Top Things to Know: The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest
Published: February 14, 2019
- According to the 2015 Institute of Medicine report, Strategies to Improve Cardiac Arrest Survival: A Time to Act, ≈395 000 people suffer an out-of-hospital cardiac arrest (OHCA) each year in the United States. The survival rate is 6% to 10%, resulting in >350 000 deaths per year, making sudden cardiac arrest virtually synonymous with sudden cardiac death.
- Over the past 20 years, a significant body of evidence has emerged highlighting the importance of significant coronary artery disease (CAD) in patients presenting with ventricular fibrillation (VF)/pulseless ventricular tachycardia (pVT) and OHCA.
- The purpose of this paper is to present the available evidence of the potential benefit of emergent cardiac catheterization laboratory (CCL) access and subsequent interventions in patients with OHCA based (on the basis of) on initial presentation with shockable and nonshockable rhythms and the presence of refractory cardiac arrest.
- Current guidelines recommend early coronary angiography (CAG) and reperfusion for postarrest patients manifesting ST-segment elevation after return of spontaneous circulation (ROSC) is achieved.
- Currently, there is no consensus guideline on the use of CAG and coronary revascularization in patients without ST-segment elevation on electrocardiogram (ECG).
- Current evidence suggests that early access to the CCL in patients resuscitated from VF/pVT cardiac arrest is associated with 2- to 3-fold higher functionally favorable survival rates than more conservative approaches of late or no access to the CCL. The effect of early CCL in nonshockable rhythms remains undefined.
- The evidence suggests that patients resuscitated from OHCA, especially those with presenting shockable rhythms, should be considered for early CAG, identification of reversible causes, and revascularization when indicated.
- The role of extracorporeal life support-based resuscitation for refractory OHCA should also have special considerations. Based on the available evidence, healthcare systems planning to initiate extracorporeal life support–based resuscitation for refractory OHCA should implement system-structural protocols that target a 9-1-1 call to VA-ECMO support interval of <60 minutes. They should also provide multidisciplinary postresuscitation critical care, including comprehensive medical and surgical support services. This will be critical for the effective expansion of extracorporeal life support programs.
- Coronary artery disease is a common substrate, and its severity is a potential trigger for OHCA, especially in the case of shockable rhythms. Patients with VF/pVT OHCA should be considered at the highest severity of a continuum of acute coronary syndromes. Patients with VF/pVT have a significant burden of CAD: acute, chronic, or acute on chronic.
- Efforts should be undertaken with an understanding of the resource requirements to fully optimize the entire chain of survival after cardiac arrest.
Citation
Yannopoulos D, Bartos JA, Aufderheide TP, Callaway CW, Deo R, Garcia S, Halperin HR, Kern KB, Kudenchuk PJ, Neumar RW, Raveendran G, on behalf of the American Heart Association Emergency Cardiovascular Care Committee. The evolving role of the cardiac catheterization laboratory in the management of patients with out-of-hospital cardiac arrest: a scientific statement from the American Heart Association [published online ahead of print February 14, 2019]. Circulation. doi: 10.1161/CIR.0000000000000630.