Quick case: It’s 3am. A 55yM, with a pmhx of chubbiness, DM, HTN is brought in by EMS after being found down. He is pulse-less, with an initial rhythm of ventricular fibrillation. He is shocked appropriately and exquisite ACLS is performed. He regains pulses 20 minutes after EMS arrival…Now he’s dropped off in your ED, comatose, tachycardic, and hypotensive.
Nursing staff transfers him over to your monitors; you run through your ABCs. You record an ECG that shows sinus tachycardia with widespread ST depressions., consistent with ischemia.
You suspect an acute myocardial infarction (type 1, the thrombotic kind) as the precipitant of this fatal dysrhythmia and you page the cardiology fellow. 3 pages later, a voice with the enthusiasm of a DMV operator asks what the ECG shows. Then, flatly asks why you’ve woken him/her in the absence of a STEMI?
You recall hearing something somewhere out there in the blogosphere that cardiac catheterization after ROSC is a good thing for patients….and your voice trails off…
This sucker is me. Last week.
So I ask, what is the data on post-arrest cardiac cath? STEMI or no STEMI? Are there guidelines to befuddle us?
Some background: epidemiologically speaking (in our chubby country), ACS is the presumed culprit in cardiac arrest ~30-60% of the time.[1] For those with STEMI on their post-ROSC ECG, there is little debate. For those without STEMI, there has been considerable debate and numerous, if paltry, studies: all coming from big retrospective cardiac arrest registries, and all fraught with the nasty biases of retrospect.
In Paris, all patients with ROSC after OHCA (out-of-hospital cardiac arrest) get cath’ed. They dug their data and found that if you got cath’ed, you did better.[2] In this retrospective series, they identified patients with ROSC after a not-obviously non-cardiac cause. Among these patients and without STEMI, they found an incidence of 58% with at least one coronary stenosis. Among these, only a quarter underwent successful PCI. Their primary outcome was successful PCI vs none, and they found a statistically significant association of PCI with survival.What does this mean for us? Nothing. Which of those “stenoses” was an acute thrombus rupture? No idea. What else did patients going for cath receive? Extra-care, extra attention? Maybe they were selected for cath because they were less moribund, or because they had witnessed-arrests with levine’s sign…
A recent publication in Resuscitation by Hollenback focuses specifically on v fib and pulseless v tach arrest without post-ROSC STEMI.[3] Also a retrospective cohort, from 6 tertiary care centers, they looked at early cardiac cath, defined as within 24 of ROSC, to late or no cath. They found a significant association with early cath and survival, ~65% vs 46%. However, here’s the meat. Within this early cath cohort, successful PCI was not associated with added benefit. What?!?! Those getting cath’ed do better, but those who actually have intervention on some possible “culprit lesion” don’t do better. Suggests that something other than PCI is driving this data. Retrospective, biases abound.
Guidelines gobble-dee-gook: The International Liaison Committee on Resuscitation recommends cath on post-ROSC patients with STEMI. For those without STEMI, consider cath in those for whom ACS is suspected. Hmm. Should we suspect ACS one to two thirds of the time. Yes? Should we push for cath? Maybe.
So back to philosophy: to cath or not to? We like to ask it, but its academic. We don’t decide whom to cath. We decide for whom we press for cath. It’s frustrating for a nascent doc to believe that an intervention is indicated and then have to specialist tell you why he/she ain’t gonna do it. But the truth is, we don’t take them to the lab, the OR, or to the endoscopy suite. We don’t assume that responsibility; it’s someone else’s. All we can do is gather all the necessary info, resuscitate, prep and make a cogent case. The rest is up to our colleagues. And document.
1. Anyfantakis ZA, Baron G, Aubry P, et al. Acute coronary angiographic findings in survivors of out-of-hospital cardiac arrest. Am Heart J 2009; 157: 312–318
2. Dumas F, Cariou A, Manzo-Silberman S, et al. Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Circ Cardiovasc Interv 2010; 3: 200–207.
3. Ryan D. Hollenbeck, John A. McPherson, et al. Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI, Resuscitation, Volume 85, Issue 1, January 2014, Pages 88-95,
4. Jerry P. Nolan, Robert W. Neumar, et al. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation – December 2008 (Vol. 79, Issue 3, Pages 350-379,
Jay Khadpe MD
- Editor in Chief of "The Original Kings of County"
- Assistant Professor of Emergency Medicine
- Assistant Residency Director
- SUNY Downstate / Kings County Hospital
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5 Comments
Carl · January 27, 2014 at 4:10 pm
I find this especially tough at our shop where we have to press so hard to make diagnostic let alone transfer and stenting happen. Especially in the middle of the night or when cards is backed up (i.e. every day).
Cathing and stenting still have risks. Lots of people have lesions and these aren’t necessarily the cause of their cardiac arrest.
Is it the “maximal medical therapy” that is the difference? Does a CCU admission that different from ICU with cards on board? Cooling these patients we know work.
JoshS · February 2, 2014 at 11:27 pm
I talk about this all the time. I think we should be sending a lot of these patients to the cath lab. I venture to say that this might even be more useful than cooling – yes I said that. I have never been sold that cooling is the greatest thing since the defibrillator.
I believe that any patient with cardiac arrest with evidence of infarct/ischemia should probably go to the cath lab. If there is an acute occlusion then, whetever you do for this patient, without revascularization their chances of a good outcome is poor.
There is also a part of me that thinks that any patient with cardiac arrest of unknown etiology may benefit from cath, but I have nothing to back that up.
I understand that this is unlikely to happen at this institution, but that does not mean we cannot continue to do what we think is best for patients. Some of you may (I don’t know why) end up working at another institution where this is more realistic.
JS
Ian deSouza · February 7, 2014 at 9:46 pm
Nice work, Freedman. I agree with those above and suspect that the benefit of therapies in many subsets of critical patients (i.e. acute CVA, severe sepsis, post-arrest/cooled, STEMI) – and some more than others – are likely due to the focused attention they get and not necessarily the individual therapies themselves. So until someone really teases out the real benefit of these interventions, we should continue with these treatment protocols while keeping the risks of each therapy fresh in our minds.
Carl · March 9, 2014 at 11:23 am
new article on this again concludes its a great thing. However Not everyone gets cath and you have to think there is a huge bias on who gets cathed.
Hollenbeck RD et al. Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest. Resuscitation. 2014 Jan;85(1):88-95. PMID: 23927955.
Carl · March 9, 2014 at 11:47 am
ooop. I can’t delete that last comment I realize that article was covered. Anyway EM Rap covered this in march’s episode.