Out-of-hospital Cardiac Arrest. Franz R. Eberli MD, FESC, FAHA Cardiology Triemli Hospital Zurich, Switzerland

Transcription

1 Out-of-hospital Cardiac Arrest Franz R. Eberli MD, FESC, FAHA Cardiology Triemli Hospital Zurich, Switzerland

2 Conflict of Interest I have no conflict of interest to disclose regarding this presentation.

3 Out-of-hospital Cardiac Arrest (OHCA) Scope of the problem Current guidelines OHCA due to ST-elevation MI OHCA with other ECG pattern Invasive strategy during cardiac arrest

4 Introduction Out-of-hospital cardiac arrest defined as Cessation of cardiac mechanical activity that is confirmed by the absence of signs of circulation and that occurs outside of the hospital setting 1) OHCA each year in the USA % have cardiac etiology 2) ~10 000/year OHCA in Switzerland =1/1 000/year = every 1-2 hours an OHCA in Switzerland 3) Overall survival: 8-10 % 1) 1) Roger VL et al. Circulation 2011;123:e18-209, 2) Nichol G et al. Circulation 2008;117: ) Von Planta et al. SAEZ 2001;82:

5 Registry evaluating only OHCA with presumed cardiac etiology received resuscitative efforts (CPR + defibrillation) Oct 2005 Dec 2010: OHCA records non cardiac etiology excluded n= OHCA (cardiac etiology: MI, arrhythmia) Mean age: 64±18 years, 61 % males Overall survival rate: 26.3 % to hospital admission 9.6 % to hospital discharge 6.9 % survived with good or moderate cerebral performance

6 CARES Registry: OHCA Survival Dependent on Presenting Arrest Rhythm and Bystander Assistance MMWR Vol. 60, No. 8, p11

7 Out-of-hospital Cardiac Arrest and Percutaneous Coronary Intervention Can a routine invasive strategy improve the outcome in out-ofhospital cardiac arrest patients?

8 Out-of-hospital Cardiac Arrest (OHCA) Scope of the problem Current guidelines OHCA due to ST-elevation MI OHCA with other ECG pattern Invasive strategy during cardiac arrest

9 Consensus Statement From the International Liaison Committee on Resuscitation Circulation 2008;118:

10 No Benefit of Thrombolysis During Resuscitation for Out-of-hospital Cardiac Arrest TROICA Trial: NEJM 2008;359:

11 Benefit of Therapeutic Hypothermia in the Treatment of Out-of-Hospital Cardiac Arrest The Hypothermia after Cardiac Arrest Study Group. NEJM 2002;346: Protocol Survival

12 Out-of-hospital Cardiac Arrest (OHCA) Scope of the problem Current guidelines OHCA due to ST-elevation MI OHCA with other ECG pattern Invasive strategy during cardiac arrest

13 Causes of Out-of-Hospital Cardiac Arrest 70 % Coronary artery disease1), 2) 50% acute coronary syndrome 4) 15 % Primary arrhythmia 3) 11 % Pulmonary embolism 3) 4 % Other STEMI: 96 % significant coronary artery lesion NSTEMI: 58 % significant coronary artery lesion 4) 1) Spaulding, NEJM 1997;336:1629, 2) Silvast T, J Intern Med 1991;229:331-5, 3) Böttiger et al, NEJM 2008;359: , 4) Dumas et al, Circ Cardiovasc Interv 2010;3:

14 Immediate Coronary Angiography in Survivors of Out-of-Hospital Cardiac Arrest Spaulding CM et al. New Engl J Med 1997;336: Prospective Single Center Study 9/1994-8/ patients with OHCA (Out-of-hospital cardiac arrest) 852 no resuscitation 910 CPR attempted -> 312 ROSC (= Return of spontaneous circulation) 186 survived to hospital 101 excluded (71 obvious non-cardiac cause, 30 age >75y) 85 patients were admitted to the cardiac catheterization laboratory

15 Immediate Coronary Angiography in Survivors of Out-of-Hospital Cardiac Arrest Spaulding CM et al. New Engl J Med 1997;336:

16 Circ Cardiovasc Interv 2010;3: Registry of patients with OHCA excluded all patients with extracardiac causes of OHCA included patients with return of spontaneous circulation (ROSC) stable hemodynamic conditions n=435 overall population n=134 (31 %) ST-segment elevation n=301 (69 %) other ECG pattern (ST-depression 29 %, conduction disorders 20 %, nonspecific changes 9 %, no abnormalities 11 %)

17 PROCAT-Registry: ECG Does not Adequately Predict Coronary Lesions Dumas et al. Circ Cardiovasc Interv 2010;3:

18 PROCAT-Registry: Angiographic Findings, PCI Success and Survival Dumas et al. Circ Cardiovasc Interv 2010;3: ST-elevation (n=134) Coronary lesions 128 = 96% PCI success 110 = 90% Overall survival = 39 % Other ECG patterns (n=301) Coronary lesions n=176 = 58% PCI attempted n=92 PCI success n=78 (85%) n=110 n=18 n=78 n=223 (78/301 = 26%)

19 PROCAT-Registry: In Multivariate Logistic Regression Analysis Successful PCI is Associated with Better Prognosis Dumas et al. Circ Cardiovasc Interv 2010;3: Therapeutic hypothermia was not predictive of outcome in multivariate analysis.

