- Email: [email protected]
Coronary Angiography After Out-of-Hospital Cardiac Arrest
JACC: CARDIOVASCULAR INTERVENTIONS
VOL. 10, NO. 9, 2017
ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER
Letters TO THE EDITOR
treatment when an arrest is not caused by an acute coronary problem; significant benefits would have to accrue to revascularization in patients with acute coronary to overcome the liability of delays in others.
Coronary Angiography After Out-of-Hospital Cardiac Arrest
Because it is not evident that immediate catheterization benefits patients with OHCA in any circumstance other than STEMI, we should not compel practitioners to approach all OHCA with a uniform care plan. Although routine revascularization in sur-
Management of out-of-hospital cardiac arrest (OHCA)
vivors of OHCA without STEMI may lead to superior
is problematic, and several issues remain unresolved.
outcomes, benefits must be demonstrated through
One is whether all patients who survive to reach the
properly conducted study. This practice does not
hospital after OHCA should undergo immediate car-
currently receive a Class I indication from any major
diac catheterization and revascularization. Random-
guideline documents to the best of our knowledge.
ized trial data are lacking in this area, but benefits were suggested in porcine model experimental results published recently by JACC: Cardiovascular Interventions (1). In an accompanying editorial (2), statements were made that were not accurate. The editorial states “AHA/ACC/European Society of Cardiology practice guidelines . recommend (Class I) immediate coronary angiography for post-arrest patients with or without ST-segment elevation on their initial electrocardiogram (ECG) and who do not have
*Andrew Doorey, MD Kirk N. Garratt, MD William W. Weintraub, MD *Christiana Care Health System 4755 Ogletown-Stanton Road Newark, Delaware 19718 E-mail: [email protected] http://dx.doi.org/10.1016/j.jcin.2017.02.009 Please note: All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
another clear, noncardiac cause for their arrest (3,4,6).” However, the 2013 American College of Cardiology Foundation/American Heart Association guideline
for
ST-segment
myocardial
infarction
(STEMI) (3) makes a Class I recommendation only if the electrocardiogram shows STEMI. Angiography in patients without STEMI is discussed, but no specific recommendation is made. The 2012 European Society of Cardiology Guideline for the Management of STEMI (4) also provides a Class I indication for survivors of OHCA with evidence of STEMI, whereas immediate angiography for those without STEMI is given a 2A recommendation with level of evidence B. The third
REFERENCES 1. Kern KB, Hanna JM, Young HN, et al. Importance of both early reperfusion and therapeutic hypothermia in limiting myocardial infarct size post–cardiac arrest in a porcine model. J Am Coll Cardiol Intv 2016;9:2403–12. 2. Ornato JP. The need for both therapeutic hypothermia and early coronary angiography after out-of-hospital cardiac arrest. J Am Coll Cardiol Intv 2016; 9:2413–5. 3. Gara PTO, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol 2013;61:e78–140. 4. Steg PG, James SK, Atar D, et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33:2569–619.
citation supporting the author’s claim is not a
5. Fanari Z, Abraham N, Kolm P, et al. Aggressive measures to decrease “door to balloon” time and incidence of unnecessary cardiac catheterization: potential
guideline statement, but an editorial written by the
risks and role of quality improvement. Mayo Clin Proc 2015;90:1614–22.
investigators of the porcine model. It is important to note that their opinions have not yet been adopted by
REPLY: Coronary Angiography After
practice guidelines.
Out-of-Hospital Cardiac Arrest
We contend that immediate angiography in OHCA survivors without STEMI is a difficult clinical decision
I thank Drs. Doorey, Garratt, and Weintraub for cor-
that must consider all benefits and risks. We reported
recting my statement and pointing out that the level
an increase in mortality confounding efforts to reduce
1 guidelines for percutaneous coronary intervention
door-to-balloon times aggressively, driven in part by
following out-of-hospital cardiac arrest currently
survivors of OHCA (5). Trips to the catheterization
only apply to patients with ST-segment elevation
laboratory can delay appropriate diagnosis and
myocardial infarction. The optimal management of
VOL. 10, NO. 9, 2017
ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER
Letters TO THE EDITOR
treatment when an arrest is not caused by an acute coronary problem; significant benefits would have to accrue to revascularization in patients with acute coronary to overcome the liability of delays in others.
