Published online Jun 26, 2014. doi: 10.4330/wjc.v6.i6.444
Revised: February 7, 2014
Accepted: April 16, 2014
Published online: June 26, 2014
Processing time: 180 Days and 12.7 Hours
Coronary artery disease is the most frequent cause of sudden cardiac death. There is general consensus that immediate coronary angiography with percutaneous coronary intervention (PCI) should be performed in all conscious and unconscious patients with ST-elevation myocardial infarction in post-resuscitation electrocardiogram. In these patients acute coronary thrombotic lesion (“ACS” lesion) suitable for PCI is typically present in more than 90%. PCI in these patients is not only feasible and safe but highly effective and there is evidence of improved survival with good neurological outcome. PCI of the culprit lesion is the primary goal while PCI of stable obstructive lesions may be postponed unless post-resuscitation cardiogenic shock is present.
Core tip: There is general consensus that immediate coronary angiography with percutaneous coronary intervention (PCI) should be performed in all conscious and unconscious patients with ST-elevation myocardial infarction in postresuscitation electrocardiogram. In these patients, acute coronary thrombotic lesion (“ACS” lesion) suitable for PCI is typically present in more than 90%. PCI in these patients is not only feasible and safe but highly effective and there is evidence of improved survival with good neurological outcome. PCI of the culprit lesion is the primary goal while PCI of stable obstructive lesions may be postponed unless postresuscitation cardiogenic shock is present.
- Citation: Gorjup V, Noc M, Radsel P. Invasive strategy in patients with resuscitated cardiac arrest and ST elevation myocardial infarction. World J Cardiol 2014; 6(6): 444-448
- URL: https://www.wjgnet.com/1949-8462/full/v6/i6/444.htm
- DOI: https://dx.doi.org/10.4330/wjc.v6.i6.444
Coronary artery disease has been documented in almost 80% of patients after resuscitated sudden cardiac arrest (CA)[1,2]. In the past, most of these patients died either due to profound cardiac failure or post-resuscitation brain injury without any causative treatment[3]. In year 2002 introduction of hypothermia, which was demonstrated to improve survival and neurological outcome of comatose patients, significantly changed the field of post-resuscitation treatment that became more intensive and cause-oriented[4,5]. Besides, due to better pre-hospital “chain of survival” increasing numbers of patients after resuscitated cardiac arrest are being nowadays admitted[6]. These include also patients with ST-elevation myocardial infarction (STEMI) in post-resuscitation electrocardiogram (ECG) requiring immediate coronary angiography (CAG) and percutaneous coronary intervention (PCI).
Despite the lack of randomized trials demonstrating effectiveness of immediate CAG and PCI in patients with resuscitated CA, we gradually increased the number of patients undergoing such immediate invasive coronary strategy. We extrapolated knowledge from randomized studies on acute coronary syndrome patients[7] and generated our own experience on combination of immediate invasive coronary strategy mild induced hypothermia[8,9]. After favorable experience with STEMI patients in post-resuscitation ECG, we applied the same protocol also to patients without STEMI in whom no obvious non-coronary cause of cardiac arrest was present. We were encouraged also by increasing number of independent peer-review experience by other investigators in more than 3500 patients cumulatively (Table 1). Patient selection and time to invasive procedure in these studies was different therefore results cannot be compared. Nevertheless we can appreciate that urgent PCI is feasible and highly effective in this population. There is also recent meta analysis of 10 observational studies showing immediate invasive coronary strategy to as independent predictor of survival (OR = 2.78; 95%CI: 1.89-4.10, P < 0.001)[10].
