Key result
Critical coronary stenosis requiring PCI was present in 84% of STE-OHCA patients compared to 40% of NSTE-OHCA patients, with a notably high rate of 48% in NSTE-OHCA patients with an initial shockable rhythm.
Why the study?
Whether OHCA patients without obvious ST-segment elevation following ROSC should receive coronary angiography as part of a standardised diagnostic work-up is debated.
Does a standardized diagnostic work-up including early coronary angiography identify critical coronary stenosis and affect survival in comatose OHCA patients based on ECG patterns and initial rhythm?
Observational (n=517)
No
Does a standardized diagnostic work-up including early coronary angiography identify critical coronary stenosis and affect survival in comatose OHCA patients based on ECG patterns and initial rhythm?
Absolute Event Rate: 84% vs 40%
p-value: p=<0.001
Early coronary angiography reveals a high rate of critical coronary stenosis in STE-OHCA and in NSTE-OHCA with an initial shockable rhythm, suggesting these patients benefit most from routine early invasive assessment.
Early angiography may be low-yield in non-shockable NSTE-OHCA; leaves open refined selection criteria for post-arrest CAG.
BACKGROUND: Myocardial infarction is the most frequent cause for out-of-hospital cardiac arrest (OHCA) in adults. Patients with ST-segment elevations (STE) following return of spontaneous circulation (ROSC) are regularly admitted to the catheterisation laboratory for urgent coronary angiography. Whether patients without obvious STE (NSTE) should receive coronary angiography as part of a standardised diagnostic work-up following OHCA is still debated. METHODS: We analysed a cohort of 517 subsequent OHCA patients admitted at our institution who received a standardised diagnostic work-up including coronary angiography and therapeutic hypothermia. Patients were 63±14 years old, 76% were male. Overall, 180 (35%) had ST-elevation in the post-ROSC ECG, 317 (61%) had shockable rhythm (ventricular fibrillation or tachycardia) at first ECG. ROSC was achieved after 26±21 minutes. RESULTS: Critical coronary stenosis requiring PCI was present in 83% of shockable and 87% of non-shockable STE-OHCA and in 48% of shockable and 22% of non-shockable NSTE-OHCA patients. In-hospital survival was 61% in shockable and 55% in non-shockable STE-OHCA and 60% in shockable and 28% in non-shockable NSTE-OHCA. CONCLUSION: Standardised admission diagnostics in OHCA patients undergoing therapeutic hypothermia with a strict admission protocol incorporating ECG and coronary catheterisation shows a high rate of relevant coronary stenosis in STE-OHCA irrespective of the initial rhythm and in NSTE-OHCA with initial shockable rhythm. Based on the unfavourable outcome and low PCI rate observed in NSTE-OHCA patients with a primary non-shockable ECG rhythm it might be reasonable to restrict routine early coronary angiography to patients with primary shockable rhythms and/or ST-segment elevations after ROSC.
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Garcheva et al. (2021) conducted an observational in Out-of-hospital cardiac arrest (OHCA) (n=517). ST-segment elevation (STE) on post-ROSC ECG vs. Non-ST-segment elevation (NSTE) was evaluated on Critical coronary stenosis requiring percutaneous coronary intervention (PCI) (p=<0.001). Critical coronary stenosis requiring PCI was present in 84% of STE-OHCA patients compared to 40% of NSTE-OHCA patients, with a notably high rate of 48% in NSTE-OHCA patients with an initial shockable rhythm.
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