Early PCI encouraged after out-of-hospital cardiac arrest in certain patients

Issue: February 2015

CHICAGO — Among patients with out-of-hospital cardiac arrest who were admitted after successful return of spontaneous circulation, those who received immediate PCI had better short- and long-term survival than those who did not undergo the procedure.

Perspective from Stephen R. Bailey, MD

For the study, Guillaume Geri, MD, with the medical intensive care unit, Cochin Hospital, Paris, and colleagues prospectively enrolled all non-trauma out-of-hospital cardiac arrest (OHCA) patients after successful return of spontaneous circulation who were admitted to a cardiac arrest center from 2000 to 2012.

Guillaume Geri

The researchers examined the association between immediate PCI and survival at 30 days, 2 years and 10 years, and evaluated other potential predicting factors. Furthermore, they used a propensity score method to analyze the impact of PCI on 30-day and long-term survival in matched patients.

Overall, 1,723 patients (71.5% men; median age, 59.9 years) were analyzed during a median of 2 years of follow-up. OHCA was witnessed in 86.7% of patients, and occurred in a public space in 32.2% of patients and with an initial shockable rhythm (ventricular fibrillation/ventricular tachycardia) in 54.6% of cases.

Therapeutic hypothermia was utilized in 71% of patients, whereas immediate PCI was performed in 27.8% of patients.

At 30 days, survival was higher in the immediate PCI group compared with those who did not undergo the procedure (43% vs. 27.5%). This finding remained consistent at 2 years (40.1% vs. 23.4%) and 10 years (38% vs. 20.2%). Immediate PCI also yielded better survival at 30 days (adjusted OR=0.71; P=.02) and during the long term (adjusted HR=0.44; P<.01).

Similarly, among the propensity score matched cohort, long-term survival was better in the PCI arm (adjusted HR=0.29; 95% CI, 0.14-0.61).

“Early coronary angiography and PCI, if required, should be considered in all non-trauma OHCA patients without an obvious extracardiac cause,” Geri told Cardiology Today’s Intervention. – by Brian Ellis

For more information:

Geri G. Abstract #13359. Presented at: American Heart Association Scientific Sessions; Nov. 15-19, 2014; Chicago.

Disclosure: Geri reports no relevant financial disclosures.

Perspective

Stephen R. Bailey, MD

This study gives us some assurance to a question that we have asked often: Do we really make a difference by mobilizing everybody and trying to do this intervention? This particular study says yes. It is different than what we see in the United States. Gupta and colleagues reported in the American Journal of Cardiology in 2014 from a US population of more than 117,000 infarcts that about 1,700 of those had OHCA and were resuscitated. Survival rates were half of what was observed in [the Paris study], about 20%. Many patients didn’t have MI; they had cardiac arrest in the absence of MI for other reasons. We know that the Paris and US populations were much different. They were younger in Paris than in the United States in the National Cardiovascular Data Registry (NCDR). Also, the systems in Europe, particularly in Paris, are different. They are organized to have mobile coronary care units; they began hypothermia onsite very early; they had the ability to make diagnoses that in many US cities and locations we are unable to do. In Paris, 32% of cardiac arrests were in public places and 87% were witnessed arrests.

We are on the right track by looking at this. It requires systems that are different than how we currently treat STEMI. We need more science. We need to look carefully at what the confounding benefit of hypothermia might be. I think those are areas we are going to learn more about. But today, in my practice, if you have spontaneous return of circulation and are in our ED, we are going to move fast, we are going to work hard and we are going to accept the fact that we are going to help some of these patients.

Stephen R. Bailey, MD

Chief, Division of Cardiology

Janey Briscoe Distinguished Chair in Cardiology

University of Texas Health Science Center at San Antonio

Cardiology Today’s Intervention Editorial Board member

Disclosures: Bailey reports no relevant financial disclosures.