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After cardiac arrest: emergency coronary angiography for all?

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28 diapositives · 555 Views · Jul 30, 2014

After cardiac arrest: emergency coronary angiography for all?. Giuseppe Biondi-Zoccai , MD Sapienza University of Rome , Italy giuseppe.biondizoccai@uniroma1.it. Learning goals. Scope of the problem Rationale for emergency coronary angiography When perusing it What does it entail

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  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