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The Role of Cardiac Catheterization after Cardiac Arrest

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      Coronary angiography after cardiac arrest is important to ascertain potential treatable causes of cardiac arrest, salvage myocardium, and potentially increase long-term survival. The cause of adult out-of-hospital cardiac arrest is typically myocardial ischemia. More than 50% of such resuscitated individuals will have an acutely occluded epicardial coronary on emergency coronary angiography. This includes three in four with ST-segment elevation and one in three without ST-segment elevation. In the latter the only reliable method of detection is coronary angiography. Numerous cohort studies, now including more than 8000 patients, have shown an association between survival and early coronary angiography and/or percutaneous coronary intervention. Public reporting of percutaneous coronary intervention 30-day mortality rates has been an impediment for extending this therapy to all resuscitated individuals who experienced out-of-hospital cardiac arrest, since current databases to do fully risk-adjust rates for this subgroup. Sincere efforts are under way to correct this situation.

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      Most cited references 55

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      Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association.

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        Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.

        Cardiac arrest outside the hospital is common and has a poor outcome. Studies in laboratory animals suggest that hypothermia induced shortly after the restoration of spontaneous circulation may improve neurologic outcome, but there have been no conclusive studies in humans. In a randomized, controlled trial, we compared the effects of moderate hypothermia and normothermia in patients who remained unconscious after resuscitation from out-of-hospital cardiac arrest. The study subjects were 77 patients who were randomly assigned to treatment with hypothermia (with the core body temperature reduced to 33 degrees C within 2 hours after the return of spontaneous circulation and maintained at that temperature for 12 hours) or normothermia. The primary outcome measure was survival to hospital discharge with sufficiently good neurologic function to be discharged to home or to a rehabilitation facility. The demographic characteristics of the patients were similar in the hypothermia and normothermia groups. Twenty-one of the 43 patients treated with hypothermia (49 percent) survived and had a good outcome--that is, they were discharged home or to a rehabilitation facility--as compared with 9 of the 34 treated with normothermia (26 percent, P=0.046). After adjustment for base-line differences in age and time from collapse to the return of spontaneous circulation, the odds ratio for a good outcome with hypothermia as compared with normothermia was 5.25 (95 percent confidence interval, 1.47 to 18.76; P=0.011). Hypothermia was associated with a lower cardiac index, higher systemic vascular resistance, and hyperglycemia. There was no difference in the frequency of adverse events. Our preliminary observations suggest that treatment with moderate hypothermia appears to improve outcomes in patients with coma after resuscitation from out-of-hospital cardiac arrest.
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          Targeted temperature management at 33°C versus 36°C after cardiac arrest.

          Unconscious survivors of out-of-hospital cardiac arrest have a high risk of death or poor neurologic function. Therapeutic hypothermia is recommended by international guidelines, but the supporting evidence is limited, and the target temperature associated with the best outcome is unknown. Our objective was to compare two target temperatures, both intended to prevent fever. In an international trial, we randomly assigned 950 unconscious adults after out-of-hospital cardiac arrest of presumed cardiac cause to targeted temperature management at either 33°C or 36°C. The primary outcome was all-cause mortality through the end of the trial. Secondary outcomes included a composite of poor neurologic function or death at 180 days, as evaluated with the Cerebral Performance Category (CPC) scale and the modified Rankin scale. In total, 939 patients were included in the primary analysis. At the end of the trial, 50% of the patients in the 33°C group (235 of 473 patients) had died, as compared with 48% of the patients in the 36°C group (225 of 466 patients) (hazard ratio with a temperature of 33°C, 1.06; 95% confidence interval [CI], 0.89 to 1.28; P=0.51). At the 180-day follow-up, 54% of the patients in the 33°C group had died or had poor neurologic function according to the CPC, as compared with 52% of patients in the 36°C group (risk ratio, 1.02; 95% CI, 0.88 to 1.16; P=0.78). In the analysis using the modified Rankin scale, the comparable rate was 52% in both groups (risk ratio, 1.01; 95% CI, 0.89 to 1.14; P=0.87). The results of analyses adjusted for known prognostic factors were similar. In unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C. (Funded by the Swedish Heart-Lung Foundation and others; TTM number, NCT01020916.).

            Author and article information

            1The University of Arizona Sarver Heart Center, 1501 N. Campbell Avenue, Tucson, AZ 85724, USA
            Author notes
            Correspondence: Karl B. Kern, MD, FACC, FSCAI, FAHA, Professor of Medicine, The Gordon A. Ewy, M.D. Distinguished Endowed Chair of Cardiovascular Medicine, Sarver Heart Center, The University of Arizona, 1501 N. Campbell Avenue, Tucson, AZ 85724, USA, Tel.: +1-520-6262477, Fax: +1-520-6260200, E-mail: kernk@
            Cardiovascular Innovations and Applications
            Compuscript (Ireland )
            July 2018
            August 2018
            : 3
            : 2
            : 137-148
            cvia20170026 10.15212/CVIA.2017.0026
            Copyright © 2018 Cardiovascular Innovations and Applications

            This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 Unported License (CC BY-NC 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See



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