Elsevier

Resuscitation

Volume 85, Issue 11, November 2014, Pages 1533-1540
Resuscitation

Clinical paper
Cardiac catheterization is associated with superior outcomes for survivors of out of hospital cardiac arrest: Review and meta-analysis

https://doi.org/10.1016/j.resuscitation.2014.08.025Get rights and content

Abstract

Aims

Survivors of out-of-hospital cardiac arrest (OHCA) have a high rate of morbidity and mortality. Invasive cardiac assessment with coronary angiography offers the potential for improving outcomes by facilitating early revascularization. The aim of the present study was to review the published data on early coronary angiography for survivors of OHCA, and its impact on survival and neurological outcomes.

Methods

Medline, Embase and PubMed were searched with a structured search query. The primary outcome was in-hospital (or if not available, 30 day or 6 month) survival. Rates of survival with good neurological outcome were a secondary endpoint. The time period of the search was from 1 January 1980 to 1 January 2014. Data was pooled with means and 95% CI interval calculated. Meta-analysis of the main outcomes was performed using a weighted random effects model.

Results

Following review of all identified records, 105 relevant full text articles were retrieved. Fifty had adequate outcome information stratified by the use of coronary angiography for analysis. In studies where a control group was available for comparison, the overall survival in the acute angiography group was 58.8% versus 30.9% in the control group (Odds ratio 2.77, 95% CI 2.06–3.72). Survival with good neurological outcome (as per the Utstein framework) in the early angiography group was 58% versus 35.8% in the control group (Odds ratio 2.20, 95% CI 1.46–3.32).

Conclusions

Early coronary angiography in patients following OHCA is associated with improved outcome and better survival.

Introduction

Out-of-hospital cardiac arrest (OHCA) is an important source of death and disability; and ischemic heart disease is recognized as the most frequent cause of OHCA.1 In patients with acute coronary syndrome who do not experience OHCA, a routine early invasive strategy has been shown to improve patient outcomes.2 Survivors of OHCA represent a group with high rates of morbidity and mortality.3 However, owing to a lack of randomized clinical trial evidence uncertainty remains concerning the role of early invasive cardiac assessment. An analysis of non-randomized studies showed that significant coronary artery disease is highly prevalent among OHCA patients who did not have an obvious non-cardiac etiology. Early angiography in these patients is feasible and may improve outcomes.4 There has been considerable work published in the area since this analysis, as well as the continued adoption of mild therapeutic hypothermia (MTH) in comatose patients in conjunction with invasive assessment and management pathways.5 Part of the rationale for a benefit of routine acute angiography is the identification and appropriate revascularization of patients with acute coronary occlusions that occur without attendant significant ischemic changes on ECG.6, 7 On this basis, the current study is a systematic review and meta-analysis of the potential role of acute coronary angiography in the management pathway of patients who are survivors of OHCA.

Section snippets

Inclusion criteria

Data collection was performed using the method outlined in the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement.8 The focus of the systematic review and meta-analysis was to quantitatively describe the outcomes associated with early coronary angiography in the setting of OHCA, and where possible to compare these outcomes to contemporaneously reported controls. The primary outcome measure was the pooled outcome data of survival (to hospital discharge), and

Studies included

After removing duplicates, 2361 articles were identified. Following filtering to exclude letters to the editor, meeting abstracts, reviews and non-human studies, 1317 articles were then screened (title and abstract), resulting in a list of 105 full manuscripts that were then retrieved. These manuscripts were assessed in full, resulting in 50 articles that were included in the systematic review and meta-analysis. This is shown in Fig. 1.

Patients with STEMI and OHCA

Patients with STEMI and OHCA with ongoing coma represent a

Discussion

The results of the current analysis support the current American Heart Association (AHA) class I guideline recommendation that in the setting of resuscitated OHCA with an initial ECG showing STEMI, immediate coronary angiography and PCI is the appropriate management strategy.11 Given the body of evidence around STEMI and reperfusion therapies and the relatively good neurological outcome of the subset of OHCA patients with STEMI, it is unlikely that a randomized controlled trial will ever be

Conclusions

Current data suggest an association between acute coronary angiography and improved outcomes, including survival, following OHCA. Data quality is limited by the fact that no randomized studies assessing the role of acute angiography in patients with OHCA have been performed. Based on available data, a routine early acute invasive strategy in this patient population (especially for patients with STEMI) is reasonable where ACS is the suspected cause of the arrest. Randomized studies, particularly

Conflict of interst statement

Relevant disclosures or conflicts of interest: Nil.

Disclosures

None relevant.

References (72)

  • P. Radsel et al.

    Angiographic characteristics of coronary disease and postresuscitation electrocardiograms in patients with aborted cardiac arrest outside a hospital

    Am J Cardiol

    (2011)
  • A.M. From et al.

    Acute myocardial infarction due to left circumflex artery occlusion and significance of ST-segment elevation

    Am J Cardiol

    (2010)
  • W.K. Stribling et al.

