In OHCA patients, acute coronary occlusion was associated with higher risk of cardiovascular-related death

Among patients with non-ST elevation out-of-hospital cardiac arrest (OHCA), 1 in 5 were found to have acute coronary occlusion – shown to be a significant predictor of cardiovascular mortality – with no significant difference in the occurrence of acute coronary occlusion between hemodynamically stable and unstable patients, according to a new single-center study.

Alessandro Spirito, MD, of Bern University Hospital, Switzerland, and the Icahn School of Medicine, New York, and colleagues reported these findings in a manuscript published Monday online and in the Feb. 7 issue of the Journal of the American College of Cardiology.

OHCA may occur due to ischemic or non-ischemic causes. Current guidelines suggest that hemodynamically stable patients may undergo delayed angiography while unstable patients should have immediate angiography similar to those presenting with ST-Elevation myocardial infarction (MI). Randomized control trials (RCTs) have not shown a mortality benefit to early angiography in non-ST elevation OHCA. However, the rate of coronary occlusion was much lower in prior RCTs compared to other studies, and the effectiveness of using hemodynamic status to determine the need for early angiography is unknown.

Spirito and colleagues included all patients with OHCA without ST elevation between 2011 and 2019 at Bern University Hospital, of whom 169 were stable hemodynamically and 217 were unstable. The patients’ mean age was 62 years in the stable OHCA group and 67 years in unstable OHCA group (p<0.001), while diabetes and chronic kidneys disease were more prevalent in the unstable OHCA group.

Acute coronary occlusions were found in 19.5% of stable and 24.0% of unstable OHCA patients (P = 0.407). The presence of coronary occlusions was predicted by initial chest pain and shockable rhythm, but not by hemodynamic status. Acute coronary occlusion was associated with an increased risk of cardiovascular death (adjusted hazard ratio [HR]: 2.74; 95% confidence interval [CI]: 1.22-6.15) but not of all-cause death (adjusted HR: 0.72; 95% CI: 0.44-1.18).

Karl B. Kern of the University of Arizona provided the editorial comment. He summarized the history of studies in this area and emphasized that the prevalence of coronary occlusion in OHCA patients without ST-elevation is not trivial — 22.3% in a cohort that almost all has early angiography. With this in mind, he stated, “a subgroup of 20% should not be denied a therapy known to be effective at improving quality of life (better left ventricular function) and long-term outcomes when enough patients are included in such studies.”

“We know that time is muscle and that acutely occluded coronary arteries need to be reperfused in a timely fashion in everyone, including those not lucky enough to have ST-segment elevation on their electrocardiogram after resuscitation from out-of-hospital cardiac arrest,” Kern concluded.

Sources:

Spirito A, Vaisnora L, Papadis A, et al. Acute Coronary Occlusion in Patients With Non-ST-Segment Elevation Out-of-Hospital Cardiac Arrest. J Am Coll Cardiol. 2023;81:446–456.

Kern KB. Timely Reperfusion for Everyone. Except for Some Out-of-Hospital Cardiac Arrest Patients? J Am Coll Cardiol. 2023;81:457–459.

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