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PCI After ROSC Without ST Elevation

Question Type:
Intervention
Full Question:
Among adult patients with ROSC after cardiac arrest without 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 (O)?
Consensus on Science:
For the critical outcome of hospital mortality in patients with ROSC after cardiac arrest without ST elevation on ECG, we have identified very-low-quality evidence (downgraded for risk of bias) from 2 observational studies(Bro-Jeppesen 2012, 291-301; Hollenbeck 2014, 88-95) enrolling 513 patients showing benefit from emergency cardiac catheterization laboratory evaluation compared with catheterization laboratory evaluation later in the hospital stay or no catheterization (OR, 0.51; 95% CI, 0.35–0.73) (Figure 14). For the critical outcome of neurologically favorable survival (CPC 1 or 2) in patients with ROSC after cardiac arrest without ST elevation on ECG, we have identified very-low-quality evidence (downgraded for risk of bias) from 2 observational studies(Bro-Jeppesen 2012, 291-301; Hollenbeck 2014, 88-95) enrolling 513 patients showing benefit from emergency cardiac catheterization laboratory evaluation compared with catheterization laboratory evaluation later in the hospital stay or no catheterization (OR, 1.96; 95% CI, 1.35–2.85).
Treatment Recommendation:
We suggest emergency* cardiac catheterization laboratory evaluation in comparison with cardiac catheterization later in the hospital stay or no catheterization in select† adult patients who are comatose after ROSC after OHCA of suspected cardiac origin without ST elevation on ECG (weak recommendation, very-low-quality evidence). *Time Frame for Treatment In the evidence reviewed, the time frame was variably defined, but 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. Unlike the review pertaining to ST elevation, all of the studies without ST elevation enrolled comatose patients exclusively. The decision to undertake emergency catheterization was frequently made at the discretion of the treating physician. A variety of factors such as patient age, duration of CPR, hemodynamic instability, presenting cardiac rhythm, neurologic status upon hospital arrival, and perceived likelihood of cardiac etiology influenced the decision to undertake the intervention. Values, Preferences, and Task Force Insights In making this recommendation, we are emphasizing similar values to those outlined above for STEMI. There is a smaller body of evidence for emergency intervention in patients without ST elevation after OHCA with ROSC in comparison to those with ST elevation: The population studied was smaller, the magnitude of the effect was slightly smaller, and the proportion of patients that went on to have PCI was smaller. Therefore, we believed that a weak recommendation was appropriate. We understand that this recommendation represents a departure from most existing guidelines for the treatment of the general population of non–ST elevation ACS patients without OHCA. Catheterization laboratory evaluation included coronary angiography and early revascularization of acute coronary occlusions or significant stenosis as indicated.
CoSTR Attachments:
885-Bias Table.pdf    
885-Data Collection Table.pdf    
885-Evidence Profile Table.pdf    
885-Forest Plot Table.pdf    

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