Clinical paperCardiac catheterization is associated with superior outcomes for survivors of out of hospital cardiac arrest: Review and meta-analysis☆
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.
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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.2014.08.025.