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Three Part Question

In [adult patients without ST-elevation on the electrocardiogram after a cardiac arrest] does [the addition of an early percutaneous coronary intervention to therapeutic hypothermia] improve [survival]?

Clinical Scenario

A 64 years old woman is suddenly unresponsive and pulseless. A few minutes after prompt cardiopulmonary resuscitation initiation by her husband, the paramedics arrive on site. Defibrillation is performed twice with an external defibrillator. Return of spontaneous circulation is achieved but she stays unconscious. On emergency department arrival, her vital signs are stable and she is normothermic. The electrocardiogram is not showing any ST-elevation. You decide to put this patient on therapeutic hypothermia. You ask yourself if a coronary angiography with or without percutaneous coronary intervention could improve her chances of survival.

Search Strategy

No bestbet was found on this topic.

MEDLINE (using PUBMED 1966 to November week 3, 2013), EMBASE (1980 to 2013 week 45) and Cochrane library were searched for relevant articles.

Medline: (angioplasty, balloon, coronary[MeSH] OR heart catheterization[MeSH] OR balloon dilation, coronary artery[MeSH] OR percutaneous coronary intervention) AND (heart arrest[MeSH] OR cardiac arrest)) AND mortality

EMBASE: ('percutaneous coronary intervention'/exp OR 'transluminal coronary angioplasty'/exp OR 'heart catheterization'/exp) AND ('heart arrest'/exp OR 'sudden cardiac death'/exp OR 'cardiac arrest') AND mortality

Cochrane library: ('heart catheterization' OR percutaneous coronary intervention' OR 'coronary angioplasty') AND ('cardiac arrest' OR 'heart arrest')

Search Outcome

Four hundred and seventy-nine articles were found with Medline, 411 with Embase and 38 with the Cochrane library. Studies reporting survival data for post-cardiac arrest patients without ST-elevation who received a coronary angiography are presented in this review. Most studies were excluded because survival data were not stratified for the presence or the absence of ST-elevation on the electrocardiogram. Two retrospective observational studies were included and are summarized in the table. No further articles were found by scanning the references of relevant papers.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hollenbeck RD, et al. 2014 USA	Total: 754 comatose patients treated with therapeutic hypothermia following out-of-hospital cardiac arrest; Initial VT/VF without STEMI: 269; Initial VT/VF without STEMI who received early coronary angiography: 122.	Retrospective observational study of a prospective cohort from 2005 to 2011	Mortality	Improved survival with early coronary angiography (66.5% vs 48.6%; p=0.017)	Retrospective observational study; No standardized protocol to select eligible post-cardiac arrest patients for application of therapeutic hypothermia or coronary angiography.
			Cerebral performance category scale (CPC)	Improved neurological outcome (CPC 1 or 2) with early coronary angiography (60.7% vs 44.5%; p=0.017)
Bro-Jeppesen J, et al. 2012 Denmark	Total: 479 out-of-hospital cardiac arrest of suspected cardiac cause; Without STEMI: 279; Without STEMI who received coronary angiography: 82.	Retrospective observational study of prospective cohort from 2004 to 2010	Mortality	No diminution of mortality with early coronary angiography (66% vs 54%; p= 0.11)	Single center retrospective study; No standardized protocol to select eligible post-cardiac arrest patients for therapeutic hypothermia or coronary angiography.
			Cerebral performance category scale (CPC)	Early coronary angiography not associated with better neurologic outcome (CPC 1 or 2) (100% vs 90%; p=0.14)

Comment(s)

In a previous study, a significant number of occlusive lesions were found on coronary angiographies performed on post-cardiac arrest patients despite the absence of the classic ST-elevation on the electrocardiogram (Larsen et al. 2012). This raises the question whether all patients without STEMI should have an early coronary angiography with or without percutaneous coronary intervention after a cardiac arrest of a presumed cardiac aetiology. Moreover, a recent retrospective observational study showed that a successful PCI was associated with markedly reduced mortality compared with failed PCI in a population of post-cardiac arrest patients without ST-elevation on the electrocardiogram (Dumas et al. 2010). The two studies included in our review were looking at the mortality and the neurologic outcome using early coronary angiography but they are observational in nature, so the results should be interpreted with caution. - Larsen JB, Ravkilde J. Acute coronary angiography in patients resuscitated from out-of-hospital cardiac arrest—A systematic review and meta-analysis. Resuscitation. 2012;83:1427–33. - Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, Empana JP, Carli P, Mira JP, Jouven X, Spaulding C. Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT registry. Circ Cardiovasc Interv. 2010;3(3):200-7.

Editor Comment

BF

Clinical Bottom Line

Studies showed conflicting results about the benefit of early coronary angiography in association with therapeutic hypothermia for patients without ST-elevation on the electrocardiogram after a cardiac arrest. A multicenter, prospective, randomized study is required to evaluate the potential benefits on mortality and morbidity of this procedure for this specific population. Our review has highlighted an important area for further research on post-cardiac arrest management in patients without ST-elevation on there electrocardiogram.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Hollenbeck RD, McPherson JA, Mooney MR, Unger BT, Patel NC, McMullan PW Jr, Hsu CH, Seder DB, Kern KB. Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI Resuscitation 2014 Jan;85(1):88-95.
2. Bro-Jeppesen J, Kjaergaard J, Wanscher M, Pedersen F, Holmvang L, Lippert FK, Møller JE, Køber L, Hassager C. Emergency coronary angiography in comatose cardiac arrest patients: do real-life experiences support the guidelines? European Heart Journal Acute Cardiovascular Care 2012;1(4):291-301.