PCI best for resuscitated arrest patients, despite neurologic status

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When resuscitated cardiac arrest patients with STEMI are being evaluated in the emergency department, serious consideration should be given to emergent angiography and revascularization, regardless of neurologic status. These patients should be treated with the same urgency as patients with acute STEMI without cardiac arrest, according to a study in the February 3 issue of the Journal of the American College of Cardiology.

Immediately after resuscitation from cardiac arrest owing to STEMI, many patients show signs of neurologic impairment, and benefits of PCI and subsequent prognosis are not well defined. 

Vinay R. Hosmane, MD, and colleagues at the Christiana Care Health System, Newark, Del., retrospectively identified 98 STEMI patients resuscitated from cardiac arrest (67 out of hospital, 31 within the ED).  

Survival to discharge was 64 percent in the whole group, broken down as:

  • 96 percent of the alert patients
  • 93 percent of the minimally responsive patients, and
  • 44 percent of the unresponsive patients.

This benefit was maintained long term: 60 percent of patients were alive post-discharge at 15 months. In addition, 92 percent of survivors had a full neurologic recovery.

Outcomes by Level of Consciousness Post-Resuscitation: Patients who were alert or at least minimally responsive post-resuscitation had better survival and a better chance of full neurologic recovery than patients who remained unresponsive. Even in the subset of patients who were unresponsive, nearly one-half survived, and most had full neurologic recovery. Source: JACC, Hosmane et al, February 2009.
Predictors of survival were shorter time to return of spontaneous circulation (ROSC), younger age, neurologic status post-resuscitation (alert or minimally responsive), and male sex.  

Researchers found that for every one-minute increase in time to ROSC, the odds of dying increased by 11 percent. For every five-year increment in age, the odds of dying increased by 34 percent. In addition, women were almost six times more likely to die compared with men. 

Neurologic recovery was predicted by similar variables: shorter time to ROSC, neurologic status post-resuscitation and younger age. 

In the unresponsive group, unwitnessed arrest, prolonged ROSC, and older age were associated with increased risk of death, and older age and prolonged ROSC predicted poor neurologic recovery. 

Interestingly, investigators found that 88 percent of the unresponsive patients who survived had full neurologic recovery. “This is an important observation because not knowing the ultimate outcomes in these patients often causes the greatest uncertainty in the initial management strategy,” the authors wrote. 

Hosmane and colleagues also found significantly lower in-hospital mortality for revascularized patients than non-revascularized patients in the entire group and in the subgroup of unresponsive patients.  

While those who arrested in the hospital fared better overall then those who arrested out of hospital, researchers noted that the latter group “still did relatively well.” Witnessed arrests in the field had a high rate of CPR, which researchers attributed to “the large number of laypersons trained in CPR through the Public Access Defibrillation Trial and Delaware’s First State-First Shock Program, designed to train bystanders in CPR and automated external defibrillator use.”