OHCA without ST-segment elevation.
To develop treatments and improve outcomes in patients with OHCA, we conducted the CRITICAL study, a multicentre, prospective observational data registry in Osaka, Japan, designed to accumulate both pre- and in-hospital data on OHCA treatments among patients.11 Using this database, the present study aimed to investigate the diagnostic accuracy of STEMI equivalents following ROSC in patients with OHCA to diagnose ACS and coronary artery stenosis.
Section snippets
Study design and setting
In this study, we analysed the CRITICAL study database. A complete description of the study methodology has been described previously.11 This report followed the Standards for Reporting of Diagnostic Accuracy statement.12
Population and settings
The target area of the CRITICAL study was Osaka Prefecture in Japan, which has an area of 1,897 km2 and a residential population of 8,839,469 as of 2015; 48.1% of the population are male, 25.8% of whom are aged ≥65 years.13 In 2013, Osaka had 535 hospitals (108,569 beds).11 A
Results
The patient flowchart based on the Utstein format is shown in Fig. 2. From 8,091 patients with OHCA between 2012 and 2019, 2,491 cases of cardiac arrest of non-medical origin, 3,561 cases without an initial rhythm of VF or pVT, 285 cases without ROSC, and 175 cases in which a 12-lead ECG was not performed were excluded. Consequently, 368 patients were included in the ECG analysis. We evaluated the ECGs of these patients and excluded patients with VF (n = 28), VT (n = 5), pulseless electrical
Summary
This study aimed to investigate whether STEMI equivalents on ECG obtained after ROSC in patients with OHCA can be used to identify patients with ACS with non-ST-segment elevations using a large, multicentre, prospective OHCA registry in Osaka, Japan. The results showed that STEMI equivalents did not have useful diagnostic performance for the diagnosis of ACS in patients with OHCA without ST-segment elevation.
Comparison with previous studies
To the best of our knowledge, this is the first study to investigate the diagnostic
Conclusions
We found that the diagnostic accuracy of STEMI equivalents of a single 12-lead ECG alone after ROSC in patients with OHCA without ST-segment elevation to diagnose ACS was insufficient. Further investigation on the diagnostic test accuracy evaluation considering the measurement timing and temporal changes of the ECG after ROSC is required to determine whether urgent catheterisation is needed.
Ethical approval
This study was conducted in accordance with the principles of the Declaration of Helsinki. The Ethics Committee of Kyoto University and each participating institution approved the study protocol and retrospective analysis, and the need for written informed consent was waived (approval ID: R1045).
Availability of data and materials
The datasets and/or analyses in this study are not publicly available because of the lack of permission from the ethics committee.
CRediT authorship contribution statement
Satoshi Yoshimura: Conceptualization, Methodology, Software, Resources, Formal analysis, Data curation, Writing – original draft, Writing – review & editing, Visualization. Takeyuki Kiguchi: Conceptualization, Methodology, Writing – review & editing. Taro Irisawa: Investigation, Resources, Project administration. Tomoki Yamada: Investigation, Resources. Kazuhisa Yoshiya: Investigation, Resources. Changhwi Park: Investigation, Resources. Tetsuro Nishimura: Investigation, Resources. Takuya Ishibe:
Conflicts of interest
None.
Acknowledgements
We thank all EMS personnel for collecting the Utstein data and Ms. Ikuko Nakamura and Yumiko Murai for supporting the CRITICAL study.
This study was supported by scientific research grants from JSPS KAKENHI of Japan (22H03313 to Iwami and 22 K09139 to Kitamura).
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