    Left circumflex occlusion in acute myocardial infarction (from the National Cardiovascular Data Registry)

    Am J Cardiol

    (2011)
  • B. Bendz et al.

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

    Resuscitation

    (2004)
  • V. Gorjup et al.

    Acute ST-elevation myocardial infarction after successful cardiopulmonary resuscitation

    Resuscitation

    (2007)
  • V.R. Hosmane et al.

    Survival and neurologic recovery in patients with ST-segment elevation myocardial infarction resuscitated from cardiac arrest

    J Am Coll Cardiol

    (2009)
  • J.K. Kahn et al.

    Primary coronary angioplasty for acute myocardial infarction complicated by out-of-hospital cardiac arrest

    Am J Cardiol

    (1995)
  • P.C. Keelan et al.

    Early direct coronary angioplasty in survivors of out-of-hospital cardiac arrest

    Am J Cardiol

    (2003)
  • R. Knafelj et al.

    Primary percutaneous coronary intervention and mild induced hypothermia in comatose survivors of ventricular fibrillation with ST-elevation acute myocardial infarction

    Resuscitation

    (2007)
  • O. Koeth et al.

    Fate of patients with prehospital resuscitation for ST-elevation myocardial infarction and a high rate of early reperfusion therapy (results from the PREMIR [prehospital myocardial infarction registry])

    Am J Cardiol

    (2012)
  • C.H. Lee et al.

    In-hospital versus out-of-hospital cardiac arrest complicating myocardial infarction: survival after percutaneous coronary revascularization

    Int J Cardiol

    (2005)
  • H.S. Lim et al.

    Survival in patients with myocardial infarction complicated by out-of-hospital cardiac arrest undergoing emergency percutaneous coronary intervention

    Int J Cardiol

    (2013)
  • R. Maze et al.

    The impact of therapeutic hypothermia as adjunctive therapy in a regional primary PCI program

    Resuscitation

    (2013)
  • D. Mylotte et al.

    Primary percutaneous coronary intervention in patients with acute myocardial infarction, resuscitated cardiac arrest, and cardiogenic shock: the role of primary multivessel revascularization

    JACC: Cardiovasc Interv

    (2013)
  • N. Richling et al.

    Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac arrest due to acute ST-segment elevation myocardial infarction and its effect on outcome

    Am J Emerg Med

    (2007)
  • Z. Siudak et al.

    Out-of-hospital cardiac arrest in patients treated with primary PCI for STEMI Long-term follow up data from EUROTRANSFER registry

    Resuscitation

    (2012)
  • M.A. Velders et al.

    Association between angiographic culprit lesion and out-of-hospital cardiac arrest in ST-elevation myocardial infarction patients

    Resuscitation

    (2013)
  • S. Zimmermann et al.

    Out-of-hospital cardiac arrest and percutaneous coronary intervention for ST-elevation myocardial infarction: long-term survival and neurological outcome

    Int J Cardiol

    (2013)
  • Z.A. Anyfantakis et al.

    Acute coronary angiographic findings in survivors of out-of-hospital cardiac arrest

    Am Heart J

    (2009)
  • J. Chelly et al.

    Benefit of an early and systematic imaging procedure after cardiac arrest: insights from the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) registry

    Resuscitation

    (2012)
  • G. Sideris et al.

    Value of post-resuscitation electrocardiogram in the diagnosis of acute myocardial infarction in out-of-hospital cardiac arrest patients

    Resuscitation

    (2011)
  • S. Bulut et al.

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

    Resuscitation

    (2000)
  • V.B. Nanjayya et al.

    Immediate coronary angiogram in comatose survivors of out-of-hospital cardiac arrest-an Australian study

    Resuscitation

    (2012)
  • M. Werling et al.

    Treatment and outcome in post-resuscitation care after out-of-hospital cardiac arrest when a modern therapeutic approach was introduced

    Resuscitation

    (2007)
  • D. Zanuttini et al.

    Impact of emergency coronary angiography on in-hospital outcome of unconscious survivors after out-of-hospital cardiac arrest

    Am J Cardiol

    (2012)
  • S.W. Waldo et al.

    Comparison of clinical characteristics and outcomes of cardiac arrest survivors having versus not having coronary angiography

    Am J Cardiol

    (2013)
  • Cited by (109)

    • Extracorporeal cardiopulmonary resuscitation location, coronary angiography and survival in out-of-hospital cardiac arrest

      2023, American Journal of Emergency Medicine
      Citation Excerpt :

      The best location for safe and timely implementation of ECPR is currently uncertain. Acute coronary syndrome is a major reversible cause of OHCA in adults with presumed cardiac etiology; emergency coronary angiography (CAG) identifies culprit coronary arteries and enables immediate treatment through percutaneous coronary intervention (PCI) in resuscitated OHCA patients [13,14]. Current resuscitation guidelines recommend performing emergency CAG in OHCA patients with suspicious cardiac origin and ST elevation on electrocardiogram immediately after ROSC [6,7].

    View all citing articles on Scopus

    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.2014.08.025.

    View full text