Skip to main content

Coronary Angiography in Patients With Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: A Systematic Review and Meta-Analysis

Coronary

J Am Coll Cardiol Intv, 13 (19) 2193–2205
Sections

Central Illustration

Abstract

Objectives

The authors conducted a meta-analysis to study clinical outcomes in patients who underwent early versus nonearly coronary angiography (CAG) in the setting of out-of-hospital cardiac arrest (OHCA) without ST-segment elevation.

Background

The benefit of performing early CAG in patients with OHCA without STE remains disputed.

Methods

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from inception until February 21, 2020. Early and nonearly CAG patients were identified on the basis of the definitions mentioned in respective published studies. The primary outcome studied was 30-day mortality. Secondary outcomes were neurological status and the rate of percutaneous coronary intervention (PCI) following cardiac arrest.

Results

Of 4,516 references, 11 studies enrolling 3,581 patients were included in the final meta-analysis. Random-effects analysis showed no differences in 30-day mortality (risk ratio [RR]: 0.86; 95% confidence interval [CI]: 0.71 to 1.04; p = 0.12; I2 = 74%), neurological status (RR: 1.08; 95% CI: 0.94 to 1.24; p = 0.28; I2 = 69%), and rate of PCI (RR: 1.22; 95% CI: 0.94 to 1.59; p = 0.13; I2 = 67%) between the 2 groups. Diabetes mellitus, chronic renal failure, previous PCI, and lactate level were found to be significant predictors of 30-day mortality on meta-regression (p < 0.05).

Conclusions

This analysis shows that there is no significant difference in 30-day mortality, neurological status, or rate of PCI among patients with OHCA without STE treated with early versus nonearly CAG. Thirty-day mortality is determined by presentation comorbidities rather than revascularization.

  • 1. Gorjup V., Radsel P., Kocjancic S.T., Erzen D., Noc M. "Acute ST-elevation myocardial infarction after successful cardiopulmonary resuscitation". Resuscitation 2007;72:379-385.

    CrossrefMedlineGoogle Scholar
  • 2. Akin M., Sieweke J.-T.T., Zauner F., et al. "Mortality in patients with out-of-hospital cardiac arrest undergoing a standardized protocol including therapeutic hypothermia and routine coronary angiography: experience from the HACORE registry". J Am Coll Cardiol Intv 2018;11:1811-1820.

    View ArticleGoogle Scholar
  • 3. Hwang W.S., Park J.S., Kim S.J., Hong Y.S., Moon S.W., Lee S.W. "A system-wide approach from the community to the hospital for improving neurologic outcomes in out-of-hospital cardiac arrest patients". Eur J Emerg Med 2017;24:87-95.

    CrossrefMedlineGoogle Scholar
  • 4. O’Gara P.T., Kushner F.G., Ascheim D.D., et al. "2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol 2013;61:e78-e140.

    View ArticleGoogle Scholar
  • 5. Hollenbeck R.D., McPherson J.A., Mooney M.R., et al. "Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI". Resuscitation 2014;85:88-95.

    CrossrefMedlineGoogle Scholar
  • 6. Welsford M., Bossard M., Shortt C., Pritchard J., Natarajan M.K., Belley-Côté E.P. "Does early coronary angiography improve survival after out-of-hospital cardiac arrest? A systematic review with meta-analysis". Can J Cardiol 2018;34:180-194.

    CrossrefMedlineGoogle Scholar
  • 7. Kern K.B., Lotun K., Patel N., et al. "Outcomes of comatose cardiac arrest survivors with and without ST-segment elevation myocardial infarction importance of coronary angiography". J Am Coll Cardiol Intv 2015;8:1031-1040.

    View ArticleGoogle Scholar
  • 8. Elfwén L., Lagedal R., James S., et al. "Coronary angiography in out-of-hospital cardiac arrest without ST elevation on ECG—short- and long-term survival". Am Heart J 2018;200:90-95.

    CrossrefMedlineGoogle Scholar
  • 9. Lemkes J.S., Janssens G.N., van der Hoeven N.W., et al. "Coronary angiography after cardiac arrest without ST-segment elevation". N Engl J Med 2019;380:1397-1407.

