Outofhospital cardiac arrest survivors sent for emergency angiography

Out-of-hospital cardiac arrest survivors sent for emergency angiography: a clinical score for predicting acute myocardial infarction Floriane Zeyons, Laurence Jesel, Olivier Morel, Hélène Kremer, Nathan Messas, Sebastien Hess, Ulun Crimizade, Philippe Reydel, Laurent Tritsch and Patrick Ohlmann - Eur Heart J Acute Cardiovasc Care. 2017 Mar; 6(2): 103 -111. Floriane Zeyons, MD University Hospital of Strasbourg, France

Introduction Out of hospital cardiac arrest (OHCA) High mortality : 90% of all OHCA, 75% when admitted alive to the hospital Cardiac origin : 70%, mainly acute myocardial infarction (AMI) Acute myocardial infarction (AMI): Better outcome with emergency angioplasty, the sooner the better The usual clinical and electrical signs may be absent => So, should all OHCA cases be immediately referred to the cath lab ?

Introduction Problem for the patient: Unnecessary procedure , potentially harmful Can delay some of the treatment, or other exams Problem for other patients : Risk of congesting the cath lab

Methods Retrospective, single center study Consecutive survivors of OHCA referred to the cath lab between 2009 and 2013 Analysis : Initial ECG from the SMUR unit (mobile emergency medical system) In hospital medical and biological findings Results of the coronary angiogramm 3 groups of patients : Group 1 : AMI related OHCA Groupe 2 : Chronic CAD related OHCA Group 3 : Non CAD related OHCA Objective : To identify predictors of AMI among survivors of OHCA

General results 177 patients included Group 1 : 76 (43%) – Group 2 : 27 (15%) – Group 3 : 74 (42%) PCI : 95 (54%) Group 1 : 95% Group 2 : 67% Group 3: 8% Survival rate 33% Group 1: 41% Group 2 : 44% Group 3 : 22%

Results : clinical characteristics

Results : ECG findings

Results : predictors of AMI

Results : AMI diagnostic score Item Number of points Chest pain before the arrest 1 Shockable initial rhythm 1 ST-segment elevation in any lead (including a. VR) 2 >1 >2 >3 >0

Discussion 1 The rate of AMI (43%) and CAD (73%) in our population is coherent with other studies Only 54% of the patients received PCI Group 3 : Although in the end CAD was not the cause of the arrest, 8% had PCI => excessive treatment ?

Discussion 2 Using an extended definition of ST elevation to include lead a. VR increases the sensitivity Added values of using the score: A) To rule out AMI : Score of 0 : low probability of AMI => ICU first, echocardiography, biology, etc… B) To better appreciate the likelihood of AMI High score=> insist on coronary angiogram before anything else. 2015 ESC guidelines : OHCA patients without a clear STEMI or ACS => short stop in the ICU/emergency room to rule out other causes of cardiac arrest

Discussion 3 Limitations of the study : Retrospective Coronary angiogramm registry Single center Limited number of patient

Take home messages AMI in only 43% of cases Look for ST elevation in a. VR The diagnostic score integrating chest pain before the arrest, a shockable initial rhythm, and ST elevation in any lead helps evaluate the likelihood of AMI With a score of 0, AMI is highly unlikely A stop to the ICU before rushing in the cath lab might be a valid strategy for those patients. Results need to be confirmed in a large-scale prospective study