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Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock
Published on: June 12, 2021
Emergency Percutaneous Coronary Intervention in Post-Cardiac Arrest Patients Without ST-Segment Elevation Pattern:
Florence Dumas1, Wulfran Bougouin2, Guillaume Geri2
1INSERM U970 (team 4), Parisian Cardiovascular Research Center-PARCC, Paris Descartes University, Paris, France; Emergency Department, Cochin-Hotel-Dieu Hospital, APHP & Paris Descartes University, Paris, France.
Insights
Early invasive strategy with percutaneous coronary intervention (PCI) in out-of-hospital cardiac arrest (OHCA) patients without ST-segment elevation (STE) significantly improves patient outcomes. This approach is particularly beneficial for OHCA patients with a shockable rhythm.
Area of Science:
- Cardiology
- Emergency Medicine
- Critical Care
Background:
- Emergent coronary angiography and reperfusion are standard for ST-elevation OHCA but debated for non-ST-elevation.
- An early invasive strategy involving coronary angiography and potential percutaneous coronary intervention is evaluated in non-ST-elevation OHCA patients.
Purpose of the Study:
- To assess the relationship between an early invasive strategy and patient outcomes in out-of-hospital cardiac arrest (OHCA) patients without ST-segment elevation (STE).
- To identify predictive factors for the requirement of percutaneous coronary intervention (PCI) in this patient group.
Main Methods:
- A cohort of 958 out-of-hospital cardiac arrest patients who underwent emergent coronary angiography was analyzed.
- Logistic regression was used to investigate the association between early PCI and favorable outcomes in 695 non-ST-elevation patients.
- Patient characteristics were prospectively collected in the PROCAT database.
Main Results:
- Among 695 non-ST-elevation OHCA patients, 29% required PCI.
- A favorable outcome was observed in 43% of patients who received PCI versus 33% without PCI (p=0.02).
- PCI was associated with a nearly 2-fold increase in favorable outcomes (aOR 1.80; p=0.02), with shockable rhythm being the sole independent predictor for PCI requirement.
Conclusions:
- A culprit coronary lesion is found in about one-third of non-ST-elevation OHCA patients.
- Emergent PCI in these patients is linked to a significantly higher rate of favorable outcomes.
- The findings support an invasive strategy for non-ST-elevation OHCA patients, especially those with a shockable initial rhythm.
Objectives:
In a large cohort of out-of-hospital cardiac arrest (OHCA) patients without ST-segment elevation (STE), the study assessed the relationship between the use of an early invasive strategy and patient outcome.
Background:
Emergent coronary angiogram (CAG) and reperfusion are currently a standard of care in patients resuscitated from an OHCA with ST-segment elevation (STE). However, using a similar invasive strategy is still debated in patients without STE.
Methods:
In the absence of an obvious extracardiac cause, for many years our practice has had to perform an emergent CAG in all OHCA patients (STE and no STE) at admission, followed by percutaneous coronary intervention (PCI) when required. All patients' characteristics are prospectively collected in the PROCAT (Parisian Registry Out-of-Hospital Cardiac Arrest) database. Focusing on non-STE patients and using logistical regression, we investigated the association between early PCI and favorable outcome (cerebral performance category 1 to 2 at discharge) and we searched predictive factors for PCI requirement.
Results:
During the study period (2004 to 2013), we investigated 958 OHCA patients with an emergent CAG. Among them 695 of 958 (73%), mostly male (76%), and average 60 years of age had no evidence of STE on the post-resuscitation electrocardiography. A PCI was deemed necessary in 199 of 695 (29%). A favorable outcome was observed in 87 of 200 (43%) in patients with PCI compared with 164 of 495 (33%) in patients without PCI (p = 0.02). After adjustment, PCI was associated with a better outcome (adjusted odds ratio: 1.80 [95% confidence interval: 1.09 to 2.97]; p = 0.02). The other predictive factors of favorable outcome were a shorter resuscitation length (<20 min), an initial shockable rhythm, and a lower dose of epinephrine during resuscitation (p < 0.001). An initial shockable rhythm (adjusted odds ratio: 2.83 [95% confidence interval: 1.84 to 4.36]; p < 0.001) was the sole independent indicator for PCI requirement.
Conclusions:
A culprit coronary lesion requiring PCI was found in nearly one-third of OHCA patients without STE. In these patients, emergent PCI was associated with a nearly 2-fold increase in the rate of favorable outcome. These findings support the use of an invasive strategy in these patients, particularly in those resuscitated from a shockable rhythm.
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