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After cardiac arrest: emergency coronary angiography for all?
Giuseppe Biondi-Zoccai, MD
Sapienza University of Rome, [email protected]
Learning goals
• Scope of the problem• Rationale for emergency coronary
angiography• When perusing it• What does it entail• Case study
Learning goals
• Scope of the problem• Rationale for emergency coronary
angiography• When perusing it• What does it entail• Case study
Cardiac arrest has dismal prognosis
Yonemoto et al, Circulation 2011
Difficult to appraise neurologic status shortly after cardiac arrest
Booth et al, JAMA 2004
LR(+) = sensitivity / (1 – specificity) useful if >10 LR (-) = (1 – sensitivity) / specificity useful if <0.1
Coronary angiography after OHCA remains underused
Aufderheide et al, Lancet 2011
Learning goals
• Scope of the problem• Rationale for emergency coronary
angiography• When perusing it• What does it entail• Case study
Coronary occlusions are common
Spaulding et al, New Engl J Med 1997
Systematic invasive management may be beneficial
Dumas et al, Circ Cardiovasc Interv 2010
Systematic invasive management may be beneficial
Dumas et al, Circ Cardiovasc Interv 2010
Systematic invasive management may be beneficial
Dumas et al, Circ Cardiovasc Interv 2010
Learning goals
• Scope of the problem• Rationale for emergency coronary
angiography• When perusing it• What does it entail• Case study
Even without ST-elevation or new LBBB
Spaulding et al, N Engl J Med 1997; Dumas et al, Circ Cardiovasc Interv 2010
Troponin is not very useful either, but…
Dumas et al, Crit Care Med 2012
…if you wish to pinpoint patients
Primary predictive model for coronary occlusion after OHCA: 1st dose of adrenaline <2 mg (OR=2), smoking (OR=2.0), VF/VT as initial rhythm
(OR=1.7); other predictors were cTnI >4.7 ng/mL (OR=3.6), ↑ST (OR=10.2)
Dumas et al, Crit Care Med 2012
Learning goals
• Scope of the problem• Rationale for emergency coronary
angiography• When perusing it• What does it entail• Case study
Decision to cath must be made ASAP
Strote et al, Am J Cardiol 2002
Radial access is paramount
Agostoni et al, J Am Coll Cardiol 2004
Hypothermia is recommended
Bernard et al, N Engl J Med 2002; Holzer et al, New Engl J Med 2002
May be combined with brain CT
Chelly et al, Resuscitation 2002
Learning goals
• Scope of the problem• Rationale for emergency coronary
angiography• When perusing it• What does it entail• Case study
Case studyAge: 40 yearsGender: maleComorbidities: type 1 diabetes mellitusDiagnosis: acute myocardial infarction Prehospital events/management: VF treated with DC shock, followed by PEA; manual chest compression, repeat IV adrenaline boluses, tracheal intubation, mechanical ventilationHospital events/management: systemic thrombolysis with alteplase attempted without success; LUCAS deployment and…
Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011
Baseline coronary angiography
Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011
Predilation on left main-circumflex
Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011
Left main-anterior descending stenting
Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011
Coronary angiography after stenting
Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011
Take home messages• Patients achieving ROSC after OHCA should be
thoroughly appraised for non-cardiac conditions.
• Emergent coronary angiography is recommended routinely unless prognosis is very dire.
• Emergent coronary angiography can be considered in very selected cases before ROSC if patient/procedural features suggest reasonable likelihood of ROSC.
Many thanks for your attention
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