Clinical PaperSurvival of resuscitated cardiac arrest patients with ST-elevation myocardial infarction (STEMI) conveyed directly to a Heart Attack Centre by ambulance clinicians☆
Introduction
There is growing evidence that rapid access to angiography and emergency percutaneous coronary intervention (PCI) for patients resuscitated from out-of-hospital cardiac arrest (OHCA) secondary to ST-elevation myocardial infarction (STEMI) is associated with improved survival as reviewed by Kern and Rahman.1 It has also been reported that conscious STEMI patients resuscitated from cardiac arrest and treated with PCI can be expected to have the same prognosis as those treated with PCI who have not suffered a cardiac arrest.2
Whereas the benefits of ambulance services directly conveying STEMI patients to the catheter laboratory for reperfusion therapy have been previously documented,3, 4, 5, 6 the role of the ambulance service in the direct admission of those whose STEMI has been complicated by OHCA has not been fully explored.
Ambulance services in the UK traditionally convey OHCA patients directly to a hospital Emergency Department (ED). In late 2010, the London Ambulance Service embarked on a new clinical care pathway enabling ambulance clinicians to bypass the nearest ED and transfer STEMI patients with a return of spontaneous circulation (ROSC) following an OHCA directly to the catheter laboratory of the nearest Heart Attack Centre (HAC) for immediate angiography and emergency PCI if indicated. Decisions to convey these patients to a HAC are made at the sole discretion of the ambulance clinicians, based on their clinical observations and 12-lead electrocardiogram (ECG) interpretation.
This study reports, over a one year period, the outcome of direct ambulance service admissions for this select group of patients with the aim of demonstrating the effectiveness of this pathway and the ability of ambulance clinicians to make such conveyance decisions.
Section snippets
Design
This is a retrospective descriptive review of data sourced from the London Ambulance Service's (LAS) OHCA registry over a one-year period (1st April 2011 – 31st March 2012). Ethics approval was not required as this study reports audit data.
Patient population
All adult patients (≥18 years of age) were included if they were conveyed directly to one of eight HACs in London after experiencing an OHCA, had a ROSC, and ST-elevation was visible in two or more adjacent EGC leads (as interpreted by the attending
Results
During the study period a total of 206 adult (≥18 yr age) OHCA patients who achieved ROSC and had clear evidence of ST-elevation on the 12-lead ECG were conveyed directly to a HAC by LAS clinicians. All patients were admitted to the HAC within 125 min of the call for emergency help (median 63 min).
66% of patients survived to be discharged from hospital; 98% of these survived 30 days post-discharge, and 97% were still alive at one year (Table 1).
Those who survived to be discharged from hospital
Discussion
Survival in our cohort of resuscitated OHCA STEMI patients who were taken directly to a HAC was much higher than expected considering the survival rates we have reported historically for those taken to hospital (12–32%),8 and is similar to other reports of comparable patients directly admitted for PCI.1 The finding that two-thirds of our patients survived to hospital discharge, with the majority being alive one year later, demonstrates the effectiveness of a system that enables ambulance
Conclusion
Our study demonstrates excellent survival outcomes for patients with STEMI complicated by OHCA after direct conveyance to a HAC with the intention of immediate PCI. Our data further supports the role of ambulance clinicians in making autonomous clinical referral decisions.
Conflicts of interest statement
None declared.
Acknowledgments
We would like to thank Philip Ogden and Yvette Thomas from the London Ambulance Service for their role in helping to collect the data reported in this paper. We are also grateful to Professor Douglas Chamberlain for his advice and comments on a draft of this paper.
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Increases in survival from out-of-hospital cardiac arrest: a five year study
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Emergent percutaneous coronary intervention for resuscitated victims of out-of-hospital cardiac arrest
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Cited by (0)
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.09.010.