Top Things to Know: The Cardiac Catheterization Laboratory Management of the Comatose Adult Patient with an Out of Hospital Cardiac Arrest
Published: December 19, 2023
Prepared by Setri Fugar MD, Fellow in Training Medical College of Wisconsin, Member of the AHA CLCD Interventional Care Committee
- About 350,000 people in the United States present with an out of hospital cardiac arrest (OHCA) each year with only 6-10% surviving to discharge. Survival rates vary by gender, race and arrest location with the lowest survival rates seen amongst Black/African American and Hispanic/Latino irrespective of gender.
- The cardiac catheterization laboratory can be a useful setting to provide resuscitation, and to stabilize a patient with sudden cardiac arrest of varying cardiac etiologies.
- In the comatose patient OHCA with return of spontaneous circulation (ROSC), the focus of initial management is to minimize the neurologic damage and to treat the underlying cause of cardiac arrest. Though coronary artery disease is the most prevalent risk factor for OHCA, its role as etiology has decreased over the years.
- The initial assessment of the resuscitated post-cardiac arrest patient should include a focused clinical history to understand the presence of cardiac risk factors, family history of cardiac arrest, attempt to determine the time of collapse to initiation of CPR, adequacy of CPR, perform a thorough physical exam, and evaluate the accompanying ECG and laboratory results with the aim of identifying and reversing the cause of the event.
- Point of care ultrasound/echocardiogram is a valuable tool in assessing OHCA patients providing useful information in patients with hemodynamic compromise to assess RV or LV dysfunction, valvular or structural abnormalities, estimate intravascular volume and to assess for hemodynamically significant effusion.
- Multiple clinical prediction tools, such as the cardiac arrest hospital prognosis (CAHP) score and the Targeted temperature management (TTM) score, have been developed to aid in determining the prognosis of patients presenting with OHCA based on pre-arrest, intra-arrest, and post-arrest characteristics.
- The goal of invasive management in the cardiac catheterization laboratory is to identify and treat a culprit coronary lesion responsible for the clinical presentation, and to provide MCS for hemodynamically or electrically unstable patients when indicated.
- Most patients presenting with OHCA do not have STE on post arrest ECG, however, observational studies have shown that nearly 1 out of 3 of these victims have acute coronary occlusion. Multiple randomized clinical trials recently published, however, have failed to show a difference in survival outcomes with early coronary angiography in this group of patients.
- Mechanical Circulatory devices can play a major role in patients with OHCA and hemodynamic or electrical instability. Extracorporeal cardiopulmonary resuscitation (ECPR) is the utilization of ECMO emergently after failure of conventional CPR.
- Successful management of patients with OHCA patients requires a multidisciplinary team in which the interventional cardiologist and cardiac catheterization play a key role and likely an individualized approach given the uncertainty of neurologic outcomes.
Citation
Tamis-Holland JE, Menon V, Johnson NJ, Kern KB, Lemor A, Mason PJ, Rodgers M, Serrao GW, Yannopoulos D; on behalf of the Interventional Cardiovascular Care Committee and the Acute Cardiac Care and General Cardiology Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; and Council on Cardiovascular and Stroke Nursing. Cardiac catheterization laboratory management of the comatose adult patient with an out-of-hospital cardiac arrest: a scientific statement from the American Heart Association. Circulation. Published online December 19, 2023. doi: 10.1161/CIR.00000000000001199