Author + information
- Received October 8, 2018
- Revision received January 9, 2019
- Accepted January 15, 2019
- Published online April 15, 2019.
- Jacob C. Jentzer, MDa,b,∗ (, )
- Joerg Herrmann, MDa,
- Abhiram Prasad, MDa,
- Gregory W. Barsness, MDa,c and
- Malcolm R. Bell, MDa
- aDepartment of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- bDivision of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
- cDepartment of Radiology, Mayo Clinic, Rochester, Minnesota
- ↵∗Address for correspondence:
Dr. Jacob C. Jentzer, Mayo Clinic, Department of Cardiovascular Medicine, 200 First Street SW, Rochester, Minnesota 55905.
• Coronary artery disease is the leading cause of out-of-hospital cardiac arrest (OHCA), and both early coronary angiography and percutaneous coronary intervention have been associated with improved survival after OHCA.
• Guidelines recommend immediate coronary angiography for OHCA patients with ST-elevation myocardial infarction, cardiogenic shock or recurrent ventricular arrhythmias, and consideration should be given to performing coronary angiography for all OHCA patients without an apparent noncardiac arrest etiology.
• The decision to perform early coronary angiography for OHCA patients should balance the potential benefit of treating a coronary culprit lesion with the possibility of severe anoxic brain injury which could mitigate this benefit. Ongoing randomized clinical trials will provide needed evidence to guide these clinical decisions.
Out-of-hospital cardiac arrest (OHCA) is frequently triggered by acute myocardial ischemia. Coronary angiography is an important component of post-resuscitation care for patients with OHCA without an evident noncardiac cause, to identify underlying coronary artery disease and allow revascularization. Most patients undergoing coronary angiography after OHCA have obstructive coronary artery disease, and nearly one-half of patients have acute coronary occlusion. Early coronary angiography and percutaneous coronary intervention after OHCA have been associated with improved survival in observational studies, but these studies demonstrate selection bias, and randomized trials are lacking. Selection of patients for coronary angiography after OHCA can be challenging, particularly in comatose patients whose outcomes are driven primarily by anoxic brain injury. As for other patients with acute coronary syndromes, patients with ST-segment elevation after OHCA have a high probability of acute coronary occlusion warranting emergent coronary angiography. Patients with cardiogenic shock after OHCA are a high-risk population also requiring emergent coronary angiography. Among patients in stable condition after OHCA without ST-segment elevation, other clinical predictors can be used to identify those needing early coronary angiography to identify obstructive coronary artery disease. Despite the challenges with early neurological prognostication in comatose patients with OHCA, those with multiple objective markers of poor prognosis appear less likely to benefit from revascularization, and early coronary angiography may be reasonably deferred in appropriately selected patients meeting these criteria. The authors propose an algorithm to guide patient selection for coronary angiography after OHCA that combines clinical predictors of acute coronary occlusion and early clinical predictors of severe brain injury.
- coronary angiography
- coronary artery disease
- myocardial infarction
- percutaneous coronary intervention
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 8, 2018.
- Revision received January 9, 2019.
- Accepted January 15, 2019.
- 2019 American College of Cardiology Foundation
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