    CrossrefMedlineGoogle Scholar
  • 10. Kim Y.J., Kim Y.H., Lee B.K., et al. "Immediate versus early coronary angiography with targeted temperature management in out-of-hospital cardiac arrest survivors without ST-segment elevation: a propensity score-matched analysis from a multicenter registry". Resuscitation 2019;135:30-36.

    CrossrefMedlineGoogle Scholar
  • 11. Dankiewicz J., Nielsen N., Annborn M., et al. "Survival in patients without acute ST elevation after cardiac arrest and association with early coronary angiography: a post hoc analysis from the TTM trial". Intensive Care Med 2015;41:856-864.

    CrossrefMedlineGoogle Scholar
  • 12. Desch S., Freund A., Graf T., et al. "Immediate unselected coronary angiography versus delayed triage in survivors of out-of-hospital cardiac arrest without ST-segment elevation: design and rationale of the TOMAHAWK trial". Am Heart J 2019;209:20-28.

    CrossrefMedlineGoogle Scholar
  • 13. Elfwén L., Lagedal R., Nordberg P., et al. "Direct or subacute coronary angiography in out-of-hospital cardiac arrest (DISCO)—an initial pilot-study of a randomized clinical trial". Resuscitation 2019;139:253-261.

    CrossrefMedlineGoogle Scholar
  • 14. Patterson T., Perkins G.D., Joseph J., et al. "A Randomised Trial of Expedited Transfer to a Cardiac Arrest Centre for Non-ST Elevation Ventricular Fibrillation Out-of-Hospital Cardiac Arrest: the ARREST pilot randomised trial". Resuscitation 2017;115:185-191.

    CrossrefMedlineGoogle Scholar
  • 15. Hauw-Berlemont C., Lamhaut L., Diehl J.-L., et al. "Emergency Versus Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest With No Obvious Non-Cardiac Cause of Arrest: design of the EMERGE trial". Am Heart J 2020;222:131-138.

    CrossrefMedlineGoogle Scholar
  • 16. Viana-Tejedor A., Ariza-Solé A., Martínez-Sellés M., et al. "Role of coronary angiography in patients with a non-diagnostic electrocardiogram following out of hospital cardiac arrest: rationale and design of the multicentre randomized controlled COUPE trial". Eur Hear J Acute Cardiovasc Care 2020Jun25. [E-pub ahead of print]..

    CrossrefMedlineGoogle Scholar
  • 17. Rab T., Kern K.B., Tamis-Holland J.E., et al. "Cardiac arrest: a treatment algorithm for emergent invasive cardiac procedures in the resuscitated comatose patient". J Am Coll Cardiol 2015;66:62-73.

    View ArticleGoogle Scholar
  • 18. O’Connor R.E., Brady W., Brooks S.C., et al. "Part 10: acute coronary syndromes: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care". Circulation 2010;122:suppl 3: S787-S817.

    CrossrefMedlineGoogle Scholar
  • 19. Al-Khatib S.M., Stevenson W.G., Ackerman M.J., et al. "2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society". J Am Coll Cardiol 2018;72:e91-e220.

    View ArticleGoogle Scholar
  • 20. Kleissner M., Sramko M., Kohoutek J., Kautzner J., Kettner J. "Impact of urgent coronary angiography on mid-term clinical outcome of comatose out-of-hospital cardiac arrest survivors presenting without ST-segment elevation". Resuscitation 2015;94:61-66.

    CrossrefMedlineGoogle Scholar
  • 21. Garcia S., Drexel T., Bekwelem W., et al. "Early access to the cardiac catheterization laboratory for patients resuscitated from cardiac arrest due to a shockable rhythm: the Minnesota Resuscitation Consortium Twin Cities Unified Protocol". J Am Heart Assoc 2016;5:1-10.

    CrossrefGoogle Scholar
  • 22. Bro-Jeppesen J., Kjaergaard J., Wanscher M., et al. "Emergency coronary angiography in comatose cardiac arrest patients: do real-life experiences support the guidelines?"Eur Hear J Acute Cardiovasc Care 2012;1:291-301.

    CrossrefMedlineGoogle Scholar
  • 23. Tateishi K., Abe D., Iwama T., Hamabe Y., Aonuma K., Sato A. "Clinical value of ST-segment change after return of spontaneous cardiac arrest and emergent coronary angiography in patients with out-of-hospital cardiac arrest: diagnostic and therapeutic importance of vasospastic angina". Eur Heart J Acute Cardiovasc Care 2018;7:405-413.

