INVASIVE STRATEGIES
FOR PATIENTS WITH
RESUSCITATED SUDDEN
CARDIAC ARREST
Marko Noc, MD, PhD, FESC
University Medical Center
Ljubljana-Slovenia
NO CONFLICT OF INTEREST
TO DECLARE
SUDDEN CARDIAC ARREST IS
A MAJOR HEALTH PROBLEM
Incidence of EMS treated sudden out-of-hospital
Cugh SS. JACC 2004;44:1268-75
cardiac arrest is 36-81/100.000
Cobb SS. JAMA 2002;288:3009-13
CPR
on the field
Reestablishment of
Spontaneous circulation
ROSC (40-50%)
Urgent transport
to hospital
Ristagno G, et al. Brain microcirculation in pigs. Resuscitation 2008;77:229-34.
SUDDEN CARDIAC ARREST-WHY
AN ISSUE FOR INTERVENTIONAL
CARDIOLOGIST?
• Sudden cardiac arrest is usually a coronary event
Urgent CAG (84)
Normal
17 (20%)
Nonobstructive CAD
7 (8%)
Obstructive CAD
60 (71%)
Single vessel
Multivessel
Isolated LM
22
37
1
Coronary occlusion
40 (48%)
Spaulding CM. N Engl J Med 1997;336:1629-33.
OUR STRATEGY- IMMEDIATELY
DEFINE A CORONARY SUBSTRATE
Urgent coronary angiography regardless of ECG
and level of consciousness after ROSC unless:
• Nonishemic etiology of cardiac arrest is obvious
• Severe pre-arrest comorbidities
• Comatose survivor with no realstic hope for
neurological recovery
SCIENTIFIC SUPPORT FOR URGENT
INVASIVE STARTEGY ?
• No randomized trials
• Multivariante analysis of registries
Author
Spaulding
Anafantakis
Reynolds
Nielsen
Dumas
n
85
72
241
986
714
Multivariante predictor of survival
Successful PCI (OR 5.2; p=0.004)
Not PCI attempt
CAG/PCI strategy (OR 2.16; p=0.02)
CAG/PCI strategy (OR 1.56; p=0.008)
Successful PCI (OR 2.06; p=0.013)
Spaulding CM. N Engl J Med 1997;336:1629-33
Anyfantakis ZA. Am Heart J 2009;157:312-8.
Reynolds JC. J Intensive Care Med 2009;March 25,
doi;1177
Nielsen N, et al. Acta Anaesthesiol Scand
2009;53:926-934
Dumas. Circ Cardiovasc Interv 2010;3:200-7
Consecutive patients with resuscitated cardiac
arrest of pressumed cardiac origin (2003-2008)
n=462
No STEMI 220 (48%)
STEMI 242 (52%)
Excluded (136)
-65 Nonischemic cause
-12 prearrest comorbidities
-26 CNS recovery unlikely
-26 Decision of an attending
-7 Death before cath lab
Excluded (18)
-1 Nonischemic cause
-14 CNS recovery not likely
- 2 Decision of attending
- 1 Death before cath lab
Urgent CAG 224 (93%)
ROSC to CAG:
128+/-67 min
Radsel P, et al. Submitted 2011
Urgent CAG 84 (38%)
URGENT CORONARY ANGIOGRAPHY IN PATIENTS
WITH RESUSCITATED SUDDEN CARDIAC ARREST
STEMI
(n=224)
No STEMI
(n=84)
p
Normal angiogram
1%
33%
<.001
Nonobstuctive disease
1%
1%
0.679
>1 obstructive stenosis
97%
66%
<.001
>1 Stable
8%
40%
<.001
> 1 Pressumed acute
89%
26%
<.001
Unprotected LM
7%
13%
0.115
Multivessel CAD
51%
57%
0.395
>1 Occlusion
80%
44%
<.001
>1 CTO
20%
34%
0.011
> 1 Pressumed acute
69%
13%
<.001
Radsel P, et al. Submitted 2011
ABSENCE OF “STEMI” IN POSTRESUSCITION
ECG DOES NOT EXCLUDE PRESENCE OF
ACUTE OCLUSION
Predictive value
Positive
Negative
Chest discomfort
and ST-elevation
87%
Spaulding CM. N Engl J Med 1997;336:1629-33.
