523348 research-article2014
ACC0010.1177/2048872614523348European Heart Journal: Acute Cardiovascular CareSideris et al.
EUROPEAN SOCIETY OF CARDIOLOGY ®
Original scientific paper
Favourable 5-year postdischarge survival of comatose patients resuscitated from out-of-hospital cardiac arrest, managed with immediate coronary angiogram on admission
European Heart Journal: Acute Cardiovascular Care 2014, Vol. 3(2) 183–191 © The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2048872614523348 acc.sagepub.com
Georgios Sideris1,2,3,*, Sebastian Voicu1,2,3,*, Demetris Yannopoulos4, Jean-Guillaume Dillinger1,2,3, Julien Adjedj1,3, Nicolas Deye1,2,3, Papa Gueye1,3,5, Stéphane Manzo-Silberman1,2,3, Isabelle Malissin1,2,3, Damien Logeart1,2,3, Nikos Magkoutis1, Dragos D Capan6, Siham Makhloufi7, Bruno Megarbane1,3,8, Benoit Vivien5,9,10, Alain Cohen-Solal1,2,3, Didier Payen1,3,5, Frédéric J Baud1,3,8 and Patrick Henry1,2,3
Abstract Aims: On-admission coronary angiogram (CA) with angioplasty (percutaneous coronary intervention, PCI) may improve survival in patients resuscitated from out-of-hospital cardiac arrest (OHCA), but long-term survival data are scarce. We assessed long-term survival in OHCA patients managed with on-admission CA and PCI if indicated and compared survival rates in patients with/without acute coronary syndrome (ACS). Methods: Retrospective single-centre study including patients aged ≥18 years resuscitated from an OHCA without noncardiac cause, with sustained return of spontaneous circulation, undergoing on-admission CA with PCI if indicated. ACS was diagnosed angiographically. Survival was recorded at hospital discharge and at 5-year follow up. Survival probability was estimated by Kaplan–Meier survival curves. Results: A total of 300 comatose patients aged 56 years (IQR 48–67 years) were included, 36% with ST-segment elevation. All had on-admission CA; 31% had ACS. PCI was attempted in 91% of ACS patients and was successful in 93%. Hypothermia was performed in 84%. Survival to discharge was 32.3%. After discharge, 5-year survival was 81.7±5.4%. Survival from admission to 5 years was 26.2±2.8%. ACS patients had better survival to discharge (40.8%) compared with non-ACS patients (28.5%, p=0.047). After discharge, 5-year survival was 92.2±5.4% for patients with ACS and 73.4±8.6% without ACS (hazard ratio, HR, 2.7, 95% CI 0.8–8.9, p=0.1). Survival from admission to 5 years was 37.4±5.2% for ACS patients, 20.7±3.0%, for non-ACS patients (HR 1.5, 95% CI 1.12–2.0, p=0.0067). Conclusions: OHCA patients undergoing on-admission CA had a very favourable postdischarge survival. Patients with OHCA due to ACS had better survival to discharge at 5-year follow up than patients with OHCA due to other causes.
1Lariboisière
10Necker
2INSERM
*These
Hospital, Paris, France. U942, Paris, France. 3Université Denis Diderot, Paris, France. 4University of Minnesota, Minneapolis, USA. 5SAMU de Paris, APHP, Paris, France. 6Workplace Safety and Insurance Board, Toronto, Canada. 7Hôpital Fernand Widal, Paris, France. 8INSERM U705, Paris, France. 9Université Paris Descartes - Paris V, Paris, France
Hospital, APHP, 75743 Paris Cedex 15, France. authors contributed equally to this work and are co-first authors of this manuscript.
