Author + information
- Vinay R. Hosmane, MD, MPH⁎ (, )
- Andrew J. Doorey, MD,
- Niksad Abraham, MBBS,
- Vivek K. Reddy, MD and
- Ehasanur Rahman, MD
- ↵⁎Christiana Care Health System, Section of Cardiology, Room 2E99, 4745 Ogletown-Stanton Road, Newark, Delaware 19716
As an institution that has a great interest in and has studied cardiac arrest and ST-segment elevation myocardial infarction (STEMI) (1), we read with great interest and agree with Dr. Kern (2) that we should provide “operators and medical centers the opportunity to do what is best for the individual STEMI patient, without fear of unfair inflation of their overall reported mortality figures.”
We agree that “such a change cannot come too soon” for those cardiac arrest STEMI victims comatose on arrival to the hospital. However, we now fear that with aggressive door-to-balloon-time initiatives and our prior report on STEMI and out of hospital cardiac arrest (OHCA), that operators are performing emergent percutaneous coronary intervention (PCI) too often in comatose patients when STEMI does not in fact truly exist.
A recent abstract from our institution by Abraham et al. (3), presented at the most recent American College of Cardiology Scientific Sessions, noted that aggressive catheterization was performed in patients with noncardiac causes of ST-segment elevation on electrocardiogram. Many of these patients had OHCA and the catheterization delayed the diagnosis and treatment of the primary etiology. Subsequent work-up showed that the cause of mortality was varied and included sepsis, hyperkalemia, intracranial hemorrhage, aortic dissection, left ventricular aneurysm, and pulmonary embolism.
We are now victims of our own success in that we had concluded in 2009 that “resuscitated patients with STEMI in the ED should be seriously considered for emergent revascularization regardless of neurologic status. These patients should be treated with the same urgency as patients with acute STEMI without cardiac arrest (1).”
We agree with Dr. Kern and advocate aggressive evaluation and treatment of comatose OHCA patients found to have diagnostic STEMI with emergent PCI and therapeutic hypothermia. However, we emphasize not to push every arrest patient to the catheterization laboratory without appropriate evaluation in the emergency department to ensure coronary obstruction as an etiology for the event. Not infrequently, these ST-segment changes are concurrent with another catastrophic event that leads to ischemic changes on the electrocardiogram.
Though, the mantra has always been “time is myocardium,” a 5-min delay in door-to-balloon time to practice sound clinical medicine is unlikely to cause higher mortality and morbidity. However, delaying treatment of the true etiology of arrest by performing emergent catheterization may, in fact, do so.
- American College of Cardiology Foundation
- Hosmane V.R.,
- Mustafa N.G.,
- Reddy V.K.,
- et al.
- Kern K.B.
- Abraham N.,
- Zhu D.,
- Morrone D.,
- DiSabatino A.,
- Murphy D.,
- Doory A.