Post Arrest Care: The Role of Early Coronary Angiography and PCI

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Valerie Martin
5 years ago
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Ewy, MD Distinguished Endowed Chair of Cardiovacular Medicine

1 Post Arrest Care: The Role of Early Coronary Angiography and PCI Karl B. Kern, MD Professor of Medicine The Gordon A. Ewy, MD Distinguished Endowed Chair of Cardiovacular Medicine University of Arizona Sarver Heart Center, Tucson, Arizona AHA ECC Chairman,

2 Karl B. Kern, MD FINANCIAL DISCLOSURE: Scientific Advisory Board Member: PhysioControl Inc. Zoll Medical GRANT/RESEARCH SUPPORT: PhysioControl Inc. Gootter Foundation Arizona Biomedical Research Commission

3 Number of Patients Outcomes From OOH CA pts Δ= 60% Largest drop off occurs In hospital, where 75% Of those initially resuscitated die pts Δ=75% Δ= 50% 10 pts 5 pts 0 Pre-arrest ROSC Hosp DC Surv at 1 yr

4 15 (26%) Resuscitation 2007;73:29-39

5 What Makes the Difference? Aggressive Post Resuscitation Care Two major factors: Mild Therapeutic Hypothermia Early Coronary Angiography & PCI

7 The TTM Trial Nielsen et al

Making sense of the post-arrest trials no cooling 36% HACA 33 o C 53% 100% VF no cooling 33 o C 0 10 20 30 40 50

8 Making sense of the post-arrest trials no cooling 36% HACA 33 o C 53% 100% VF no cooling 33 o C Bernard % 26% survival 49% 100% VF 36 o C 52% TTM 80% VF/VT 33 o C 50% Both arms are active Rx! How can this be?

9 What Do We Know about Early Coronary Angiography & PCI All the data to date is from non-randomized registries

10 Greatest influence on subsequent CNS function is the speed/ease of resuscitation Gorjup et al. Resuscitation 2007;72:

11 Survival Post Cardiac Arrest After Early PCI Author/Date Surv to DC Good Neuro among Surv Kahn /11 4/6 Spaulding /84 30/32 Lin /10 NA Bulut /10 NA Borger van der Berg /42 NA Keelan /15 9/11 Bendz /40 NA Quintero-Moran /27 NA Gorjup /135 72/90 Garot /186 88/102 Richling /46 22/24 Markusohn /25 17/19 Werling /13 NA Pleskot /20 11/14 Hosmane /98 58/63 Anyfantakis /72 33/35 Reynolds /96 NA Dumas / / Era Totals: 18 reports; n= 1,395 pts 727/1,395 (52%) 504/567 (89%)* Includes both conscious and comatose pts upon arrival at the cath lab

12 2015

13 2015

14 Univariate Kaplan Meier survival curves with (w/) or without (w/o) immediate percutaneous coronary intervention (PCI). Guillaume Geri et al. Circ Cardiovasc Interv. 2015;8:e Copyright American Heart Association, Inc. All rights reserved.

15 Circ Cardiovasc Interv. 2015;8:e

16 CAD and OOH Cardiac Arrest 70% of Adult victims of OOH CA have CAD Culprit Vessel Concept

17 The worst presentation of ACS is not STEMI but rather Cardiac Arrest!

18 Potential Value of Coronary Angiography Post Arrest Identify culprit coronary lesion Restore coronary flow Salvage myocardium? Reduce risk of Re-arrest? Improve hemodynamics of CNS perfusion? Improve Survival

19 Who Should Go to the Cath Lab Post Resuscitation? Patients resuscitated from OHCA Associated with a STEMI Patients resuscitated from OHCA Without ST Elevation

20 ILCOR 2015 Resuscitation Science Review Hospital Reperfusion Decisions After ROSC We recommend emergency cardiac catheterization laboratory evaluation in comparison with cardiac catheterization later in the hospital stay or no catheterization in select adult patients with ROSC after out-of-hospital cardiac arrest (OHCA) of suspected cardiac origin with ST elevation on ECG. Welsford M, et al; on behalf of the Acute Coronary Syndrome Chapter Collaborators. Part 5: acute coronary syndromes: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2015;132(suppl 1):S146 S176.

