after cardiac arrest: emergency coronary angiography for all?

After cardiac arrest: emergency coronary angiography for all?

Giuseppe Biondi-Zoccai, MD

Sapienza University of Rome, Italygiuseppe.biondizoccai@uniroma1.it

Learning goals

• Scope of the problem• Rationale for emergency coronary

angiography• When perusing it• What does it entail• Case study

Learning goals

• Scope of the problem• Rationale for emergency coronary

angiography• When perusing it• What does it entail• Case study

Cardiac arrest has dismal prognosis

Yonemoto et al, Circulation 2011

Difficult to appraise neurologic status shortly after cardiac arrest

Booth et al, JAMA 2004

LR(+) = sensitivity / (1 – specificity) useful if >10 LR (-) = (1 – sensitivity) / specificity useful if <0.1

Coronary angiography after OHCA remains underused

Aufderheide et al, Lancet 2011

Learning goals

• Scope of the problem• Rationale for emergency coronary

angiography• When perusing it• What does it entail• Case study

Coronary occlusions are common

Spaulding et al, New Engl J Med 1997

Systematic invasive management may be beneficial

Dumas et al, Circ Cardiovasc Interv 2010

Systematic invasive management may be beneficial

Dumas et al, Circ Cardiovasc Interv 2010

Systematic invasive management may be beneficial

Dumas et al, Circ Cardiovasc Interv 2010

Learning goals

• Scope of the problem• Rationale for emergency coronary

angiography• When perusing it• What does it entail• Case study

Even without ST-elevation or new LBBB

Spaulding et al, N Engl J Med 1997; Dumas et al, Circ Cardiovasc Interv 2010

Troponin is not very useful either, but…

Dumas et al, Crit Care Med 2012

…if you wish to pinpoint patients

Primary predictive model for coronary occlusion after OHCA: 1st dose of adrenaline <2 mg (OR=2), smoking (OR=2.0), VF/VT as initial rhythm

(OR=1.7); other predictors were cTnI >4.7 ng/mL (OR=3.6), ↑ST (OR=10.2)

Dumas et al, Crit Care Med 2012

Learning goals

• Scope of the problem• Rationale for emergency coronary

angiography• When perusing it• What does it entail• Case study

Decision to cath must be made ASAP

Strote et al, Am J Cardiol 2002

Radial access is paramount

Agostoni et al, J Am Coll Cardiol 2004

Hypothermia is recommended

Bernard et al, N Engl J Med 2002; Holzer et al, New Engl J Med 2002

May be combined with brain CT

Chelly et al, Resuscitation 2002

Learning goals

• Scope of the problem• Rationale for emergency coronary

angiography• When perusing it• What does it entail• Case study

Case studyAge: 40 yearsGender: maleComorbidities: type 1 diabetes mellitusDiagnosis: acute myocardial infarction Prehospital events/management: VF treated with DC shock, followed by PEA; manual chest compression, repeat IV adrenaline boluses, tracheal intubation, mechanical ventilationHospital events/management: systemic thrombolysis with alteplase attempted without success; LUCAS deployment and…

Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011

Baseline coronary angiography

Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011

Predilation on left main-circumflex

Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011

Left main-anterior descending stenting

Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011

Coronary angiography after stenting

Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011

Take home messages• Patients achieving ROSC after OHCA should be

thoroughly appraised for non-cardiac conditions.• Emergent coronary angiography is

recommended routinely unless prognosis is very dire.

• Emergent coronary angiography can be considered in very selected cases before ROSC if patient/procedural features suggest reasonable likelihood of ROSC.

Many thanks for your attention

For these slides and further ones on similar topics feel free to visit:

www.metcardio.org/slides.html

For additional details or queries feel free to contact me directly:

giuseppe.biondizoccai@uniroma1.it