Dallas 2015

TFQO: Darren Walters #422EVREVs: EVREV 1: Darren Walters COI #422EVREV 2: Chris Ghaemmaghami COI #89

Taskforce: Acute Coronary Syndrome

PCI after ROSC with ST-elevation ACS 340

Dallas 2015COI Disclosure Chris Ghaemmaghami COI #89

Commercial/industry• none

Potential intellectual conflicts• none

Darren Walters COI #317Commercial/industry• none

Potential intellectual conflicts• Editor IJC, HLC• Meta analysis author, Resuscitation 2014: 85:1533–1540

Dallas 20152010 CoSTR

In Out of Hospital Cardiac Arrest patients with ST elevation myocardial infarction or new LBBB on ECG following return of spontaneous circulation , early angiography and Primary Percutaneous Coronary Interevntion should be considered.

Dallas 2015C2015 PICO

Population:Among adult patients who are experiencing ROSC after cardiac arrest with evidence of ST-elevation on ECG Intervention:emergent cath lab evaluation Comparison: cardiac catheterization later in the hospital stay or no catheterizationOutcomes:Outcome Importance :survival to hospital discharge with good neurological outcome 9-Critical survival to hospital discharge 9-Critical

Dallas 2015Inclusion/Exclusion& Articles Found

PubMed Search StringsDate PubMed Search Completed("Angioplasty"[MeSH] OR "Angioplasty, Balloon"[MeSH] OR angioplasty[TIAB] OR PTCA[TIAB] OR “Balloon Dilatation” [TIAB] OR "Cardiac Catheterization"[MeSH] OR “heart catheterization”[TIAB] OR PCI[TIAB] OR PPCI[TIAB] OR "Percutaneous Coronary Intervention"[MeSH] OR “percutaneous coronary intervention”[TIAB] OR “percutaneous transluminal coronary angioplasty”[TIAB] OR catheterisation[TIAB] OR catheterization[TIAB] OR "coronary angiography"[MeSH] OR angiography[TIAB] OR "Atherectomy"[MeSH]) AND ("heart arrest"[MeSH] OR "cardiac arrest"[TIAB] OR "cardiac arrests"[TIAB] OR "cardiovascular arrest"[TIAB] OR "cardiovascular arrests"[TIAB] OR "heart arrest"[TIAB] OR "heart arrests"[TIAB] OR "asystole"[TIAB] OR "pulseless electrical activity"[TIAB] OR "cardiopulmonary arrest"[TIAB] OR "cardiopulmonary arrests"[TIAB] OR "cardio-pulmonary arrest"[TIAB] OR "cardio-pulmonary arrests"[TIAB] OR "cardiopulmonary resuscitation"[MeSH] OR "cardiopulmonary resuscitation"[TIAB] OR "cardiopulmonary resuscitations"[TIAB] OR "Heart Massage"[MeSH] OR "Advanced Cardiac Life Support"[TIAB] OR "return of spontaneous circulation"[TIAB] OR ROSC[TIAB] OR “spontaneous circulation”[TIAB] OR ("Blood Circulation"[MeSH] AND "Recovery of Function"[MeSH])) NOT (animal[MeSH] NOT humans[MeSH]) NOT ((adolescent[MeSH] OR child[MeSH] or infant[MeSH] OR child*[TIAB] OR infant*[TIAB] OR adolescent*[TIAB] OR "Pediatrics"[MeSH] OR pediatric*[TIAB] OR paediatric*[TIAB]) NOT adult[Mesh]) NOT ("letter"[Publication Type] OR "comment"[Publication Type] OR "editorial"[Publication Type] or Case Reports[Publication Type])

