PCI advised for some out-of-hospital cardiac arrests

By Larry Hand

NEW YORK (Reuters Health) - Early angiography and percutaneous coronary intervention (PCI) produces positive outcomes after out-of-hospital cardiac arrest (OHCA), even in patients without ST-segment elevation, and especially in men older than 50 with an initial shockable rhythm, according to new research from France.

Although the strategy is common for patients with ST-segment elevation, it is debatable for patients without it, according to the researchers.

Dr. Florence Dumas, of the Parisian Cardiovascular Research Center, Paris Descartes University, and colleagues conducted a study into associations between early PCI and favorable outcomes in 958 OHCA patients with data in the Parisian Registry Out-of-Hospital Cardiac Arrest (PROCAT).

The registry holds data of patients from the Paris system for management of OHCA, which starts with mobile emergency units that deliver out-of-hospital resuscitation. Patients who achieve return of spontaneous circulation (ROSC) are referred to a center with an intensive care unit (ICU) and constant coronary intervention care facilities.

Patients without an obvious extra-cardiac cause are admitted directly to the cardiac catheterization laboratory where they undergo immediate coronary angiography (CAG) and left ventricular angiography. PCI is done if indicated on CAG and patients then go to the ICU.

Dr. Dumas and colleagues analyzed registry data from 2004 through 2013 on 695 patients with sustained ROSC with no extra-cardiac cause and with the absence of ST-segment elevation. The mean age was 60, and 66% were male.

Eighty-seven of the 200 patients who had PCI had favorable outcomes, compared with 164 of the 495 who did not have PCI (43% vs 33%, p=0.02). After adjusting for 11 potential confounders, the researchers calculated the odds ratio for PCI being associated with a favorable outcome at 1.80 (p=0.02), based on patients' cerebral performance category score on hospital dismissal.

They found other predictive factors to be a shorter resuscitation time (<20 minutes), an initial shockable rhythm, and a lower dose of epinephrine during resuscitation (p<0.001). Initial shockable rhythm was the only independent indicator for PCI requirement (OR 2.83, p<0.001).

"Male patients of more than 50 years of age with an initial shockable rhythm seem to benefit the most from this invasive strategy, with a rate of coronary lesion of 40%. In this subgroup, when PCI was performed, the rate of favorable outcome was high (48%)," the researchers wrote.

They concluded, "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."

Dr. Jaoquin E. Cigarroa, of Oregon Health and Science University, Portland, who wrote an accompanying editorial, told Reuters Health by email, "Pre-hospital care, including a uniform system to rapidly identify and reach patients with OHCA, to initiate treatment and transfer them to a dedicated hospital with an evaluation and treatment algorithm, is important for the rapid identification of potential beneficiaries of a comprehensive, multidisciplinary approach including coronary angiography."

"Further research in this challenging subset of patients is required to understand which patients are best served by immediate coronary artery revascularization and mechanical support, if required," he added.

In his editorial, he concluded, "Clearly, systems of care in the United States should learn from the Parisian OHCA structure and standardize care so patients can benefit. . . . Future randomized trials will ultimately answer the question of whether early angiography and PCI improve neurological outcome and survival in this large subset of patients with OHCA without ST-segment elevation."

Dr. Dumas did not respond to requests for comment.

SOURCE: http://bit.ly/1XY0O51 and http://bit.ly/1N6IB4N

JACC Cardiovasc Interv 2016.

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