Author | Year | n | Comatose | STEMI | CA-PCI | PCI success | MIH | Survival | CPC 1 or 2 | Survival comatose | CPC 1 or 2 comatose | Survival concious |
Kahn | 1995 | 11 | 7 (64) | 11/11 (100) | 11 (100) | 7/11 (64) | N | 6/11 (55) | 6/11 (55) | 3/7 (43) | 3/7 (43) | 3/4 (75) |
Spaulding | 1997 | 84 | NA | 34/84 (40) | 37 (44) | 28/37 (76) | N | 32/84 (38) | 30/84 (36) | NA | NA | NA |
Lin | 1998 | 10 | NA | 10/10 (100) | 10 (100) | 10/10 (100) | N | 9/10 (90) | NA | NA | NA | NA |
Bulut | 2000 | 10 | NA | 10/10 (100) | 10 (100) | 8/10(80) | N | 4/10 (40) | NA | NA | NA | NA |
McCollough | 2002 | 22 | NA | 22/22 (100) | 22 (100) | 22/22 (100) | N | 9/22 (41) | NA | NA | NA | NA |
Keelan | 2003 | 15 | 13 (87) | 15/15 (100) | 15 (100) | 14/15 (93) | N | 11/15 (73) | 9/15 (60) | NA | NA | NA |
Bendz | 2004 | 40 | 36 (90) | 40/40 (100) | 40 (100) | 38/40 (95) | N | 29/40 (73) | NA | NA | NA | NA |
Quintero-Moran | 2006 | 27 | NA | 27/27 (100) | 27 (100) | 23/27 (85) | NA | 18/27 (67) | NA | NA | NA | NA |
Sunde | 2007 | 47 | NA | NA | 30 (64) | NA | Y | NA | NA | NA | NA | NA |
Gorjup | 2007 | 135 | 86 (64) | 135 (100) | 109 (81) | 102/109 (94) | Y | 90/135 (67) | 74/135 (55) | 44/86 (51) | 25/86 (29) | 49/49 (100) |
Garot | 2007 | 186 | NA | 186 (100) | 186 (100) | 161/186 (87) | Y | 103/186 (70) | 89/186 (48) | NA | NA | NA |
Richling | 2007 | 46 | NA | 46 (100) | 46 (100) | NA | NA | 24/46 (52) | 22/46 (48) | NA | NA | NA |
Markusohn | 2007 | 25 | 18 (72) | 25 (100) | 25 (100) | 22/25 (88) | Y | 19/25 (76) | 17/25 (68) | NA | NA | NA |
Werling | 2007 | 24 | NA | NA | 13 (54) | NA | NA | 16/24 (67) | NA | NA | NA | NA |
Hovdenes | 2007 | 49 | 49 (100) | NA | 36 (73) | NA | Y | 41/49 (84) | 34/49 (69) | 41/49 (84) | 34/49 (69) | NA |
Valente | 2008 | 31 | 31 (100) | 31 (100) | 31 (100) | NA | NA | 23/31 (74) | NA | 23/31 (74) | NA | NA |
Mager | 2008 | 21 | NA | 21 (100) | 21 (100) | NA | NA | 18/21 (86) | NA | NA | NA | NA |
Wolfrum | 2008 | 16 | 16 (100) | 16 (100) | 16 (100) | 16/16 (100) | Y | 12/16 (75) | NA | 12/16 (75) | 11/16 (69) | NA |
Pleskot | 2008 | 20 | NA | NA | 19 (95) | 17/19 (89) | NA | NA | NA | NA | NA | NA |
Peels | 2008 | 44 | NA | 44 (100) | 44 (100) | 38/44 (86) | NA | 22/44 (50) | NA | NA | NA | NA |
Merchant | 2008 | 30 | NA | 13 (43) | 30 (20) | 17/19 (89) | NA | 22/30 (80) | NA | NA | NA | NA |
Hosmane | 2009 | 98 | 73 (74) | 98 (100) | 64 (65) | 62/64 (97) | Y | 63/98 (64) | 57/98 (58) | 39/73 (53) | 33/73 (45) | 24/25 (96) |
Anyfantakis | 2009 | 72 | NA | 23 (32) | 27 (38) | 24/27 (89) | NA | 35/72 (49) | 33/72 (46) | NA | NA | NA |
Reynolds | 2009 | 96 | NA | 42 (44) | NA | NA | Y | 52/96 (54) | NA | NA | NA | NA |
Lettieri | 2009 | 99 | NA | 99 (100) | 99 (100) | 79/99 (80) | NA | 77/99 (78) | 72/99 (73) | NA | NA | NA |
Pan | 2010 | 49 | NA | 49 (100) | 49 (100) | 42/49 (86) | NA | 31/49 (63) | NA | NA | NA | NA |
Batista | 2010 | 20 | NA | 10 (50) | 20 (100) | NA | Y | 8/20 (40) | 6/20 (30) | NA | NA | NA |
Dumas | 2010 | 435 | NA | 134 (31) | 202 (46) | 177/202 (88) | Y | 171/435 (39) | 160/435 (37) | NA | NA | NA |
Stub | 2011 | 62 | 62 (100) | 27 (44) | 31 (50) | 29/31 (94) | Y | NA | NA | NA | NA | NA |
Tomte | 2011 | 252 | NA | NA | NA | NA | NA | 140/252 (56) | NA | NA | NA | NA |
Radsel | 2011 | 212 | 171 (81) | 158 (75) | 165 (78) | 150/165 (91) | Y | 154/212 (73) | 108/212 (51) | 113/171 (66) | 73/171 (43) | 41/41 (100) |
Mooney | 2011 | 101 | NA | 68 (67) | 56 (55) | NA | NA | NA | NA | NA | NA | NA |
