Routine angiography in survivors of out of hospital cardiac arrest with return of spontaneous circulation: a single site registry
© Wijesekera et al.; licensee BioMed Central Ltd. 2014
Received: 14 July 2013
Accepted: 24 February 2014
Published: 3 March 2014
Coronary revascularization in resuscitated out of hospital cardiac arrest (OOHCA) patients has been associated with improved survival.
This was a retrospective review of patients with OOHCA between 01/07/2007 and 31/03/2009 surviving to hospital admission. Cardiac risk factors, demographics, treatment times, electrocardiogram (ECG), angiographic findings and in-hospital outcomes were recorded.
Of the 78 patients, 63 underwent coronary angiography. Traditional cardiac risk factors were common in this group. Chest pain occurred in 33.3% pre-arrest, 59.0% were initially treated at a peripheral hospital, 83.3% had documented ventricular tachycardia or ventricular fibrillation, 55.1% had specific ECG changes, 65.4% had acute myocardial infarction (AMI) as the cause of OOHCA and the majority had multi-vessel disease. ST elevation strongly predicted AMI. The in-hospital survival was 67.9% with neurological deficit in 13.2% of survivors. The group of patients who had an angiogram were more likely to have AMI as a cause of cardiac arrest (71.4% vs 40.0%, p = 0.01) and more likely to have survived to discharge (74.6% vs 40.0%, p < 0.01). Poor outcome was associated with older age, cardiogenic shock, longer transfer times, diabetes, renal impairment and a long duration to return of spontaneous circulation.
Acute myocardial infarction was the commonest cause of OOHCA and a high rate of survival to discharge was seen with a strategy of routine angiography and revascularization.
KeywordsCardiac arrest Myocardial infarction OOHCA Angiography Therapeutic hypothermia
Out of hospital cardiac arrest (OOHCA) is a leading cause of death in the developed world [1, 2]. Coronary artery disease is the cause in up to 90% of cases . Greater than 50% of deaths due to acute myocardial infarction (AMI) occur outside the hospital setting and early ventricular arrhythmias is the most common mechanism of death [4, 5], of which ventricular fibrillation is the commonest type. In Australia it is estimated that 15,000 people suffer a cardiac arrest every year, with an incidence estimated at between 9 and 89 per 100,000 person years . The one year survival is estimated at 11.5% . Incorporation of angiography and revascularization into the post resuscitation care of patients with OOHCA and return of spontaneous circulation (ROSC) has been shown in non-randomized case series to be associated with high rates of survival compared to historical controls .
The authors’ hospital was one of only two public hospitals that provided acute cardiac catheterization services to an area of approximately 562,000 km2 with a population of 1.6 million. In the case of acute ST elevation myocardial infarction (STEMI), due to the large distances involved in regional Queensland, there is no protocol for ambulances to bypass regional hospitals to transport the patient to a percutaneous coronary intervention (PCI) center. The patient is transported to the nearest Emergency Department (ED), where thrombolysis would be considered in the case of STEMI.
The aim of this study was to evaluate the factors associated with survival, in the setting of a strategy that favored routine angiography and revascularization, in patients surviving to hospital admission following OOHCA.
The study is compliant with the Declaration of Helsinki and was approved by the Human Research Ethics Committee at the The Prince Charles Hospital (approval number HREC/13/QPCH/303).
In the AMI subgroup, 56.9% (29/51 patients) did not have chest pain prior to the event. In those with a non-AMI cause of arrest, 12.5% (3/24 patients) reported chest pain immediately preceding the event where the cause of arrest was myocarditis, dilated cardiomyopathy and cause unknown in one.
Therapeutic hypothermia in intubated patients
Therapeutic hypothermia (cooling) was administered in 54/65 (83.1%) of intubated patients (status unknown in two patients transferred from elsewhere). In those admitted direct to TPCH 23/30 (76.7%) of intubated patients were cooled; in the seven patients that did not: three regained consciousness immediately after DC cardioversion, one was coagulopathic, one was assessed as already being “cool and shut down”, in one the cause of shock was unclear and in one patient the decision for comfort measures was made early on during resuscitation.
Access to coronary angiography
In this cohort, 63 patients (80.8%) had coronary angiography performed during the admission. There were 15 patients who did not have angiography. In five, this was because the cause was not thought to be AMI (primary ventricular arrhythmia in one, established dilated cardiomyopathy in four). One patient had a diagnosis of myocarditis based on history, however, died within two hours of arrival in hospital while being prepared for angiography. One patient was known to have severe coronary disease but had refused intervention. The remaining eight patients were assessed to have severe neurological deficit negating any benefit of revascularization (in six of these patients a clinical diagnosis of AMI was made and none of them survived, and in the two other patients the cause of arrest was not identified).
