Clinical paperAcute coronary angiography in patients resuscitated from out-of-hospital cardiac arrest—A systematic review and meta-analysis☆
Introduction
Out-of-hospital cardiac arrest (OHCA) has a poor prognosis and is a leading cause of death. The incidence of OHCA treated by the emergency medical service in Europe has been estimated to be approximately 275,000 persons per year with a survival of 10.7% for all rhythms and 21.2% for ventricular fibrillation arrest.1 The most frequent cause of OHCA is ischaemic heart disease.2 Acute coronary angiography (CAG) with percutaneous coronary intervention (PCI) is the treatment of choice in patients with acute coronary syndrome (ACS) with ST-segment elevation (STEMI) or new left bundle branch block (LBBB) in the electrocardiogram (ECG) without preceding cardiac arrest.3 The prognostic value of acute CAG following return of spontaneous circulation (ROSC) after OHCA is less clear, especially in comatose survivors. The topic was evaluated in the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (2010 CoSTR).4 The recommendation was: acute CAG should be considered in STEMI or clinical suspicion of coronary ischaemia as a likely cause of the arrest, and that it may be reasonable to be included in a systematic standardised post cardiac arrest protocol. Several new studies have emerged. The aim of this study was to make an updated systematic review of the evidence on performing acute CAG following ROSC after OHCA.
Section snippets
Methods
The study was conducted in accordance with the principles stated by the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group and the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) group.5, 6 In short, we defined a structured question describing the Population, Intervention, Comparison and Outcome (PICO). This was followed by literature search and critical appraisal of the evidence. The eligible studies were summarised in tables, and the outcome was
Eligible studies
The literature search is illustrated in the flow diagram in Fig. 1. Thirty-two studies met the criteria for inclusion in the review. Ten were included in the meta-analysis. Seven studies were classified as supporting acute CAG following ROSC after OHCA, and the remaining 25 studies were neutral. Twelve studies were not considered in the 2010 CoSTR, primarily due to publication after completion of the 2010 CoSTR evaluation process. Table 1 summarises the LOE and design of the included studies:
Discussion
The high rate of mortality associated with OHCA calls for optimised treatment both before and after ROSC. No randomised trials exist evaluating the use of acute CAG following successful resuscitation from OHCA (Table 1).
Limitations
The search strategy only included three databases. Non-English articles were excluded. Relevant articles could be missing in the review, but this is less likely as the reference lists of the included articles and the 2010 CoSTR were screened. The classification of the studies as supporting, neutral and opposing PICO is debatable. We have used a more conservative approach than in the 2010 CoSTR evaluation process by only allowing studies to be classified as supporting if adjusted statistical
Conclusions
No randomised studies exist on acute CAG following OHCA. An increasing number of observational studies support feasibility and a possible survival benefit of an early invasive approach. Acute CAG is associated to a better survival in studies on resuscitated patients with heterogeneous aetiology to OHCA. Systematic acute CAG following OHCA without an obvious non-cardiac aetiology should be strongly considered irrespective of electrocardiographic findings due to a high prevalence of CAD and
Conflict of interest statement
None.
Acknowledgements
The authors thank chief librarian Conni Skrubbeltrang and librarian assistant Jacob Borg Andersen from the Medical Library at Aalborg University Hospital for valuable help on performing the database search. We thank research secretary Hanne Madsen from the Department of Cardiology at Aalborg University Hospital for assisting in the final preparation of the manuscript.
Funding: No external funding was used in the preparation of the manuscript.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.08.337.