Emergency coronary angiography and interventions in comatose patients resuscitated after out-of-hospital cardiac arrest treated with mild therapeutic hypothermia

Abstract

Purpose. In many patients (pts.) resuscitated (ROSC) after out-of-hospital cardiac arrest (OHCA) due to ventricular fibrillation (VF) early coronary angiography (Angio) and interventions (PCI) improve outcomes. Furthermore, mild therapeutic hypothermia (TH) improves neuro-protection and outcomes. However, TH may increase the risk of bleeding and can interfere with the effectiveness of antithrombotic drugs routinely used during PCI. Methods. Observational prospective analysis of all pts with ROSC after OHCA admitted alive to the emergency room (ER) of a tertiary center from March 27, 2004 to December 31, 2012 treated with TH and undergoing early Angio and PCI. Results. From March 2004 to December 2012, 141 (42.4%) out of 332 comatose pts. after OHCA were treated with TH (median age: 64.5 (interquartile range (IQR) 55-73) yrs, males: 67%, first shockable rhythm: 70%, witnessed OHCA: 94%, interval OHCA-resuscitation <20 min: 81%). Ninety-seven pts (69%) underwent early Angio, and 45 (32%) of them PCI. Baseline characteristics of pts undergoing PCI were similar to those of pts without PCI, although most of the former had ST elevation myocardial infarction at the first EKG after ROSC and less comorbidities. Fifteen percent of pts undergoing PCI were in cardiogenic shock and 18% had an intra-aortic balloon pump implanted. In 36% of pts the PCI was performed through the radial approach. Multivessel PCI was performed in 31%, target vessel was the left anterior descending in 35%. Post-PCI TIMI 3 flow was achieved in 92% of pts and 87% had >1 stent implanted (12% DES, 88% BMS). All pts received unfractionated heparin (70 U/kg bolus), 300 mg aspirin and 300 mg loading dose clopidogrel (12%, 600 mg loading dose) post-PCI; abciximab was infused in 43%. One major bleeding (gastric) was observed in a pt treated with abciximab (5 RBC packs transfused) who later survived. Hemoglobin, hematocrit, RBC and platelets were mildly reduced during TH in both groups. No stent thrombosis occurred. Conclusions. Emergency Angio and PCI in combination with TH and aggressive antithrombotics are feasible and safe in comatose pts. resuscitated after OHCA (with first observed rhythm shockable). Thus, a mature STEMI network can be further developed to include a TH protocol and interventions for resuscitated OHCA. (Figure Presented).