Predicting the Presence of an Acute Coronary Lesion Among Patients Resuscitated From Cardiac Arrest

Abstract

Background-A mechanism to stratify patients resuscitated from a cardiac arrest according to the likelihood of an acute coronary lesion would have significant utility. We thus sought to develop and validate a risk prediction model for the presence of an acute coronary lesion among patients resuscitated from an arrest. Methods and Results-All subjects undergoing coronary angiography after resuscitation from a cardiac arrest were identified in an ongoing institutional registry from 2009 to 2014. Backwards stepwise selection of candidate covariates was used to create a logistic regression model for the presence of an angiographic culprit lesion and internally validated with bootstrapping. A clinical point score was generated and its prognostic abilities compared with contemporary measures. Among 247 subjects undergoing coronary angiography after resuscitation from a cardiac arrest, 130 (52%) had an acute lesion in a coronary artery. A multivariable model-including angina, congestive heart failure symptoms, shockable arrest rhythm (ventricular fibrillation/ventricular tachycardia), and ST-elevations-had excellent discrimination (optimism corrected C-Statistic, 0.88) and calibration (Hosmer-Lemeshow P=0.540) for an acute coronary lesion. Compared with electrocardiographic findings alone, a point score based on this model more accurately predicted the presence of an acute lesion among patients resuscitated from a cardiac arrest (integrated discrimination improvement, 0.10; 95% confidence interval, 0.04-0.19; P<0.001). Conclusions-Patients with a cardiac arrest can be risk stratified for the presence of an acute coronary lesion using 4 easily measured variables. This simple risk score may be used to improve patient selection for emergent coronary angiography among resuscitated patients. (Circ Cardiovasc Interv. 2015;8:e002198.

SCAI cardiogenic shock classification after out of hospital cardiac arrest and association with outcome

“…A culprit lesion was classified as an atherothrombotic occlusion with presence of thrombus and/or easy passage of the coronary guidewire and any lesion over 70% in a single angiographic plane that the clinician treated as a culprit or with evidence of less than TIMI III flow. These definitions are in accordance with previously published articles in this area 10,11 . MCS devices were implanted at clinicians' discretion.…”

Contemporary Management of Out-of-hospital Cardiac Arrest in the Cardiac Catheterisation Laboratory: Current Status and Future Directions

“…In patients with STEMI, the area under the curve (AUC) was 0.88, but the discriminant ability of the ACS2 score was significantly lower in patients without ST elevation (AUC = 0.74). [76] Objective prediction of futility on arrival to the cardiac catheterisation laboratory is another important consideration but currently remains a significant challenge. Risk algorithms and biomarkers hold significant potential in this regard, but these have currently failed to translate to the clinical realm, partly because they have had limited application and validation on arrival, when emergency treatment decisions are made.…”

How Much Is Enough

“…[15][16][17][18] Vyas et al report on 4029 postcardiac arrest patients from the Cardiac Arrest Registry to Enhance Survival (CARES) database between January 2010 and December 2013. 15 CARES is a large national prospective emergency medical systems-based registry involving over 800 emergency medical service agencies in 21 states with a catchment area of over 80 million people.…”

“…17 The heterogeneity of cardiac arrest patients makes it difficult to predict the presence of coronary artery disease and its implication in cardiac arrest. The recognition that coronary artery disease is often the precursor to cardiac arrest has led to its inclusion in the guidelines for emergent angiography and revascularization.…”

“…Attempts to identify which postarrest patients would specifically benefit from an early coronary angiography, including the schematic reported here by Waldo et al, still require validation in separate populations from which the risk stratification system was developed. 17 Forty percent of the population from whom the Waldo schematic is developed had in-hospital cardiac arrest, where the pathogenesis of cardiac arrest is less likely to be acute coronary ischemia. Furthermore, the reliability of obtaining a history of angina or heart failure from a comatose postarrest patient arriving by ambulance without family members may be difficult.…”