Abstract 15636: Percutaneous Intervention (PCI) Improves Outcomes in Out of Hospital Cardiac Arrest (OHCA) Patients Receiving Coronary Angiography

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Michael G Scutella ◽  
Francis Pike ◽  
James Fitzgibbon ◽  
Lindsey Kowalski ◽  
Clifton Callaway ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Brain Injury ◽  
Coronary Angiography ◽  
Treatment Effect ◽  
Cerebral Performance Category ◽  
Early Brain Injury ◽  
Average Treatment Effect ◽  
Severe Brain Injury ◽  
Acute Coronary Occlusion ◽  
Improved Outcomes

Introduction: Acute coronary occlusion is common after OHCA. PCI may reduce subsequent cardiac death and improve cerebral perfusion thus improving outcomes. Recent studies suggest these benefits may be attenuated in patients with more severe brain injury. Hypothesis: PCI will more strongly associate with improved outcome than just coronary angiography (CA) after OHCA with loss of association in those with greatest brain injury. Methods: In subjects with OHCA with unclear arrest etiology, we examined the association between CA (with or without PCI) and PCI with 1) hospital survival; 2) discharge cerebral performance category (CPC); 3) discharge modified Rankin scale (mRS); 4) discharge destination. All outcomes were dichotomized and associations adjusted for propensity to perform 1) CA and 2) PCI based on associated pre-CA factors. This analysis was repeated after stratifying the cohort based on early brain injury as measured by Pittsburgh Cardiac Arrest Category (PCAC) dichotomized as PCAC 4 (severe injury) and PCAC 1-3 (mild to moderate). Results: Early (<24 h) CA was performed in 284/600 (47%) OHCA and PCI in 151/284 CA (53%). In unadjusted analysis, performance of both CA and PCI was strongly associated with improved outcomes (all p < 0.0001). Adjustment based on propensity to perform CA reduced the average treatment effect (ATE) to a non-significant 7-8% trend whereas adjustment based on propensity to perform PCI demonstrated a highly significant ATE of ~14-15% (p < 0.01) whereas those with less severe brain injury had trends to benefit with CA, which became significant (most p<0.01) with PCI. Conclusion: Early selection for CA of OHCA survivors likely to require PCI without severe brain injury is associated with substantial outcome benefits. The observed treatment effect is significantly reduced in patients with early signs of significant brain injury.

Abstract 11617: Personalizing Outcomes After Child Cardiac Arrest (POCCA): A Preliminary Biomarker Report

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Ericka L Fink ◽  
Patrick M Kochanek ◽  
Ashok Panigrahy ◽  
Sue R Beers ◽  
Rachel P Berger ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Brain Injury ◽  
Cerebral Performance Category ◽  
Pediatric Intensive Care ◽  
Early Brain Injury ◽  
Unfavorable Outcome ◽  
Neurofilament Light ◽  
Multicenter Observational Study ◽  
Child Centered ◽  
One Year