20 OHCA in Patients with STEMI: Survival and Neurologic Recovery Dependent on Responsiveness after CPR Hosmane VR et al. JACC 2009;53: Overall survival =64 % 98 STEMI 77 Revascularization 64 PCI 62 PCI successful 13 CABG 10 normal/non-obstructive CAD 1 died 10 inoperable 3-VCAD

21 OHCA in Patients with STEMI: Predictors of Death Hosmane VR et al. JACC 2009;53:

22 Predictors of 6-month Survival After Emergency PCI in Resuscitated Patients after Cardiac Arrest Complicating STEMI Dumas F et al. Circ Cardiovasc Interv 2010;3: month survival = 54 % 6 month survival free of neurologic sequelae = 47 %

23 Predictors of 6-month Survival After Emergency PCI in Resuscitated STEMI-Patients Dumas F et al. Circ Cardiovasc Interv 2010;3:

24 Predictors Excluding Cardiogenic Shock Dumas F et al. Circ Cardiovasc Interv 2010;3:

25 Timely Beginning of CPR and Prompt Restoration of Spontaneous Circulation Determine Survival in Resuscitated STEMI-Patients Dumas F et al. Circ Cardiovasc Interv 2010;3: CPR onset 6 minutes ROSC within 16 minutes survival

26 Acute Coronary Angiographic Findings in Survivors of OHCA do not Support Routine PCI Am Heart J 2009;157: patients admitted after OHCA 64 % had coronary artery disease 37.5 % clinical and angiographic evidence of ACS (16.7 % acute occlusion, 25 % plaque rupture and thrombus) In 24 patients = 33 % PCI successful Overall hospital survival = 48.6 % PCI no independent correlate of survival

27 OHCA: Factors Contributing to Better Survival Arrest Characteristics Mooney MR et al. Circulation 2011;124: Variable Survival OR Age 75 y >75 y Arrest witnessed no yes Bystander CPR no yes Prehospital cooling no yes Initial rhythm asystole/pea VF/VT STEMI no yes Frequency % 65/110 13/30 11/25 67/115 21/44 52/86 42/80 36/60 7/32 68/102 34/72 44/

28 Treatment Characteristics Contributing to Survival Mooney MR et al. Circulation 2011;124:

29 Factors in Favor of Immediate Invasive Approach in Patients with Out-of-hospital Cardiac Arrest (OHCA) ST elevation myocardial infarction Short time interval arrest beginning CPR Short time interval CPR to ROSC Suspected ACS Younger age Responsive after CPR Absence of cardiogenic shock

30 Factors in Favor of Conservative Approach in Patients with Out-of-hospital Cardiac Arrest (OHCA) Long time interval arrest beginning CPR Long time interval CPR to ROSC No return of spontaneous circulation Cardiogenic shock/hemodynamically unstable No ACS suspected Primary VF 2 to known pathology (e.g. CMP) ECG pattern other than ST elevation Older age Female gender Recurrent arrhythmias

31 Out-of-hospital Cardiac Arrest (OHCA) Scope of the problem Current guidelines OHCA due to ST-elevation MI OHCA with other ECG pattern Invasive strategy during cardiac arrest

32 Circ J 2010;74: patients who failed conventional CPR Inclusion: <75 y, presumed cardiac cause, collapse to EMS arrival <15 min, AED used, persistent cardiac arrest on arrival in ER Exclusion: Temperature <30 C, successful ROSC within 10 min in ER, pregnancy, refusal of family to give informed consent 102 Hypothermia induced after ROSC (post-rosc cooling group) 69 Hypthermia induced during cardiac arrest (intraarrest cooling group)

33 Intra-arrest PCI During Extracorporal CPR (ECMO) plus IABP and mild Hypothermia: Protocol of Surugadai Nihon University Hospital, Tokyo, Japan Circ J 2010;74:77-85

34 Intra-arrest PCI Under Cardio-pulmonary Bypass: Survival Dependent on Early Initiation of CPD Circ J 2010;74:77-85 Q1 = <95 min, Q2 = min, Q3 = min, Q4 = >286 min

35 86 ACS patients unresponsive to conventional CPR Rapid response extracorporeal membrane oxygenation (ECMO) Inclusion: Age y, VF, <15 min from arrest to CPR, failure to achieve ROSC within 20 min Exclusion: Terminal illness, aortic dissection

36 Rapid Response ECMO and Intra-arrest PCI: In-hospital Care and Outcome Kagawa et al. Circulation 2012

37 Hyperinvasive Approach to Out-of-hospital Cardiac Arrest Using Mechanical Chest Compression Device, Pre Hospital Intraarrest Cooling, Extracorporeal Life Support and Early Invasive Assessment Compared to Standard of Care. A Randomized Parallel Groups Comparative Study Proposal. Prague OHCA Study Jan Belohlavek et al. Journal of Translational Medicine 2012;10:163 Patients with witnessed out-of-hospital arrest and unsuccessful CPR (no return of spontaneous circulation)

38 Conclusion 1. Cardiac mortality is high in patients with out-of-hospital cardiac arrest. 2. In OHCA patients with ST elevation ECG primary PCI is improving outcome and is recommended as routine treatment strategy. 3. In patients with other ECG patterns, in whom ACS is suspected an invasive strategy should be considered. 4. The decision for an invasive evaluation is however greatly influenced by patient characteristics and the success of the CPR. 5. In younger patients with initial unsuccessful CPR a hyperinvasive approach (cardiopulmonary bypass, intraarrest PCI) might be attempted.