![Page 1: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/1.jpg)
Columbia University Medical CenterColumbia University Medical CenterThe Cardiovascular Research FoundationThe Cardiovascular Research Foundation
The Role of the Cardiac The Role of the Cardiac CathCath Lab FollowingLab Following
Cardiac ArrestCardiac Arrest
Ajay J. Ajay J. KirtaneKirtane, MD, SM, MD, SM
![Page 2: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/2.jpg)
Conflict of Interest DisclosureConflict of Interest Disclosure
•• Ajay J. Ajay J. KirtaneKirtane
Consultant/Honoraria/Lecture Fees from Consultant/Honoraria/Lecture Fees from Medtronic Medtronic CardioVascularCardioVascular, Abbott , Abbott Vascular, Boston Scientific, St. Jude Vascular, Boston Scientific, St. Jude Medical, Medicines CompanyMedical, Medicines CompanyAdvisor to Medtronic Advisor to Medtronic CardioVascularCardioVascular
![Page 3: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/3.jpg)
Level of Evidence for Primary PCI Level of Evidence for Primary PCI Following Resuscitated Cardiac ArrestFollowing Resuscitated Cardiac Arrest•• Virtually all randomized trials of primary Virtually all randomized trials of primary
PCI have excluded patients with cardiac PCI have excluded patients with cardiac arrestarrest
•• The majority of data is therefore The majority of data is therefore observationalobservational
•• Observational studies of cardiac arrest Observational studies of cardiac arrest are typically small, and patient selection are typically small, and patient selection (especially for invasive procedures) (especially for invasive procedures) plays a large role in outcomesplays a large role in outcomes
![Page 4: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/4.jpg)
StableStable11--2VD2VD
The Spectrum of CADThe Spectrum of CAD
DeathDeathMIMIRiskRisk
3VD3VD LMLM STEMISTEMIACSACS
![Page 5: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/5.jpg)
StableStable11--2VD2VD
The Spectrum of CADThe Spectrum of CAD
DeathDeathMIMIRiskRisk
3VD3VD LMLM STEMISTEMIACSACS
![Page 6: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/6.jpg)
The The PathophysiologyPathophysiology of AMIof AMI
Ruptured plaque with luminal and Ruptured plaque with luminal and intraplaqueintraplaqueocclusive thrombusocclusive thrombus
![Page 7: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/7.jpg)
9.3%
7.4%7.0%5.3%
0%
2%
4%
6%
8%
10%
12%
Death Death (excl shock)
Even
t rat
e
Lysis PCI
23 Randomized Trials of PCI vs. Lysis23 Randomized Trials of PCI vs. 23 Randomized Trials of PCI vs. LysisLysis
p=0.0002p=0.0002 p=0.0003p=0.0003
N = 7,739N = 7,739
KeeleyKeeley, , GrinesGrines. Lancet 2003;361:13. Lancet 2003;361:13--2020
![Page 8: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/8.jpg)
6.8%
1.0%2.0%2.5%
0.1%1.0%
0%
2%
4%
6%
8%
Reinfarction Hemorrhagic stroke Total stroke
Even
t rat
e
Lysis PCI
P<0.0001
N = 7,739N = 7,739
P<0.0001
p=0.0002
KeeleyKeeley, , GrinesGrines. . LancetLancet 2003;361:132003;361:13--2020
23 Randomized Trials of PCI vs. 23 Randomized Trials of PCI vs. LysisLysis
![Page 9: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/9.jpg)
The RIKSThe RIKS--HIA HIA RegistryRegistry
Consecutive pts admitted in 75 of Consecutive pts admitted in 75 of 78 hospitals with 78 hospitals with CCUsCCUs in Sweden in Sweden (N=26,206 (N=26,206 STEMIsSTEMIs))
StenestrandStenestrand U et al. U et al. JAMAJAMA 2006;296:17492006;296:1749--5656
Unadjusted Cumulative MortalityUnadjusted Cumulative Mortality
0
5
10
15
20
0 100 200 300 4000
5
10
15
20
0 100 200 300 400DaysDays
Cum
ulat
ive
Mor
talit
y, %
Cum
ulat
ive
Mor
talit
y, %
InIn--Hospital Hospital ThrombolysisThrombolysisPrePre--hospital hospital ThrombolysisThrombolysisPrimary PCIPrimary PCI