Embase Search StringsDate Embase Search Completed('angioplasty'/exp OR angioplasty:ti,ab OR PTCA:ti,ab OR “Balloon Dilatation”:ti,ab OR 'heart catheterization'/exp OR "cardiac catheterization":ti,ab OR “heart catheterization”:ti,ab OR PCI:ti,ab OR PPCI:ti,ab OR 'percutaneous coronary intervention'/exp OR “percutaneous coronary intervention”:ti,ab OR “percutaneous transluminal coronary angioplasty”:ti,ab OR catheterisation:ti,ab OR catheterization:ti,ab OR 'angiocardiography'/exp OR angiography:ti,ab OR 'atherectomy'/exp OR atherectomy:ti,ab) AND ('heart arrest'/exp OR “Out of Hospital Cardiac Arrest”:ti,ab OR “Out-of-Hospital Cardiac Arrest”:ti,ab OR “Out of Hospital Cardiac Arrests”:ti,ab OR “Out-of-Hospital Cardiac Arrests”:ti,ab OR (("out-of-hospital":ti,ab OR “out of hospital”:ti,ab OR “outside of hospital”:ti,ab) AND cardiac:ti,ab AND arrest*:ti,ab) OR "cardiac arrest":ti,ab OR "cardiac arrests":ti,ab OR "cardiovascular arrest":ti,ab OR "cardiovascular arrests":ti,ab OR "heart arrest":ti,ab OR "heart arrests":ti,ab OR "asystole":ti,ab OR "pulseless electrical activity":ti,ab OR "cardiopulmonary arrest":ti,ab OR "cardiopulmonary arrests":ti,ab OR "cardio+pulmonary arrest":ti,ab OR "cardio+pulmonary arrests":ti,ab OR 'resuscitation'/exp OR "cardiopulmonary resuscitation":ti,ab OR CPR:ti,ab OR 'heart massage'/exp OR "Advanced Cardiac Life Support":ti,ab OR "ACLS":ti,ab OR 'return of spontaneous circulation'/exp OR "return of spontaneous circulation":ti,ab OR ROSC:ti,ab OR “spontaneous circulation”:ti,ab OR “post resuscitation”:ti,ab OR “post-resuscitation”:ti,ab OR “post cardiac arrest”:ti,ab OR “post-cardiac arrest”:ti,ab) NOT (('adolescent'/exp OR 'child'/exp OR 'infant'/exp OR child*:ab,ti OR infant*:ab,ti OR adolescent*:ab,ti OR 'pediatrics'/exp OR pediatric*:ab,ti OR paediatric*:ab,ti) NOT 'adult'/exp) NOT ('animal'/exp NOT 'human'/exp) NOT ([editorial]/lim OR [letter]/lim OR 'case report'/de) AND [embase]/lim

Cochrane Search StringsDate Cochrane Search Completed([mh "Angioplasty"] OR [mh "Angioplasty, Balloon"] OR angioplasty:ti,ab OR PTCA:ti,ab OR “Balloon Dilatation” :ti,ab OR [mh "Cardiac Catheterization"] OR “heart catheterization”:ti,ab OR PCI:ti,ab OR PPCI:ti,ab OR [mh "Percutaneous Coronary Intervention"] OR “percutaneous coronary intervention”:ti,ab OR “percutaneous transluminal coronary angioplasty”:ti,ab OR catheterisation:ti,ab OR catheterization:ti,ab OR [mh "coronary angiography"] OR angiography:ti,ab OR [mh "Atherectomy"]) AND ([mh "heart arrest"] OR “Out of Hospital Cardiac Arrest” :ti,ab OR “Out-of-Hospital Cardiac Arrest” :ti,ab OR “Out of Hospital Cardiac Arrests”:ti,ab OR “Out-of-Hospital Cardiac Arrests”:ti,ab OR (("out-of-hospital":ti,ab OR “out of hospital”:ti,ab OR “outside of hospital”:ti,ab) AND cardiac:ti,ab AND arrest*:ti,ab) OR "cardiac arrest":ti,ab OR "cardiac arrests":ti,ab OR "cardiovascular arrest":ti,ab OR "cardiovascular arrests":ti,ab OR "heart arrest":ti,ab OR "heart arrests":ti,ab OR "asystole":ti,ab OR "pulseless electrical activity":ti,ab OR "cardiopulmonary arrest":ti,ab OR "cardiopulmonary arrests":ti,ab OR "cardio-pulmonary arrest":ti,ab OR "cardio-pulmonary arrests":ti,ab OR [mh "cardiopulmonary resuscitation"] OR "cardiopulmonary resuscitation":ti,ab OR CPR:ti,ab OR [mh "Heart Massage"] OR "Advanced Cardiac Life Support":ti,ab OR "ACLS":ti,ab OR "return of spontaneous circulation":ti,ab OR ROSC:ti,ab OR “spontaneous circulation”:ti,ab OR “post resuscitation”:ti,ab OR “post-resuscitation”:ti,ab OR “post cardiac arrest”:ti,ab OR “post-cardiac arrest”:ti,ab OR ([mh "Blood Circulation"] AND [mh "Recovery of Function"])) NOT (([mh adolescent] OR [mh child] or [mh infant] OR child*:ab,ti OR infant*:ab,ti OR adolescent*:ab,ti OR [mh "Pediatrics"] OR pediatric*:ab,ti OR paediatric*:ab,ti) NOT [mh adult])

Dallas 2015Inclusion/Exclusion& Articles Found

Inclusions/ExclusionsIncluded studies with outcomes delineated for patients without ST elevation

4529 articles initially identified15 Articles included Profile tables

RCTs – 0Meta analysis 2 (Camuglia 2014 1533, Larsen 2012 1427)non-RCTs – 15 outcomes deathnon-RCTs – 9 outcomes neurologicExcluded - 4514

