1. After cardiac arrest: emergency coronary angiography for all? Giuseppe Biondi-Zoccai, MD Sapienza University of Rome, Italy giuseppe.biondizoccai@uniroma1.it

2. Learning goals Scope of the problem Rationale for emergency coronary angiography When perusing it What does it entail Case study

3. Learning goals Scope of the problem Rationale for emergency coronary angiography When perusing it What does it entail Case study

4. Cardiac arrest has dismal prognosis Yonemoto et al, Circulation 2011

5. 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

6. Coronary angiography after OHCA remains underused Aufderheide et al, Lancet 2011

7. Learning goals Scope of the problem Rationale for emergency coronary angiography When perusing it What does it entail Case study

8. Coronary occlusions are common Spaulding et al, New Engl J Med 1997

9. Systematic invasive management may be beneficial Dumas et al, Circ Cardiovasc Interv 2010

10. Systematic invasive management may be beneficial Dumas et al, Circ Cardiovasc Interv 2010

11. Systematic invasive management may be beneficial Dumas et al, Circ Cardiovasc Interv 2010

12. Learning goals Scope of the problem Rationale for emergency coronary angiography When perusing it What does it entail Case study

13. Even without ST-elevation or new LBBB Spaulding et al, N Engl J Med 1997; Dumas et al, Circ Cardiovasc Interv 2010

14. Troponin is not very useful either, but… Dumas et al, Crit Care Med 2012

15. …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

16. Learning goals Scope of the problem Rationale for emergency coronary angiography When perusing it What does it entail Case study

17. Decision to cath must be made ASAP Strote et al, Am J Cardiol 2002

18. Radial access is paramount Agostoni et al, J Am Coll Cardiol 2004

19. Hypothermia is recommended Bernard et al, N Engl J Med 2002; Holzer et al, New Engl J Med 2002

20. May be combined with brain CT Chelly et al, Resuscitation 2002

21. Learning goals Scope of the problem Rationale for emergency coronary angiography When perusing it What does it entail Case study

22. 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

23. Baseline coronary angiography Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011

24. Predilation on left main-circumflex Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011

25. Left main-anterior descending stenting Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011

26. Coronary angiography after stenting Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011

27. 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.

28. Many thanks for your attention For these slides and further ones on similar topics feel free to visit: www.metcardio.org/slides.html For additional details or queries feel free to contact me directly: giuseppe.biondizoccai@uniroma1.it