# at Risk# at RiskIn Hospital TLIn Hospital TL 1426014260 1232212322 1210012100 1193111931PrehospitalPrehospital TLTL 27362736 24912491 24602460 24422442Primary PCIPrimary PCI 60306030 56615661 56075607 55555555
15.9%
10.3%7.6%
![Page 10: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/10.jpg)
SHOCK TrialSHOCK Trial
7063
5647 50 55
0
20
40
60
80
30 days 6 months 12 months
Mor
talit
y (%
)
Medical stabilization Emergency revascularization
302 pts with cardiogenic shock within 36302 pts with cardiogenic shock within 36°° of AMI of AMI & ST& ST↑↑/new LBBB randomized to emergency/new LBBB randomized to emergency
revasc. (n=152) or initial medical care (n=150)revasc. (n=152) or initial medical care (n=150)
p=NS P<0.05 P<0.05
HochmanHochman J et al. J et al. NEJMNEJM
![Page 11: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/11.jpg)
0
2
4
6
8
10
0 60 120 180 240 300 360
Primary PCI: Primary PCI: Impact of Total Ischemic TimeImpact of Total Ischemic Time
Time from symptom onset to balloonTime from symptom onset to balloon
1 ye
ar m
orta
lity
1 ye
ar m
orta
lity
De Luca G et al. De Luca G et al. CircCirc 2004;109:12232004;109:1223--55
N=1791 STEMI ptsN=1791 STEMI pts5.8% 1 year mortality5.8% 1 year mortalityQuadratic regressionQuadratic regression
RR for 1RR for 1--year mortality for each 30 minute year mortality for each 30 minute delay of 1.08 [1.01 to 1.15], delay of 1.08 [1.01 to 1.15], p=0.041p=0.041
Y=2.86 (+1.46) + 0.0045XY=2.86 (+1.46) + 0.0045X11 + 0.000043X+ 0.000043X22
p<0.001p<0.001
![Page 12: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/12.jpg)
Impact of Patient Risk on the Relationship Impact of Patient Risk on the Relationship Between DBT and MortalityBetween DBT and Mortality
2300 pts undergoing primary PCI (Moses Cone)2300 pts undergoing primary PCI (Moses Cone)
BrodieBrodie BR et al. BR et al. JACCJACC 2006;47:2892006;47:289––9595
High risk = High risk = KillipKillip class 3/4, age >70 years, or anterior infarctionclass 3/4, age >70 years, or anterior infarction
Car
diac
Sur
viva
l %C
ardi
ac S
urvi
val %
YearsYears
p<0.0001p<0.0001
00--1.41.41.51.5--1.91.92.02.0--2.92.9>>3.03.0
High Risk PatientsHigh Risk Patients
DoorDoor--toto--Balloon Time (hrs)Balloon Time (hrs)
(n=1,307)(n=1,307)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11
Car
diac
Sur
viva
l %C
ardi
ac S
urvi
val %
YearsYears
p=0.54p=0.5400--1.41.41.51.5--1.91.92.02.0--2.92.9>>3.03.0
Low Risk PatientsLow Risk Patients
DoorDoor--toto--Balloon Time (hrs)Balloon Time (hrs)
(n=993)(n=993)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11
![Page 13: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/13.jpg)
NRMI: Multivariate Adjusted Impact of Incremental NRMI: Multivariate Adjusted Impact of Incremental PCI Delay Stratified by Age, MI Location PCI Delay Stratified by Age, MI Location
and Presentation Delayand Presentation Delay
Pinto DS et al. Circulation 2006;114:2019-2025
PCI R
elat
ed D
elay
(DB
-DN
) Whe
rePC
I and
Fib
rono
lytic
Mor
talit
y A
re E
qual
(Min
)
Non Ant MI65+ YRS
Ant MI65+ YRS
Non Ant MI
<65 YRS
Ant MI<65 YRS
0-120 PrehospitalDelay (min)
121+
0
60
120
180
168 20,424
1079,812
5841,774 40
19,517
435,296
10316,119
1483,739
17910,614
192,509 ptsat 645 hospitals
![Page 14: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/14.jpg)
Distal Protection and Distal Protection and ThrombectomyThrombectomyin AMIin AMI
Macroscopic embolic debris can be Macroscopic embolic debris can be retrieved from >75% of casesretrieved from >75% of cases
![Page 15: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/15.jpg)
16.2
9.87.5
18.3
12.515
0
5
10
15
20
25
Emerald (n=501) AIMI (n=480) K altoft et al (n=225)
Infa
rct size
(%
LV)
C ontrol (N=208)Dis tal protec tion or thrombectomy