Direct transfers to TPCH
Total out of hospital cardiac arrests
Males (mean age 61.5 yrs, range 18–84, SD ± 14.9)
Female (mean age 63.4 yrs, range 34–91, SD ± 16.9)
Total number of patients with AMI
Transfers from peripheral hospitals
Direct presentations to TPCH
All coronary angiograms during the same period
- Mean age (in years)
- Mean age (in years)
All STEMI patientsa
- Mean age (years)
- Mean age (years)
Mean body mass index (BMI) kg/m2 (Range 18.8–55.6, SD ± 5.5)
Aboriginal or Torres Strait Island origin
Any history of smoking
Known history of ischaemic heart disease
History of previous myocardial infarction
Documentation of illicit drug use at time of cardiac arrest
History of cardiomyopathy
Family history of ischaemic heart disease
Renal failure (GFR <60 ml/min)
Events immediately following cardiac arrest
Chest pain prior to event
Treatment (at the scene): CPR
Median time (in min) to ROSC (n = 67), IQR 10.0–27.5
Patients with initial treatment at a peripheral hospital
Thrombolysis in ambulance (of the 30 STEMI patients)
Initial rhythm by ambulance
Pulseless electrical activity
Ambulance ECG after ROSC
Ventricular tachycardia (unavailable and undocumented in 18 patients)
GCS 3 on arrival of paramedics at the scene
Brought to hospital intubated or GCS 3
Characteristics in the emergency department
Congestive heart failure
Abnormal left ventricular (LV) functionc
Requirement for inotropes
Intubation at any time during the first 24 hours
Insertion of balloon pump
First ECG in hospital
Pulseless electrical activity
Specific ECG changes (ST elevation or depression)
Any ST segment changes (including non-specific)
QRS duration >120 ms
Myocardial territories identified on ECGe
Initial treatment in ami patient subgroup
Heparin or Enoxaparin
Glycoprotein IIb IIIA receptor blocker
Thrombolysis (by ambulance or hospital)
As a proportion of all AMI patients
For patients with ST elevation on ECG
Timing of coronary angiogram
Emergent angiogram in entire group
Emergent angiogram in TPCH presentations
Emergent angiogram in peripheral hospital presentations
AMI patient group
Of the 51 AMI patients, six did not have coronary angiography for the following reasons: five had severe neurological injury and one had known severe coronary disease and declined intervention. All direct transfers to TPCH with STEMI received primary PCI. A total of 34 patients had coronary intervention attempted: 29 patients (85.3%) had bare metal stents placed, four patients (11.8%) had drug eluting stents placed, one patient (2.9%) had a failed procedure, and in one case (2.9%) the type of stent was unknown. One patient who underwent emergency PCI developed pericardial tamponade and died despite being taken for emergency cardiac surgery. This patient had not received thrombolysis but had received dual antiplatelet therapy, heparin and GPIIbIIIa inhibitor therapy. There were no other major bleeding episodes recorded in the other patients, and no other major complications were noted that were attributed to cardiac catheterization.
Initial ECG in AMI patients who underwent coronary angiography
Initial ECG post arrest and angiographic findings
Ecg changes in those who had angiogram
AMI patients (45 patients)
ST elevation (STE)
CVO in patients with STE on ECG
ST depression (STD)
CVO in patients with STD on ECG
Non-specific ECG changes
CVO in patients with non-specific ECG changes
CVO in patients with a normal ECG
Non AMI patients (18 patients)
Non-specific ECG changes
Angiogram findings in ami patients (45 patients)
Number of vessels diseaseda
3 V + LMCA
Culprit vessel (Acute lesions)
Culprit vessel occlusion
In STEMI subgroup
In NSTEMI subgroup
Recommended treatment based on angiogram
Patients undergoing immediate PCI to culprit vesselb
Cause of arrest and in-hospital outcomes
Cause of arrest and in-hospital outcomes
All patients 78 patients
Group A 63 patients
Group B 15 patients
Cause of OOHCA
Acute myocardial infarction
Survived to discharge
Neurological deficit (in survivors)
AICD recommended (in survivors)
AMI patients who had angiogram
AMI patients who did not have angiogram
Comparing those who survived to discharge (good outcome) versus those who died during admission (poor outcome), older age (on average, those with a good outcome were eight years younger), diabetes, renal impairment, lower GCS by paramedics, longer transfer time to first hospital, longer transfer time to TPCH, longer duration to ROSC, presence of congestive heart failure and requirement for inotropes were all associated with a poor outcome. Initial treatment at a peripheral center was associated with good outcome, presumably because those with a poor prognosis were not transferred. A shockable rhythm on ECG was associated with a good prognosis. Coronary angiography and aspirin use was associated with a good prognosis which is at least partially attributable to the selection process.