Dallas 2015Inclusion/Exclusion& Articles Found

List Inclusions/ExclusionsCriteriaInclusion:("Angioplasty"[MeSH] OR "Angioplasty, Balloon"[MeSH] OR angioplasty[TIAB] OR PTCA[TIAB] OR “Balloon Dilatation” [TIAB] OR "Cardiac Catheterization"[MeSH] OR “heart catheterization”[TIAB] OR PCI[TIAB] OR PPCI[TIAB] OR "Percutaneous Coronary Intervention"[MeSH] OR “percutaneous coronary intervention”[TIAB] OR “percutaneous transluminal coronary angioplasty”[TIAB] OR catheterisation[TIAB] OR catheterization[TIAB] OR "coronary angiography"[MeSH] OR angiography[TIAB] OR "Atherectomy"[MeSH]) AND ("heart arrest"[MeSH] OR "cardiac arrest"[TIAB] OR "cardiac arrests"[TIAB] OR "cardiovascular arrest"[TIAB] OR "cardiovascular arrests"[TIAB] OR "heart arrest"[TIAB] OR "heart arrests"[TIAB] OR "asystole"[TIAB] OR "pulseless electrical activity"[TIAB] OR "cardiopulmonary arrest"[TIAB] OR "cardiopulmonary arrests"[TIAB] OR "cardio-pulmonary arrest"[TIAB] OR "cardio-pulmonary arrests"[TIAB] OR "cardiopulmonary resuscitation"[MeSH] OR "cardiopulmonary resuscitation"[TIAB] OR "cardiopulmonary resuscitations"[TIAB] OR "Heart Massage"[MeSH] OR "Advanced Cardiac Life Support"[TIAB] OR "return of spontaneous circulation"[TIAB] OR ROSC[TIAB] OR “spontaneous circulation”[TIAB] OR ("Blood Circulation"[MeSH] AND "Recovery of Function"[MeSH])) Exclusion: (animal[MeSH] NOT humans[MeSH]) NOT ((adolescent[MeSH] OR child[MeSH] or infant[MeSH] OR child*[TIAB] OR infant*[TIAB] OR adolescent*[TIAB] OR "Pediatrics"[MeSH] OR pediatric*[TIAB] OR paediatric*[TIAB]) NOT adult[Mesh]) NOT ("letter"[Publication Type] OR "comment"[Publication Type] OR "editorial"[Publication Type] or Case Reports[Publication Type])

2361 articles filtering 1317,105 full articles,50relevant papers, 27reporting survival data for STEMI PCI ROSCRCTs, nilnon-RCTs 27 Meta analysis 2 (Camuglia 2014 1533, Larsen 2012 1427)Included 15 studies reporting survival dataIncluded 9 studies reporting neurological outcome.

Dallas 20152015 Proposed Treatment Recommendations

We suggest emergent cardiac catheterization lab evaluation in comparison to cardiac catheterization later in the hospital stay or no catheterization may be considered in selected adult patients who are comatose and are experiencing ROSC after OHCA of suspected cardiac origin with evidence of ST-elevation on ECG (weak recommendation, low quality of evidence).

Dallas 2015 Risk of Bias in studies

Dallas 2015Evidence profile table(s)

Dallas 2015 Risk of Bias in studiessurvival

Dallas 2015 Risk of Bias in studiesneurologic Outcome

Dallas 2015Proposed Consensus on Science statements

For the Critical outcome of “survival to hospital discharge” we have identified very low quality evidence (downgraded for risk of bias) from 15 observational studies (Hollenbeck 2014 88, Mooney 2011 206, Gräsner 2011 1649, Cronier 2011 R122, Bulut 2000 155, Bro-Jeppesen 2012 291, Aurore 2011 73, Nanjayya 2012 699, Reynolds 2009 179, Strote 2012 451, Tømte 2011 1186, Waldo 2013 1253, Nielsen 2009 926, Werling 2007 40, Zanuttini 2012 1723) enrolling 3800 patients showing benefit (OR 2.83 95% CI 2.44 – 3.27).

Dallas 2015Proposed Consensus on Science statements

For the Critical outcome of “survival to hospital discharge with neurological good outcome” we have identified very low quality evidence (downgraded for risk of bias) from 9 observational studies (Hollenbeck 2014 88, Mooney 2011 206, Gräsner 2011 1649, Bro-Jeppesen 2012 291, Nanjayya 2012 699, Reynolds 2009 179, Strote 2012 451, Tømte 2011 1186, Nielsen 2009 926), enrolling 2919 patients showing benefit (OR 2.54 95% CI 2.17 – 2.99).

Dallas 2015Draft Treatment Recommendations

We suggest emergent cardiac catheterization lab evaluation in comparison to cardiac catheterization later in the hospital stay or no catheterization may be considered in selected adult patients who are comatose and are experiencing ROSC after OHCA of suspected cardiac origin with evidence of ST-elevation on ECG (weak recommendation, low quality of evidence). Values and preferences statement: In making this recommendation, we place a higher value on survival and good neurologic outcome over resource utilization

Dallas 2015Knowledge Gaps

Specific research requiredA randomized control trial Among adult patients who are experiencing ROSC after cardiac arrest with evidence of ST-elevation on ECG to compare whether emergent cath lab evaluation and intervention (where appropriate) versus cardiac catheterization later in the hospital stay or no catheterization survival to hospital discharge with good neurological outcome or survival to hospital discharge.