Post Cardiac Arrest: PCI and Thrombolytics
Cardiovascular, Critical Care / Resuscitation
- 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?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Patients should be transferred as soon as feasible to a regional critical care setting, ideally capable of invasive coronary procedures.
More Detailed Guidelines
- Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Position Statement on the Optimal Care of the Postarrest Patient
- Part 8: Post–Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
- 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction
Mozaffarian D, Benjamin EJ, Go AS, et al. Executive Summary: Heart Disease and Stroke Statistics–2016 Update: A Report From the American Heart Association. Circulation. 2016;133(4):447-454. doi:10.1161/CIR.0000000000000366.
Daya MR, Schmicker RH, Zive DM, et al. Out-of-hospital cardiac arrest survival improving over time: Results from the Resuscitation Outcomes Consortium (ROC). Resuscitation. 2015;91:108-115. doi:10.1016/j.resuscitation.2015.02.003.
Dumas F, Cariou A, Manzo-Silberman S, et al. Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Circ Cardiovasc Interv. 2010;3(3):200-207. doi:10.1161/CIRCINTERVENTIONS.109.913665.
Koeth O, Zahn R, Bauer T, et al. Primary percutaneous coronary intervention and thrombolysis improve survival in patients with ST-elevation myocardial infarction and pre-hospital resuscitation. Resuscitation. 2010;81(11):1505-1508. doi:10.1016/j.resuscitation.2010.06.018.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jul 13, 2017
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