After cardiac arrest: emergency coronary angiography for all?

1. After cardiac arrest: emergency coronary angiography for all? Giuseppe Biondi-Zoccai, MD Sapienza University ofRome, Italy giuseppe.biondizoccai@uniroma1.it

2. Learninggoals • Scope of the problem • Rationaleforemergencycoronaryangiography • Whenperusingit • Whatdoesitentail • Case study

3. Learninggoals • Scope of the problem • Rationaleforemergencycoronaryangiography • Whenperusingit • Whatdoesitentail • Case study

4. Cardiacarresthasdismalprognosis Yonemotoet al, Circulation 2011

5. Difficulttoappraiseneurologic status shortlyaftercardiacarrest LR(+) = sensitivity / (1 – specificity) usefulif >10 LR (-) = (1 – sensitivity) / specificityusefulif <0.1 Boothet al, JAMA 2004

6. Coronaryangiographyafter OHCA remainsunderused Aufderheideet al, Lancet 2011

7. Learninggoals • Scope of the problem • Rationaleforemergencycoronaryangiography • Whenperusingit • Whatdoesitentail • Case study

8. Coronaryocclusions are common Spauldinget al, New Engl J Med 1997

9. Systematic invasive management maybebeneficial Dumas et al, Circ Cardiovasc Interv 2010

10. Systematic invasive management maybebeneficial Dumas et al, Circ Cardiovasc Interv 2010

11. Systematic invasive management maybebeneficial Dumas et al, Circ Cardiovasc Interv 2010

12. Learninggoals • Scope of the problem • Rationaleforemergencycoronaryangiography • Whenperusingit • Whatdoesitentail • Case study

13. EvenwithoutST-elevation or new LBBB Spaulding et al, N Engl J Med 1997; Dumas et al, Circ Cardiovasc Interv 2010

14. Troponinisnotveryusefuleither, but… Dumas et al, Crit Care Med 2012

15. …ifyouwishtopinpointpatients Primarypredictivemodelforcoronaryocclusionafter OHCA: 1st dose ofadrenaline <2 mg (OR=2), smoking (OR=2.0), VF/VT asinitialrhythm (OR=1.7); otherpredictorswerecTnI >4.7 ng/mL (OR=3.6), ↑ST (OR=10.2) Dumas et al, Crit Care Med 2012

16. Learninggoals • Scope of the problem • Rationaleforemergencycoronaryangiography • Whenperusingit • Whatdoesitentail • Case study

17. Decisiontocathmustbemade ASAP Strote et al, Am J Cardiol 2002

18. Radialaccessisparamount Agostoni et al, J Am CollCardiol 2004

19. Hypothermiaisrecommended Bernard et al, N Engl J Med 2002; Holzer et al, New Engl J Med 2002

20. May becombinedwithbrain CT Chelly et al, Resuscitation 2002

21. Learninggoals • Scope of the problem • Rationaleforemergencycoronaryangiography • Whenperusingit • Whatdoesitentail • Case study

22. Case study Age: 40 years Gender: male Comorbidities: type 1 diabetes mellitus Diagnosis: acute myocardial infarction Prehospital events/management: VF treated with DC shock, followed by PEA; manual chest compression, repeat IV adrenaline boluses, tracheal intubation, mechanical ventilation Hospital events/management: systemic thrombolysis with alteplase attempted without success; LUCAS deployment and… Biondi-Zoccaiet al, HSR Proc Intensive Care CardiovascAnesth2011

23. Baselinecoronaryangiography Biondi-Zoccaiet al, HSR Proc Intensive Care CardiovascAnesth2011

24. Predilation on leftmain-circumflex Biondi-Zoccaiet al, HSR Proc Intensive Care CardiovascAnesth2011

25. Leftmain-anteriordescendingstenting Biondi-Zoccaiet al, HSR Proc Intensive Care CardiovascAnesth2011

26. Coronaryangiographyafterstenting Biondi-Zoccaiet al, HSR Proc Intensive Care CardiovascAnesth2011

27. Take home messages • Patientsachieving ROSC after OHCA shouldbethoroughlyappraisedfornon-cardiacconditions. • Emergentcoronaryangiographyisrecommendedroutinelyunlessprognosisisvery dire. • Emergentcoronaryangiography can beconsidered in veryselectedcasesbefore ROSC ifpatient/proceduralfeaturessuggestreasonablelikelihoodof ROSC.

28. Manythanksforyourattention Fortheseslides and furtherones on similartopicsfeel free tovisit: www.metcardio.org/slides.html Foradditionaldetails or queriesfeel free tocontact me directly: giuseppe.biondizoccai@uniroma1.it