Blood-based brain injury biomarkers show promise to prognosticate outcome for children resuscitated from cardiac arrest. The objective of this multicenter, observational study was to validate promising biomarkers to accurately prognosticate outcome at 1 year. Early brain injury biomarkers will be associated with outcome at one year for children with cardiac arrest. Fourteen centers in the US enrolled children aged < 18 years with in- or out-of-hospital cardiac arrest and pediatric intensive care unit admission if pre-cardiac arrest Pediatric Cerebral Performance Category score was 1-3. Glial fibrillary acidic protein (GFAP), ubiquitin carboxyl-terminal esterase L1 (UCHL1), neurofilament light (NfL), and Tau protein concentrations were measured in samples drawn post-arrest day 1 using Quanterix Simoa 4-Plex assay. The primary outcome was unfavorable outcome at one year (Vineland Adaptive Behavioral Scale < 70). Of 164 children enrolled, 120 children had evaluable data (n=50 with unfavorable outcome). Children were median (interquartile range) 1 (0-8.5) years of age, 41% female, and 60% had asphyxia etiology. Of children with unfavorable outcome, 93% had unwitnessed arrests and 43 died. While all 4 day 1 biomarkers were increased in children with unfavorable vs. favorable outcome at 1-year post-arrest, NfL had the best univariate area under the receiver operator curve to predict 1 year outcome at 0.731. In a multivariate logistic regression, NfL concentration trended toward significance on day 1 and was associated with unfavorable outcome at 1-year on days 2 and 3 (day 1: Odds Ratio [95% Confidence Interval] 1.004 [1.000-1.008], p=.062; day 2: 1.005 [1.002-1.008], p=.003, and day 3: 1.002 [1.001-1.004], p=.003, respectively). UCHL1 was associated with outcome on days 2: 1.005 [1.002-1.009], p=.003 and 3: 1.001 [1.000-1.002], p=.019) and Tau trended toward association with outcome on days 2: 1.003 [1.000-1.005], p=.08) and 3: 1.001 [1.000-1.002], p=.077. Brain injury biomarkers predict unfavorable outcome post-pediatric cardiac arrest. Accuracy of biomarkers alone and together with other prognostication tools should be evaluated to predict long term child centered outcomes post-cardiac arrest.

Abstract 15738: New Left Bundle Branch Block (LBBB) as a Predictor of Coronary Occlusion After Out-of-Hospital Cardiac Arrest (OHCA)

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Lindsey Kowalski ◽  
Jacob Jentzer ◽  
James Fitzgibbon ◽  
Michael Scutella ◽  
Clifton Callaway ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Coronary Angiography ◽  
Sensitivity And Specificity ◽  
Coronary Occlusion ◽  
New Left ◽  
Current Standard ◽  
Acute Coronary Occlusion ◽  
Cast Doubt ◽  
St Elevation ◽  
Few Data

Introduction: In the setting of recent cardiac arrest, it is controversial whether new LBBB with or without Sgarbossa Criteria is an ST elevation (STE) equivalent for predicting acute coronary occlusions. The 2010 AHA guidelines recommend urgent coronary angiography after OHCA when either STE or new LBBB is present. These guidelines are extrapolated from the non-arrest population with few data from OHCA patients. Hypothesis: New LBBB on EKG early after OHCA will have a weaker association with acute coronary occlusion than STE. Methods: This was a retrospective 2 center study of 284 OHCA subjects who underwent early coronary angiography (within 24 hours of resuscitation). The post-resuscitation EKG was reviewed by a study investigator (LK) with cardiology over reading (JJ). Subjects with either STE or new LBBB were identified. Cardiologists performed percutaneous intervention (PCI) at their discretion when a culprit lesion or acute thrombus was found. We calculated the sensitivity and specificity for STE, LBBB, and STE + LBBB (current standard) for predicting PCI and the odds ratio (OR) and 95% confidence intervals (CI) for the association between these EKG findings and PCI. OR were calculated relative to subjects with no STE or LBBB. Results: Of the 284 patients, 125 presented with STE and 19 presented with new LBBB resulting in 144 patients meeting AHA criteria for angiography. None of the LBBB met Sgarbossa Criteria. PCI was performed in 95/125 (76%) of those with STE, 4/19 (21%) of those with LBBB and 99/144 (69%) with either finding. The sensitivity and specificity of STE for PCI were 62% and 77% and the unadjusted OR was 5.82 (95% CI: 3.45, 9.83; p < 0.001). The sensitivity and specificity of ST elevation or new LBBB for PCI was 65% and 66% (OR =3.72 [95% CI: 2.28, 6.09; p < 0.001]). New LBBB was inversely associated with PCI (OR = 0.21 [95% CI: 0.07, 0.66; p = 0.0075]. Survival was higher in those who underwent PCI with STE (OR 8.23 [95% CI: 3.31, 20.48; p <0.0001]) but not in those with LBBB (OR of 0.60 [95% CI: 0.09, 4.01; p=0.5950]). Conclusions: Our findings confirm STE after OHCA is strongly associated with coronary occlusion amenable to PCI, but cast doubt on using new LBBB as an STE equivalent. These findings mirror recent reports about LBBB in non-OHCA patients.