Corresponding author: Sebastian Voicu, Medical and Toxicological Intensive Care Unit, Lariboisière Hospital, APHP, 75475 Paris Cedex 10, France. Email: [email protected]
Downloaded from acc.sagepub.com at Bobst Library, New York University on July 14, 2015
184
European Heart Journal: Acute Cardiovascular Care 3(2)
Keywords Acute coronary syndrome, coronary angiography, heart arrest, long-term survival Received: 17 October 2013; accepted: 7 January 2014
Introduction Management of out-of-hospital cardiac arrest (OHCA) is complex, challenging, and continuously evolving, but overall survival remains poor, and most patients die due to neurological or circulatory failure. Despite low in-hospital survival of OHCA patients, long-term survival after hospital discharge is good1 and varies according to the population studied and the therapeutic interventions.2 Acute coronary artery occlusion is the main cause of OHCA3 and data from nonrandomized studies suggest that immediate coronary angiogram (CA) on admission may be a useful diagnostic and therapeutic procedure.3–8 According to recent guidelines CA is recommended in OHCA patients with ST-elevation myocardial infarction and should be considered in patients with high suspicion of ongoing infarction.9 Although no randomized studies exist to date, CA is performed immediately on admission in several centres.3,4,6–8,10,11 Survival to hospital discharge of patients managed with immediate on-admission CA and angioplasty (percutaneous coronary intervention, PCI), if indicated, is well documented,3–5 but there is little data on long-term survival. Even though several studies found higher long-term survival in OHCA of cardiac origin compared to noncardiac origin,12,13 data on patients with angiographically defined acute coronary syndrome (ACS) compared with those without ACS are scarce. This is an important issue since the benefit of CA with PCI occurs especially in this population. In our centre, routine CA with PCI is performed on admission to the hospital before transfer to the intensive care unit (ICU), for all OHCA patients without an obvious noncardiac cause. The main purpose of the present study was to assess the long-term survival of the patients managed with this strategy. The secondary purpose was to evaluate long-term survival of patients with ACS compared with patients without ACS.
Methods This study was conducted according to the principles of the Declaration of Helsinki (2008 version) of the World Medical Association. The ethics committee of our institution approved the study and no informed consent was required from the patients or the next of kin. The prehospital management of the patients in Paris, France has been previously described.14 After successful resuscitation according to guidelines,15 patients are
transferred to our centre directly to the catheterization laboratory for routine CA on admission.
Population We included in this retrospective single-centre study all comatose patients admitted for OHCA between January 2002 and August 2011, ≥18 years old (no upper age limit) with sustained return of spontaneous circulation16 (ROSC), regardless of the initial OHCA rhythm and electrocardiogram (ECG) changes. In order to avoid the inclusion of a heterogeneous population, we excluded patients with inhospital cardiac arrest or obvious noncardiac cause (e.g. trauma, drowning, poisoning, drug overdose, hypovolaemic shock, accidental hypothermia, electrocution). We also excluded patients with Glasgow Coma Scale (GCS)>7 on admission, patients with refractory OHCA (absence of ROSC despite resuscitation attempts until hospital admission), or unsustained ROSC (impossibility to maintain circulation with palpable pulse and systolic blood pressure >80 mmHg for >20 min).16
Patient management on admission and CA On admission to the catheterization laboratory, cardiologists performed CA and PCI if indicated and ICU doctors managed ventilation and circulatory function and initiated/ continued therapeutic hypothermia using cold intravenous saline (4°C)17 with target temperature of 32–34°C. Therapeutic hypothermia was maintained during 24 hours and was performed in all patients including those with asystole or pulseless electrical activity as initial rhythm.17 CA was performed through femoral or radial access using standard technique. PCI was attempted if a culprit lesion considered responsible for the OHCA was found. Coronary artery flow was assessed according to Thrombolysis in Myocardial Infarction (TIMI) classification.18 Coronary stenoses were considered significant if ≥50%.3,5,10 ACS was defined angiographically in accordance with previous data11 by the presence of a main coronary artery occlusion (TIMI 0 or 1)18 easily crossed by an angioplasty wire3 or lesions with TIMI 2 or 3 flow19 suggestive of ruptured plaques (Ambrose type II)20 with evidence of fresh thrombus.18 PCI was considered successful if postangioplasty blood flow was TIMI 3 and residual stenosis was
ACC0010.1177/2048872614523348European Heart Journal: Acute Cardiovascular CareSideris et al.
