Elsevier

Resuscitation

Volume 83, Issue 6, June 2012, Pages 699-704
Resuscitation

Clinical paper
Immediate coronary angiogram in comatose survivors of out-of-hospital cardiac arrest—An Australian study,☆☆

https://doi.org/10.1016/j.resuscitation.2011.12.004Get rights and content

Abstract

Introduction

The role of immediate coronary angiography and percutaneous coronary intervention (angio ± PCI), amongst comatose survivors of out-of-hospital cardiac arrest is unclear. This study was undertaken to evaluate if immediate angio ± PCI compared to no initial intervention improves neurological outcome at hospital discharge amongst comatose survivors of out-of-hospital pulseless ventricular tachycardia (pVT) or ventricular fibrillation (VF).

Methods

All patients admitted to Intensive Care Unit (ICU) following an out-of-hospital VF/pVT arrest from 1/1/2003 to 31/12/2008 were included. Outcome of patients who underwent immediate angio ± PCI was compared to those who did not undergo any intervention before admission to ICU. Good outcome was defined as survival to hospital discharge with Cerebral Performance Category (CPC) score of 1 or 2.

Results

Thirty-five patients (30 Males, 5 Females, mean age 60.3 ± 10.1), underwent angio ± PCI prior to ICU admission. A further 35 patients (20 Males, 15 Females, mean age 61.1 ± 17.6 years) were admitted directly to ICU without undergoing any intervention. Forty percent (14/35) of patients who had immediate coronary intervention survived to hospital discharge with a good outcome compared to 31% (11/35) patients who did not undergo any intervention. After adjusting for other covariates, the probability of good outcome at hospital discharge was related to severity of illness (SAPS-II) score at ICU admission (adj OR = 0.87, 95% CI 0.81–0.94, p < 0.01). Immediate angio ± PCI compared to no intervention was associated with an improved outcome but this difference was statistically not significant (adj OR 1.32, 95% CI 0.26–7.87, p = 0.78).

Conclusion

Immediate angio ± PCI in comatose survivors of out-of-hospital VF/pVT arrest did not lead to better neurological outcome at hospital discharge.

Introduction

Sudden cardiac arrest is one of the leading causes of death in developed countries including Australia.1 Comatose survivors of out-of-hospital cardiac arrest (OHCA) constitute a significant subgroup of patients that are admitted and managed in the Intensive Care Unit (ICU). The age-standardised incidence of OHCA in Australia is 52.6 events/100,000 person-years.2 Despite efforts at improving links in the chain of survival following a cardiac arrest, long-term survival remains dismally low with the survival rate ranging from 1.25% to 11.5% in various observational studies.2, 3, 4, 5 Many survivors have severely impaired level of functioning and poor quality of life due to hypoxemic ischaemic brain injury.6

Data from observational studies suggests that 95% of deaths following sudden cardiac arrest occur due to an acute coronary artery occlusion.7 Hence, reperfusion therapies like thrombolysis and percutaneous intervention (PCI) have been recommended to clinicians to improve outcome.8 However, the role of immediate thrombolysis and coronary intervention has been questioned since a publication by Anyfantakis et al.9 reported that only 37.5% of survivors of OHCA have demonstrable lesions on coronary angiogram.10 Evidence of lack of benefit with immediate thrombolysis, was provided by the Thrombolysis in Cardiac Arrest (TROICA) trial.11 This multi-centre trial showed that thrombolysis with Tenecteplace during advanced life support in subjects with OHCA, compared to placebo, did not improve survival (14.7% vs. 17%; p = 0.36; RR, 0.87; 95% CI 0.65–1.15).

Evidence in favour of immediate angiogram and PCI (angio ± PCI) amongst survivors of OHCA is limited to single-centre, observational studies, that have shown improved patient outcomes compared to historical controls.12, 13, 14, 15, 16 It is not clear whether such a strategy is useful for comatose survivors of OHCA in whom prognosis is determined by the neurological injury suffered at the time of cardiac arrest. We therefore conducted a study to look at neurological outcomes of comatose survivors who underwent immediate PCI following return of spontaneous circulation (ROSC) from out-of-hospital ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) arrest.

Section snippets

Study design

The study was a single centre, observational study conducted by a retrospective review of records of patients admitted to ICU of Westmead Hospital, a tertiary care hospital in New South Wales (NSW), Australia between January 2003 and December 2008. The study was approved by the local human research ethics committee that waived the need for informed consent.

Patients

All patients ≥18 years of age admitted to ICU following successful ROSC after out-of-hospital VF/pVT arrest were included in the study.

Patient characteristics

Between January 2003 and December 2008, there were 5418 admissions to the ICU. Amongst these, 113 cases (2.09%) were identified as admissions following OHCA. Of these, 70 cases had VF/pVT as the first monitored rhythm. Thirty-five patients amongst them had immediate angio ± PCI (intervention group) while the remaining 35 patients were admitted directly to the ICU from ED (non-intervention group). One patient in the latter group had percutaneous intervention and another patient had coronary artery

Discussion

In this observational study of comatose survivors of out-of hospital VF/pVT, we found that a strategy of immediate coronary angiogram followed by revascularization was not associated with improvement in neurological outcome at hospital discharge. Instead, we found that such a strategy was associated with a prolongation of ICU and hospital length of stay, more intervention and potentially, increased use of resources. We noted a trend towards improved outcome in the intervention group and

Conclusions

In comatose survivors of out-of-hospital VF/pVT, a strategy of immediate angio ± PCI compared to no intervention, improved survival with good neurological recovery at hospital discharge but this difference was statistically not significant and estimates of this difference in outcome were imprecise. This calls for the conduct of a large randomised control trial to address the research question at hand.

Conflict of interest statement

None declared.

Acknowledgements

We thank Mr. Kevin McGeechan, Department of Biostatistics, School of Public Health, University of Sydney, for his guidance with statistical analysis. We thank Ms. Carolyn Kim, Data Manager, Westmead ICU for helping extract patient data from the ICU database.

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      The international guidelines recommended performing an immediate coronary angiography and reperfusion therapy in patients resuscitated from OHCA; however, the guidelines are less clear for the timing of coronary interventions [5,18]. The definition of timing of immediate coronary angiography varied between studies: several studies considered an immediate angiography as a procedure performed before admission to the ICU [11–14]; another study considered it as within 6 h after hospital admission [15]; and another study considered it as within 12 h after arrest [16]. In our study, we classified the time from arrest to PCI (total ischemic time) into 5 groups, which were within 90 min, each 30 min interval up to 3 h, and longer than 3 h to evaluate the effect of time for PCI after resuscitation on survival outcomes.

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    A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.12.004.

    ☆☆

    This study was presented as a free paper at the Australian New Zealand Intensive Care Society (ANZICS) Annual Scientific Meeting in Perth, October 2009.

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