HPI: A 65-year-old man presents to the ED with substernal chest pain that radiated to the back and is associated with nausea. An ECG is obtained on arrival and is interpreted as normal. While obtaining a history, the patient becomes unresponsive and has a witnessed ventricular fibrillation arrest that responds to chest compressions. His post arrest ECG showed inferior STEMI.
Before watching this week’s video, ask yourself these questions:
- How frequently will patients with STEMI present with an initially normal ECG?
- How accurate is the post-ROSC ECG in predicting STEMI?
- In which post arrest patients is emergent cath lab activation indicated?
Key Teaching Points
- Key point: post-arrest patients benefit from urgent cath unless there is an obvious non-cardiac cause
- STEMI patients post-arrest should go to the cath lab (Class IB in national guidelines, 2013)
- Non-STE ACS patients that develop hemodynamic or electrical instability (e.g. VT/VF arrest should have urgent cath (Class IA, 2014)
- STEMI patients post-arrest who remain comatose should go to the cath lab unless they have multiple unfavorable resuscitation features (Rab et al., 2015)
- NSTE-ACS patients post-arrest who remain comatose should be assessed for unfavorable resuscitation features and urgent cath should be considered. Immediate consultation with cardiology and intensive care is recommended (Rab et al., 2015)
- Post-arrest STEMI should have cath lab activation, with consideration of survival benefit/risk ratio, especially if multiple unfavorable resuscitation features are present
- Post-arrest non-STE ACS should strongly consider cath lab activation after assessment for unfavorable resuscitation features, consult interventional cath.
- ACS can occur in the presence of a NORMAL ECG!
- O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. J Am Coll Cardiol. 2013;61(4):e78–e140. PMID: 23256914.
- Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(24):e139–228. PMID: 25260718.
- Rab T, Kern KB, Tamis-Holland JE, et al. Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient. J Am Coll Cardiol. 2015;66(1):62–73. PMID: 26139060.
- Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39(2):119–77. PMID: 28886621.
- Reynolds JC, Callaway CW, Khoudary El SR, et al. Coronary angiography predicts improved outcome following cardiac arrest: propensity-adjusted analysis. Journal of Intensive Care Medicine 2009;24(3):179–86. PMID: 19321536.
- Ewy GA, Kern KB. Recent advances in cardiopulmonary resuscitation: cardiocerebral resuscitation. J Am Coll Cardiol 2009;53(2):149–57. PMID: 19130982
- Dumas F, Cariou A, Manzo-Silberman S, et al. Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Circ Cardiovasc Interv 2010;3(3):200–7. PMID: 20484098.
- Radsel P, Knafelj R, Kocjancic S, Noc M. Angiographic characteristics of coronary disease and postresuscitation electrocardiograms in patients with aborted cardiac arrest outside a hospital. Am J Cardiol 2011;108(5):634–8. PMID: 21676367.
- Aurore, A., Jabre, P., Liot, P., Margenet, A., Lecarpentier, E., & Combes, X. (n.d.). Predictive factors for positive coronary angiography in out-of-hospital cardiac arrest patients. European Journal of Emergency Medicine.,18(2), 73-76. PMID: 20664351.
- Larsen JM, Ravkilde J. Acute coronary angiography in patients resuscitated from out-of-hospital cardiac arrest–a systematic review and meta-analysis. Resuscitation 2012;83(12):1427–33. PMID: 22960567.
- Zanuttini D, Armellini I, Nucifora G, et al. Impact of emergency coronary angiography on in-hospital outcome of unconscious survivors after out-of-hospital cardiac arrest. Am J Cardiol 2012;110(12):1723–8. PMID: 22975468.
- Chelly J, Mongardon N, Dumas F, et al. Benefit of an early and systematic imaging procedure after cardiac arrest: insights from the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) registry. Resuscitation 2012;83(12):1444–50. PMID: 22922264.
- Hollenbeck RD, McPherson JA, Mooney MR, et al. Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI. Resuscitation 2014;85(1):88–95. PMID: 23927955.
- Kim MJ, Ro YS, Shin SD, et al. Association of emergent and elective percutaneous coronary intervention with neurological outcome and survival after out-of-hospital cardiac arrest in patients with and without a history of heart disease. Resuscitation 2015; 97:115–21. PMID: 26384459.
- Redfors B, Råmunddal T, Angerås O, et al. Angiographic findings and survival in patients undergoing coronary angiography due to sudden cardiac arrest in western Sweden. Resuscitation 2015; 90:13–20. PMID: 25698668.
- Choudry, F., Weerackody, R., Timmis, A., et al. Importance of primary percutaneous coronary intervention for reducing mortality in ST-elevation myocardial infarction complicated by out of hospital cardiac arrest. European Heart Journal., 4(4), 378-385. PMID: 25326470.
- Salam I, Hassager C, Thomsen JH, et al. Editor’s Choice-Is the pre-hospital ECG after out-of-hospital cardiac arrest accurate for the diagnosis of ST-elevation myocardial infarction? Eur Heart J Acute Cardiovasc Care 2016;5(4):317–26. PMID: 25943555.
- Millin MG, Comer AC, Nable JV, et al. Patients without ST elevation after return of spontaneous circulation may benefit from emergent percutaneous intervention: A systematic review and meta-analysis. Resuscitation 2016; 108:54–60. PMID: 27640933.
Kudos: Thanks to Drs. Michael Gulenay & Kevin Taylor for sharing this week’s case!