21 2015 AHA CPR Guidelines 2015 Recommendations Updated Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG (Class I, LOE B-NR). O Connor RE, et al. Part 9: acute coronary syndromes: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S483 S500.

22 2015 AHA CPR Guidelines 2015 Recommendations Updated Coronary angiography is reasonable in post cardiac arrest patients where coronary angiography is indicated regardless of whether the patient is comatose or awake (Class IIa, LOE C-LD). O Connor RE, et al. Part 9: acute coronary syndromes: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S483 S500.

23 61 yr old male walked to the fire station c/o of feeling badly Collapsed in front of fire fighters No pulse, no response AED: 2 shocks delivered; 2 nd resulted in perfusing rhythm Remained unresponsive though BP=150/100

24 1 st ECG in Emergency Dept after Resuscitation

29 Hypothermia applied for 24 hrs Did not awaken for 8 days, Day 9, awoke and now is totally normal, including higher cerebral functions.

30 What Do You Find at Cath in the Post Resuscitated STEMI Patient?

31 Kern KB et al. JACC Intv 2015;8:

32 INTCAR-Cardiology 1.0 ST Elevation on initial PR ECG Kern KB et al. JACC Intv 2015;8:

33 INTCAR-Cardiology 1.0 Culprit Vessel Found at Angiography Among Those with STEMI Post Arrest Kern KB et al. JACC Intv 2015;8:

34 INTCAR-Cardiology 1.0 Culprit Vessel Occluded 7% 93% STEMI Kern KB et al. JACC Intv 2015;8:

35 80% have identified culprit vessel 93% of such culprits are acutely occluded.80 X.93 =.74 3 of every 4 such patients have an acutely occluded culprit

36 INTCAR-Cardiology 1.0 STEMI: Culprit Vessel RCA p < Kern KB et al. JACC Intv 2015;8:

37 Who Else Should Go to the Cath Lab Post Resuscitation? Patients resuscitated from OHCA Associated with a STEMI Patients resuscitated from OHCA Without ST Elevation?

38 2015 ILCOR 2015 Evaluations Hospital Reperfusion Decisions After ROSC We suggest emergency cardiac catheterization laboratory evaluation in comparison with cardiac catheterization later in the hospital stay or no catheterization in select adult patients who are comatose with ROSC after OHCA of suspected cardiac origin without ST elevation on ECG. Welsford M, et al; on behalf of the Acute Coronary Syndrome Chapter Collaborators. Part 5: acute coronary syndromes: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2015;132(suppl 1):S146 S176.

39 2015 AHA CPR Guidelines 2015 Recommendations Updated Emergency coronary angiography is reasonable for select (electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG (Class IIa, LOE B-NR). O Connor RE, et al. Part 9: acute coronary syndromes: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S483 S500.

40 40 M: Masters Swimmer Swam usual morning work-out Felt less well than usual Collapsed in the Shower CC-Only provided quickly (1-2 min) by off-duty Fire-fighter AED on site; shocked twice EMS arrival: + pulse and BP, but unresponsive

41 Initial EKG in Emergency Department Post Resuscitation from OOH VFCA

44 Echo after PCI: Global Hypokinesis LVEF = 20% Warmed up after 24 hours COMPLETELY NORMAL CNS Function Discharged 5 days later Business trip the following week LVEF >50% at follow-up 6 weeks later

45 Newsweek Cover July 23, 2007 Brian Duffield, patient of Dr. Kern s at the University of Arizona Sarver Heart Center treated with all three aspects of Cardiocerebral Resuscitation