Abstract 335: The Impact of Early Coronary Angiography on Outcomes in Out-of-hospital Cardiac Arrest: The Singapore Experience

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Shir Lynn Lim ◽  
Yee How Lau ◽  
Mark Chan ◽  
Terrance Chua ◽  
Huay Cheem Tan ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Coronary Angiography ◽  
Clinical Outcomes ◽  
Obstructive Coronary Artery Disease ◽  
Cerebral Performance Category ◽  
National Database ◽  
Epinephrine Administration ◽  
Neurological Outcomes ◽  
The Impact ◽  
Hospital Cardiac Arrest

Background and Aim: The benefit of early coronary angiography (CAG) and revascularization in resuscitated out-of-hospital cardiac arrest (OHCA) is unclear. We evaluated the association between early CAG and clinical outcomes in these patients. Methods: Data on all resuscitated adult OHCA cases of cardiac etiology between 2011-2015 were extracted from the prospective Singapore Pan-Asian Resuscitation Outcomes Study and linked with data from the national database of cardiac procedures. The 30-day survival and neurological outcomes (good outcome defined as Cerebral Performance Category [CPC] 1 or 2) were compared between patients undergoing early CAG (within 1-calender day) and patients not undergoing early CAG. Inverse probability weighted estimator was used to adjust for propensity to perform early CAG and PCI. Results: Of 976 consecutive patients who survived to admission (mean age 64±13, 73.7% males), 401 (41.1%) patients underwent CAG and obstructive coronary artery disease (CAD) was present in 352 (87.8%), of whom 284 (70.8%) underwent revascularization. Patients who underwent early CAG (n=337[34.5%]) were significantly different compared to those who underwent delayed or no CAG (n=639[65.5%]) (Table 1). Early CAG and PCI patients had improved survival and better neurological outcomes (adjusted odds ratio [AOR] 3.806 [95% CI 1.675 - 8.648] and AOR 3.075 [95% CI 1.119 - 8.451]), compared to those without. The odds of survival decreased with epinephrine administration (AOR 0.357 [95% CI 0.199 - 0.640]), but increased with an initial shockable rhythm (AOR 6.587 [95% CI 3.659 - 11.861]). The rates of bleeding (2% vs 0%, p=0.300) and stroke (1.6% vs 1.9%, p=0.880) were not increased with early intervention. Conclusion: Early CAG and PCI after OHCA were associated with improved clinical outcomes after OHCA without increasing complications. Further studies are required to identify the characteristics of patients who would benefit most from this invasive strategy.

scholarly journals Clinical Trials in Cardiac Arrest and Subarachnoid Hemorrhage: Lessons from the Past and Ideas for the Future

2013 ◽  
Vol 2013 ◽  
pp. 1-42
Author(s):  
Jennifer A. Frontera
Keyword(s):  
Clinical Trials ◽  
Cardiac Arrest ◽  
Subarachnoid Hemorrhage ◽  
Brain Injury ◽  
Randomized Clinical Trials ◽  
Early Brain Injury ◽  
Aneurysm Rupture ◽  
Neurological Outcomes ◽  
Injury Research ◽  
The Brain

Introduction. Elevated intracranial pressure that occurs at the time of cerebral aneurysm rupture can lead to inadequate cerebral blood flow, which may mimic the brain injury cascade that occurs after cardiac arrest. Insights from clinical trials in cardiac arrest may provide direction for future early brain injury research after subarachnoid hemorrhage (SAH).Methods. A search of PubMed from 1980 to 2012 and clinicaltrials.gov was conducted to identify published and ongoing randomized clinical trials in aneurysmal SAH and cardiac arrest patients. Only English, adult, human studies with primary or secondary mortality or neurological outcomes were included.Results. A total of 142 trials (82 SAH, 60 cardiac arrest) met the review criteria (103 published, 39 ongoing). The majority of both published and ongoing SAH trials focus on delayed secondary insults after SAH (70%), while 100% of cardiac arrest trials tested interventions within the first few hours of ictus. No SAH trials addressing treatment of early brain injury were identified. Twenty-nine percent of SAH and 13% of cardiac arrest trials showed outcome benefit, though there is no overlap mechanistically.Conclusions. Clinical trials in SAH assessing acute brain injury are warranted and successful interventions identified by the cardiac arrest literature may be reasonable targets of the study.

