OUT OF HOSPITAL CARDIAC ARREST. Dr Julian Strange MD, FRCP Consultant Cardiologist Bristol Heart Institute

Transcription

1 OUT OF HOSPITAL CARDIAC ARREST Dr Julian Strange MD, FRCP Consultant Cardiologist Bristol Heart Institute

2 NO CONFLICT OF INTEREST TO DECLARE

3 Optimal guidelines What we probably should do What we say we do What we actually do Markers of poor outcome Future directions

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5 1. Sunde K. et al. Resuscitation : Tømte O.,et al. Resuscitation :

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8 Option A: Straight to ED (+/- CT head) and then ITU for cooling with cardiology review later Option B: Straight to ED (+/- CT head) then Cathlab Option C: Straight to Cathlab

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12 Sudden cardiac arrest is often a coronary event Urgent CAG (84) Normal 17 (20%) Nonobstructive CAD 7 (8%) Obstructive CAD 60 (71%) Single vessel 22 Multivessel 37 Isolated LM 1 Coronary occlusion 40 (48%) Spaulding CM. N Engl J Med 1997;336:

13 Influence of admitting hospital on alive discharges and discharges with good neurological status Discharged alive Hospital discharge with good neurological status Odds ratio (95% CI) P value Odds ratio (95% CI) P value Hospital with PCI capability 2.39 (1.33 to 4.28) (1.51 to 6.56) Coronary angiography 4.57 (2.20 to 9.50) < (3.03 to 12.55) <0.001 Therapeutic hypothermia 5.31 (1.91 to 14.77) (1.26 to 7.69) Crit Care Sep 12;16(5)

14 PCI for OOHCA with NSTEMI post ROSC? An acronym too far?

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17 PCI for OOHCA with NSTEMI post ROSC? An acronym too far? Likely cardiac event Dumas et al. 301pts with no STEMI 58% had acute coronary lesion ECG are not reliable post ROSC what can help guide Sideris et al. 165pts with OOHCA Presenting in VF predicted MI, with an odds ratio of 7.4 for MI Presenting in asystole made it much less likely, with an OR or 0.17 Can we treat an OOHCA NSTEMI like normal NSTEMIs Dumas F. Circ Cardiovasc Inter Jun 1;3(3):200-7 Sideris G. Resusitation Sep;82(9):

18 Predictors of Hospital Mortality

19 What is limiting the adoption of angiography in ROSC OOHCA patients Outcomes: Perceived poor success rates Increase in individual MACE rate Increase in departmental MACE rate Confusion: Lack of randomized data Clinical justification Coordination of pathway and capacity: Complex pathway Inherent cathlab delays ITU bed blocking/resistance Cardiac ward becoming a brain injury unit

20 6.03 to 6.11: Out Of Hospital Cardiac Arrest. As out of hospital arrest carries its own very specific high risk features we felt it critical to try to capture some key features of patients presenting in this way for PCI.

21 Survival but with what? CPC of 1 in 93% The other 7% all died within 2 years Kern K.B. Resuscitation :

22 Temperature curves: HACA 2002 versus TTM 2013* *Nielsen N et al. N Engl J Med 2013;369:

23 Targeted Temperature Management

24 UHBristol Arrests Year Number Mortality % Pred. mortality Angio % ITU bed stay ~

25 3 beds in use 2 bed in use 1 bed in use

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27 Survivors in the last 12 months Leigh Bracey Tina Brain Gordon Reece Andrew Avent Gladys Smith David Rawlings Elaine Moorey Robert Payne Brian Woodfield Phillip Giles Brian White Terrence Woodcock Keith Douglas Mark Verden Michael Chard Leonard Grant Paul Coulson Karen Gee David Bainton Richard Flint Trudy Chapman Keith Archer Alexander Barber Phillip North Michael Hurst Michael Heskins Raymond Mardle Anne Marie Mitchell Keith Joseph Paul Hirst John Hoskin Andrew Williams Mark Britton Lindsay Walker George Earle Shaun Ogbourne Patrick Mcginness James Harding Kathleen Sandford John Monks John Quinnell John Patterson David Mansfield Edward Cannon William Kinghan Anthony Hole Derek Orchard Will Purdom Charmaine Swatton Kim Gunningham Stanley Ivor Robert Gardiner Austin Burke Marjorie Blunt Alan Seer Geoffrey Hancox Sarah Giles