61%
ANGIOGRAPHIC CHARACTERISTICS OF
PRESUMED ACUTE CULPRIT LESION
STEMI
No STEMI
(n=204)
(n=23)
Proximal location
46%
48%
0.824
Mean stenosis, %
98+6
98+3
0.839
Thrombus score
2.7+2.1
1.2+1.8
0.004
TIMI 0-1
77%
48%
<0.001
Rentrop (0-3)
0.25+0.60
0.37+0.90
0.464
Radsel P, et al. Submitted 2011
p
OUR REVASCULARIZATION STRATEGY
Urgent coronary
angigraphy
Presumed acute
culprit lesion
PCI of culprit
Additional nonculprit PCI only if
patient unstable*
Stable obstructive
CAD with normal flow
Comatose
after ROSC
None or PCI of
obvious lesion**
Conscious
after ROSC
Urgent
PCI/CABG
Nonobstructive
CAD/no CAD
Search for
aletrnative
cause of cardiac
arrest
* If ischemia/hemodynamic instability after successful IRA PCI and IABP
**If considered responsible for cardiac arrest (?) or beneficial for hemodyanmic stability
URGENT PCI
STEMI
(n=224)
No STEMI
(n=84)
p
PCI/Urgent CAG
94%
38%
<0.001
PCI-acute lesion
94%
69%
<0.001
Stenting
85%
78%
0.329
TIMI 3
83%
84%
0.896
IABP
22%
17%
0.497
Radsel P, et al. Submitted 2011
IF THE “CHAIN OF SURVIVAL” WORKED, THE
PATIENT WOKE UP IMMEDIATELY AFTER
ROSC (28%)
Survival
STEMI
97%
No STEMI
100%
Take home message: “Conscious” survivor of cardiac
arrest – treat him as a “very high” risk ACS
IF PATIENT REMAINED COMATOSE DESPITE
ROSC (72%), POSTRESUSCITATION BRAIN
INJURY WILL OCCUR
Survival
CPC 1-2
STEMI
65%
44%
No STEMI
69%
47%
- Severity of postresuscitation brain injury can not be
securely predicted on hospital admission
IMMEDIATE EMS CONTACT VERSUS SELFPRESENTATION IN ACS
In case of prehospital sudden cardiac arrest...
...emergency medical team is present and “converts”
comatose into conscious survivor of sudden cardiac arrest
MILD INDUCED HYPOTHERMIA (32-34 C)
IS „EVIDENCE BASED“ TREATMENT OF
POSTRESUSCITATION BRAIN INJURY
Independent randomized clinical trials
N Engl J Med 2002;
346:557-63
Number needed to treat 7 !!!
N Engl J Med 2002;
346:549-56.
WE COMBINED PPCI AND MILD INDUCED
HYPOTHERMIA IN COMATOSE SURVIVORS
OF CARDIAC ARREST WITH STEMI
• 40 patients undergoing PPCI+MIH (2003-2005) were compared
to 32 historical controls undergoing only PPCI and no MIH (2000-2003)
• Combination of PPCI+MIH was feasable and safe without increase in
arrhythmias, hemodynamic instability, oxygen reqirements for
mechanical ventilation, renaly dysfunction….
• Addition of MIH to PPCI significantly improved survival with good
neurological recovery compared to historical controls
Knafelj R, et al. Resuscitation 2007; 74;227-34.
ADDITION OF “MIH” IN COMATOSE SURVIVORS
OF CARDIAC ARREST DOES NOT COMPROMISE
RESULTS OF PCI
MIH (40)
No MIH (32)
p
Post PCI TIMI 2/3,%
>70% ST resolution,%
Stent thrombosis
90
68
2.5
88
59
0
.41
.64
1.0
Sustained VT,%
Repeat VF,%
P- AF,%
DC/cardioversion,%
Antiarrhytmics,%
13
20
18
30
33
19
19
16
34
53
.69
.87
.92
.89
.13
Need for IAPB,%
Vasopressors,%
Inotropes,%
20
65
48
22
53
59
.92
.44
.44
Knafelj
R, et
2007; 74;227-34.
Knafelj
R,al.etResuscitation
al. Resuscitation
2007;74:227-34.
PPCI AND “MIH” IN COMATOSE SURVIVORS
OF CARDIAC ARREST WITH STEMIFEASALBLE AND SAFE
Author
PPCI llb///a Stent Open IRA
IABP
Knafelj
36
18
32
36
8
Hovdenes
36
NA
NA
NA
23
Koutouzis
1
NA
1
1
0
Wolfrum
16
15
16
16
5
Schefold
25
16
16
NA
NA
Together
114
64%
93%
93%
34%
Noc M. Interventional Cardiology 2008; (Volume 9, Number 4);123-5.
CATH LAB FOR COMATOSE
SURVIVORS OF CARDIAC ARREST ?
GET A CICU INTENSIVIST
TO THE CATH LAB !
-Control of respiration,
hemodynamics, rhythm,
hypothermia, IABP…
-ACLS due to reccurent
cardiac arrest
-Portable echo to identify
cause of hemodynamic
instability if present
COMPETENT CARDIAC INTENSIVE CARE UNIT- ESSENTIAL
FOR SURVIVAL OF COMATOSE PATIENTS
AFTER RESUSCITATED CARDIAC ARREST
“FAST TRACK” FOR COMATOSE SURVIVORS
OF OUT-OF-HOSPITAL CARDIAC ARREST
1.
Start effective
hypotermia
already on the
field
2.
Urgent
transport to
„24-7“ PCI center
without
unneccesary
stops
3.
Urgent CAG+PCI
during ongoing
hypothermia
4.
Hypotermia
and intensive
care support
CONSECUTIVE COMATOSE SURVIVORS OF
OUT-OF-HOSPITAL CARDIAC ARREST ADMITTED TO
LJUBLJANA UNIVESITY MEDICAL CENTER
Urgent CAG/PCI
Hypotermia
1995-7 (78)
0%
0%
2006-8 (149) p
70%
<.001
90%
<.001
60
40
p<.0001
62%
40%
20
Tadel KS,
et al.
Acute Cardiac
Care, 2010
24%
15%
0
1995-97
2006-8
Survival
CPC 1-2
COMPLEMENT „STEMI NETWORK“ TO
BECOME “ACUTE CARDIAC NETWORK”
STEMI
+
NSTE-ACS
with high risk
features
+
Resuscitated
sudden
cardiac arrest