AMI:AMI: Attempts to Decrease Infarct SizeAttempts to Decrease Infarct SizeHave been mostly met with frustrationHave been mostly met with frustration
The concept of reducing embolic loadThe concept of reducing embolic load
Stone GW et al. Stone GW et al. JAMAJAMA 20052005
Distal protectionDistal protection(GuardWire Plus)(GuardWire Plus)
Passive thrombus Passive thrombus aspiration (Rescue)aspiration (Rescue)
Active thrombectomy Active thrombectomy (AngioJet)(AngioJet)
Ali A et al. Ali A et al. JACCJACC 20062006 Kaltoft A et al. Kaltoft A et al. JAMAJAMA 20052005
P=0.26P=0.018 P=0.004
![Page 16: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/16.jpg)
RCA Occlusion (Inferior STEMI)RCA Occlusion (Inferior STEMI)
![Page 17: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/17.jpg)
Direct Stent ImplantationDirect Stent Implantation
![Page 18: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/18.jpg)
Final AngiogramFinal Angiogram
![Page 19: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/19.jpg)
StableStable11--2VD2VD
The Spectrum of CADThe Spectrum of CAD
DeathDeathMIMIRiskRisk
3VD3VD LMLM STEMISTEMIACSACS
![Page 20: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/20.jpg)
Mehta SR et al. Mehta SR et al. JAMAJAMA 2005;293:29082005;293:2908--29172917
SourceSourceRoutine Routine invasiveinvasive
Selective Selective invasiveinvasive
TIMI IIIBTIMI IIIB 86/740 (11.6)86/740 (11.6) 101/733 (13.8)101/733 (13.8)VANQWISHVANQWISH 152/462 (32.9)152/462 (32.9) 139/458 (30.3)139/458 (30.3)MATEMATE 16/111 (14.4)16/111 (14.4) 11/90 (12.2)11/90 (12.2)FRISC IIFRISC II 127/1222 (10.4)127/1222 (10.4) 174/1235 (14.1)174/1235 (14.1)TACTICSTACTICS 81/1114 (7.3)81/1114 (7.3) 105/1106 (9.5)105/1106 (9.5)VINOVINO 4/64 (6.3)4/64 (6.3) 15/67 (22.4)15/67 (22.4)RITARITA 95/895 (10.6)95/895 (10.6) 118/915 (12.9)118/915 (12.9)TotalTotal 561/4608 (12.2)561/4608 (12.2) 663/4604 (14.4)663/4604 (14.4)
Favors RoutineInvasive
Favors SelectiveInvasive
OR, 0.82[0.72-0.93]
P<0.001
0.1 1.0 10
MetaMeta--analysis of Conservative vs. analysis of Conservative vs. Invasive Strategies in ACSInvasive Strategies in ACS
9,212 randomized pts in 7 trials9,212 randomized pts in 7 trials
Composite death or MI from rand to latest FUComposite death or MI from rand to latest FU
18%18%⇓⇓
![Page 21: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/21.jpg)
TIMI IIIBTIMI IIIBTIMI IIIB
9 Randomized Trials9 Randomized TrialsN=10,412N=10,412
ConservativeConservative(N=920)(N=920)
InvasiveInvasive(N=6618)(N=6618)
VANQWISHVANQWISHVANQWISHMATEMATEMATE
FRISC IIFRISC IIFRISC II
TACTICS-TIMI 18
TACTICSTACTICS--TIMI 18TIMI 18
VINOVINOVINO
RITA-3RITARITA--33
TRUCS TRUCS TRUCS
Optimal Strategy for ACSOptimal Strategy for ACS
N=2874N=2874
ICTUSICTUSICTUS
c/o Chris Cannon
![Page 22: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/22.jpg)
When to Take a Patient to the LabWhen to Take a Patient to the Lab
Mehta et al, NEJM 2009
![Page 23: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/23.jpg)
Mehta et al, NEJM 2009
![Page 24: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/24.jpg)
Mehta et al, NEJM 2009
![Page 25: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/25.jpg)
Mehta et al, NEJM 2009
![Page 26: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/26.jpg)
StableStable11--2VD2VD
The Spectrum of CADThe Spectrum of CAD
DeathDeathMIMIRiskRisk
3VD3VD LMLM STEMISTEMIACSACS
![Page 27: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/27.jpg)
There is a Wide-Range of Morbidity/Mortality among “Stable Angina” Patients
Hachamovitch et al, Circulation 2003;107:2900-07
% Total Ischemic Myocardium
0% 1- 5% 5-10% 11-20% >20%
Car
diac
Dea
th R
ate
(%)
(1.9
yr F
U)
N=7110 N=1331 N=718 N=545 N=252
N=9,956 pts
5.4% cardiac mortality in 1.9 years -
Is this “stable” angina?