    CrossrefMedlineGoogle Scholar
  • 24. Wilson M., Grossestreuer A.V., Gaieski D.F., Abella B.S., Frohna W., Goyal M. "Incidence of coronary intervention in cardiac arrest survivors with non-shockable initial rhythms and no evidence of ST-elevation MI (STEMI)". Resuscitation 2017;113:83-86.

    CrossrefMedlineGoogle Scholar
  • 25. Barbarawi M., Zayed Y., Kheiri B., et al. "Optimal timing of coronary intervention in patients resuscitated from cardiac arrest without ST-segment elevation myocardial infarction (NSTEMI): A systematic review and meta-analysis". Resuscitation 2019;144:137-144.

    CrossrefMedlineGoogle Scholar
  • 26. Patel J.K., Thippeswamy G., Kataya A., Loeb C.A., Parikh P.B. "Predictors of obstructive coronary disease and mortality in adults having cardiac arrest". Am J Cardiol 2018;122:12-16.

    CrossrefMedlineGoogle Scholar
  • 27. Larsen J.M., Ravkilde J. "Acute coronary angiography in patients resuscitated from out-of-hospital cardiac arrest—a systematic review and meta-analysis". Resuscitation 2012;83:1427-1433.

    CrossrefMedlineGoogle Scholar
  • 28. Nielsen N., Hovdenes J., Nilsson F., et al. "Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest". Acta Anaesthesiol Scand 2009;53:926-934.

    CrossrefMedlineGoogle Scholar
  • 29. Merchant R.M., Abella B.S., Khan M., et al. "Cardiac catheterization is underutilized after in-hospital cardiac arrest". Resuscitation 2008;79:398-403.

    CrossrefMedlineGoogle Scholar
  • 30. Reynolds J.C., Callaway C.W., El Khoudary S.R., Moore C.G., Alvarez R.J., Rittenberger J.C. "Coronary angiography predicts improved outcome following cardiac arrest: propensity-adjusted analysis". J Intensive Care Med 2009;24:179-186.

    CrossrefMedlineGoogle Scholar
  • 31. Casella G., Carinci V., Cavallo P., et al. "Combining therapeutic hypothermia and emergent coronary angiography in out-of-hospital cardiac arrest survivors: optimal post-arrest care for the best patient". Eur Heart J Acute Cardiovasc Care 2015;4:579-588.

    CrossrefMedlineGoogle Scholar
  • 32. Shin J., Ko E., Cha W.C., et al. "Impact of early coronary angiography on the survival to discharge after out-of-hospital cardiac arrest". Clin Exp Emerg Med 2017;4:65-72.

    CrossrefMedlineGoogle Scholar
  • 33. Lam D.H., Glassmoyer L.M., Strom J.B., et al. "Factors associated with performing urgent coronary angiography in out-of-hospital cardiac arrest patients". Catheter Cardiovasc Interv 2018;91:832-839.

    CrossrefMedlineGoogle Scholar
  • 34. Moutacalli Z., Georges J.L., Ajlani B., et al. "Immediate coronary angiography in survivors of out-of-hospital cardiac arrest without obvious extracardiac cause: who benefits?"Ann Cardiol Angeiol (Paris) 2017;66:260-268.

    CrossrefMedlineGoogle Scholar
  • 35. Søholm H., Kjaergaard J., Bro-Jeppesen J., et al. "Prognostic implications of level-of-care at tertiary heart centers compared with other hospitals after resuscitation from out-of-hospital cardiac arrest". Circ Cardiovasc Qual Outcomes 2015;8:268-276.

    CrossrefMedlineGoogle Scholar
  • 36. Staudacher , den Uil C., Jewbali L., et al. "Timing of coronary angiography in survivors of out-of-hospital cardiac arrest without obvious extracardiac causes". Resuscitation 2018;123:98-104.

    CrossrefMedlineGoogle Scholar
  • 37. Sauneuf B., Dupeyrat J., Souloy X., et al. "The CAHP (cardiac arrest hospital prognosis) score: a tool for risk stratification after out-of-hospital cardiac arrest in elderly patients". Resuscitation 2020;148:200-206.

    CrossrefMedlineGoogle Scholar