Clinical value of ST-segment change after return of spontaneous cardiac arrest and emergent coronary angiography in patients with out-of-hospital cardiac arrest: Diagnostic and therapeutic importance of vasospastic angina

2017 ◽  
Vol 7 (5) ◽  
pp. 405-413 ◽  
Author(s):  
Kazuya Tateishi ◽  
Daisuke Abe ◽  
Tooru Iwama ◽  
Yuichi Hamabe ◽  
Kazutaka Aonuma ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Coronary Angiography ◽  
Predictive Value ◽  
Neurological Outcome ◽  
Cerebral Performance Category ◽  
Vasospastic Angina ◽  
Clinical Value ◽  
St Segment ◽  
Coronary Lesions ◽  
Hospital Cardiac Arrest

Background: We investigated the association between initial ST-segment change after return of spontaneous circulation (ROSC) and the incidence of acute coronary lesions in patients with out-of-hospital cardiac arrest (OHCA), and clinical outcomes of patients with OHCA caused by vasospastic angina pectoris (VSA). Methods: Among 2779 OHCA patients in our institution, all patients with ROSC underwent emergent coronary angiography (CAG) except for those with an obvious extra-cardiac cause of OHCA. Initial ST-segment changes after ROSC were reviewed, and 30-day survival and neurological outcome (Cerebral Performance Category) were evaluated. Results: Of the 155 patients, 52 (34%) had ST-segment elevation (STE) and 103 (66%) had non-STE. Significant coronary culprit lesions were present in 81% of patients with STE and in 33% of patients with non-STE ( P<.001). Percutaneous coronary intervention (PCI) was successful in 60 patients (93.8%) and failed in 4 patients (6.2%). Among 155 patients, 74 patients (47.7%) had favorable neurological prognosis, and 104 patients (67.1%) were alive at 30 days. ST-segment analysis showed good positive predictive value (81%) but low negative predictive value (68%) in diagnosing the presence of acute coronary lesions. VSA was found in 5 patients (9.6%) in the STE group and in 12 patients (11.7%) in the non-STE group. Of these 17 patients, 9 (52.9%) had favorable neurological outcome and 14 (82.4%) were alive at 30 days. Conclusion: An acute culprit lesion may be the cause of OHCA even in the absence of STE. In survivors of OHCA with normal coronary arteries, spasm provocation testing should be performed to detect VSA as a cause of the arrest.

scholarly journals Association of deranged cerebrovascular reactivity with brain injury following cardiac arrest: a post-hoc analysis of the COMACARE trial

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Johanna Laurikkala ◽  
Anders Aneman ◽  
Alexander Peng ◽  
Matti Reinikainen ◽  
Paul Pham ◽  
...  
Keyword(s):  
Carbon Dioxide ◽  
Cardiac Arrest ◽  
Brain Injury ◽  
Cerebral Performance Category ◽  
Cerebrovascular Reactivity ◽  
Chronic Hypertension ◽  
Post Hoc Analysis ◽  
Poor Outcome ◽  
Arterial Blood ◽  
Post Hoc