Cathed (Group A) 63 patients
Non-cathed (Group B) 15 patients
Good outcome (Group C) 53 patients
Poor outcome (Group D) 25 patients
Males, no. (%)
Diabetes, no. (%) *
Hypertension, no. (%) 
Hyperlipidaemia, no. (%) 
History of IHD, no. (%) 
Serum creatinine μmol/L, median(IQR)
GFR ml/min, median(IQR)
History of smoking, no. (%) 
Peri cardiac arrest factors
Time, min to first hospital, median(IQR) 
Time, hrs to TPCH, median(IQR)
History of chest pain, no. (%) 
Time to ROSC in min, median(IQR) 
Treated at a peripheral hospital, no. (%)
Initial rhythm VF/VT, no. (%)
ST elevation, no. (%)
QTc in milliseconds, mean(±SD) 
Assessments and tests
GCS by paramedics, mean(±SD) 
CCF in ED, no. (%)
First measured LVEF, mean(±SD) 
Initial serum K mmol/L, mean(±SD)
Initial serum Mg mmol/l, mean(±SD) 
Peak CK in IU/L, median(IQR) 
Peak Troponin I in μmol/L, median(IQR) 
Use of inotropes, no. (%)
Heparin/Enoxaparin, no. (%) 
Aspirin, no. (%) 
Clopidogrel, no. (%) 
Balloon pump, no. (%)
ICU stay in days, median(IQR)
Coronary angiogram at any time, no. (%)
Initially presenting to TPCH
Emergent coronary angiogram, no. (%)
Coronary angiogram at any time, no. (%)
OOHCA caused by AMI, no. (%)
Survived to discharge, no. (%)
Neurological deficit, no. (%)
Neurological deficit in survivors, no. (%)
Multivariate logistic regression
Variables known to be associated with poor outcomes together with those variables from the univariate analysis with p <0.1 were included. The final model was limited to a maximum of five variables due to the limited number of events (32). Age was centered on its median value in the sample (64 years). Glasgow coma score (GCS) in the ED was the most important predictor of a good outcome in that no patient who arrived in the ED with a GCS of >8 died. Exact logistic regression was used to assess the association of GCS with good outcome. The median unbiased estimate of the effect of ED GCS >8 compared to the intubated patient on good outcome was an odds ratio of 13.6 with a very large 95% confidence interval (2-∞). There was no difference in outcome between the intubated group and those that had a GCS ≤8 in the ED.
When ED GCS was included in a standard logistic regression model, the fact that there were no events in the GCS >8 group rendered the model uninformative. Variables other than GCS were included in a standard logistic regression model. In summary, lower age, the absence of cardiogenic shock, a transfer from another hospital and not being cooled were associated with the outcome (survival without neurological injury). Not being cooled was confounded on the better ED GCS. Once again, it is likely that the transferred patients represented a better prognostic group.
Standard multivariate logistic regression diagnostics was performed. The Hosmer Lemeshow goodness of fit test was not significant (p = 0.46) and the area under the receiver operating characteristic curve was 0.81 even when the ED GCS was not included Please see accompanying Additional file 2 for tabular data.
Ischaemic heart disease is the most common substrate in OOHCA and therefore the demographics reflect a high incidence of cardiac risk factors as has been reported elsewhere [6, 12, 13]. This study cohort represents those with a better prognosis partly due to selection of those who survived to hospital admission. Our immediate success rates for PCI was 97.1% compared to 76% reported by Spaulding . When we identified a culprit lesion, this was located proximal or mid vessel, which has been shown to be a strong predictor of cardiac arrest  – possibly related to a larger area of ischaemic myocardium. Anyfantakis, in a study of routine emergency coronary angiography in unselected survivors of OOHCA, found that 37.5% had angiographic or clinical evidence of AMI as a cause for the cardiac arrest . They found ST elevation on the admission ECG to be a strong independent correlate of AMI and suggested this as a method of triaging patients for emergent cardiac catheterization, which our findings support.
Despite a high incidence of AMI in this study, chest pain was documented in only 33%, although, anoxic brain injury may cause amnesia to pre-arrest symptoms. Spaulding et al found that ST elevation and chest pain to be poorly predictive of acute coronary occlusion  in the OOHCA setting, hence, the absence of these should not preclude coronary angiography. Our finding of 12.5% of patients with ST depression and 14.3% of patients with non-specific ECG changes having culprit vessel occlusion (Table 2) supports this. ST segment elevation on initial ECG is highly predictive of an ischaemic etiology, and the International Liaison Committee on Resuscitation recommends such patients undergo immediate coronary angiography .