![Page 28: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/28.jpg)
6.7%
3.7%3.3%
1.0%
2.9%
4.8%
1.8% 2.0%
0%
2%
4%
6%
8%
10% Medical RxRevasc
Mitigated Gradient with Revascularization
% Total Ischemic Myocardium1- 5% 5-10% 11-20% >20%
Car
diac
Dea
th R
ate
1331 56 718 109 545 243 252 267
P <.0001
Hachamovitch et al Circulation. 2003; 107:2900-2907.
![Page 29: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/29.jpg)
0.0%
15.6%
22.3%
39.3%
0%
10%
20%
30%
40%
Dea
th o
r MI R
ate
(%)
Rates of Death or MI by ResidualRates of Death or MI by ResidualIschemia on 6Ischemia on 6--18m MPS18m MPS
p=0.002p=0.002
0%(n=23)
p=0.023p=0.023
p=0.063p=0.063
1%-4.9%(n=141)
5%-9.9%(n=88)
>10%(n=62)
Shaw, et al, AHA 2007 and Circulation 2008
![Page 30: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/30.jpg)
Revascularization: The Bottom LineRevascularization: The Bottom Line•• Revascularization improves prognosis Revascularization improves prognosis
(hard clinical endpoints) in:(hard clinical endpoints) in:STEMI (timeSTEMI (time--dependent)dependent)NSTACS (moderately timeNSTACS (moderately time--dependent)dependent)Stable CAD with high ischemic burden (less Stable CAD with high ischemic burden (less timetime--dependent)dependent)
•• Prompt revascularization therefore Prompt revascularization therefore has the potential to improve has the potential to improve outcomes in appropriately selected outcomes in appropriately selected patients with cardiac arrest!!patients with cardiac arrest!!
![Page 31: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/31.jpg)
Etiologies of Cardiac ArrestEtiologies of Cardiac Arrest•• Coronary Heart Disease (>65%)Coronary Heart Disease (>65%)
Coronary Occlusion (Coronary Occlusion (↑↑frequent on autopsy)frequent on autopsy)ArrhythmiaArrhythmiaPump DysfunctionPump Dysfunction
•• Structural Heart Disease (10%)Structural Heart Disease (10%)Valvular DiseaseValvular DiseaseHOCMHOCMCoronary AnomaliesCoronary Anomalies
•• Other: Takotsubo, Primary Arrhythmias, etcOther: Takotsubo, Primary Arrhythmias, etc•• NonNon--cardiac / metabolic abnormalities (30%?)cardiac / metabolic abnormalities (30%?)
![Page 32: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/32.jpg)
Diagnoses in 72 Pts with Cardiac Arrest Diagnoses in 72 Pts with Cardiac Arrest Undergoing Routine CatheterizationUndergoing Routine Catheterization
Anyfantakis et al, Am Heart J 2009
PCI performed in one-third of patients
![Page 33: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/33.jpg)
Use and Utility of Angiography afterUse and Utility of Angiography afterInIn--Hospital VF ArrestHospital VF Arrest
•• Of 110 patients with confirmed VFOf 110 patients with confirmed VF--arrest at a major US academic hospital, arrest at a major US academic hospital, only 30 (27%) received angiography only 30 (27%) received angiography within 1 day of the arrestwithin 1 day of the arrest•• Less than half had STEMI or new LBBBLess than half had STEMI or new LBBB•• More than half underwent PCIMore than half underwent PCI
•• Performance of angiography has been Performance of angiography has been associated with increased survival (but associated with increased survival (but this association is quite confounded)this association is quite confounded)
Merchant et al, Resuscitation 2008Werling et al, Resuscitation 2007
![Page 34: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/34.jpg)
A Case for Immediate Angiography forA Case for Immediate Angiography forSurvivors of OutSurvivors of Out--ofof--Hospital ArrestHospital Arrest•• 85 (selected) patients with no obvious 85 (selected) patients with no obvious
nonnon--cardiac cause of arrestcardiac cause of arrest•• Coronary occlusions seen in 48% of ptsCoronary occlusions seen in 48% of pts•• Clinically significant CAD in 71% of ptsClinically significant CAD in 71% of pts•• Mean LVEF 34%Mean LVEF 34%•• 38% Survival; predictors were:38% Survival; predictors were:
No need for inotropes on transportNo need for inotropes on transportSuccessful angioplastySuccessful angioplastyShorter time from arrest to presentationShorter time from arrest to presentation
Spaulding et al, NEJM 2007
![Page 35: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/35.jpg)
History
MarkersEKG
Problems with the Diagnosis of Problems with the Diagnosis of Ischemic CAD in Arrest PatientsIschemic CAD in Arrest Patients
Often Difficult to Obtain
Too LongTo Wait!
