Angiography Urged in All Resuscitated Out-of-Hospital Arrest

BRISBANE, AUSTRALIA — Authors of a new review are calling for more routine use of coronary angiography among patients with resuscitated out-of-hospital cardiac arrest (OHCA), saying that relying on ECG alone may cost lives^[1].

Dr Anthony Camuglia (University of Queensland, Brisbane, Australia) and colleagues publish their review and meta-analysis in the November 2014 issue of Resuscitation showing that in OHCA patients—a group with what Camuglia termed "notoriously poor prognosis"—survival was nearly doubled among those who underwent acute angiography as compared with patients not treated with urgent angiography. Survival with good neurological outcome, a secondary end point in the analysis, was also almost twice as high among patients who got angiograms to determine whether or not urgent revascularization was warranted.

To heartwire , Camuglia explained that postresuscitation ECG is the typical screening method used in OHCA patients, but "ECG is imperfect at defining a coronary syndrome as the cause for arrest and cannot be relied on to define who will benefit from early angiography, especially for left circumflex occlusion/subtotal occlusion."

Camuglia et al's analysis considered 105 full-text articles, of which 50 included "adequate outcome information" according to whether or not patients had undergone timely coronary angiography, 15 contained a comparison of early angiography vs no early angiography, and none were randomized. Survival was defined as in-hospital unless that information was unavailable, in which case 30-day or 6-month outcomes were used.

As reported in the paper, overall survival among OHCA patients who underwent an early invasive cardiac assessment was 58.8% vs 30.9% (odds ratio 2.77, 95% CI 2.06–3.72). Similarly, survival with good neurological outcome was 58% in the early-invasive-assessment group, as compared with 35.8% in the control group.

The current ACC/AHA guidelines for STEMI in the setting of OHCA give immediate coronary angiography and PCI a class I recommendation, so long as an initial ECG indicates STEMI. The problem, write the authors, is that ECG may not be the best gatekeeper for identifying patients who could benefit. In one series, they write, ECG found no ST-elevation in 16.4% of OHCA patients who in fact had a vessel with TIMI 2 flow or less and in 32% of patients who had culprit lesions with 70% stenosis or greater. In this same study, they continue, one in 10 patients had an acute lesion with TIMI flow 0.

As such, write the authors, "the 12-lead ECG should not be solely relied upon to exclude acute epicardial coronary artery thrombosis, because of its relatively low sensitivity for detecting acute arterial occlusion in this patient population."

There are no randomized trials assessing the role of angiography in OHCA patients, and such trials are unlikely, Camuglia et al write. "Based on available data, a routine early acute invasive strategy in this patient population (especially for patients with STEMI) is reasonable where ACS is suspected."

Commenting on the study for heartwire by email, Dr Bruce Adams (University of Texas Health Sciences Center, San Antonio) said early cardiac catheterization in post–cardiac-arrest patients is not widely utilized at this point, "but it sure should be."

He said too often the cardiologists wait for neurological recovery or STEMI on the ECG, instead of taking certain patients into the lab based solely on clinical grounds. For example, a patient with electrical storm without obvious STEMI should probably be aggressively cathed, he said. "There is an important emerging effort to regionalize care of cardiac-arrest victims—just as we do for trauma, STEMI, and stroke now."

Minnesota and Arizona are leaders in the US in these efforts, he added.

Camuglia, likewise, observed that "the French are really at the cutting edge in this area in terms of clinical implementation and have adopted routine immediate coronary angiography for all comatose survivors of OHCA regardless of whether there is a STEMI pattern on postresuscitation ECG in many centers," including most of Paris.

Camuglia and coauthors and Adams report they have no relevant financial relationships .

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