Abstract Background Impaired cerebrovascular reactivity (CVR) is one feature of post cardiac arrest encephalopathy. We studied the incidence and features of CVR by near infrared spectroscopy (NIRS) and associations with outcome and biomarkers of brain injury. Methods A post-hoc analysis of 120 comatose OHCA patients continuously monitored with NIRS and randomised to low- or high-normal oxygen, carbon dioxide and mean arterial blood pressure (MAP) targets for 48 h. The tissue oximetry index (TOx) generated by the moving correlation coefficient between cerebral tissue oxygenation measured by NIRS and MAP was used as a dynamic index of CVR with TOx > 0 indicating impaired reactivity and TOx > 0.3 used to delineate the lower and upper MAP bounds for disrupted CVR. TOx was analysed in the 0–12, 12–24, 24–48 h time-periods and integrated over 0–48 h. The primary outcome was the association between TOx and six-month functional outcome dichotomised by the cerebral performance category (CPC1-2 good vs. 3–5 poor). Secondary outcomes included associations with MAP bounds for CVR and biomarkers of brain injury. Results In 108 patients with sufficient data to calculate TOx, 76 patients (70%) had impaired CVR and among these, chronic hypertension was more common (58% vs. 31%, p = 0.002). Integrated TOx for 0–48 h was higher in patients with poor outcome than in patients with good outcome (0.89 95% CI [− 1.17 to 2.94] vs. − 2.71 95% CI [− 4.16 to − 1.26], p = 0.05). Patients with poor outcomes had a decreased upper MAP bound of CVR over time (p = 0.001), including the high-normal oxygen (p = 0.002), carbon dioxide (p = 0.012) and MAP (p = 0.001) groups. The MAP range of maintained CVR was narrower in all time intervals and intervention groups (p < 0.05). NfL concentrations were higher in patients with impaired CVR compared to those with intact CVR (43 IQR [15–650] vs 20 IQR [13–199] pg/ml, p = 0.042). Conclusion Impaired CVR over 48 h was more common in patients with chronic hypertension and associated with poor outcome. Decreased upper MAP bound and a narrower MAP range for maintained CVR were associated with poor outcome and more severe brain injury assessed with NfL. Trial registration ClinicalTrials.gov, NCT02698917.

scholarly journals Role of coronary angiography in patients with a non-diagnostic electrocardiogram following out of hospital cardiac arrest: Rationale and design of the multicentre randomized controlled COUPE trial

2019 ◽  
Vol 9 (4_suppl) ◽  
pp. S131-S137
Author(s):  
Ana Viana-Tejedor ◽  
Albert Ariza-Solé ◽  
Manuel Martínez-Sellés ◽  
Manuel Jiménez Mena ◽  
Montserrat Vila ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Coronary Angiography ◽  
Cerebral Performance Category ◽  
Coronary Intervention ◽  
Controlled Clinical Trial ◽  
Cardiac Events ◽  
St Segment Elevation ◽  
Randomized Controlled ◽  
Hospital Cardiac Arrest

Background: Coronary artery disease (CAD) is a major cause of out-of-hospital cardiac arrest (OHCA). The role of emergency coronary angiography (CAG) and percutaneous coronary intervention (PCI) following cardiac arrest in patients without ST-segment elevation myocardial infarction (STEMI) remains unclear. Aims: We aim to assess whether emergency CAG and PCI, when indicated, will improve survival with good neurological outcome in post-OHCA patients without STEMI who remain comatose. Methods: COUPE is a prospective, multicentre and randomized controlled clinical trial. A total of 166 survivors of OHCA without STEMI will be included. Potentially non-cardiac aetiology of the cardiac arrest will be ruled out prior to randomization. Randomization will be 1:1 for emergency (within 2 h) or deferred (performed before discharge) CAG. Both groups will receive routine care in the intensive cardiac care unit, including therapeutic hypothermia. The primary efficacy endpoint is a composite of in-hospital survival free of severe dependence, which will be evaluated using the Cerebral Performance Category Scale. The safety endpoint will be a composite of major adverse cardiac events including death, reinfarction, bleeding and ventricular arrhythmias. Conclusions: This study will assess the efficacy of an emergency CAG versus a deferred one in OHCA patients without STEMI in terms of survival and neurological impairment.

scholarly journals Myoclonus after Cardiac Arrest: Where Do We Go from Here?