Often abnormalin post-arrest setting
![Page 36: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/36.jpg)
Diagnostic Dilemmas in Cardiac ArrestDiagnostic Dilemmas in Cardiac ArrestImmediate post-arrest EKG
![Page 37: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/37.jpg)
Diagnostic Dilemmas in Cardiac ArrestDiagnostic Dilemmas in Cardiac ArrestAfter ventilation/sodium bicarbonate (3 min later)
![Page 38: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/38.jpg)
Diagnostic Dilemmas in Cardiac ArrestDiagnostic Dilemmas in Cardiac Arrest35 minutes after initial EKG
![Page 39: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/39.jpg)
Diagnostic Dilemmas in Cardiac ArrestDiagnostic Dilemmas in Cardiac Arrest4 hours post-arrest
![Page 40: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/40.jpg)
Diagnostic Dilemmas in Cardiac ArrestDiagnostic Dilemmas in Cardiac ArrestThe next morning (12 hours post-arrest)
![Page 41: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/41.jpg)
Müller et al, Ann Emerg Med 2008
MI at MI at DischargeDischarge
No MI at No MI at DischargeDischarge
ST Elevation on ST Elevation on Admission EKGAdmission EKG 37 3 40
No ST Elevation on No ST Elevation on EKGEKG 11 24 35
48 27 77
Ability of 12Ability of 12--lead EKG to Diagnose lead EKG to Diagnose STEMI after Resuscitated ArrestSTEMI after Resuscitated Arrest
Out of hospital EKG: PPV 88% and NPV 69%Sensitivity 77% and Specificity 83%
![Page 42: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/42.jpg)
Summary of PCI Outcomes DataSummary of PCI Outcomes Data•• Studies of primary PCI for STEMI after Studies of primary PCI for STEMI after
resuscitated cardiac arrest:resuscitated cardiac arrest:•• 7 studies, 458 patients; successful 7 studies, 458 patients; successful
PCI in 89%PCI in 89%•• 66% survival, 58% neuro recovery66% survival, 58% neuro recovery•• Lower survival / recovery in Lower survival / recovery in
comatose patientscomatose patients•• PCI also performed in 34 patients PCI also performed in 34 patients
undergoing active resuscitationundergoing active resuscitation•• 88% success, 41% survival88% success, 41% survival
Noc and Radsel, Curr Op Crit Care 2008
![Page 43: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/43.jpg)
PCI for STEMI after ResuscitationPCI for STEMI after Resuscitation
Gorjup et al, Resuscitation 2007
![Page 44: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/44.jpg)
OROR 95% CI95% CI
Time from Arrest to 1Time from Arrest to 1stst
Responder (per min)Responder (per min) 0.67 0.54-0.84
ROSC time (per 10 min)ROSC time (per 10 min) 0.43 0.25-0.66
Absence of ShockAbsence of Shock 12.66 3.39-47.62
Absence of DiabetesAbsence of Diabetes 7.30 1.80-29.41
Absence of prior PCIAbsence of prior PCI 10.99 1.65-71.43
Correlates of 6Correlates of 6--Month Survival in STEMI Month Survival in STEMI Patients With Cardiac ArrestPatients With Cardiac Arrest
Garot et al, Circulation 2007
186 PCI patients; overall survival 54%
![Page 45: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/45.jpg)
Outcomes in STEMI Patients with Outcomes in STEMI Patients with Cardiac Arrest (n=98)Cardiac Arrest (n=98)
96% 96%93%
71%
44% 39%
0
25
50
75
100
Alert (n=25)Minimally Responsive (n=14)Unresponsive (n=59)
