after cardiac arrest: emergency coronary angiography for all? giuseppe biondi-zoccai, md sapienza...
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After cardiac arrest: emergency coronary angiography for all?
Giuseppe Biondi-Zoccai, MD
Sapienza University of Rome, [email protected]
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Learning goals
• Scope of the problem• Rationale for emergency coronary
angiography• When perusing it• What does it entail• Case study
![Page 3: After cardiac arrest: emergency coronary angiography for all? Giuseppe Biondi-Zoccai, MD Sapienza University of Rome, Italy giuseppe.biondizoccai@uniroma1.it](https://reader030.vdocuments.us/reader030/viewer/2022032517/56649c995503460f949560eb/html5/thumbnails/3.jpg)
Learning goals
• Scope of the problem• Rationale for emergency coronary
angiography• When perusing it• What does it entail• Case study
![Page 4: After cardiac arrest: emergency coronary angiography for all? Giuseppe Biondi-Zoccai, MD Sapienza University of Rome, Italy giuseppe.biondizoccai@uniroma1.it](https://reader030.vdocuments.us/reader030/viewer/2022032517/56649c995503460f949560eb/html5/thumbnails/4.jpg)
Cardiac arrest has dismal prognosis
Yonemoto et al, Circulation 2011
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Difficult to appraise neurologic status shortly after cardiac arrest
Booth et al, JAMA 2004
LR(+) = sensitivity / (1 – specificity) useful if >10 LR (-) = (1 – sensitivity) / specificity useful if <0.1
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Coronary angiography after OHCA remains underused
Aufderheide et al, Lancet 2011
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Learning goals
• Scope of the problem• Rationale for emergency coronary
angiography• When perusing it• What does it entail• Case study
![Page 8: After cardiac arrest: emergency coronary angiography for all? Giuseppe Biondi-Zoccai, MD Sapienza University of Rome, Italy giuseppe.biondizoccai@uniroma1.it](https://reader030.vdocuments.us/reader030/viewer/2022032517/56649c995503460f949560eb/html5/thumbnails/8.jpg)
Coronary occlusions are common
Spaulding et al, New Engl J Med 1997
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Systematic invasive management may be beneficial
Dumas et al, Circ Cardiovasc Interv 2010
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Systematic invasive management may be beneficial
Dumas et al, Circ Cardiovasc Interv 2010
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Systematic invasive management may be beneficial
Dumas et al, Circ Cardiovasc Interv 2010
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Learning goals
• Scope of the problem• Rationale for emergency coronary
angiography• When perusing it• What does it entail• Case study
![Page 13: After cardiac arrest: emergency coronary angiography for all? Giuseppe Biondi-Zoccai, MD Sapienza University of Rome, Italy giuseppe.biondizoccai@uniroma1.it](https://reader030.vdocuments.us/reader030/viewer/2022032517/56649c995503460f949560eb/html5/thumbnails/13.jpg)
Even without ST-elevation or new LBBB
Spaulding et al, N Engl J Med 1997; Dumas et al, Circ Cardiovasc Interv 2010
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Troponin is not very useful either, but…
Dumas et al, Crit Care Med 2012
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…if you wish to pinpoint patients
Primary predictive model for coronary occlusion after OHCA: 1st dose of adrenaline <2 mg (OR=2), smoking (OR=2.0), VF/VT as initial rhythm
(OR=1.7); other predictors were cTnI >4.7 ng/mL (OR=3.6), ↑ST (OR=10.2)
Dumas et al, Crit Care Med 2012
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Learning goals
• Scope of the problem• Rationale for emergency coronary
angiography• When perusing it• What does it entail• Case study
![Page 17: After cardiac arrest: emergency coronary angiography for all? Giuseppe Biondi-Zoccai, MD Sapienza University of Rome, Italy giuseppe.biondizoccai@uniroma1.it](https://reader030.vdocuments.us/reader030/viewer/2022032517/56649c995503460f949560eb/html5/thumbnails/17.jpg)
Decision to cath must be made ASAP
Strote et al, Am J Cardiol 2002
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Radial access is paramount
Agostoni et al, J Am Coll Cardiol 2004
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Hypothermia is recommended
Bernard et al, N Engl J Med 2002; Holzer et al, New Engl J Med 2002
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May be combined with brain CT
Chelly et al, Resuscitation 2002
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Learning goals
• Scope of the problem• Rationale for emergency coronary
angiography• When perusing it• What does it entail• Case study
![Page 22: After cardiac arrest: emergency coronary angiography for all? Giuseppe Biondi-Zoccai, MD Sapienza University of Rome, Italy giuseppe.biondizoccai@uniroma1.it](https://reader030.vdocuments.us/reader030/viewer/2022032517/56649c995503460f949560eb/html5/thumbnails/22.jpg)
Case studyAge: 40 yearsGender: maleComorbidities: type 1 diabetes mellitusDiagnosis: acute myocardial infarction Prehospital events/management: VF treated with DC shock, followed by PEA; manual chest compression, repeat IV adrenaline boluses, tracheal intubation, mechanical ventilationHospital events/management: systemic thrombolysis with alteplase attempted without success; LUCAS deployment and…
Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011
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Baseline coronary angiography
Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011
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Predilation on left main-circumflex
Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011
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Left main-anterior descending stenting
Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011
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Coronary angiography after stenting
Biondi-Zoccai et al, HSR Proc Intensive Care Cardiovasc Anesth 2011
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Take home messages• Patients achieving ROSC after OHCA should be
thoroughly appraised for non-cardiac conditions.
• Emergent coronary angiography is recommended routinely unless prognosis is very dire.
• Emergent coronary angiography can be considered in very selected cases before ROSC if patient/procedural features suggest reasonable likelihood of ROSC.
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Many thanks for your attention
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