Elsevier

Resuscitation

Volume 150, May 2020, Pages 121-129
Resuscitation

Clinical paper
Short- and long-term outcomes of out-of-hospital cardiac arrest following ST-elevation myocardial infarction managed with percutaneous coronary intervention

https://doi.org/10.1016/j.resuscitation.2020.03.003Get rights and content

Abstract

Aim

Out-of-hospital cardiac arrest (OHCA) is frequently associated with ST-elevation myocardial infarction (STEMI) and has a high mortality. We aimed to identify differences in characteristics and very long-term outcomes for STEMI patients with and without OHCA managed with percutaneous coronary intervention (PCI).

Methods

We analysed data from 12,637 PCI patient procedures for STEMI in the multi-centre Melbourne Interventional Group registry between January 2005 and December 2018. Multivariable models examined associations with OHCA presentation and 30-day mortality. Long-term outcomes were assessed through linkage with the Australian National Death Index.

Results

Compared with patients without OHCA (N = 11,580), patients with OHCA (N = 1057) were younger, more often male, had less cardiovascular risk factors, and more often presented with cardiogenic shock. OHCA preceded an increasing proportion of STEMI PCI cases from 2005 to 2018 (2.4% vs. 9.2%). Factors independently associated with OHCA presentation were younger age, male gender, prior valve surgery, multi-vessel disease, LAD culprit, small vessel diameter, and renal impairment on presentation. Patients with OHCA had lower procedural success, higher rates of bleeding and stroke, larger infarct size (measured by peak CK), and higher 30-day mortality (37% vs. 5%; all p < 0.05). Cardiogenic shock, renal impairment and lower ejection fraction were independently associated with 30-day mortality. Long-term mortality was 44% vs. 20% (median follow-up 4.6 years), with Cox regression analysis demonstrating no difference in survival if patients survived beyond 30 days (HR 1.18, 95% CI 0.95–1.47).

Conclusions

OHCA has a high short-term mortality and precedes an increasing proportion of STEMI PCI cases. Thirty-day survivors have an excellent long-term prognosis.

Introduction

Out-of-hospital cardiac arrest (OHCA) is a leading cause of global mortality.1, 2, 3 Advances in pre-hospital and in-hospital systems of care over several decades have led to improvements in survival.4 Nonetheless, recent estimates of overall survival from event to hospital admission and hospital discharge are approximately 30% and 10%, respectively.4, 5 Ischaemic heart disease is responsible for the vast majority of OHCA,4 with ST-elevation myocardial infarction (STEMI) representing around 70% of these cases.6

The major determinants of outcomes among OHCA patients relate to neurological injury, myocardial dysfunction, systemic ischemia / reperfusion response, and the underlying cause of OHCA; together termed the post-cardiac arrest syndrome.7 In the case of STEMI, immediate coronary angiography and percutaneous coronary intervention (PCI) targets both the underlying cause of OHCA and myocardial dysfunction. A number of observational studies have identified early revascularisation in this cohort improves outcomes.3, 8, 9, 10 In this setting, current guidelines provide a Class I recommendation for immediate coronary angiography and PCI for these patients.11, 12 Recent PCI STEMI cohorts report that the incidence of OHCA is between 7–12%.8, 13, 14 However, data for these patients remain limited with no PCI outcome data beyond 10-years available in the literature. Further studies are required on outcome determinants that can be targeted to improve care.

The present study aims to analyse differences in clinical and procedural characteristics between patients with and without OHCA among a large cohort of PCI procedures for STEMI including assessment of factors associated with OHCA presentation. Further, we aim to identify determinants of short- and long-term outcomes to discern potential treatment targets that might improve survival in this high-risk group.

Section snippets

Study design

We performed a registry-based study of all consecutive PCI procedures for STEMI included in the Melbourne Interventional Group (MIG) registry between 1st January 2005 and 31st December 2018. The cohort was divided into patients presenting with STEMI with and without OHCA to assess differences in patient and procedural characteristics, identify predictors of survival, and assess short-, medium- and long-term outcomes.

Data sources and setting

The MIG registry is a voluntary PCI registry that prospectively collects data

Study population

A total of 12,637 patient procedures for ST-elevation myocardial infarction were included: 1057 (8.4%) cases with OHCA, 11,580 cases without OHCA. The methods for derivation of the cohort are presented in Supplemental Figure  I.

Baseline characteristics

Among patients who underwent PCI for STEMI (Table 1), patients with OHCA were younger (mean age 61.2 ± 12.5 years vs. 63.6 ± 12.7 years), more often male (85% vs. 78%), with lower rates of hypertension, dyslipidaemia, diabetes mellitus, and previously diagnosed coronary

Discussion

This registry-based study presents a detailed analysis of outcomes for patients presenting with OHCA among a large cohort of PCI procedures for STEMI. The five major findings of the study are: (1) cardiogenic shock rates and requirements for inotropic or mechanical support are markedly higher in patients presenting with OHCA; (2) short-term mortality is high, especially with longer transit times; (3) factors associated with OHCA presentation largely seem to relate to ischemic territory size;

Conclusions

In this large registry-based study, we have demonstrated an increasing frequency of OHCA among our STEMI PCI cohort with high short-term mortality, but excellent long-term outcomes among patients surviving to 30-days out to a maximum of 14 years. Factors that increase ischemic burden were associated with OHCA presentation among patients presenting with STEMI in our cohort, and the presence of cardiogenic shock had the biggest impact on early mortality. In this setting, strategies to reduce time

Conflicts of interests

Professor Duffy’s work is supported by a National Health and Medical Research Council of Australia (NHMRC) grant. Professor Reid is supported by a NHMRC Principal Research Fellowship (reference no. 1136372). A/Prof Stub is supported by a NHF Future Leader Fellowship (reference no. 101908), and a Viertel Foundation Clinical Investigator award.

The Melbourne Interventional Group acknowledges funding from Abbott Vascular, Astra-Zeneca, BMS and Pfizer. These companies do not have access to data and

Acknowledgments

MIG Data Management Centre, CCRE, Monash University:

Professor Chris Reid, Dr Nick Andrianopoulos, Ms Angela Brennan, Dr. Diem Dinh, Ms Harriet Carruthers.

MIG Steering Committee:

Professor Chris Reid, Associate Professor Andrew Ajani, Professor Stephen Duffy,

Associate Professor David Clark, Dr Melanie Freeman, Dr Chin Hiew,

Associate Prof Ernesto Oqueli, Dr Nick Andrianopoulos, Dr Diem Dinh, Ms Angela Brennan.

The following investigators, data managers and institutions participated in the MIG

References (27)

  • E. Andrew et al.

    Long-term survival following out-of-hospital cardiac arrest

    Heart

    (2017)
  • D. Stub et al.

    Post cardiac arrest syndrome: a review of therapeutic strategies

    Circulation

    (2011)
  • M.C. Kontos et al.

    Cardiac arrest and clinical characteristics, treatments and outcomes among patients hospitalized with ST-elevation myocardial infarction in contemporary practice: a report from the national cardiovascular data registry

    Am Heart J

    (2015)
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