The Parisian Regional Out of hospital Cardiac Arrest Trial, enrolled 435 patients who had no obvious extracardiac cause for OOHCA and all underwent immediate coronary angiography and PCI if indicated . At least one significant coronary artery lesion was found in almost all patients with STEMI on ECG (128/134; 96%) and in a significant proportion of patients without STEMI (176/301; 58%). PCI was successful in 99/128 STEMI patients, and in 78/176 patients without STEMI. Hospital survival was 40%. Multivariate analysis confirmed that a successful PCI was an independent predictor of survival irrespective of the initial post-resuscitation ECG (odds ratio 2.06; 95% CI 1.16–3.66). Spaulding  also found successful PCI to be an independent predictor of survival. Bendz  showed that PCI in a select group of patients with STEMI following resuscitated OOHCA had a good outcome with both an in-hospital and two year survival of 72.5%. Others have shown a survival benefit in those undergoing coronary angiography versus those who did not - 67% vs 18% in some studies .
A meta-analysis by Larsen et al found a high prevalence of significant coronary disease in patients after resuscitated OOHCA, and they recommend consideration of emergent coronary angiography in the absence of a non-cardiac cause for arrest . Zanuttini  found that in a group of resuscitated OOHCA patients, there was a high incidence of coronary disease and ST elevation on ECG predicted culprit coronary lesions. They also found that emergency angiography and successful PCI was independently related to in-hospital mortality and survival after OOHCA. Similar to our findings, these investigators also found that the absence of ST elevation should not prevent a patient having coronary angiography. Sunde  has shown that incorporation of a standardized post-cardiac arrest protocol which included PCI (where clinically indicated) was associated with improved hospital discharge rates, neurological outcome and one year survival compared to historical controls.
The 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations  as well as the European Resuscitation Council guidelines , recommend that coronary angiography be considered in the post cardiac arrest patient. In our experience this strategy of routine angiography in selected patients was associated with a high rate of survival to discharge (67.9%) and survival without significant neurological impairment (86.8% of survivors). In the direct admissions to TPCH, even those having non-emergent angiography, the median door to needle time of 2.7 days is in keeping with our policy of performing the angiogram early on in the admission.
We found coma to be a common feature in patients following resuscitated OOHCA and this should not delay revascularization. Neurological prognostication is difficult early in the course of OOHCA. The decision not to perform emergent coronary angiography was based on clinical evaluation that included factors such as greater than 60 min to ROSC, advanced age, poor pre-morbid functional status, history of severe cognitive impairment, asystole as the presenting rhythm and presence of an obvious non-ischaemic cause for arrest. With our strategy of routine angiography in these patients, we did not find therapeutic hypothermia to be an obstacle, and the overall procedural complication rate was low.
The small sample size and retrospective nature of the study causes selection bias. The pre-hospital setting was poorly documented (especially in those transferred from elsewhere). It was difficult to accurately ascertain how many OOHCA were witnessed and, in some cases, time to ROSC. The incorporation of patients transferred from other centers introduced selection bias as only those with good prognosis are expected to have been transferred. It follows therefore, that those transferred from peripheral centers should not be denied coronary angiography (if clinically indicated). Using the published incidence of OOHCA in Australia , the patients treated at this institution (as a percentage of the estimated total in the population serviced by TPCH), ranged from as low as 11% to as high as 100%. The lower estimate would suggest that a significant number are not being transferred, presumably related to poor prognosis or death, however, such wide-ranging estimates are difficult to interpret.
Most survivors of OOHCA have multi vessel coronary disease and AMI is the leading cause of arrest. Absence of symptoms or ST elevation on ECG should not delay or prevent coronary angiography. In our experience, in patients surviving to hospital admission following OOHCA, a strategy of routine coronary angiography and revascularization is safe and associated with a high rate of survival to discharge.
Vishva A. Wijesekera, FRACP
Daniel V. Mullany, MMedSc, FANZCA, FCICM
Catherina A. Tjahjadi, MBBS
Darren L. Walters FRACP, FCSANZ, FSCAI, MPhil, Grad Cert Mang
DW is the director of the cardiac catheter laboratory, the executive chair of the Heart Lung Institute and the executive director of the Prince Charles Hospital. DM is an intensive care specialist at The Prince Charles Hospital. VW and CT are cardiology trainees at this institution.
Out of hospital cardiac arrest
Ccute myocardial infarction
The Prince Charles Hospital
ST segment elevation myocardial infarction
Return of spontaneous circulation
Intensive care unit
Percutaneous coronary intervention
Culprit vessel occlusion
Glasgow coma scale
Glomerular filtration rate (in ml/min)
Body mass index
Left anterior descending coronary artery
Right coronary artery
Left circumflex coronary artery
Left main coronary artery
Coronary artery bypass graft
We would like to thank Michael Savage, senior cardiac scientist at the cardiac catheter laboratory, as well as Lyn Munck and Rachel Bushell of the Critical Care Research Group at The Prince Charles Hospital who assisted in data collection.
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