Long-term prognosis after out-of-hospital cardiac arrest and primary percutaneous coronary intervention

doi:10.1016/j.resuscitation.2004.04.006

Resuscitation

Volume 63, Issue 1, October 2004, Pages 49-53

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Abstract

Aims: To study the long-term survival after out-of-hospital cardiac arrest and successful cardiopulmonary resuscitation (CPR) in patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). Material and methods: In-hospital and 2-year survival of 40 patients treated with primary PCI after out-of-hospital cardiac arrest and STEMI was compared with that of a reference group of 325 STEMI patients, without cardiac arrest, also treated with primary PCI in the same period. Results: In the group with out-of-hospital cardiac arrest, both in-hospital and 2-year mortality was 27.5%. In the reference group, in-hospital and 2-year mortality was 4.9 and 7.1%, respectively. After discharge from hospital there was no significant difference in mortality between the groups. Conclusion: Long-term prognosis is good in selected patients after successful out-of-hospital CPR and STEMI treated with primary PCI.

Sumàrio

Objetivos: Estudiar la sobrevida a largo plazo después de paro cardiaco extrahospitalario(OHCA) y reanimación cardiopulmonar exitosa (CPR) en pacientes con infarto agudo de miocardio con elevación del segmento ST (STEMI) tratados con intervención coronaria percutánea primaria (PCI). Material y métodos: Se compararon la sobrevida intrahospitalaria y a 2 años de 40 pacientes tratados con PCI después de paro cardiaco extrahospitalario y STEMI, con aquellos de un grupo de referencia de 325 pacientes de STEMI , sin paro cardiaco, también tratados con PCI primaria en el mismo perı́odo. Resultados: En el grupo con paro cardiaco extrahospitalario, la mortalidad intrahospitalaria y a dos años fue 27.5%. En el grupo de referencia, la mortalidad intrahospitalaria y a dos años fue de 4.9 y 7.1 %, respectivamente. Después del alta no hubo diferencia significativa en la mortalidad de los distintos grupos. Conclusiones: El pronóstico a largo plazo es bueno en pacientes seleccionados después de CPR extrahospitalaria exitosa y STEMI tratado con PCI primario.

Resumen

Objectivos: Estudar a sobrevida a longo prazo, após paragem cardı́aca pré-hospitalar e reanimação cardio-pulmonar (CPR) com sucesso em doentes com enfarte agudo do miocárdio e elevação do segmento ST (STEMI) tratados com intervenção percutânea (PCI) primária.

Material e métodos: A sobrevida intra-hospitalar e aos 2 anos de 40 doentes tratados com PCI primária após paragem cardı́aca pré-hospitalar e STEMI foi comparada com a de um grupo de referência de 325 doentes STEMI sem paragem cardı́aca, também tratados com PCI primária no mesmo perı́odo.

Resultados:No grupo com paragem cardı́aca pré-hospitalar a mortalidade intra-hospitalar e aos 2 anos foi de 27,5%. No grupo de referência a mortalidade intra-hospitalar e aos 2 anos foi de 4,9 e 7,1%, respectivamente. Após alta do hospital não houve diferença significativa na mortalidade entre os grupos.

Conclusão:O prognóstico a longo prazo é bom em doentes seleccionados após CPR pré-hospitalar com sucesso e STEMI tratado com PCI primária.

Introduction

The prognosis after out-of-hospital cardiac arrest is generally poor due to cerebral and cardiac injury. The majority (80–90%) of these patients suffer from critical stenosis or acute occlusion of the coronary vessels and one important goal of treatment is therefore to achieve adequate reperfusion rapidly and normalization of the haemodynamics [1], [2]. To address the importance of this issue, we hypothesised that long-term survival of survivors of out-of-hospital cardiac arrest and acute myocardial infarction may be dependent on the degree of myocardial salvage (i.e. coronary reperfusion). During the last decade several reports have shown that primary percutaneous coronary intervention (PCI) is safe and restores blood flow in over 95% of the patients with acute ST-segment elevation myocardial infarction (STEMI) [3], [4], [5], [6].

Survivors of cardiac arrest with STEMI, treated with PCI, should in theory have the same prognosis as other STEMI patients treated with PCI. However, the prognosis may also be influenced by non-cardiac organ damage (e.g. brain, kidneys, lungs) due to prolonged cardiopulmonary resuscitation (CPR). The aim of the present study was to observe the long-term survival after out-of-hospital cardiac arrest and successful CPR in patients with STEMI treated with PCI. In-hospital and long-term mortality (i.e. 2 years) was compared with that of a reference group of STEMI patients treated with primary PCI.

