Emergency percutaneous coronary intervention in patients with ST-elevation myocardial infarction complicated by out-of-hospital cardiac arrest: Early and medium-term outcome

doi:10.1016/j.ahj.2008.10.018

American Heart Journal

Volume 157, Issue 3, March 2009, Pages 569-575.e1

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https://doi.org/10.1016/j.ahj.2008.10.018 Get rights and content

Background

The role of emergency reperfusion therapy in patients with ST-elevation myocardial infarction (STEMI) resuscitated after an out-of-hospital cardiac arrest (OHCA) has not been clearly established yet. The aim of this study was to evaluate the in-hospital and postdischarge outcomes of STEMI patients surviving OHCA and undergoing emergency angioplasty (percutaneous coronary intervention [PCI]) within an established regional network.

Methods

We prospectively collected data on 2,617 consecutive patients with STEMI treated with emergency PCI in 2005; in-hospital and 6-month outcomes of 99 patients who had experienced OHCA were compared with those of 2,518 patients without OHCA. The OHCA patients also underwent a cerebral performance evaluation after 12 months.

Results

OHCA patients were at higher clinical risk at presentation (cardiogenic shock 26% vs 5%, P < .0001). Percutaneous coronary intervention was successful in 80% of the OHCA and 89% of the non-OHCA patients (P = NS). In-hospital mortality rates were 22% and 3%, respectively (P < .0001). Independent predictors of in-hospital mortality among OHCA patients were longer delay between the call to the emergency medical system and the start of cardiopulmonary resuscitation (odds ratio [OR] 3.5, P = .03), nonshockable initial rhythms (OR 10.5, P = .002), cardiogenic shock (OR 3.05, P = .035), and a Glasgow Coma Scale score of 3 on admission (OR 2.9, P = .032). The 6-month composite rate of death, myocardial infarction, and revascularization among OHCA patients surviving the acute phase was comparable to that of non-OHCA patients (16% vs 13.9%, P = NS), and 87% of them showed a favorable neurologic recovery after 1 year.

Conclusions

Resuscitated OHCA patients undergoing emergency PCI for STEMI have worse clinical presentation and higher in-hospital mortality compared to those without OHCA. However, subsequent cardiac events are similar, and neurologic recovery is more favorable than reported in most previous series.

Section snippets

Study population

The data come from the LombardIMA (Lombardia acute myocardial infarction) registry, which collects data relating to PCI in STEMI in Lombardy, a region in Northern Italy with a population of nearly 9.5 million inhabitants. The network includes 67% of the PCI centers in the region. A Web-based prospective electronic Case Report Form was used to collect data on 2,617 STEMI patients who underwent PCI between January and December 2005, 99 of whom (3.8%) had experienced OHCA. Demographic, clinical,

Baseline patient characteristics and procedural aspects

During the study period, 99 (3.8%) of 2,617 consecutive patients undergoing emergency PCI for STEMI had survived OHCA. Table I shows the prehospital data of the OHCA survivors. The median resuscitation time was 7 minutes, although cardiac arrest occurred after the ambulance was called in 19 patients and in the presence of emergency medical team in 3 patients. At the time of first medical aid, 90 patients presented with ventricular fibrillation or pulseless ventricular tachycardia, whereas 9

Discussion

The present study reports the largest prospective population, described so far, of consecutive STEMI patients with OHCA treated by emergency angioplasty and allows the formulation of more firm conclusions compared with previously available evidence. A first piece of information is the incidence of OHCA among STEMI patients treated with emergency PCI, which in our registry was 3.8%, a figure lower than previously reported.¹⁴ Second, the present study shows that OHCA patients admitted with a

Conclusions

Patients with STEMI complicated by OHCA who were resuscitated by the EMS and surviving up to emergency PCI have a worse clinical presentation and experience a higher in-hospital mortality compared with those who did not have OHCA. Unfavorable prognostic factors are a longer resuscitation time, the presence of nonshockable rhythms, cardiogenic shock, and severe neurologic impairment on admission. However, an aggressive approach including rapid out-of-hospital rescue and emergency PCI, with

