Case Report

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American Journal of Emergency Medicine

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American Journal of Emergency Medicine 34 (2016) 118.e1-118.e3

Emergency coronary angiography in out-of-hospital cardiac arrest patients without STEMI

Abstract

Current guideline recommends that immediate Coronary angiography should be considered in all Postcardiac arrest patients in whom acute coronary syndrome is suspected. In the setting of out-of-hospital cardiac arrest (OHCA), obtaining clinical data such as chest discomfort and medical diseases associated with acute coronary syndrome can be difficult. Therefore, emergency physicians depend on electrocardio- graphic findings after return of spontaneous circulation (ROSC) when they have to decide whether emergency CAG should be performed. In clinical practice, the usefulness of emergency CAG evaluation of OHCA pa- tients without ST-segment elevation myocardial infarction is debatable. We describe 2 OHCA patients who did not exhibit ST-segment elevation after ROSC and received underwent emergency CAG.

In these cases, we will discuss the role of emergency CAG in the pa- tients without ST-segment elevation on post-ROSC electrocardiography. Most adult out-of-hospital cardiac arrest (OHCA) patients have coronary artery disease [1], and even patients devoid of clinical features suggestive of acute coronary artery disease have a high prevalence of coronary artery lesions. In clinical practice, emergency physicians are often confronted with the difficult decision of whether emergency coronary angiography (CAG) should be performed in patients resusci- tated from sudden cardiac arrest. Such a decision is classically based on electrocardiographic data obtained after the return of spontaneous circulation (ROSC), although ECG affords poor diagnostic capability. Currently, emergency CAG is strongly recommended for patients with ST-segment elevation evident on post-ROSC ECG [2]. However, in OHCA patients who had no signs of ST-segment elevation myocardial infarction (MI), the role of emergency CAG remains unclear. We report 2 patients for whom post-ROSC ECG revealed diffuse ST-segment depression and discuss whether the patients presenting

without ST-segment elevation benefit from emergency CAG.

A 60-year-old man was brought to our emergency department (ED) by emergency medical service personnel. Approximately 20 minutes be- fore his arrival, a passerby found him lying unconscious on the street and performed chest compression. The emergency rescuers reported that his pulse was not palpable, and asystole was the first rhythm record- ed on scene. On arrival in the ED, he was comatose and lacked a femoral pulse. cardiac monitoring revealed asystole, and cardiopulmonary resus- citation (CPR) was began. Initial arterial blood gas analysis revealed pH of 7.011, PaCO2 of 70.0 mm Hg, HCO^- concentration of 17.9 mmol/L, and lac- tic acid concentration of 11.2 mmol/L. Five minutes later, ROSC was noted. His blood pressure was 120/80 mm Hg, and his pulse was 114 beats per minute. His post-ROSC ECG revealed a sinus rhythm, ST-segment eleva- tion in the Lead aVR, and ST-segment depression in the inferior leads (II,

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III, and aVF) as well as leads V4 through V6 (Fig. 1). Other general labora- tory test results were normal, and cardiac enzyme levels showed troponin I, 0.00 ng/mL (reference range, 0-0.05 ng/mL) and creatine kinase-MB,

0.40 ug/L (reference range, 0.5-5.0 ug/L). At this point, although cardiac enzyme levels were not elevated, triple vessel coronary artery disease or left main coronary artery occlusion was considered to be a likely cause of the cardiac arrest, and a cardiology consultation was scheduled. Emergency CAG revealed that the coronary vessels were normal, and, therefore, percutaneous coronary intervention (PCI) was not performed. He was admitted to the intensive care unit, and an ECG obtained 3 days later revealed only mild left-side ventricular diastolic dysfunction; the heart was otherwise normal. During his Intensive care unit stay, he remained comatose, and a diagnosis of brain death ensued.

A 58-year-old man presented to our ED after an OHCA. He had been of normal good health apart from diarrhea that had commenced 1 day prior. On the morning of admission, he was well until 30 minutes before admission, at which time his wife found him unconscious at home. Emergency medical service personnel arrived at the scene 7 minutes later and transported him to the ED while performing CPR. Defibrillation was not applied because his first recorded rhythm was asystole.

On arrival at the ED, he did not respond to voice or a sternal rub, and

no femoral pulse was palpable. Chest compression commenced imme- diately, and his first monitored rhythm was asystole. The initial arterial blood gas analysis revealed metabolic acidosis with pH of 6.963, PaCO2 of

29.9 mm Hg, HCO^- concentration of 6.8 mmol/L, and lactic acid concen-

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tration of 17.5 mmol/L. During the resuscitation, sodium bicarbonate was administered for severe acidosis and hyperkalemia (7.3 mmol/L). After 10 minutes of CPR, ROSC was achieved. His blood pressure was 60/40 mm Hg, and his pupils were unreactive to light. An initial ECG performed after ROSC revealed atrial fibrillation; ST-segment depression in leads 1, V4, and V5; and ST-segment elevation in leads aVR and V1 (Fig. 2). The serum troponin I and creatine kinase-MB levels were remarkable at 0.26 ng/mL and 18.45 ug/L, respectively. Based on the ECG findings and elevated cardiac enzyme levels, we suspected that acute MI was the likely cause of the cardiac arrest, and a cardiologist was consulted to plan a coronary artery intervention. As the patient was being prepared for emergency CAG, a computed tomography of the head was taken and revealed no abnormalities. Coronary angiography was performed 2 hours after ROSC, but no occlusions were evident in the 3 coronary arteries. On the echocardiogram, regional wall motion abnormalities involving the anterior wall and inferior septum were ob- served. However, these were not correlated with the vascular territories of the major 3 coronary arteries. On the second hospital day, the patient died of refractory hypotension and acidosis.