EUROPEAN SOCIETY OF CARDIOLOGY ®
Original scientific paper
Favourable 5-year postdischarge survival of comatose patients resuscitated from out-of-hospital cardiac arrest, managed with immediate coronary angiogram on admission
European Heart Journal: Acute Cardiovascular Care 2014, Vol. 3(2) 183–191 © The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2048872614523348 acc.sagepub.com
Georgios Sideris1,2,3,*, Sebastian Voicu1,2,3,*, Demetris Yannopoulos4, Jean-Guillaume Dillinger1,2,3, Julien Adjedj1,3, Nicolas Deye1,2,3, Papa Gueye1,3,5, Stéphane Manzo-Silberman1,2,3, Isabelle Malissin1,2,3, Damien Logeart1,2,3, Nikos Magkoutis1, Dragos D Capan6, Siham Makhloufi7, Bruno Megarbane1,3,8, Benoit Vivien5,9,10, Alain Cohen-Solal1,2,3, Didier Payen1,3,5, Frédéric J Baud1,3,8 and Patrick Henry1,2,3
Abstract Aims: On-admission coronary angiogram (CA) with angioplasty (percutaneous coronary intervention, PCI) may improve survival in patients resuscitated from out-of-hospital cardiac arrest (OHCA), but long-term survival data are scarce. We assessed long-term survival in OHCA patients managed with on-admission CA and PCI if indicated and compared survival rates in patients with/without acute coronary syndrome (ACS). Methods: Retrospective single-centre study including patients aged ≥18 years resuscitated from an OHCA without noncardiac cause, with sustained return of spontaneous circulation, undergoing on-admission CA with PCI if indicated. ACS was diagnosed angiographically. Survival was recorded at hospital discharge and at 5-year follow up. Survival probability was estimated by Kaplan–Meier survival curves. Results: A total of 300 comatose patients aged 56 years (IQR 48–67 years) were included, 36% with ST-segment elevation. All had on-admission CA; 31% had ACS. PCI was attempted in 91% of ACS patients and was successful in 93%. Hypothermia was performed in 84%. Survival to discharge was 32.3%. After discharge, 5-year survival was 81.7±5.4%. Survival from admission to 5 years was 26.2±2.8%. ACS patients had better survival to discharge (40.8%) compared with non-ACS patients (28.5%, p=0.047). After discharge, 5-year survival was 92.2±5.4% for patients with ACS and 73.4±8.6% without ACS (hazard ratio, HR, 2.7, 95% CI 0.8–8.9, p=0.1). Survival from admission to 5 years was 37.4±5.2% for ACS patients, 20.7±3.0%, for non-ACS patients (HR 1.5, 95% CI 1.12–2.0, p=0.0067). Conclusions: OHCA patients undergoing on-admission CA had a very favourable postdischarge survival. Patients with OHCA due to ACS had better survival to discharge at 5-year follow up than patients with OHCA due to other causes.
1Lariboisière
10Necker
2INSERM
*These
Hospital, Paris, France. U942, Paris, France. 3Université Denis Diderot, Paris, France. 4University of Minnesota, Minneapolis, USA. 5SAMU de Paris, APHP, Paris, France. 6Workplace Safety and Insurance Board, Toronto, Canada. 7Hôpital Fernand Widal, Paris, France. 8INSERM U705, Paris, France. 9Université Paris Descartes - Paris V, Paris, France
Hospital, APHP, 75743 Paris Cedex 15, France. authors contributed equally to this work and are co-first authors of this manuscript.