Cronier | 2011 | 91 | NA | 50 (55) | 46 (51) | 43/46 (93) | Y | 60/91 (66) | NA | NA | NA | NA |
Moellmann | 2011 | 65 | NA | 36 (55) | 65 (100) | 64/65 (98) | NA | 46/65 (71) | NA | NA | NA | NA |
Nanjayya | 2012 | 35 | 35 (100) | 31 (89) | 21 (60) | NA | Y | 20/35 (57) | 14/35 (40) | 20/35 (57) | 14/35 (40) | NA |
Bro-Jeppesen | 2012 | 360 | 360 (100) | 116 (32) | 198 (55) | 101/122 (83) | Y | 219/360 (61) | 207/360 (58) | 219/360 (61) | 207/260 (58) | NA |
Zanuttini | 2012 | 93 | 93 (100) | 32 (34) | NA | NA | Y | 50/93 (54) | 36/93 (39) | 50/93 (54) | 36/93 (39) | NA |
Liu | 2012 | 81 | 24 (30) | 81 (100) | 49 (60) | 42/49 (86) | N | 36/81 (44) | NA | NA | NA | NA |
Zimmermann | 2013 | 48 | 48 (100) | 48 (100) | 44 (92) | 37/44 (84) | Y | 32/48 (67) | 16/48 (33) | 32/48 (67) | 16/48 (33) | NA |
Hollenbeck | 2013 | 269 | 269 (100) | 0 (0) | 122 (45) | NA | Y | 151/269 (56) | NA | 151/269 (56) | NA | NA |
Velders | 2013 | 224 | 108 (48) | 224 (100) | 217 (97) | NA | Y | 183/218 (84) | 168/218 (77) | NA | NA | NA |
Skupaj | 3655 | 1499/1804 (83) | 2012/3263 (62) | 2253/3179 (71) | 1373/1553 (88) | 2036/3384 (60) | 1158/2241 (52) | 747/1238 (60) | 452/838 (54) | 117/119 (98) |
Pubmed observational cohort studies on utilization of immediate CAG/PCI in patients with resuscitated sudden cardiac arrest (Table 1)[1,8,11-49].
According to revascularization guidelines for STEMI without preceding CA[50], CA-PCI should be primary directed towards “ACS lesions” for which we can assume direct cause-effect relationship with CA (Figure 1). The rationale is to reduce infarct size and improve hemodynamic and electrical stability. Patients who regain consciousness after return of spontaneous circulation have excellent prognosis (Table 1). Their survival is comparable or is even better that in general STEMI population without preceding CA. This may be partly explained by shorter ischemic times because of shorter patient delay. Index multi vessel and not only “culprit” PCI seems to be indicated only patients with post-resuscitation cardiogenic shock[51]. We can speculate that complete revascularization improves left ventricular function, which may facilitate survival from post-resuscitation cardiogenic shock.
Nowadays, there is a question whether we should base our revascularization strategy for patients with STEMI in post-resuscitation ECG on non-randomized observational cohort studies. We believe, based on our experience and experience of others, that it would be very difficult to perform such prospective randomized trial. On the other hand we think such trial is needed for patients without STEMI in post-resuscitation ECG. However, regardless of this, we thing patients with resuscitated cardiac arrest should be included in existing “STEMI networks” with direct transportation to the specialized “cardiac arrest centers” of excellence. Because of critical role of immediate CAG and PCI, interventional cardiologists should be an essential member of post-resuscitation team. However, when treating post CA patients we should avoid futility. In unfavorable settings of cardiac arrest (unwitnessed arrest, long delays to pre-hospital team arrival, no BLS, “non-shockable” first rhythm, long ACLS, recurrent arrest) or severe pre-arrest comorbidities, aggressive post-resuscitation treatment is not likely to result in quality survival.
P- Reviewers: Cebi N, Taguchi I, Tentzeris I S- Editor: Gou SX L- Editor: A E- Editor: Liu SQ
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