In both cases presented here, ECG revealed diffuse ST-segment de- pression with ST-segment elevation in lead aVR. Such ECG findings are

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118.e2 S.K. Han et al. / American Journal of Emergency Medicine 34 (2016) 118.e1-118.e3

Fig. 1. Electrocardiographic after ROSC of a 60-year-old man showing sinus rhythm with ST-segment elevation in lead aVR and ST-segment depression in the multiple leads (II, III, aVF, and V4 through V6).

generally suggestive of multivessel coronary artery disease and occlu- sions of the left main coronary artery and the proximal left anterior de- scending coronary artery [3-5]. As patients exhibiting such ECG findings experience higher mortality in a setting of MI, emergency CAG is

thought to be appropriate for evaluating the need for PCI. In our patients, CAG was performed within 2 hours after ROSC. However, no abnormal findings suggestive of acute coronary artery lesions were observed in either patient. Regrettably, the neurologic outcome of case

Fig. 2. Electrocardiographic after ROSC of a 58-year-old man. In lead aVR and V1, ST-segment elevation is observed. ST-segment depression is shown in lead I, V4, and V5.

S.K. Han et al. / American Journal of Emergency Medicine 34 (2016) 118.e1-118.e3 118.e3

1 was poor, and the final outcome of case 2 was terminal. Although emergency CAG appears to have been unhelpful to our patients, the current guidelines recommend emergency CAG to be performed for postcardiac arrest patients when coronary ischemia is a presumed or likely cause of such arrest. We assume that this recommendation is based on the following facts.

First, coronary artery disease is a major cause of sudden cardiac death. In 1 postmortem study, coronary thrombi were observed in 74% of patients who had died within 6 hours of the onset of cardiac symptoms [6]. Spaulding et al [7] analyzed 84 patients who underwent CAG after OHCA and reported that clinically significant coronary artery disease was evident in 60 (71%). In other studies, the prevalence of acute coronary artery lesions in postcardiac arrest patients was similarly high (63.9%-72.2%) [8-10]. Moreover, the prevalence of such lesions in patients lacking ST-segment elevation after ROSC was significant, ranging from 24% to 33% [10-12], although lower than the prevalence among patients exhibiting ST-segment elevation (85%-89%) [10,11]. Thus, the nonnegligible prevalence of coronary artery lesions in cardiac arrest patients even without ST-segment elevation on post-ROSC ECG may serve as the basis for recommendations of emergency CAG and PCI.

Second, positive effects of coronary artery intervention have been demonstrated in several studies. Dumas et al [9] reported that immediate coronary angioplasty improved hospital survival after cardiac arrest. In the cited work, patients who underwent successful PCI experienced a higher survival rate than did patients who did not undergo PCI or in whom the procedure failed (51% vs 31%, P b .001). Improvements in survival rates were observed in patients both with and without ST-segment elevation. Successful PCI was an independent predictor of a good outcome (odds ratio, 2.06; 95% confidence interval, 1.16-3.66) regardless of post-ROSC ECG findings. Strote et al [13] evaluated the relationship between early cardiac catheterization and survival rate in patients resuscitated from OHCA. Patients were divided into the group who underwent acute catheterization within 6 hours (the <= 6 hours group, n = 61) and the group in whom catheterization was deferred for greater than 6 hours or who did not undergo catheterization during hospitalization (the N 6 hours group, n = 179). Patients catheterized within 6 hours experienced higher survival rates (72% in the

<= 6 hours group vs 49% in the greater than 6 hours group, P = .001). The effect of routine CAG associated with potential PCI was evaluated by Cronier et al [14]. The cited authors studied 111 consecutive patients with OHCA caused by ventricular arrhythmia; routine CAG was performed on 91 Hemodynamically stable patients regardless of their ECG patterns. The survival rate was 54%, and this was markedly higher than that of patients who received neither emergency CAG nor a thera- peutic hypothermia procedure. It was suggested that routine CAG associated with potential PCI may improve the prognosis of OHCA patients with cardiac arrest caused by ventricular arrhythmia.

We wish to emphasize that post-ROSC ECG is less capable of diagnosing acute coronary lesions than is ECG performed on patients before any cardiac arrest. Ongoing ischemia during arrest and resuscita- tion, the use of intravenous drugs such as epinephrine, electrolyte abnormalities, and defibrillation may affect ECG data from OHCA survi- vors. Earlier studies also emphasized the poor negative predictive value of post-ROSC ECG in terms of the diagnosis of significant coronary artery lesions [9,11].

The current guidelines are supported not by data from randomized controlled studies but rather by those of several observational studies.

Therefore, such guidelines lack evidentiary weight. Furthermore, in patients for whom poor neurologic recoveries are expected after ROSC, the performance of routine emergency CAG is of debatable utility. Nevertheless, no study opposing emergency CAG has been reported.

Therefore, based on the aforementioned findings, we believe that it re- mains (perhaps temporarily) reasonable to perform emergency CAG in OHCA patients, irrespective of the post-ROSC ECG findings.

Sang Kyoon Han, MD Soon Chang Park, MD Sung Hwa Lee, MD Seok Ran Yeom, MD Sung Wook Park, MD?

Department of Emergency Medicine Pusan National University Hospital, Busan, Korea

?Corresponding author. Department of Emergency Medicine Pusan National University Hospital, 179 Gudeok-Ro, Seo-Gu Busan, 602-739, Republic of Korea. Tel.: +82 51 240 7503;

fax: +82 51 253 6472

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.05.027

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