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Temporal Trends in Identification, Management, and Clinical Outcomes After Out-of-Hospital Cardiac Arrest: Insights
Tiffany Patterson1, Gavin D Perkins2, Yahma Hassan3
1From the Cardiovascular Division, The Rayne Institute BHF Centre of Research Excellence, King's College London, St. Thomas' Hospital, United Kingdom (T.P., Y.H., S.R.R.); tiffanypatterson05@gmail.com.
Insights
Early reperfusion therapy, including coronary angiography and percutaneous coronary intervention, significantly reduces mortality in out-of-hospital cardiac arrest (OHCA) patients with acute coronary syndrome (ACS). This approach improves survival rates for both ST-elevation and non-ST-elevation myocardial infarction cases.
Area of Science:
- Cardiology
- Emergency Medicine
- Public Health
Background:
- Survival rates for out-of-hospital cardiac arrest (OHCA) vary widely and remain poor.
- Early reperfusion therapy is recommended for ST-elevation myocardial infarction (STEMI) to reduce mortality.
- Management strategies for non-ST-elevation acute coronary syndrome (NSTE-ACS) following OHCA are less clear.
Purpose of the Study:
- To examine trends in OHCA patients treated for ACS in England and Wales.
- To assess the impact of interventional management, specifically coronary angiography with percutaneous coronary intervention (PCI), on clinical outcomes in this population.
- To evaluate the association between coronary angiography±PCI and mortality in OHCA patients with ACS.
Main Methods:
- Analysis of the Myocardial Ischaemia National Audit Project (MINAP) database, a national registry of acute coronary syndrome (ACS) admissions.
- Examination of temporal trends over a 5-year period (2009-2013) for OHCA cases presenting with ACS.
- Application of Cox proportional hazards models to assess the impact of coronary angiography on mortality, considering time-varying exposure.
Main Results:
- Out of 410,462 ACS admissions, 9,421 (2.30%) presented with OHCA.
- The proportion of OHCA cases among ACS admissions increased from 1.79% in 2009 to 2.74% in 2013.
- Coronary angiography with PCI increased in OHCA patients with ACS (54.9% in 2009 to 66.3% in 2013).
- Coronary angiography was associated with significantly reduced mortality in both STEMI (HR 0.30) and NSTE-ACS (HR 0.44) cohorts.
- Predictors of favorable outcomes aligned with criteria for coronary angiography±PCI selection.
Conclusions:
- Selection for coronary angiography±PCI is linked to decreased mortality in OHCA patients diagnosed with ACS.
- These findings underscore the importance of early reperfusion strategies in OHCA patients with ACS.
- The results advocate for a randomized controlled trial to further validate these observational findings.
Background:
There is wide variation in survival rates from out-of-hospital cardiac arrest (OHCA) and overall survival remains poor. There is an expert consensus that early reperfusion therapy in ST-elevation reduces mortality. The management of patients without ST-elevation, however, is controversial.
Methods And Results:
The Myocardial Ischaemia National Audit Project database is a national registry of all hospital admissions in England and Wales treated as an acute coronary syndrome (ACS). We examined temporal trends, over a 5-year period, of OHCAs identified by Myocardial Ischaemia National Audit Project, admitted to hospital and treated as ACS, the interventional management of these patients and clinical outcomes. Four hundred ten thousand four hundred sixty-two patients were admitted to hospital in England and Wales with ACS. Of these, 9421 presented with OHCA (2.30%). There was an increase in OHCA cases as a proportion of ACS between 2009 and 2013 (1.79% in 2009 versus 2.74% in 2013; Ptrend<0.001). The rate of coronary angiography+percutaneous coronary intervention increased in ACS patients presenting with OHCA (54.9% in 2009 [876/1595] versus 66.3% in 2013 [884/1334]; Ptrend<0.001). Cox proportional hazards model with time-varying exposure to coronary angiography demonstrated a significant reduction in mortality in both the ST-elevation (hazard ratio, 0.30; 95% confidence interval, 0.28-0.32; P<0.05) and non-ST-elevation cohort (hazard ratio, 0.44; 95% confidence interval, 0.42-0.46; P<0.001). Predictors of favorable outcome were synonymous with the selection criteria for patients undergoing coronary angiography±percutaneous coronary intervention.
Conclusions:
This observational study showed that selection for coronary angiography±percutaneous coronary intervention was associated with reduced mortality in OHCA patients diagnosed with ACS. These data support the need for a randomized controlled trial.
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