Coronary Angiography and Neurologically Intact Survival in Out-of-Hospital Cardiac Arrest Patients with Return of Spontaneous Circulation

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Date
2015-10-03
Authors
Hanuschak, Tasha
Keyword
Neurologic Outcome , STEMI , ST-elevation , Cardiac Arrest , Survival , Out-of-Hospital Cardiac Arrest , Revascularization , Coronary Angiography
Abstract
Introduction: Acute Coronary Syndrome (ACS) is prevalent in out-of-hospital cardiac arrest (OHCA) patients but only a minority receives coronary angiography. Also, evidence for the effectiveness of coronary angiography in this population is conflicting. Objectives: 1) To describe the patient and hospital-level factors that are associated with receiving coronary angiography 2) To determine if receiving coronary angiography is associated with survival to hospital discharge with favourable neurologic outcome. Methods: This was a population-based retrospective cohort study of 2578 consecutive cases of adult OHCA transported to and treated at 28 hospitals in Southern Ontario between March 1st, 2010 and December 31st, 2014. We included patients with atraumatic OHCA, who achieved return of spontaneous circulation (ROSC), and survived to at least six hours after hospital arrival. Multilevel logistic regression was used to explore the association between exposure variables and outcome variables, while accounting for clustering of patients (level 1) within hospitals (level 2) and adjusting for potential confounders. Results: Coronary angiography use varied from 13% to 70% across the hospital sites. Overall, 33%(n=863/2578) of patients received coronary angiography, 42%(n=1082/2578) survived to hospital discharge and 38%(n=960/2552) survived to hospital discharge with favourable neurologic outcome. Multilevel analysis revealed that factors positively associated with receiving coronary angiography included patient age, STEMI status, being conscious at hospital arrival, having a shockable initial cardiac rhythm, an EMS witnessed arrest, initiation of therapeutic hypothermia, receiving bystander defibrillation, and being admitted directly to a PCI centre. Receiving coronary angiography was associated with neurologically intact survival (OR=2.03, CI95 1.47-2.80, p<.0001) and survival to hospital discharge (OR=1.86, CI95 1.36-2.55, p<.0001). Similar associations were observed in the subgroup of patients without ST-elevation myocardial infarction (STEMI) (OR=2.90, CI95 1.90-4.43 and OR=2.44, CI95 1.62-3.69, respectively). Conclusions: There is significant variability in receipt of coronary angiography after cardiac arrest. We identified several patient and hospital-level factors that contribute to this variability. Neurologically intact survival amongst post cardiac arrest patients may be improved with coronary angiography, particularly for patients without STEMI. Future work should determine which post arrest patients will benefit most from urgent angiography, and our findings should be confirmed with randomized controlled trials.
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