2017 ◽  
Vol 17 (5) ◽  
pp. 265-272 ◽  
Author(s):  
Brin Freund ◽  
Peter W. Kaplan
Keyword(s):  
Cardiac Arrest ◽  
Brain Injury ◽  
Functional Status ◽  
Neurological Examination ◽  
Neurological Function ◽  
Neurological Injury ◽  
Multimodal Approach ◽  
Severe Brain Injury ◽  
Clinical Neurological Examination ◽  
Poor Functional Status

Prognostication after cardiac arrest often depends primarily on neurological function, and characterizing the extent of neurological injury hinges on neurophysiological testing and clinical neurological examination. The presence of early posthypoxic myoclonus (PHM) following cardiac arrest had been invariably associated with poor outcome, but more recent studies have shown that those with early PHM may survive with good neurological function. Electroencephalographic patterns suggestive of severe brain injury may be more valuable than the presence of PHM itself in portending poor functional status, and phenotyping PHM may also be useful in delineating benign and malignant forms. Patients with early PHM should be evaluated similarly to others who suffer cardiac arrest by using a multimodal approach in determining prognosis until further studies are performed that better characterize early PHM subtypes and their outcomes.

Abstract 12120: Intracranial Pressure Increases Both During Mild Therapeutic Hypothermia and During Rewarming Period in Post Cardiac Arrest Patients

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Hiromichi Naito ◽  
Eiji Isotani ◽  
Clifton W Callaway ◽  
Shingo Hagioka ◽  
Naoki Morimoto
Keyword(s):  
Cardiac Arrest ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Therapeutic Hypothermia ◽  
Perfusion Pressure ◽  
Cerebral Performance Category ◽  
Secondary Brain Injury ◽  
Surface Cooling ◽  
Cooling Device ◽  
Performance Category

Introduction: Elevation of intracranial pressure (ICP) may induce secondary brain injury and worsen the neurological outcome. Some studies on traumatic brain injury show that rapid rewarming can result in poorer outcomes contributory due to elevation of ICP. However, little is known about ICP during therapeutic hypothermia (TH) and rewarming period in post cardiac arrest patients. Hypothesis: We tested if there is occurrence of increased ICP during mild TH and rewarming period and whether it is related to outcome in patients resuscitated after cardiac arrest. Methods: Comatose patients resuscitated from cardiac arrest, treated with TH and ICP monitored were enrolled in the study. Surface cooling device was used for TH. Patients were maintained in target core temperature of 34 °C for 24 hrs. Thereafter, the temperature was regulated to increase to normothermia (37.0 °C) at the rate of 0.25 °C/hr. ICP and cerebral perfusion pressure (CPP) were monitored during the period. Cerebral Performance Category (CPC) scale was obtained 28 days later. Results: Data of 9 patients were analyzed (8 [89 %] men, age: 62 ± 17 years, cardiac origin 3 [33 %]/non-cardiac origin: 6 [67 %], CPC 1: 2 patients; CPC 2: 1 patient; CPC 3: 1 patient; CPC 4: 2 patients; CPC 5: 3 patients). ICP was 7.7 ± 4.4 mmHg at the beginning of TH and significantly elevated to 17.4 ± 13.3 mmHg at the end of TH (p = 0.03). ICP was 23.6 ± 19.1 mmHg at the end of rewarming which was higher than the end of TH (p = 0.04). At the end of rewarming, ICP value ranged in variety from 10 mmHg (CPC 1) to 68 mmHg (CPC 5). CPP was 81.3 ± 15.6 mmHg at the beginning of TH and was 72.1 ± 22.7 mmHg (p = 0.22) at the end of rewarming. All the cases with CPP less than 40 mmHg within 48 hrs died. Conclusions: ICP is increasing both during TH of target temperature 34°C and during rewarming at speed of 0.25 °C/hr in patients after cardiac arrest. Increment of ICP seems to be greater in cases with poorer outcome. CPP decrease was not usually observed and was limited to fatal cases.

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