Emergent Percutaneous Coronary Intervention Effective in Out-of-Hospital Cardiac Arrest With Non-ST Segment Elevation

Emergency percutaneous coronary intervention (PCI) was associated with a nearly 2-fold increase in favorable outcomes in patients resuscitated from out-of-hospital cardiac arrest with culprit coronary lesions with non-ST segment elevation (NSTE), according to data published in JACC: Cardiovascular Interventions.

Currently, emergent coronary angiogram and reperfusion are the standard of care for patients after an out-of-hospital cardiac arrest with STE. However, there is controversy surrounding the use of similar invasive strategies for patients who have NSTE.

Focusing on patients with NSTE, researchers examined the association between emergent PCI and favorable outcomes using the data from the PROCAT (Parisian registry out-of-hospital cardiac arrest) registry. They also sought to identify the characteristics of patients who would benefit most from invasive PCI.

Researchers evaluated 958 patients (average age: 60 years; 76% male) who were resuscitated from out-of-hospital cardiac arrest and had an emergent coronary angiogram between 2004 and 2013. Among these patients, 695 (73%) had no evidence of STE on a post-resuscitation echocardiogram (ECG), and 199 (29%) required PCI.

“A shockable rhythm at EMS [emergency medical service] presentation was the strongest predictor of the presence of an acute coronary lesion requiring early PCI,” the authors wrote. “Focusing on subgroups, male patients of more than 50 years of age with an initial shockable rhythm seem to benefit most from this invasive strategy, with a rate of culprit coronary lesion of 40%. In this subgroup, when PCI was performed, the rate of favorable outcome was high (48.1%).”

Of the patients who underwent PCI, 87 had favorable outcomes (43%). In comparison, only 164 of the 495 patients without PCI had favorable outcomes (33%; P=.02).

After adjustments, PCI was associated with better outcomes (odds ratio [OR]: 1.80; 95% confidence interval [CI]: 1.09-2.97; P=.02). Researchers found that a shorter resuscitation length (<20 min), an initial shockable rhythm, and a lower dose of epinephrine during resuscitation were other predictive factors of favorable outcomes (P<.001).

In addition, an initial shockable rhythm was the only independent indicator of patients who would benefit most from PCI (OR: 2.83; 95% CI: 1.84-4.36; P<.001).

In particular, this strategy was most effective among  men older than 50 years of age who were resuscitated from an initially shockable rhythm. Patients in this subgroup had a culprit coronary lesion rate of 40%, and when PCI was performed, the rate of favorable outcomes was 48.1%.

“In the absence of randomized trials, the present results support the use of an emergent invasive strategy in this specific population and may help to select the best candidates,” the authors noted.

Reference

Dumas F, Bougouin W, Geri G, et al. Emergency PCI in post-cardiac arrest patients without ST-segment elevation pattern: Insights from the PROCAT II registry. JACC Cardiovasc Interv. 2016. doi:10.1016/j.jcin.2016.02.001.