Survival Full Neurologic Recovery
Hosmane et al, JACC 2009
![Page 46: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/46.jpg)
OROR 95% CI95% CI pp
Neurologic StatusNeurologic Status
AlertAlert - - -
Min ResponsiveMin Responsive 2.1 0.1-68.1 0.69
UnresponsiveUnresponsive 47.8 3.3-549.1 0.004ROSC time (per 10 min)ROSC time (per 10 min) 2.8 1.5-5.7 0.002Age (per 5Age (per 5--yr)yr) 1.3 1.1-1.7 0.009Female GenderFemale Gender 5.9 1.2-30.1 0.034
Correlates of Death in STEMI Patients Correlates of Death in STEMI Patients Following Cardiac Arrest (n=98)Following Cardiac Arrest (n=98)
Hosmane et al, JACC 2009
Patients arresting in ED had better survival and neurologic recovery than out-of-hospital arrest patients
![Page 47: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/47.jpg)
Combining Hypothermia and PCI for Combining Hypothermia and PCI for Cardiac Arrest Patients with STEMICardiac Arrest Patients with STEMI•• Can be accomplished with minimal Can be accomplished with minimal
increases in doorincreases in door--balloon timesballoon times•• Requires regimented protocols and buyRequires regimented protocols and buy--
in / cooperation between ED, Cath Lab, in / cooperation between ED, Cath Lab, ICU units / staffICU units / staff
•• No differences in inNo differences in in--hospital hospital complications with a trend toward complications with a trend toward improved outcomes (vs. historical improved outcomes (vs. historical controls in 3 published studies)controls in 3 published studies)
Wolfrum et al, Crit Care Med 2008Knafelj et al, Resuscitation 2007Sunde et al, Resuscitation 2007
![Page 48: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/48.jpg)
“COOL-IT” Outcomes
Abbott Northwestern Hospital 53/96 55.2%
• Survival by initial rhythm– VF/VT: 47/75 62.6%– PEA/Asystole: 5/19 26.3%
• Survival by diagnosis
– Other: 20/46 43.5%– STEMI: 33/50 66.0%
Alive at hospital discharge with favourable neurological recovery
Mooney, TCT 2008
![Page 49: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/49.jpg)
CPC Comparison
42.1%
2.6%
13.2%
42.1%
50.0%
10.0%
2.5%
37.5%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
CPC 1 CPC 2 CPC 3 Death
% o
f pat
ient
s
Pre n=38Post n=40
Pre and Post Cool-It program
Mooney, TCT 2008
![Page 50: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/50.jpg)
COOLCOOL--MI MI –– A Negative TrialA Negative Trial•• Preliminary data has suggested that Preliminary data has suggested that
systemic cooling has the potential to systemic cooling has the potential to reduce infarct size (animal models of reduce infarct size (animal models of ischemia/reperfusion)ischemia/reperfusion)
•• Endovascular cooling to 33Endovascular cooling to 33ºº for 3 hrs was for 3 hrs was tested in a 357 patient randomized trialtested in a 357 patient randomized trial
•• 94% of patients tolerated the cooling94% of patients tolerated the cooling•• No difference in SPECTNo difference in SPECT--measured infarct measured infarct
size, ?possible trends in anterior size, ?possible trends in anterior infarctioninfarction
O’Neill et al, TCT 2003
![Page 51: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/51.jpg)
What About What About FibrinolyticFibrinolytic TherapyTherapy(post(post--TROICA)?TROICA)?
