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PCI After ROSC With ST Elevation

Question Type:
Intervention
Full Question:
Among adult patients with ROSC after cardiac arrest with evidence of ST elevation on ECG (P), does does emergency cardiac catheterization laboratory evaluation (I), compared with compared with cardiac catheterization later in the hospital stay or no catheterization  (C), change survival to hospital discharge with good neurological outcome, survival to hospital discharge, neurologically intact survival at 30 days, 30 day mortality (O)?
Consensus on Science:
For the critical outcome of hospital mortality in patients with ROSC after cardiac arrest with ST elevation on ECG, we have identified very-low-quality evidence (downgraded for serious risk of bias and inconsistency and upgraded for large treatment effect) from 15 observational studies(Bulut 2000, 155-161; Werling 2007, 40-45; Nielsen 2009, 926-934; Reynolds 2009, 179-186; Aurore 2011, 73-76; Cronier 2011, R122; Grasner 2011, 1649-1656; Mooney 2011, 206-214; Tomte 2011, 1186-1193; Bro-Jeppesen 2012, 291-301; Nanjayya 2012, 699-704; Strote 2012, 451-454; Zanuttini 2012, 1723-1728; Waldo 2013, 1253-1258; Hollenbeck 2014, 88-95) enrolling 3800 patients showing benefit of emergency cardiac catheterization versus cardiac catheterization later in the hospital stay or no catheterization (OR, 0.35; 95% CI, 0.31–0.41) (Figure 13). For the critical outcome of neurologically favorable survival in patients with ROSC after cardiac arrest with ST elevation on ECG, we have identified very-low-quality evidence (downgraded for serious risk of bias and inconsistency and upgraded for large treatment effect) from 9 observational studies,(Nielsen 2009, 926-934; Reynolds 2009, 179-186; Grasner 2011, 1649-1656; Mooney 2011, 206-214; Tomte 2011, 1186-1193; Bro-Jeppesen 2012, 291-301; Nanjayya 2012, 699-704; Strote 2012, 451-454; Hollenbeck 2014, 88-95) enrolling 2919 patients showing benefit of emergency cardiac catheterization versus cardiac catheterization later in the hospital stay or no catheterization (OR, 2.54; 95% CI, 2.17–2.99).
Treatment Recommendation:
We recommend emergency* cardiac catheterization laboratory evaluation in comparison with cardiac catheterization later in the hospital stay or no catheterization in select† adult patients with ROSC after OHCA of suspected cardiac origin with ST elevation on ECG (strong recommendation, low-quality evidence). *Time Frame for Treatment The time frame for emergency catheterization has been variably defined in the evidence reviewed. In general, patients were managed to minimize door-to-reperfusion times in a manner similar to the general STEMI patient population. The complexity and heterogeneity of this patient group may delay their resuscitation and management. †Patient Selection The evidence base was nonrandomized case-control studies that were subject to a high level of selection bias. The decision to undertake emergency cardiac catheterization was frequently made at the discretion of the treating physician, and the patient’s likelihood of survival is likely to have influenced the decision to undertake the intervention. A variety of factors were more likely to be associated with cardiac catheterization (Table 4): male gender, younger age, ventricular fibrillation as the presenting cardiac arrest rhythm; witnessed arrest; and bystander CPR, being supported with vasopressors or left ventricular assist devices. Those patient characteristics that were less likely to be associated with angiography were diabetes mellitus, renal failure, and heart failure. Values, Preferences, and Task Force Insights In making this recommendation, we placed a higher value on survival and good neurologic outcome over resource utilization. Although the evidence was low-quality because it involved observational studies of selected patients, the strength of the benefit was large and consistent in numerous studies. Given that the evidence derives from selected patients, this recommendation is not intended to apply to all post-ROSC patients with ST elevation; however, a systematic emergency evaluation and consideration of all of these patients is warranted. We recognize that the capacity to deliver emergency cardiac catheterization is not readily available in all healthcare settings. These recommendations are particularly relevant where primary PCI is available as part of the system of care. We suggest that emergency cardiac catheterization be incorporated in a standardized post–cardiac arrest protocol as part of an overall strategy to improve neurologically intact survival in this patient group. Targeted temperature management is now recommended in patients with ROSC after OHCA. The evidence reviewed demonstrated the feasibility of combining emergency cardiac catheterization and PCI with the early implantation of targeted temperature management.
CoSTR Attachments:
ACS ROSC with ST elevation AMSTAR_n.docx    
Forest plot of survival pcirosc.pdf    
gmtrosctable.pdf    
Neuro Forest plot ocirosc.pdf    
pcirosc evidencegenerationtable.pdf    
Should Primary PCI for STEMI gradetable.pdf    

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