Early Cardiac Cath Lab Access For Shockable ROSC Patients Improves Outcomes

Study in the Twin Cities shows substantial improvement in survival to hospital discharge with good neurologic outcome

A 54-year-old man with past medical history of mild treated hypertension collapsed at the gym and had a downtime of 1-2 minutes before CPR was started. An AED was located and applied within four minutes and there were two shocks delivered. EMS arrived within five minutes, delivered another shock and immediate return of spontaneous circulation was established. The patient came to the emergency department intubated and comatose requiring no blood pressure support. His EKG shows nonspecific T wave changes including ST depression but no STEMI. It’s 10 pm and the consulting cardiologist elects to admit him to the ICU and states she will proceed to cath “if he wakes up”.

Although this scenario reflects common practice, does it reflect best practice? The Minnesota Resuscitation Consortium has taken a different approach.

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In the Twin Cities of Minneapolis and St Paul, the emergency cardiac care community assessed best practice for patients resuscitated from out-of-hospital cardiac arrest. Consideration was given to the fact that cardiac arrest patients successfully resuscitated from shockable rhythms have a high prevalence of thrombotic and/or flow limiting coronary occlusion regardless of the presence of STEMI on the ECG(1). In 2012 the Minnesota Resuscitation Consortium (MRC) developed an organized approach for the management of all patients resuscitated from shockable rhythms to gain early access to the cardiac catheterization laboratory (CCL).

Eleven Twin Cities metropolitan hospitals with 24/7 PCI capabilities agreed to provide early (within 6 hours of arrival to the emergency department ) access to the CCL for all patients that were successfully resuscitated from VF/VT arrest regardless of the presence or absence of STEMI on the post ROSC ECG. Inclusion criteria were: witnessed or un-witnessed, age >18 and <70, cardiac arrest of presumed cardiac etiology, comatose or conscious patients. Patients with PEA or asystole, known DNR/DNI, non-cardiac etiology, significant bleeding of any cause, terminal disease were excluded. Patient outcomes were recorded in the state database Cardiac Arrest Registry to Enhance Survival.

Outcomes
In 2013, 331 patients were resuscitated from VT/VF and transferred alive to the ED. 315 had complete medical records. Of those, 231 (73.3%) were taken to the CCL per MRC protocol and 84 (26.6%) were not taken to the CCL (protocol deviations). Overall 197 (63%) patients survived to hospital discharge with good neurologic outcome (cerebral performance category (CPC) of 1 or 2). In the CCL group, 151 (65%) survived with good neurological outcome (CPC 1 or 2). Of the non-protocol patients (46) 55% survived with good neurological outcome (adjusted OR: 1.99; [1.07-3.72]. Of the CCL patients, 121 (52%) underwent PCI, and 15 (7%) had CABG. The most common reason for protocol deviation was early concern for poor neurologic outcomes.

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Patients with no ST elevation had outcomes that were similar: 203 no ST elevation patients total; 130 followed MRC protocol; 73 protocol deviations; survival was 66% for the patients without ST elevation who went to CCL versus 53% survival protocol deviations (adjusted OR:2.77; [1.31-5.85]

Discussion
A clinical protocol of early access to the CCL for patients with OHCA due to a shockable rhythm is feasible and associated with good survival with favorable neurological outcomes. These positive results were also noted in patients without ST elevation on their post-resuscitation ECG. A randomized trial evaluating access to the CCL is warranted in this very high-risk population.

The 2015 AHA Emergency Cardiac Care Guidelines stress the fundamental importance of the last link in the resuscitation chain of survival: post-resuscitation care. Excellent post-resuscitation care likely includes broader and more aggressive use of early access to the CCL for appropriate candidates who remain comatose and who do not have STEMI but at a minimum did have a presenting shockable rhythm. It is an unfortunate self-fulfilling reality that when a practitioner withholds a vital therapy from a critically ill patient because of their bias that the patient’s condition is hopeless . . . that practitioner will often be right, but for the wrong reasons.

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Special thanks to all the Twin Cities EMS medical directors and cardiologists who participated in this program. This data is in press with the Journal of American Heart Association, Garcia et al.

REFERENCE

1. Sideris G, Voicu S, Dillinger JG, et al. Value of post-resus- citation electrocardiogram in the diagnosis of acute myo- cardial infarction in out-of-hospital cardiac arrest patients. Resuscitation 2011; 82: 1148–1153.