28 IMMEDIATE CORONARY ANGIOGRAPHY AFTER VENTRICULAR FIBRILLATION OUT-OF-HOSPITAL CARDIAC ARREST: A RANDOMISED CONTROL TRIAL THE UK ARREST TRIAL Primary Investigator: Simon Redwood, Professor of Interventional Cardiology, KCL/St Thomas Hospital

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36 STEMI with ST elevation = PPCI STEMI with OOHCA and ROSC PPCI

37 Do we need guidelines? Improve the quality of healthcare Provide recommendations for the treatment and care of people by health professionals Used to develop standards to assess the clinical practice of individual health professionals Used in the education and training of health professionals

38 Sources of Variability Case identification Outcome measurement Data handling Decision to start/end of life care Pre and In-hospital care Getting a bed Getting out bed

39 Getting a bed Ambulance to nearest ED ED SpR calls Cardiology SpR Cardiology SpR calls ITU SpR ITU SpR calls ITU consultant ITU SpR calls back Cardiology SpR Cardiology SpR calls back ED SpR ED Spr calls local team for transfer Local team calls on-call anesthetic etc

40 Get out of bed test 3am 75 yo male, no history of chest pain No co-morbidity Witnessed cardiac arrest with bystander CPR Down time 35 mins VF as initial rhythm ECG:

41 Data to support urgent invasive diagnosis? No randomized trials Multivariate analysis of registries Author n Multivariate predictor of survival Spaulding 85 Successful PCI (OR 5.2; p=0.004) Reynolds 241 CAG/PCI strategy (OR 2.16; p=0.02) Nielsen 986 CAG/PCI strategy (OR 1.56; p=0.008) Dumas 714 Successful PCI (OR 2.06; p=0.013) Spaulding CM. N Engl J Med 1997;336: Anyfantakis ZA. Am Heart J 2009;157: Reynolds JC. J Intensive Care Med 2009;March 25,doi;1177 Nielsen N, et al. Acta Anaesthesiol Scand 2009;53: Dumas. Circ Cardiovasc Interv 2010;3:200-7

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43 Proposed Pathway Pre-alert and direct transfer (local anesthetic implications) Straight to cathlab (via ED and CT brain) ITU bed sourced (regional)

44 UHBristol Cardiac Arrest Sudden cardiac arrest is often a coronary event Urgent CAG (n = 66) STEMI Number 59% (39) Stented 87% (34) Survival 59% (23) No STEMI Number 41% (27) Stented 40% (11) Survival 52% (14) Survival Stented n= 45 58% Non-stented n= 21 52% Overall n= 37 56%

45 Kim F. JAMA online 17 Nov 2013 Survival to discharge (%) Intervention N = 292 VF/VT (n=583) N = 1359 Control N = 291 P Non VF/VT (n=776) Intervention N = 396 Control N = CPC 1-2 (%) P

46 Kim F. JAMA online 17 Nov 2013 Re-arrest during transport % (95% CI) Pulmonary oedema % (95% CI) Intervention Control P N= (22 29) N = (37 44) N = (18 24) N = (27 34) < 0.001

47 N Engl J Med online 17 Nov 2013

48 N Engl J Med online 17 Nov 2013

49 N Engl J Med online 17 Nov 2013

50 Therapeutic hypothermia trials: good neurological outcome

51 Is it any issue? Does it concern me? What is the impact on service?

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