1) Out-of-hospital cardiac arrest remains a major cause of death, though improvements in pre-hospital care have increased ROSC rates to 50%. 2) Significant coronary artery disease is present in 70% of cases. Coronary angiography finds acute culprit lesions in up to 90% of STEMI patients and 58% of non-STEMI patients. 3) Observational studies show the feasibility and safety of immediate invasive coronary strategies after cardiac arrest, with overall survival rates of 76% and neurological recovery in 52% of "comatose" survivors. However, randomized trials are still needed to confirm benefits.

1. The interventional management of out
hospital cardiac arrest (OHCA)
Ahmed Elborae, MSc
Associate specialist of cardiology, Aswan Heart Centre
Assistant lecturer of cardiology, Cairo University

2. Will you proceed with coronary
angiography?
• 50 year old patient, cardiac arrest ROSC
after 15 minutes, ECG STEMI but
unconscious
• 45 year old patient, cardiac arrest ROSC
after 18 minutes, Normal ECG, No obvious
cause

3. Introduction
• OHCA remains the leading cause of death in
developed countries
• OHCA admissions increased due to significant
improvements in pre hospital management
“Chain of survival”  ROSC in 50%
• Significant coronary artery disease is present
in 70% of cases

4. Not Pink

6. Clinical characteristics
• Up to 40% of initially resuscitated patients
may experience recurrent cardiac arrest
• Cardiogenic shock is present in 40%
• Different mechanisms (vasoplegia and LV
dysfunction due to myocardial stunning and
ischemia if ACS is present

7. The PCR-EAPCI Textbook – Percutaneous interventional cardiovascular medicine
The interventional management of out-of-hospital cardiac arrest
Marko Noc, Peter Radsel, Emmanouil Poulidakis, Christian Spaulding
20% 80%

8. Comatose survivors
• Unfortunately, delay in one or more components
of the pre hospital “Chain of survival” is the reality
• Time delay translated clinically with > 80% of
patients remain comatose despite ROSC
• Neurological recovery in “comatose” survivors
cannot be predicted on hospital admission when
decision for invasive strategy is to be made
• Early hospital death (<3 days) in this subgroup is
usually of cardiac origin

9. The PCR-EAPCI Textbook – Percutaneous interventional cardiovascular medicine
The interventional management of out-of-hospital cardiac arrest
Marko Noc, Peter Radsel, Emmanouil Poulidakis, Christian Spaulding
• Un witnessed arrest
• Asystole
• BLS delay > 10 minutes
• ROSC > 20 minutes
Selection of patient for invasive strategy

10. The PCR-EAPCI Textbook – Percutaneous interventional cardiovascular medicine
The interventional management of out-of-hospital cardiac arrest
Marko Noc, Peter Radsel, Emmanouil Poulidakis, Christian Spaulding
Rationale of early invasive strategy

11. Coronary angiography data
• In the presence of STEMI in post ECG, acute
culprit lesion found in up to 90%
• In absence of STEMI in the post ECG, acute
culprit lesion which may still be apparent in up
to 58%

12. Scientific evidence of invasive strategy
• No randomized trials evaluated the benefits of
immediate invasive coronary strategy
• Patients with preceding cardiac arrest have
been excluded from most of randomized trials
that demonstrated the survival benefit of
primary PCI in STEMI

13. • Many observational trials demonstrated the
feasibility and safety in both “conscious” and
“comatose” survivors cumulatively (161.908
patients)
• Among them only 43% presented with STEMI
• PCI was successful in 85%, Overall hospital
survival 76% and neurological recovery in 52%

14. Ongoing trials
• Despite this evidence, it is important to emphasize that
due to heterogeneity of patients and potential bias in
selecting less sick patients for an invasive coronary
strategy, these findings should be interpreted with
caution
• Six ongoing randomized control trials in patients with
resuscitated OHCA including PEARL, TOMAHAWK,
ARREST, EMERGE, DISCO and COUPE will hopefully
provide a more definitive answer regarding appropriate
patient selection and benefits of immediate invasive
coronary strategy

15. Anti platelets and anticoagulants
• I.V Aspirin and UFH is generally advised after
the assessment of coronary anatomy+ P2Y12i
crushed tablets via a NGT
• Early post-resuscitation state significantly
affect clopidogrel absorption and metabolism
“prodrug” with delayed onset of action up to
48 hours
• Ticagrelor “active drug” does not require
metabolic activation with only 2 hours gap

16. PCI strategy
• Femoral access may have an advantage in
hemodynamically compromised patients with
weak/absent radial pulsations who may
require concomitant implantation of assist
device
• DES is preferred as it associated with less stent
thrombosis

17. • Recently, the CULPRIT SHOCK trial (enrolled
>50% OHCA or in-hospital) demonstrated that
culprit only PCI was safer than complete
revascularization
• Because of uncertain neurological recovery at
the time of PCI, increased risk of stent
thrombosis ( 32%) and increased risk of
bleeding the immediate revascularization
strategy should be more conservative

18. Hemodynamic support
• The RCT SHOCK IABP trial enrolled (40% OHCA
with cardiogenic shock) did not demonstrate
more benefit with IABP
• So routine implantation of IABP cannot be
recommended and should be individualized
• This is true also for Impella™, Tandem Heart™
and ECMO

19. The Last Resort

20. Refractory cardiac arrest
• Only case reports or small case series of
successful PCI performed during ongoing
chest compression
• This strategy may be used in selected patients

21. E-CPR
• In highly selected cases of refractory cardiac
arrest immediate implantation of ECMO/
Impella + CAG/PCI strategy represent the last
resort
• ECMO allows organ perfusion and maintains
viability and represents a bridge until the
recovery of cardiac function

22. 20%
Survival with good neurological outcome

23. Take home message
• Out-of-hospital cardiac arrest (OHCA) remains the
leading cause of death
• The absence of STEMI does not exclude acute
lesions ( up to 58% of cases)
• Interventional cardiologists are an important
part of the post resuscitation team
• Selection for immediate CAG/PCI is individualized
to obtain maximal benefit and avoid futility
• Hemodynamic support devices may be the last
resort in refractory cardiac arrest