•• Riskier to implement many successful Riskier to implement many successful hemodynamichemodynamic diagnostic / therapeutic diagnostic / therapeutic maneuvers after maneuvers after lyticslytics are givenare given
•• Worries about use in cardiac arrest Worries about use in cardiac arrest patients (particularly prolonged CPR)patients (particularly prolonged CPR)
•• In a nonIn a non--randomized study of 147 STEMI randomized study of 147 STEMI patients with VF arrest (101 treated with patients with VF arrest (101 treated with fibrinolysisfibrinolysis and 47 treated wit primary and 47 treated wit primary PCI), there were similar outcomes with PCI), there were similar outcomes with both strategies, which is reassuringboth strategies, which is reassuring
Richling et al, Am J Emerg Med 2007
![Page 52: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/52.jpg)
PCI During Cardiac Arrest
• Gas-driven sternalcompression device with suction cup (LUCAS)• PCI feasible in 13 pts with arrest or severe hypotension / bradycardia; mean BP 81/34 mmHg
Larsen et al, Resuscitation 2007
![Page 53: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/53.jpg)
PCI Using PCI Using HemodynamicHemodynamic Support Support
Ao Tracing
Impella 2.5 Device duringLMCA Dissection
![Page 54: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/54.jpg)
Cardiac Cardiac CathCath Lab Lab ≠≠ Always a Always a StentStent!!!!!!•• Distinction between diagnostic and Distinction between diagnostic and
interventional interventional cathcath proceduresprocedures•• Diagnostic:Diagnostic:
HemodynamicHemodynamic evaluationevaluation•• Right heart catheterization / shunt evaluationRight heart catheterization / shunt evaluation•• Left heart catheterizationLeft heart catheterization•• Simultaneous LV/PCWP, LV/RVSimultaneous LV/PCWP, LV/RV
Left Left ventriculographyventriculography (ability to identify (ability to identify structural defects)structural defects)Coronary angiographyCoronary angiographyAortographyAortography
![Page 55: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/55.jpg)
Cardiac Cardiac CathCath Lab Lab ≠≠ Always a Always a StentStent!!!!!!•• Interventional Procedures:Interventional Procedures:
PercutaneousPercutaneous coronary interventioncoronary interventionIABP, IABP, hemodynamichemodynamic supportsupport•• TandemHeartTandemHeart•• ImpellaImpella
PressorPressor/Vasodilator titration/Vasodilator titrationTemporary pacemaker (Ventricular, Temporary pacemaker (Ventricular, CS/Ventricular)CS/Ventricular)PericardiocentesisPericardiocentesisPulmonary Pulmonary EmbolectomyEmbolectomyRapid access to other subspecialtiesRapid access to other subspecialties•• EP, CHF Team, CT SurgeryEP, CHF Team, CT Surgery
![Page 56: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/56.jpg)
SummarySummary•• A significant proportion of patients with A significant proportion of patients with
cardiac arrest (especially VT/VF) have cardiac arrest (especially VT/VF) have coronary occlusion or significant coronary occlusion or significant coronary artery diseasecoronary artery disease
•• There are clear data supporting primary There are clear data supporting primary PCI for STEMI (acute coronary PCI for STEMI (acute coronary occlusion), a major cause of VT/VFocclusion), a major cause of VT/VF
•• Cardiac catheterization has other Cardiac catheterization has other benefits, including making a diagnosis / benefits, including making a diagnosis / further triage / further triage / hemodynamichemodynamic supportsupport
![Page 57: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/57.jpg)
Summary (2)Summary (2)•• An early invasive strategy is preferred for An early invasive strategy is preferred for
patients with nonpatients with non--STST--elevation acute elevation acute coronary syndromes, but the timing may coronary syndromes, but the timing may be less urgentbe less urgent
•• Patients with significant Patients with significant ““stable ischemic stable ischemic CADCAD”” can benefit from revascularization, can benefit from revascularization, typically on an urgent / elective basistypically on an urgent / elective basis
•• The key question is whether all (or The key question is whether all (or selected) cardiac arrest patients should selected) cardiac arrest patients should undergo emergent angiography and/or undergo emergent angiography and/or PCI if indicatedPCI if indicated
![Page 58: Primary PCI after Cardiac Arrest - EMCrit PCI after Cardiac... · Anyfantakis et al, Am Heart J 2009 PCI performed in one-third of patients. Use and Utility of Angiography after In-Hospital](https://reader033.vdocuments.mx/reader033/viewer/2022051720/5a7600b67f8b9a63638ceee8/html5/thumbnails/58.jpg)
ConclusionsConclusions•• Integrated systems of care are being Integrated systems of care are being
implemented with success for patients implemented with success for patients with STEMI (primary PCI) as well as for with STEMI (primary PCI) as well as for cardiac arrest patients (hypothermia cardiac arrest patients (hypothermia protocols)protocols)
•• The overlap between these two areas is The overlap between these two areas is significant, and it makes sense to significant, and it makes sense to coordinate effortscoordinate efforts
•• Angiography / catheterization is likely Angiography / catheterization is likely underutilized in arrest patients and ought underutilized in arrest patients and ought to be considered 1to be considered 1stst line care for VT/VFline care for VT/VF