Clinical paperPredictive value of electrocardiogram in diagnosing acute coronary artery lesions among patients with out-of-hospital-cardiac-arrest☆
Introduction
Out-of-Hospital Cardiac Arrest (OHCA) is still a leading cause of death worldwide. Acute myocardial ischemia is known to be the most common trigger of sudden cardiac arrest.1, 2, 3 Recent data suggest that early coronary angiography and percutaneous coronary intervention after OHCA may improve hospital survival of these patients.3, 4 Decision to perform emergent coronary angiography is classically taken on the basis of electrocardiographic (ECG) findings after recovery of spontaneous circulation (ROSC). According to current guidelines, the presence of ST-segment elevation or presumed new left bundle-branch block is considered an indication for emergent coronary angiography.5 Conversely, in patients without ST-segment elevation the usefulness of emergent coronary angiography is still controversial.3, 4, 6, 7, 8 Accordingly, aim of the present study was to assess the relation between post-ROSC ECG and the presence of acute or presumed recent coronary artery lesions as possible cause of OHCA.
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Study population
Province of Udine has approximately 550,000 inhabitants, which is served by a comprehensive centrally co-ordinated ambulance system (118 Operative Station). OHCA patients in whom ROSC is achieved are referred to our Institution, which is a tertiary care referral center with intensive care unit, coronary care unit and coronary intervention facility available 24 h a day, 7 days a week.
A retrospective analysis of all patients admitted to the Catheterization Laboratory of our Institution undergoing
Results
During the study period, 126 patients who fulfilled the inclusion criteria were admitted to our Institution after resuscitation from OHCA; 35 patients did not undergo coronary angiography (Fig. 1). Ninety-one patients underwent coronary angiography and were included in the study. Eighty-five patients (93%) were comatose at the time of hospital admission.
Forty patients (44%) had ST-segment elevation on post ROSC ECG, whereas other ECG patterns were observed in the remaining 51 (56%) patients.
Discussion
The results of the present study can be summarized as follows: (1) coronary angiography demonstrates the presence of acute or presumed recent coronary artery lesions in a high proportion of OHCA survivors without ST-segment elevation on post-ROSC ECG; (2) analysis of ST-segment changes on post-ROSC ECG has a low sensitivity and negative predictive value for the identification of patients having acute or presumed recent coronary artery lesions.
Post-mortem studies documented a high prevalence of
Conclusions
The absence of ST segment elevation on post-ROSC ECG should not be considered as a criterion for not performing or delaying emergency coronary angiography in patients resuscitated from OHCA without obvious extra-cardiac cause, because acute culprit coronary lesions may be present and considered the trigger of cardiac arrest. However it is conceivable that some individual factors, such the presence of previous co-morbidities with short life expectancy and the absence of a realistic hope for
Conflict of interest statement
The authors have no conflict of interest to declare.
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Cited by (78)
Sonification enables continuous surveillance of the ST segment in the electrocardiogram
2022, American Journal of Emergency MedicineChange in out-of-hospital 12-lead ECG diagnostic classification following resuscitation from cardiac arrest
2021, ResuscitationCitation Excerpt :Thus, traditional electrocardiographic ST-segment elevation criteria have been established as having poor predictive value for coronary-artery occlusion in patients resuscitated from cardiac arrest.5,12 Further, potential confounding factors such as transient ST-segment variations in patients with subarachnoid hemorrhage,13 reversible myocardial depression,5,12 and transient ST-segment changes in survivors of cardiac arrest5,12 have been described. Most EMS systems use the out-of-hospital 12-lead ECG diagnostic classification in patients with chest pain as a definitive and reliable test for decision-making, especially the classification of STEMI.14
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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.2013.04.023