British Cardiovascular Interventional Society Consensus Position Statement on Out-of-Hospital Cardiac Arrest 1: Pathway of Care

Abstract

Out-of-hospital cardiac arrest (OHCA) affects 80,000 patients per year in the UK; despite improvements in care, survival to discharge remains lower than 10%. NHS England and several societies recommend all resuscitated OHCA patients be directly transferred to a cardiac arrest centre (CAC). However, evidence is limited that all patients benefit from transfer to a CAC, and there are significant organisational, logistic and financial implications associated with such change in policies. Furthermore, there is significant variability in interventional cardiovascular practices for OHCA. Accordingly, the British Cardiovascular Interventional Society established a multidisciplinary group to address variability in practice and provide recommendations for the development of cardiac networks. In this position statement, we recommend: the formal establishment of dedicated CACs; a pathway of conveyance to CACs; and interventional practice to standardise our approach. Further research is needed to understand the role of CACs and which interventions benefit patients with OHCA to support wide-scale changes in networks of care across the UK.

Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation

“…18,19 In this regard, dedicated cardiac arrest centers including multidisciplinary teams of interventional cardiologists, as well as emergency medicine and critical care specialists, might be best suited to find individualized clinical pathways. 20 Second, in the overall population of patients with OHCA without ST-segment elevation, the number of patients with a coronary culprit lesion is relatively low (40% in the TOMAHAWK trial). It is only for these patients that a potential benefit of immediate coronary revascularization can be expected.…”

“…Integrating models to correlate with neurologic outcome into trial designs could help to find subgroups of patients for whom early angiography might be beneficial . In this regard, dedicated cardiac arrest centers including multidisciplinary teams of interventional cardiologists, as well as emergency medicine and critical care specialists, might be best suited to find individualized clinical pathways . Second, in the overall population of patients with OHCA without ST-segment elevation, the number of patients with a coronary culprit lesion is relatively low (40% in the TOMAHAWK trial).…”

British Cardiovascular Interventional Society Consensus: a Huge Step Towards Standardised Care for Out-of-hospital Cardiac Arrest in the UK

“…Out-of-hospital cardiac arrest (OHCA) affects approximately 80,000 patients per year in the UK, with survival to hospital discharge below 10%. [ 1 ] A call to action towards a more uniform treatment strategy is much needed, and this has been addressed by the British Cardiovascular Interventional Society (BCIS) Multidisciplinary Expert Group. [ 1 ] Importantly, that document clearly defines requirements for cardiac arrest centres (CACs), as well as protocols for the initial assessment and cardiovascular management of the OHCA population, which is, as recognised by the authors, very heterogeneous in terms of post-resuscitation ECG, haemodynamic status and initial neurological presentation ( Figure 1 ).…”

“…Because ‘conscious’ OHCA survivors have no post-resuscitation brain injury and should be treated within existing acute coronary syndrome networks, the consensus document appropriately focuses on the great majority of OHCA patients with suboptimal prehospital ‘chain of survival’ and longer delays to the return of spontaneous circulation (ROSC). [ 1 , 2 ] Because of a prolonged ‘no-/low-flow’ period, post-resuscitation brain injury occurs often and most patients remain comatose despite ROSC. The brain therefore becomes an additional, and even more important, target organ because a lack of neurological recovery is one of the most catastrophic events for patients, and represents a predominant cause of hospital death.…”

“…[ 5 ] In contrast, in haemodynamically stable comatose patients without STEMI, on the basis of four randomised trials, CAG/PCI can be safely deferred and performed selectively if patients develop STEMI, recurrent cardiac arrest and/or haemodynamic instability during hospital treatment. [ 1 ] In the absence of such events, CAG/PCI may be delayed until the patient regains consciousness. Such a selective or delayed strategy reduces the need for CAG by almost 50% without any harm to the patients.…”