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Cited by (99)

Prognostic implications and outcomes of cardiac arrest among contemporary patients with STEMI treated with PCI
2021, Resuscitation Plus
Cardiac arrest (CA) complicating ST-elevation myocardial infarction (STEMI) is associated with a disproportionately higher risk of mortality. We described the contemporary presentation, management, and outcomes of CA patients in the era of primary percutaneous coronary intervention (PCI).
We reviewed 1,272 consecutive STEMI patients who underwent PCI between 1/1/2011-12/31/2016 and compared characteristics and outcomes between non-CA (N = 1,124) and CA patients (N = 148), defined per NCDR definitions as pulseless arrest requiring cardiopulmonary resuscitation and/or defibrillation within 24-hr of PCI.
Male gender, cerebrovascular disease, chronic kidney disease, in-hospital STEMI, left main or left anterior descending culprit vessel, and initial TIMI 0 or 1 flow were independent predictors for CA. CA patients had longer door-to-balloon-time (106 [83,139] vs. 97 [74,121] minutes, p = 0.003) and greater incidence of cardiogenic shock (48.0% vs. 5.9%, p < 0.001), major bleeding (25.0% vs. 9.4%, p < 0.001), and 30-day mortality (16.2% vs. 4.1%, p < 0.001). Risk score for 30-day mortality based on presenting characteristics provided excellent prognostic accuracy (area under the curve = 0.902). However, over long-term follow-up of 4.5 ± 2.4 years among hospital survivors, CA did not portend any additional mortality risk (HR: 1.01, 95% CI: 0.56–1.82, p = 0.97).
In a contemporary cohort of STEMI patients undergoing primary PCI, CA occurs in >10% of patients and is an important mechanism of mortality in patients with in-hospital STEMI. While CA is associated with adverse outcomes, it carries no additional risk of long-term mortality among survivors highlighting the need for strategies to improve the in-hospital care of STEMI patients with CA.
Effect of Location on Treatment and Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction in England & Wales
2021, American Journal of Cardiology
We investigated the incidence, management, and outcomes of acute myocardial infarction (AMI) patients according to cardiac arrest location. Patients admitted with a diagnosis of AMI between January 1, 2010 to March 31, 2017 from the Myocardial Ischaemia National Audit Project (MINAP) were studied. We used logistic regression models to evaluate predictors of the clinical outcomes and treatment strategy. The study population consisted of 580,796 patients admitted with AMI stratified into three groups: out of hospital cardiac arrest (OOHCA) (16,278[2.8%]), in-hospital cardiac arrest (IHCA) (21,073[3.7%]), plus a reference group consisting of those without cardiac arrest (non-cardiac arrest (543,418[93.5%]). IHCA declined steadily (from 666 per 1000 in 2010 to 477 per 1000 AMI with cardiac arrest admissions in 2017) with a commensurate rise in OOHCA (from 344 per 1000 to 533 per 1000 AMI with cardiac arrest admissions). Coronary angiography utilization (OOHCA 81.1% vs IHCA 60.3% vs non-cardiac arrest 70.4%, p < 0.001) and PCI (OOHCA 40% vs IHCA 32.8% vs non-cardiac arrest 45.2%, p < 0.001) were higher in OOHCA. In-hospital mortality odds were greatest for IHCA (OR 35.3, 95% CI 33.4-37.2) compared to OOHCA (OR 12.7, 95% CI 11.9-13.6), with the worse outcomes seen in patients on medical wards (OR 97.37, 95% CI 87.02-108.95) and the best outcomes seen in the emergency department (OR 8.35, 95% CI 7.32-9.53). In conclusion, outcomes of AMI complicated by cardiac arrest depended on cardiac arrest location, especially the outcomes of the IHCA.
One-year outcome of patients admitted after cardiac arrest compared to other causes of ICU admission. An ancillary analysis of the observational prospective and multicentric FROG-ICU study
2020, Resuscitation
While cardiac arrest (CA) patients discharged alive from intensive care unit (ICU) are considered to have good one-year survival but potential neurological impairment, comparisons with other ICU sub-populations non-admitted for CA purpose are still lacking. This study aimed to compare long-term outcome and health-related quality of life (HRQOL) between CA patients and patients admitted to ICU for all other causes.