48 Isolated Example?

49 57 M HS soccer match Referee Running down field-collapsed TFD Captain in stands watching match Immediate response and performed CC-Only AED on site: Defib X1 + pulse post defib EMS arrival: +Responsive/transported to UMC ED eval: BP=117/70, P=72/min Conscious but no recall Denied any precedent CP or Cardiac Hx

50 ECG upon arrival in ED Post cardiac arrest

56 Peak TpI = hrs LVEF = 68% DC home intact on Day #3

57 What Do You Find with Early Coronary Angiography Among Resuscitated Cardiac Arrest Patients Without ST Elevation?

58 Kern & Lotun et al. JACC Intv 2015;8:

59 INTCAR-Cardiology 1.0 Culprit Vessel Found at Angiography Kern KB et al. JACC Intv 2015;8:

60 INTCAR-Cardiology 1.0 Culprit Vessel Occluded 31% 69% No ST Elevation Kern KB et al. JACC Intv 2015;8:

61 33% have identified culprit vessel 69% of such culprits are acutely occluded.33 X.69 =.23 1 of every 4 such No STE patients have an acutely occluded culprit

62 INTCAR-Cardiology 1.0 No STEMI: Culprit Vessel p = NS Kern KB et al. JACC Intv 2015;8:

63 No ST Elevation but Acutely Occluded Coronary at Angiography Post Arrest Spaulding 1997: 9/85 (11%) Anyfantakis 2009: 8/44 (17%) Radsel 2011: 20/54 (36%) Gupta 2014: 916/2775 (33%) Kern 2015: 54/247 (23%) Dumas 2016: 199/695 (29%) SUMMARY: 1,206/3,900 (31%)

64 What Proportion is Enough for You to Go to the Cath Lab? 1:1? 1:2? 1:3? 1:4? 1:5? Is 1:4 or 1:3 Enough? Because that s what it is!

65 Rab & Kern et al. JACC 2015:66:62-73.

67 No absolute contraindications nor a known cut-off number of unfavorable features, but patients with multiple such features are less likely to do well

68 Not Just About Atherosclerosis!

69 27 yr old male, former Marine Training with the Tucson Fire Department Sudden witnessed collapse during training exercise Unresponsive without pulse CC-Only while AED retrieved VF per AED, shocked X 1, ROSC

70 ED Arrival 90/70 mmhg, 67 bpm, 36.4 C GCS: = 6 Intubated for airway protection

71 ED Evaluation Initial ABG post intubation/ventilation 7.34/29/306 Bicarb =19; Lactate = 7.1 Head CT negative (3 cm scalp laceration) Family declined Therapeutic Hypothermia ECG on arrival

73 Etiology of VFCA? Long QT? HCM? Atherosclerosis? To Cath Lab or Not??

77 Peak TpI = 179 Now What?

78 Follow-Up Slow Recovery: Final CPC = 2 CABG X 1V: LIMA to LAD 3 months later TFD declined to hire him! Returned to College: studied Forestry

79 7 Years Later Began to have exertional CPs NUC MPI: Med sized, mod intensity reversible defect in the Anterior/Lateral wall Failed medical management Re-cathed

80 LVEDP = 30 mmhg

88 What Next...? FFR done: RCA = 0.80 LAD = 0.84 LCx = Could Not Reach with FFR wire! But did have Positive NUC to Ant/Lat wall

89 Inadequate Perfusion of LCx Re-do CABG Re-sternotomy SVG to OM Good resolution of daily angina, now 18 months post redo CABG without recurrence of CP

Review and presentation of current literature Dr. Nainesh Patel, Lehigh Valley Health System, PA

Why the Cath Lab for the Cardiac Arrest Patient? Dr. Michael Mooney Dr. Nainesh Patel Dr. John McPhereson Dr. Paul McMullan Dr. David Seder Review and presentation of current literature Dr. Nainesh Patel,