Cardiology Corner: Post-Arrest Cardiac Catheterization
Anand Swaminathan MD and Amal Mattu MD
Take Home Points
- Guidelines recommend that patients with ROSC post-cardiac arrest and non-STEMI go to the catheterization lab if there is hemodynamic or electric instability.
- The COACT trial found no difference in mortality at 90 days when comparing immediate to delayed catheterization.
- The study had some limitations and patients with poor neurologic outcome or who did not survive to catheterization may have biased the outcome.
- The patient population appeared healthier than in the US.
- Cardiac catheterization after cardiac arrest. We have known for a long time that the patient should go immediately to the catheterization lab if there is STEMI post-ROSC. But what if the post-arrest does not show STEMI?
- We know based on the 2013 STEMI guidelines that we should send patients with post-arrest STEMI to the catheterization lab. There is still some controversy about this but the general consensus is that they should go for catheterization as quickly as possible.
- In 2014, the non-ST elevation/ACS guidelines published by the ACC/AHA listed a Class Ia recommendation for immediate invasive strategy within two hours in any patient with hemodynamic or electrical instability. You can’t get a higher recommendation than this.
- What is the hallmark of hemodynamic instability? Cardiac arrest. What is the hallmark of electrical instability? Ventricular fibrillation or pulseless ventricular tachycardia.
- Rab, T et al. Cardiac arrest: a treatment algorithm for emergent invasive cardiac procedures in the resuscitated comatose patient. J Am Coll Cardiol. 2015 Jul 7;66(1):62-73. DOI: 10.1016/j.jacc.2015.05.009
- In this article, there was an algorithm that recommended cooling and catheterization in a post-arrest patient with STEMI. If there was a post-arrest non-ST elevation patient, they should be cooled and you should discuss catheterization with your cardiologist. They recommend discussing unfavorable resuscitation features; unwitnessed arrest, initial rhythm was not ventricular fibrillation, no bystander CPR, more than 30 minutes until ROSC, ongoing CPR, severe acidosis or lactic acid greater than 7, age greater than 85 years, end stage renal disease, non-cardiac cause or traumatic arrest.
- University of Maryland has adopted this practice. Most of the literature says that if the patient has ventricular fibrillation or pulseless ventricular tachycardia, a shockable rhythm is a strong predictor of cardiac arrest due to acute coronary occlusion. It is likely best to send the patient for catheterization.
- If a ventricular fibrillation arrest patient is resuscitated and has a STEMI on ECG, about 70-80% will have an acute coronary occlusion on catheterization. If the ventricular fibrillation arrest patient has a non-ST elevation ECG, about 25-35% will have acute coronary occlusion on catheterization.
- Lemkes, JS et al. Coronary angiography after cardiac arrest without ST-segment elevation. N Engl J Med. 2019 Apr 11;380(15):1397-1407.DOI: 10.1056/NEJMoa1816897
- This was multi-center, open-label study in 550 patients with an initial shockable rhythm without STEMI on ECG. Patients were randomized to immediate catheterization versus delayed catheterization. The primary endpoint was survival at 90 days. They did not find any difference in patients that went for immediate versus delayed catheterization. There were some secondary endpoints such as neurologic outcome at 90 days. There was no difference.
- It did not appear to make a difference if they went for immediate versus delayed catheterization.
- It would be interesting to know if patients with a short downtime were more likely to benefit from early catheterization versus patients with longer downtime.
- They did not consider the history of present illness. Was the patient having chest pain prior to cardiac arrest? Did they have shortness of breath, abdominal pain or severe headache? This study included all different types of cardiac arrest.
- What was the difference between immediate versus delayed catheterization? Delayed catheterization referred to patients with a median time to catheterization of 129.9 hours. This was just over 5 days. In contrast, the immediate catheterization group had a median time to catheterization of 2.3 hours.
- Patients who did not survive to delayed catheterization or were not catheterized due to poor neurologic recovery may have biased the data and this was not discussed in the paper.
- Should we be doing catheterization on everyone right away or selectively in a delayed fashion?
- Why didn’t we find mortality benefit? There seems to be a low prevalence of cardiac disease in this population. They only found acute coronary artery occlusions in less than 20% of patients whereas other studies have found the prevalence of acute coronary occlusion in ventricular and pulseless ventricular tachycardia without ST elevation to be about 25-35%. This population in the Netherlands appears healthier than in the US. They had fewer coronary lesions.
- There was a nice editorial accompanying this article. They mentioned that less than 20% of patients in this study had acute coronary occlusion which is less than other studies. They also noted that when subgroup analysis was performed, higher risk groups such as patients with known coronary artery disease had better outcomes with immediate catheterization. Maybe the unexpected results were due to a lower risk group to start with. There was also a significant delay to targeted temperature management and we know that ventricular fibrillation patients have better outcomes with therapeutic hypothermia.
- Mattu does not plan to change his protocol. If the patient has post-arrest non-ST elevation ECG, they look at the unfavorable resuscitation features and discuss with cardiology. Most of them feel ventricular fibrillation is highly likely to be due to acute coronary artery occlusion. They do not plan to change practice as of yet. There are other studies currently under way.
Recent Related Material
EMA 2019 August Abstract 2: Angiography After Cardiac Arrest Without STEMI - COACT