Corresponding author: Sebastian Voicu, Medical and Toxicological Intensive Care Unit, Lariboisière Hospital, APHP, 75475 Paris Cedex 10, France. Email: [email protected]
Downloaded from acc.sagepub.com at Bobst Library, New York University on July 14, 2015
184
European Heart Journal: Acute Cardiovascular Care 3(2)
Keywords Acute coronary syndrome, coronary angiography, heart arrest, long-term survival Received: 17 October 2013; accepted: 7 January 2014
Introduction Management of out-of-hospital cardiac arrest (OHCA) is complex, challenging, and continuously evolving, but overall survival remains poor, and most patients die due to neurological or circulatory failure. Despite low in-hospital survival of OHCA patients, long-term survival after hospital discharge is good1 and varies according to the population studied and the therapeutic interventions.2 Acute coronary artery occlusion is the main cause of OHCA3 and data from nonrandomized studies suggest that immediate coronary angiogram (CA) on admission may be a useful diagnostic and therapeutic procedure.3–8 According to recent guidelines CA is recommended in OHCA patients with ST-elevation myocardial infarction and should be considered in patients with high suspicion of ongoing infarction.9 Although no randomized studies exist to date, CA is performed immediately on admission in several centres.3,4,6–8,10,11 Survival to hospital discharge of patients managed with immediate on-admission CA and angioplasty (percutaneous coronary intervention, PCI), if indicated, is well documented,3–5 but there is little data on long-term survival. Even though several studies found higher long-term survival in OHCA of cardiac origin compared to noncardiac origin,12,13 data on patients with angiographically defined acute coronary syndrome (ACS) compared with those without ACS are scarce. This is an important issue since the benefit of CA with PCI occurs especially in this population. In our centre, routine CA with PCI is performed on admission to the hospital before transfer to the intensive care unit (ICU), for all OHCA patients without an obvious noncardiac cause. The main purpose of the present study was to assess the long-term survival of the patients managed with this strategy. The secondary purpose was to evaluate long-term survival of patients with ACS compared with patients without ACS.
Methods This study was conducted according to the principles of the Declaration of Helsinki (2008 version) of the World Medical Association. The ethics committee of our institution approved the study and no informed consent was required from the patients or the next of kin. The prehospital management of the patients in Paris, France has been previously described.14 After successful resuscitation according to guidelines,15 patients are
transferred to our centre directly to the catheterization laboratory for routine CA on admission.
Population We included in this retrospective single-centre study all comatose patients admitted for OHCA between January 2002 and August 2011, ≥18 years old (no upper age limit) with sustained return of spontaneous circulation16 (ROSC), regardless of the initial OHCA rhythm and electrocardiogram (ECG) changes. In order to avoid the inclusion of a heterogeneous population, we excluded patients with inhospital cardiac arrest or obvious noncardiac cause (e.g. trauma, drowning, poisoning, drug overdose, hypovolaemic shock, accidental hypothermia, electrocution). We also excluded patients with Glasgow Coma Scale (GCS)>7 on admission, patients with refractory OHCA (absence of ROSC despite resuscitation attempts until hospital admission), or unsustained ROSC (impossibility to maintain circulation with palpable pulse and systolic blood pressure >80 mmHg for >20 min).16
Patient management on admission and CA On admission to the catheterization laboratory, cardiologists performed CA and PCI if indicated and ICU doctors managed ventilation and circulatory function and initiated/ continued therapeutic hypothermia using cold intravenous saline (4°C)17 with target temperature of 32–34°C. Therapeutic hypothermia was maintained during 24 hours and was performed in all patients including those with asystole or pulseless electrical activity as initial rhythm.17 CA was performed through femoral or radial access using standard technique. PCI was attempted if a culprit lesion considered responsible for the OHCA was found. Coronary artery flow was assessed according to Thrombolysis in Myocardial Infarction (TIMI) classification.18 Coronary stenoses were considered significant if ≥50%.3,5,10 ACS was defined angiographically in accordance with previous data11 by the presence of a main coronary artery occlusion (TIMI 0 or 1)18 easily crossed by an angioplasty wire3 or lesions with TIMI 2 or 3 flow19 suggestive of ruptured plaques (Ambrose type II)20 with evidence of fresh thrombus.18 PCI was considered successful if postangioplasty blood flow was TIMI 3 and residual stenosis was