In 1635 patients discharged alive from 21 European ICUs in an ancillary analysis of a prospective multicentric cohort, we compared CA causes of ICU admission to all other causes of ICU admissions (named non-CAs). The primary endpoint was one-year survival rate after ICU discharge. Secondary endpoints included HRQOL at 3, 6 and 12 months after ICU discharge using the outcome survey short form‐36 (SF36). Propensity score matching was used to consider the probability of having CA.
Of the 1635 patients, 1561 were included in this study comprised of 1447 non-CAs and 114 CAs. At one-year in the non-matched population, survival rate was greater in the CA group 89% versus the non-CA group 78% (log rank p = 0.0056). In the matched population, this difference persisted between CAs and non-CAs (log rank p = 0.049). The physical component summary of the SF36 scale was higher in the CA group than in the non-CA group at all time points in both non-matched and matched populations.
CA patients discharged alive from ICU have a better one-year survival and a better HRQOL specifically on physical functions than patients admitted to ICU for other causes.
ClinicalTrials.gov NCT01367093; registered on June 6, 2011.
Long-term survival in patients presenting with STEMI complicated by out of hospital cardiac arrest
2019, IJC Heart and Vasculature
There is limited data regarding long-term survival in patients who present with STEMI and out of hospital cardiac arrest (OHCA).
We prospectively analysed outcomes in 3521 consecutive patients who were diagnosed with STEMI and underwent primary percutaneous coronary intervention (PPCI) or coronary artery bypass surgery from 2004 to 2017. They were divided into two groups according to the presence of cardiac arrest (group I, patients with cardiac arrest; n = 156 group II, patients without cardiac arrest; n = 3365).
Patients with OHCA had higher in hospital mortality (27.7% vs 2.9%, p < 0.01), sustained VT or VF (44.6% vs 4.3%, p < 0.01) and cardiogenic shock (22.9% vs 6.8%, p < 0.01). 30-day mortality (excluding death within first 24 h) was also higher in the OHCA group (24.6% vs 3.3%, p < 0.01). There was no significant difference in recurrent AMI, TVR, stroke, major bleeds or new onset heart failure. After a mean follow-up of 18.6 months, mortality was higher in patients with OHCA (7.9% vs 3.8%, p 0.04). This was driven mainly by an increase in cardiac mortality (5% vs 1.1%, p < 0.01). OHCA was a significant predictor of mortality beyond 30 days (HR – 2.5, 95% CI 0.99–6.3). Kaplan–Meier curves and the log-rank test revealed that patients with OHCA had significantly lower survival (p < 0.01).
Patients with STEMI complicated by OHCA remain a high-risk group associated with high in hospital mortality. Beyond 30 days the occurrence of cardiac arrest was a significant predictor of all-cause and cardiac mortality.
Twenty-year trends in the characteristic, management and outcome of patients with ST–elevation myocardial infarction and out-of-hospital reanimation. Insight from the national AMIS PLUS registry 1997–2017
2019, Resuscitation
Few studies describe recent changes in the incidence, treatment and outcome of successfully resuscitated STEMI patients after out-of-hospital cardiac arrest (OHCA) compared with non-OHCA STEMI patients.
To examine temporal trends in the incidence, therapeutic management, most serious complications, mortality rate and outcome of OHCA patients fulfilling criteria of STEMI compared with a reference group of STEMI patients without OHCA.
Analysis of registry data (AMIS Plus Registry) among STEMI patients both with and without OHCA between 1997 and 2017.