Section snippets

Design

Over 3 years (May 1998–May 2001), we have followed prospectively 40 consecutive patients admitted to our hospital after successful out-of-hospital CPR with STEMI. The patients were treated with primary PCI and in-hospital and 2-year mortality were compared with that of a reference group of 325 consecutive patients with STEMI treated with primary PCI in the same period.

Logistics

The study was conducted in Oslo with a population of approximately 5 10 000 and a land area of 427 km². A one-tiered centralised

Study population

From May 1998 to May 2001 32 male and 8 female patients were treated with primary PCI after successful out-of-hospital CPR and STEMI. The total number of patients admitted to our hospital after successful out-of-hospital CPR in the same period was 144. Six of the patients had unwitnessed cardiac arrest, but this was not recognized before treatment with primary PCI. Mean age was 54 years (range 25–83). Ventricular fibrillation was the first arrhythmia detected in 90% of the patients, and

Discussion

The prognosis after out-of-hospital cardiac arrest is poor but it has been shown that early onset of CPR and defibrillation are the most important factors to improve the outcome [8], [10], [11]. Theoretically, achieving rapid and adequate coronary reperfusion should be another important strategy since the majority of the patients with out-of-hospital cardiac arrest suffer from acute coronary ischaemia (i.e. critical stenosis or acute occlusion) [1], [2]. The importance of coronary reperfusion

References (17)

E.C. Keeley et al.
Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials
Lancet
(2003)
K. Sunde et al.
Quality assessment of defribrillation and advanced life support using data from the medical control module of the defibrillator
Resuscitation
(1999)
A.J. Handley et al.
European Resuscitation Council guidelines 2000 for adult basic life support. A statement from the basic life support and automated external defibrillation working group(1) and approved by the executive committee of the European Resuscitation Council
Resuscitation
(2001)
A. Langhelle et al.
In-hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway
Resuscitation
(2003)
T.E. Auble et al.
Effect of out-of-hospital defibrillation by basic life support providers on cardiac arrest mortality: a metaanalysis
Ann. Emerg. Med
(1995)
J.K. Kahn et al.
Primary coronary angioplasty for acute myocardial infarction complicated by out-of-hospital cardiac arrest
Am. J. Cardiol
(1995)
B.W. Bottiger et al.
Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: a prospective clinical trial
Lancet
(2001)
G.W. Stone
Primary angioplasty versus thrombolysis—time for a wake-up call
Lancet
(2002)

There are more references available in the full text version of this article.

