Elsevier

Resuscitation

Volume 83, Issue 12, December 2012, Pages 1427-1433
Resuscitation

Clinical paper
Acute coronary angiography in patients resuscitated from out-of-hospital cardiac arrest—A systematic review and meta-analysis

https://doi.org/10.1016/j.resuscitation.2012.08.337Get rights and content

Abstract

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. Comparison 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.

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 coronary angiography (CAG) with percutaneous coronary intervention (PCI) is the treatment of choice in patients with acute coronary syndrome (ACS) with ST-segment elevation (STEMI) or new left bundle branch block (LBBB) in the electrocardiogram (ECG) without preceding cardiac arrest.3 The prognostic value of acute CAG following 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 Recommendations (2010 CoSTR).4 The recommendation was: acute CAG should be considered in STEMI or clinical suspicion of coronary 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.

Section snippets

Methods

The study was conducted in accordance with the principles stated by the Meta-analysis Of Observational Studies in Epidemiology (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, Intervention, Comparison and Outcome (PICO). This was followed by literature search and critical appraisal of the evidence. The eligible studies were summarised in tables, and the outcome was

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 classified 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 summarises the LOE and design of the included studies:

Discussion

The high rate of mortality associated with OHCA calls for optimised treatment both before and after ROSC. No randomised trials exist evaluating the use of acute CAG following successful resuscitation from OHCA (Table 1).

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 debatable. 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

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 following OHCA without an obvious non-cardiac aetiology should be strongly considered irrespective of electrocardiographic findings due to a high prevalence of CAD and

Conflict of interest statement

None.

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.

References (42)

  • S. Bulut et al.

    Successful out-of-hospital cardiopulmonary resuscitation: What is the optimal in-hospital treatment strategy?

    Resuscitation

    (2000)
  • R.M. Merchant et al.

    Cardiac catheterization is underutilized after in-hospital cardiac arrest

    Resuscitation

    (2008)
  • O. Tomte et al.

    Strong and weak aspects of an established post-resuscitation treatment protocol—a five-year observational study

    Resuscitation

    (2011)
  • J.A. Strote et al.

    Comparison of role of early (less than six hours) to later (more than six hours) or no cardiac catheterization after resuscitation from out-of-hospital cardiac arrest

    Am J Cardiol

    (2012)
  • J.P. Nolan et al.

    Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication

    Resuscitation

    (2008)
  • H.R. Arntz et al.

    European Resuscitation Council Guidelines for Resuscitation 2010 Section 5. Initial management of acute coronary syndromes

    Resuscitation

    (2010)
  • M.J. Davies

    Anatomic features in victims of sudden coronary death. Coronary artery pathology

    Circulation

    (1992)
  • F. Van de Werf et al.

    Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the task force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology

    Eur Heart J

    (2008)
  • L. Bossaert et al.

    Part 9: acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

    Resuscitation

    (2010)
  • D.F. Stroup et al.

    Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group

    JAMA

    (2000)
  • P.T. Morley et al.

    Part 3: evidence evaluation process: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

    Resuscitation

    (2010)
  • Cited by (0)

    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.

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