Coronary Angiography After Out-of-Hospital Cardiac Arrest
Because it is not evident that immediate catheterization benefits patients with OHCA in any circumstance other than STEMI, we should not compel practitioners to approach all OHCA with a uniform care plan. Although routine revascularization in sur-
Management of out-of-hospital cardiac arrest (OHCA)
vivors of OHCA without STEMI may lead to superior
is problematic, and several issues remain unresolved.
outcomes, benefits must be demonstrated through
One is whether all patients who survive to reach the
properly conducted study. This practice does not
hospital after OHCA should undergo immediate car-
currently receive a Class I indication from any major
diac catheterization and revascularization. Random-
guideline documents to the best of our knowledge.
ized trial data are lacking in this area, but benefits were suggested in porcine model experimental results published recently by JACC: Cardiovascular Interventions (1). In an accompanying editorial (2), statements were made that were not accurate. The editorial states “AHA/ACC/European Society of Cardiology practice guidelines . recommend (Class I) immediate coronary angiography for post-arrest patients with or without ST-segment elevation on their initial electrocardiogram (ECG) and who do not have
*Andrew Doorey, MD Kirk N. Garratt, MD William W. Weintraub, MD *Christiana Care Health System 4755 Ogletown-Stanton Road Newark, Delaware 19718 E-mail: [email protected] http://dx.doi.org/10.1016/j.jcin.2017.02.009 Please note: All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
another clear, noncardiac cause for their arrest (3,4,6).” However, the 2013 American College of Cardiology Foundation/American Heart Association guideline
for
ST-segment
myocardial
infarction
(STEMI) (3) makes a Class I recommendation only if the electrocardiogram shows STEMI. Angiography in patients without STEMI is discussed, but no specific recommendation is made. The 2012 European Society of Cardiology Guideline for the Management of STEMI (4) also provides a Class I indication for survivors of OHCA with evidence of STEMI, whereas immediate angiography for those without STEMI is given a 2A recommendation with level of evidence B. The third
REFERENCES 1. Kern KB, Hanna JM, Young HN, et al. Importance of both early reperfusion and therapeutic hypothermia in limiting myocardial infarct size post–cardiac arrest in a porcine model. J Am Coll Cardiol Intv 2016;9:2403–12. 2. Ornato JP. The need for both therapeutic hypothermia and early coronary angiography after out-of-hospital cardiac arrest. J Am Coll Cardiol Intv 2016; 9:2413–5. 3. Gara PTO, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol 2013;61:e78–140. 4. Steg PG, James SK, Atar D, et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33:2569–619.
citation supporting the author’s claim is not a
5. Fanari Z, Abraham N, Kolm P, et al. Aggressive measures to decrease “door to balloon” time and incidence of unnecessary cardiac catheterization: potential
guideline statement, but an editorial written by the
risks and role of quality improvement. Mayo Clin Proc 2015;90:1614–22.
investigators of the porcine model. It is important to note that their opinions have not yet been adopted by
REPLY: Coronary Angiography After
practice guidelines.
Out-of-Hospital Cardiac Arrest
We contend that immediate angiography in OHCA survivors without STEMI is a difficult clinical decision
I thank Drs. Doorey, Garratt, and Weintraub for cor-
that must consider all benefits and risks. We reported
recting my statement and pointing out that the level
an increase in mortality confounding efforts to reduce
1 guidelines for percutaneous coronary intervention
door-to-balloon times aggressively, driven in part by
following out-of-hospital cardiac arrest currently
survivors of OHCA (5). Trips to the catheterization
only apply to patients with ST-segment elevation
laboratory can delay appropriate diagnosis and
myocardial infarction. The optimal management of