Among 31,650 patients with STEMI, 6.8% were successfully resuscitated prior to hospital admission. Increasing incidences of hospital-admitted patients following successful out-of-hospital CPR were observed (4.5% in 1999 vs. 8.6% in 2017). OHCA STEMI patients were at higher clinical risk at presentation (36.1% vs. 2.7%; p < 0.001 with cardiogenic shock) despite a shorter time span from the onset of symptoms to hospitalization (195 min vs. 107 min; p < 0.001) and a lower prevalence of cardiovascular risk factors except smoking. More PCIs were performed in STEMI patients with OHCA (78.9% vs. 74.5% for non-OHCA patients; p < 0.001). However, over time PCI became the preferred primary intervention irrespective of the OHCA status of STEMI patients. For STEMI patients without OHCA, there was a significant correlation between PCI and time periods on in-hospital mortality (p < 0.001), which was p = 0.002 when adjusted for age and gender. For STEMI patients with OHCA, the interaction between PCI and time was unadjusted p = 0.395 and p = 0.438 when adjusted for age and gender.
Temporal Trends in the Clinical Acuity of Patients with ST-Segment Elevation Myocardial Infarction
2018, American Journal of Medicine
Despite advances in ST-segment elevation myocardial infarction (STEMI) systems of care over the last decade, studies have shown no improvement in risk-adjusted mortality. It has been hypothesized that the population presenting to the catheterization laboratory has become sicker over time, in ways not accurately captured by current mortality models. The objective of this study was to examine changes in the clinical characteristics and in-hospital case fatality rate of the STEMI population treated with early percutaneous coronary intervention (PCI).
We conducted a retrospective analysis of a nationwide inpatient database for the period 2004-2012. All patients with a diagnosis of STEMI who underwent PCI within 24 hours of admission were identified. The primary outcome was in-hospital mortality.
From 2004 to 2012 there was a consistent increase in unadjusted in-hospital mortality (3.9% in 2004 and 4.7% in 2012, odds ratio_year 1.03; 95% confidence interval 1.01-1.04). During this time there was an increase in the proportion of patients with ≥3 Elixhauser comorbidities (14.8% vs 29.0%, P_trend < .001). Intubation or cardiac arrest on presentation increased from 3.2% to 7.8% (P_trend < .001) and had a strong, independent association with mortality. After multivariable adjustment using a model that incorporated the increasing trend in intubation/cardiac arrest, mortality decreased over time (odds ratio_year 0.95; 95% confidence interval 0.94-0.97).
During a period that corresponds to improvement in STEMI quality of care, risk-adjusted in-hospital mortality declined. An increase in comorbidities, and more importantly in the proportion of patients presenting with extreme-risk features, may explain the overall “null” effect regarding in-hospital mortality despite improvements in timely reperfusion.

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^r: See Appendix A for the complete group of the LombardIMA Study Group.

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Clinical InvestigationInterventional CardiologyEmergency percutaneous coronary intervention in patients with ST-elevation myocardial infarction complicated by out-of-hospital cardiac arrest: Early and medium-term outcome

Background

Methods

Results

Conclusions

Section snippets

Study population

Baseline patient characteristics and procedural aspects

Discussion

Conclusions

Am J Cardiol

Am J Cardiol

Resuscitation

Resuscitation

J Am Coll Cardiol

Resuscitation

Resuscitation

Ann Emerg Med

Lancet

International multicentre trial protocol to assess the efficacy and safety of tenecteplase during cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest: the Thrombolysis in Cardiac Arrest (TROICA) Study

Eur J Clin Invest

Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after cardiac arrest complicating ST elevation myocardial infarction

Circulation

Long-term survival and neurologic status after resuscitation from out-of hospital cardiac arrest

Neurology

Clinical Investigation
Interventional Cardiology
Emergency percutaneous coronary intervention in patients with ST-elevation myocardial infarction complicated by out-of-hospital cardiac arrest: Early and medium-term outcome