INDEX

    Post Cardiac Arrest: PCI and Thrombolytics

    Cardiovascular, Critical Care / Resuscitation

    Last Updated Jul 13, 2017
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    By Brian Grunau, Jim Christenson, Julian Marsden, Graham Wong, Chris Fordyce

    Context

    • In treated out-of-hospital cardiac arrests, survival to hospital discharge varies from 8 – 19% even in high performing systems.1 Recent reports have demonstrated significant improvements in outcomes1 likely due to large scale improvements in OHCA care. Post arrest care likely also has important impacts on survival, but precise recommendations have little evidence to define best practices.
    • Acute coronary occlusion is the most common etiology of out-of-hospital cardiac arrests with no obvious non-cardiac cause. A significant coronary lesion is found in nearly all of those with ST-elevation myocardial infarction (STEMI) on ECG and 58% of those without STEMI—indicating the need for early recognition and treatment.3
    • High quality evidence pertaining to percutaneous intervention (PCI) and/or thrombolytic management among patients resuscitated from OHCA is lacking.
    • Observational data has demonstrated improved survival among those with successful immediate coronary angioplasty, regardless of ST segment abnormality.4
    • In STEMI, PCI and thrombolysis are both beneficial, but PCI appears to be safer and more effective when available.5

    Recommended Treatment in Resuscitated OHCA patients with STEMI

    • Primary PCI or fibrinolytic management should follow the regional STEMI protocols as used for non-cardiac arrest STEMI patients.
    • Emergent cardiac catheterization is the preferred management strategy when this therapy is available within 120 minutes from first medical contact
    • Fibrinolytic therapy should be administered if timely PCI is unavailable and there are no contraindications.
    • Current guidelines recommend the use of the Sgarbossa criteria to determine whether patients with LBBB should be considered for reperfusion therapy. A discussion with cardiology expertise is recommended in these cases.

    Recommended Treatment in Resuscitated OHCA Patient Without STEMI

    • If you have a high level of suspicion that an acute coronary occlusion was the cause of the cardiac arrest cardiac angiography should be performed as soon as feasible. Suspicion of an acute coronary occlusion should be based on: clinical history of cardiac symptoms prior to the arrest, ST-depression on the ECG, and past medical history or risk factors for coronary artery disease. Troponin levels have limited value in predicting culprit lesions.
    • Coronary angiography is essential in cases with hemodynamic instability.
    • Fibrinolytic therapy should not be given to patients without STEMI even if suspicious of a coronary cause.

    Quality Of Evidence?

    Justification

    Low

    Disposition

    Patients should be transferred as soon as feasible to a regional critical care setting, ideally capable of invasive coronary procedures.

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