DECLARATION OF CONFLICT OF INTEREST. Research grants: Sanofi-Aventis

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1 DECLARATION OF CONFLICT OF INTEREST Research grants: Sanofi-Aventis

2 Invasive management after cardiac arrest Nikolaos I Nikolaou FESC, FERC Athens, Greece

3 Survival (%) Survival from Out of Hospital Cardiac Arrest (OHCA) prospective studies EMS treated CA USA Australia Europe Asia Berdowsky et al. Resuscitation 2010

4 ROSC

5 % of deaths Survival from out of Hospital Cardiac arrest Causes of ICU death Brain Cardiac MOF Olasveegen n=129 Laver n=126

6 Survival from out of Hospital Cardiac arrest Therapeutic hypothermia N Engl J Med 2002;346:549-56

7 Survival from out of Hospital Cardiac arrest Myocardial dysfunction after ROSC Global ischemia-reperfusion injury Persistent ischemia Recurrent arrhythmias

8 No of patients Coronary angiography in survivors of OHCA (71%) (48%) 37 (44%) 28 (33%) 32 (38%) No of arrests CAD Coronary Occlusion Attempted PCI Successful PCI Hospital Survival Spaulding et al. N Engl J Med 1997

9 Coronary angiography in survivors of OHCA No need for inotropic support during transport to hospital Prtedictors of survival 3.6 (1.1 to 11.8) Successful PCI 5.2 (1.1 to 24.5) Time to return of spontaneous circulation Predictors of death 1.1 (1.02 to 1.12)/min delay Spaulding et al. N Engl J Med 1997

10 Diagnostic accuracy of ST elevation in patients with OHCA Spaulding et al. N Engl J Med 1997

11 Diagnostic accuracy of ST elevation in patients with OHCA Dumas et al. Circulation 2010

12 The high prevalence of acute coronary occlusion in survivors of OHCA The potential of PPCI to improve outcome Criteria for patient selection Spaulding et al. N Engl J Med 1997

13 Prevalence of CAD in survivors of OHCA N ST elevation CAD Culprit lesion PCI Spaulding Paris Anyfantakis Paris Muller Berlin, Total % 0,45 0,65 0,43 0,40

14 Prevalence of CAD in survivors of OHCA Dumas et al, Circ Cardiovasc Interv 2010 Gräsner et al, Critical Care 2011 Database N Coronary angiogr. PROCAT Paris, GRR Germany, PCI Total (0.27)

15 % of patients Survival of patients with OHCA undergoing PCI after ROSC Dumas Anyfantakis Muller Spaulding 0 Hospital survival CPC 1-2

16 Survival of patients with OHCA undergoing PCI after ROSC Dumas et al. Circulation 2010

17 No of patients Survival of patients with STEMI undergoing PCI after ROSC (87% ) 103 (55%) No of CA CAD PCI Hospital Survival 89 (48%) CPC1 Garot et al. Circulation 2007

18 Survival of patients with STEMI undergoing PCI after ROSC Noc et al. Curr Opin Crit Care 2007

19 Survival of patients with STEMI undergoing PCI after ROSC Bendz et al. Resuscitation 2004

20 PCI after ROSC in patients with OHCA Kern et al. Catheterization and Cardiovascular Interventions 2010

21 Survival in other studies of OHCA Gueugniaud et al. N Engl J Med 2008; 319:21-30

22 Survival of patients with STEMI undergoing PCI after ROSC Limitations of OHCA and STEMI registries Uncontrolled data Patient selection Exclusion of non-cardiac causes High rates of VF, witnessed arrest, bystander CPR Contribution of other therapies Rates of guidelines implementation Therapeutic hypothermia

23 Survival % Survival of patients with OHCA undergoing PCI after ROSC p=0.007 p=0.001 p=0.001 Control n=58 Intervention n= Discharged alive CPC 1-2 at discharge 12 m survival Sunde et al. Resuscitation 2007

24 Survival of patients with OHCA undergoing PCI after ROSC Sunde et al. Resuscitation 2007

25 Survival of patients with OHCA undergoing PCI after ROSC Martinell et al. Am j Emerg Med 2010

26 Survival of patients with OHCA undergoing PCI after ROSC

27 Survival of patients with OHCA undergoing PCI after ROSC PCI n=40 PCI+Hypothermia n= p=0.001 Survival to discharge p=0.02 p=0.001 p=0.07 CPC 1-2 6m survival 6m CPC 1-2 Knafelj et al. Resuscitation 2007

28 Good neurological outcome % Survival of patients with OHCA undergoing PCI after ROSC N=81 N= N=324 N=106 PCI 0 No PCI No Hypothermia Hypothermia Grasner et al. Crit Care 2011

29 Survival of patients with OHCA undergoing PCI after ROSC Grasner et al. Crit Care 2011

30 Bleeding requiring transfusion( %) Complications in patients with OHCA undergoing PCI after ROSC 7 6, ,8 P=0.02 All patients Hypothermia PCI+hypothermia 1 0 Nielsen et al. Acta Anaesthesiol Scand 2009

31 % of patients Patient selection for PCI after OHCA Conscious state post-rosc Alert Minimally Responsive Unresponsive Survival Full Neurological Recovery Hosmane et al. JACC 2009

32 Survival % Patient selection for PCI after OHCA Age < >75 Age PCI No PCI Cronier et al. Crit Care 2011

33 Patient selection for PCI after OHCA Age Nolan et al. Anaesthesia 2007

34 Patient selection for PCI after OHCA Prognostic scores OHCAscore = =6 ln(no-flowinterval, min)+ +9 ln (low-flow interval, min) -1434/(serum creatinine, mmol/l) ln (arterial lactate, mmol/l) 13 if the initial rhythm is VF or ventricular tachycardia (VT) Hijdra A. Eur Heart J 2007;28:1 2.

35 Patient selection for PCI after OHCA Prognostic scores Prognostication after ROSC Treatment rarely continued for long enough in sufficient patients to enable a true estimate of the false positive rate for any given prognosticator Many studies include so few patients that even if the FPR is 0%, the upper limit of the 95% confidence interval may be high Most prognostication studies have been undertaken before implementation of therapeutic hypothermia and there is evidence that this therapy makes these tests less reliable ERC guidelines for resuscitation. Resuscitation 2010

36 Invasive management after cardiac arrest Guidelines It is well recognised that post-cardiac arrest patients with ST elevation myocardial infarction (STEMI) should undergo early coronary angiography and percutaneous coronary intervention (PCI) but, because chest pain and/or ST elevation are poor predictors of acute coronary occlusion in these patients, this intervention should be considered in all post-cardiac arrest patients who are suspected of having coronary artery disease. Several studies indicate that the combination of therapeutic hypothermia And PCI is feasible and safe after cardiac arrest caused by acute myocardial infarction European Resuscitation Council Guidelines for Resuscitation Resuscitation 2010

37 Invasive management after cardiac arrest Guidelines Part 9: Post Cardiac Arrest Care : 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care> Circulation 2010

38 Invasive management after cardiac arrest Acute coronary lesions are frequently found in patients with OHCA after ROSC PCI is feasible, safe and successful in these patients Patients who regain consciousness after ROSC do not differ from other patients with ACS Angiography should also be considered in unconscious patients with suspected ACS PCI should be performed as part of a carefully planned protocol of post resuscitation care

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