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Double/dual defibrillation (DD) has been proposed as an alternative treatment for refractory ventricular fibrillation (VF). This topic has been poorly researched and data on survival rates are limited.
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DD did not improve any outcomes of interest. Therefore, it is imperative that a well-designed study in this area be conducted. Ideally, conducting a randomized controlled trial in this population should be attempted to obtain a higher level of scientific evidence.
Mechanism and extent of myocardial injury associated with out-of-hospital cardiac arrest
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Citation Excerpt :
Sudden out-of-hospital cardiac arrest (OHCA) remains the leading cause of death in developed countries with an annual incidence ranging from 36 to 81 events per 100,000 inhabitants.1 Numerous studies have demonstrated that significant coronary artery disease, either stable or with the presence of acute culprit lesion, may be found in more than 70% of patients after reestablishment of spontaneous circulation (ROSC).2,3 Following hospital admission, acute myocardial injury, documented by ischemic electrocardiographic changes and increase in cardiac biomarkers, especially cardiac troponin, is typically observed.4–6
We investigated the mechanism and extent of myocardial injury associated with out-of-hospital cardiac arrest (OHCA).
159 consecutive patients undergoing immediate coronary angiography after OHCA were included and divided into groups with acute culprit lesion (A), stable obstructive coronary disease (B) and non-obstructive or absent coronary disease (C). Post-resuscitation electrocardiogram (ECG) and serial measurements of high sensitivity cardiac troponin I (cTnI) were compared.
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Significant myocardial injury associated with OHCA occurs in the presence of acute culprit lesion while extent of myocardial injury in stable or absent coronary disease is significantly smaller and correlates with the duration and intensity of cardiac resuscitation. Admission cTnI, although combined with post-resuscitation ECG, have insufficient accuracy to securely predict presence of acute culprit lesion.
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There is limited data regarding long-term survival in patients who present with STEMI and out of hospital cardiac arrest (OHCA).
We prospectively analysed outcomes in 3521 consecutive patients who were diagnosed with STEMI and underwent primary percutaneous coronary intervention (PPCI) or coronary artery bypass surgery from 2004 to 2017. They were divided into two groups according to the presence of cardiac arrest (group I, patients with cardiac arrest; n = 156 group II, patients without cardiac arrest; n = 3365).
Patients with OHCA had higher in hospital mortality (27.7% vs 2.9%, p < 0.01), sustained VT or VF (44.6% vs 4.3%, p < 0.01) and cardiogenic shock (22.9% vs 6.8%, p < 0.01). 30-day mortality (excluding death within first 24 h) was also higher in the OHCA group (24.6% vs 3.3%, p < 0.01). There was no significant difference in recurrent AMI, TVR, stroke, major bleeds or new onset heart failure. After a mean follow-up of 18.6 months, mortality was higher in patients with OHCA (7.9% vs 3.8%, p 0.04). This was driven mainly by an increase in cardiac mortality (5% vs 1.1%, p < 0.01). OHCA was a significant predictor of mortality beyond 30 days (HR – 2.5, 95% CI 0.99–6.3). Kaplan–Meier curves and the log-rank test revealed that patients with OHCA had significantly lower survival (p < 0.01).
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Clinical and Angiographic Predictors of Mortality in Sudden Cardiac Arrest Patients Having Cardiac Catheterisation: A Single Centre Registry
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Immediate cardiac catheterisation (CC) is recommended in ST-elevation myocardial infarction (STEMI) following sudden cardiac arrest (SCA). Guidelines advise urgent CC for SCA patients without-STEMI, at clinician discretion. We examined the clinical and angiographic factors predicting mortality in SCA patients having CC.
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The study cohort comprised 104 SCA patients; mean age 61 ± 12 years, and 79% male. Immediate CC (<2 hours post-SCA) was performed in 35% overall. Compared to the without-STEMI subgroup, STEMI patients had more ventricular fibrillation (91 vs 50%; p < 0.0001), and higher mean peak serum high-sensitivity troponin-T (8.25 ± 14.7 vs 1.97 ± 6.13 ug/L; p = 0.006); in the context of higher median SS (18 vs 6.5; p = 0.002) and target-lesion SS (tSS, 10 vs 0; p < 0.001). Percutaneous coronary intervention (PCI; 75 vs 23%; p < 0.0001) and target vessel revascularisation (11 vs 0%; p = 0.005) were more frequent for STEMI. All-cause mortality was 39%, at 1.3 ± 1.5 years follow-up. Independent mortality predictors were: delayed CC (HR 4.08), serum lactate >7 mmol/L (HR 3.47), and tSS (HR 1.05).
Elevated serum lactate, tSS, and delayed CC, were predictive of longer-term mortality in SCA patients having CC. Late CC in patients without-STEMI suggest scope for improvement in real-world systems of care. Closer scrutiny of target lesion complexity may aid prognostication in SCA survivors.
Electrocardiographic Findings in Patients With Acute Coronary Syndrome Presenting With Out-of-Hospital Cardiac Arrest
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We sought to characterize presenting electrocardiographic findings in patients with acute coronary syndromes (ACSs) and out-of-hospital cardiac arrest (OHCA). In the Global Registry of Acute Coronary Events and Canadian ACS Registry I, we examined presenting and 24- to 48-hour follow-up ECGs (electrocardiogram) of ACS patients who survived to hospital admission, stratified by presentation with OHCA. We assessed the prevalence of ST-segment deviation and bundle branch blocks (assessed by an independent ECG core laboratory) and their association with in-hospital and 6-month mortality among those with OHCA. Of the 12,040 ACS patients, 215 (1.8%) survived to hospital admission after OHCA. Those with OHCA had higher presenting rates of ST-segment elevation, ST-segment depression, T-wave inversion, precordial Q-waves, left bundle branch block (LBBB), and right bundle branch block (RBBB) than those without. Among patients with OHCA, those with ST-segment elevation had significantly lower in-hospital mortality (20.9% vs 33.0%, p = 0.044) and a trend toward lower 6-month mortality (27% vs 39%, p = 0.060) compared with those without ST-segment elevation. Conversely, among OCHA patients, LBBB was associated with significantly higher in-hospital and 6-month mortality rates (58% vs 22%, p <0.001, and 65% vs 28%, p <0.001, respectively). ST-segment depression and RBBB were not associated with either outcome. Sixty-three percent of bundle branch blocks (RBBB or LBBB) on the presenting ECG resolved by 24 to 48 hours. In conclusion, compared with ACS patients without cardiac arrest, those with OHCA had higher rates of ST-segment elevation, LBBB, and RBBB on admission. Among OHCA patients, ST-segment elevation was associated with lower in-hospital mortality, whereas LBBB was associated with higher in-hospital and 6-month mortality.

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Long-term prognosis after out-of-hospital cardiac arrest and primary percutaneous coronary intervention

Abstract

Sumàrio

Resumen

Introduction

Section snippets

Design

Logistics

Study population

Discussion

Lancet

Resuscitation

Resuscitation

Resuscitation

Ann. Emerg. Med

Am. J. Cardiol

Lancet

Lancet