After cardiac arrest: emergency coronary angiography for all? Giuseppe Biondi-Zoccai, MD Sapienza University of Rome, Italy

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 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

Age: 40 years Gender: male Comorbidities: type 1 diabetes mellitus Diagnosis: acute myocardial infarction Prehospital events/management: VF treated with DC shock, followed by PEA; manual chest compression, repeat IV adrenaline boluses, tracheal intubation, mechanical ventilation Hospital 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.

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