Consider Immediate Trip to Cath Lab for Comatose Cardiac Arrest Survivors Without STEMI.

Acute coronary occlusions were common in comatose cardiac arrest survivors without ST-segment elevation myocardial infarction.
Immediate cardiac catheterization for cardiac arrest survivors with acute ST-segment-elevation myocardial infarction (STEMI) is standard practice, but whether it is beneficial in postarrest patients without STEMI is unclear. Investigators retrospectively analyzed data from 269 comatose adult patients at six U.S. medical centers who were treated with therapeutic hypothermia after cardiac arrest due to ventricular arrhythmia without evidence of STEMI on electrocardiogram (ECG).

Of 269 patients, 45% received early cardiac catheterization (either at hospital admission or during hypothermia treatment), 15% received catheterization later during hospitalization, and 39% did not receive catheterization. The early-catheterization group was more likely to be in shock on admission and to receive mechanical support (usually with an intraaortic balloon pump), aspirin, antithrombin agents, and glycoprotein IIb/IIIa inhibitors than patients who received later or no catheterization. Acute coronary occlusion was present in 26% of the early-catheterization group and 29% of the late-catheterization group.

Overall hospital mortality rate was 43.5%. Patients who received early catheterization were significantly more likely to survive than those who received late or no catheterization (66% vs. 49%) and to have good neurologic outcome (61% vs. 45%). Differences in outcomes were even more striking when the early-catheterization group was compared to the no-catheterization group.


Given that the post-resuscitation electrocardiogram may be unreliable and ST-elevation is insensitive for predicting acute coronary occlusion, it is reasonable to consider immediate cardiac catheterization for comatose survivors of arrhythmia-induced cardiac arrest, even in the absence of STEMI.

Source: NEJM

Invasive Management of ACS: The Kidneys Are All Right.

Despite early increases in acute kidney injury, invasive treatment is associated with better long-term outcomes than conservative management.
Invasive treatment options for acute coronary syndromes (ACS) might be underused in patients at high risk for renal disease because of concerns about contrast-induced renal failure and other complications. However, comparative data on renal outcomes in patients managed invasively versus conservatively are lacking. Therefore, investigators conducted a cohort study involving 10,516 patients presenting with non-ST-segment-elevation ACS in Alberta, Canada, 41% of whom received early invasive management (coronary catheterization within 2 days after hospital admission). Stratification according to baseline estimated glomerular filtration rate and propensity-score matching resulted in a cohort of 6768 participants.

Compared with conservative management, early invasive therapy was associated with an increased risk for acute renal injury (10.3% vs. 8.7%, P=0.019), but treatments did not differ in risk for dialysis (0.4% vs. 0.3%, P=0.670) during the index hospitalization. During a median follow-up of 2.5 years, the risk for progression to end-stage renal disease did not differ between the two groups (0.3 vs. 0.4 events per 100 person-years, P=0.712). Moreover, early invasive treatment was associated with reduced long-term mortality (2.4 vs. 3.4 events per 100 person-years; P<0.001). The relative reduction in mortality risk was consistent across all strata of baseline renal function.


Although early invasive treatment of acute coronary syndromes increased the risk for acute renal injury compared with conservative management, it did not affect risk for dialysis or progression to end-stage renal disease. The improvements in long-term survival at all levels of baseline renal function suggest that invasive therapy should not be withheld for fear of renal complications.

Source: NEJM

High incidence of acute coronary occlusion in patients without protocol positive ST segment elevation referred to an open access primary angioplasty programme.


Background Primary percutaneous coronary intervention (PPCI) programmes vary in admission criteria from open referral to acceptance of electrocardiogram (ECG) protocol positive patients only. Rigid criteria may result in some patients with acutely occluded coronary arteries not receiving timely reperfusion therapy.

Objective To compare the prevalence of acute coronary occlusion and, in these cases, single time point biomarker estimates of myocardial infarct size between patients presenting with protocol positive ECG changes and those presenting with less diagnostic changes in the primary angioplasty cohort of an open access PPCI programme.

Methods We retrospectively performed a single centre cross sectional analysis of consecutive patients receiving PPCI between January and August 2008. Cases were categorised according to presenting ECG—group A: protocol positive (ST segment elevation/left bundle branch block/posterior ST elevation myocardial infarction), group B: ST segment depression or T-wave inversion, or group C: minor ECG changes. Clinical characteristics, coronary flow grades and 12 h postprocedure troponin-I levels were reviewed.

Results During the study period there were 513 activations of the PPCI service, of which 390 underwent immediate angiography and 308 underwent PPCI. Of those undergoing PPCI, 221 (72%) were in group A, 41 (13%) in group B and 46 (15%) in group C. Prevalence of coronary occlusion was 75% in group A compared with 73% in group B and 63% in group C. Median 12 h postintervention troponin-I (25th–75th percentile) for those with coronary occlusion was significantly higher in group A patients; 28.9 μg/l (13.2–58.5) versus 18.1 μg/l (6.7–32.4) for group B (p=0.03); and 15.5 μg/l (3.8–22.0) for group C (p<0.001), suggesting greater infarct size in group A.

Conclusions A number of patients referred to an open access PPCI programme have protocol negative ECGs but myocardial infarction and acute coronary artery occlusion amenable to angioplasty.

Source: PMJ. BMJ


If Possible, STEMI Patients Should Go Straight to a Cath Lab.

Within a system designed to reduce time to reperfusion, mortality was lower in patients transported directly to a PCI-capable center than in those transferred from a non–PCI-capable center.

In the city of Ottawa, emergency medical system providers trained in electrocardiogram interpretation can triage patients with ST-segment-elevation myocardial infarction (STEMI) directly to a center with percutaneous coronary intervention (PCI) capability. In a registry study, investigators compared outcomes in 822 patients transported directly to a PCI-capable hospital with those in 567 patients transported initially to a non–PCI-capable hospital, then transferred for primary PCI.

The median door-to-balloon time was significantly shorter in patients transported directly for PCI (66 minutes) than in those transferred for PCI (117 minutes). At 180 days, all-cause mortality was lower in directly transported patients than in those first taken to a non–PCI-capable hospital (5.0% vs. 11.5%; P<0.001). After multivariable adjustment, direct transfer was associated with about a 50% reduction in mortality risk (odds ratio, 0.52; P=0.01).

Comment: This study strengthens evidence that standardized geographic protocols designed to reduce time to reperfusion for ST-segment-elevation myocardial infarction reduce mortality. The importance of prehospital STEMI diagnosis and systems for rapid transport and treatment are now reflected in guideline recommendations (JW Cardiol Jan 6 2010), and implementation of these practices should be a public-health priority.

Source: Journal Watch Cardiology