1. INVASIVE STRATEGIES FOR PATIENTS WITH RESUSCITATED SUDDEN CARDIAC ARREST Marko Noc, MD, PhD, FESC University Medical Center Ljubljana-Slovenia

2. NO CONFLICT OF INTEREST TO DECLARE

3. SUDDEN CARDIAC ARREST IS A MAJOR HEALTH PROBLEM CPR on the field Reestablishment of Spontaneous circulation ROSC (40-50%) Ristagno G, et al. Brain microcirculation in pigs. Resuscitation 2008;77:229-34. Urgent transport to hospital Incidence of EMS treated sudden out-of-hospital cardiac arrest is 36-81/100.000 Cugh SS. JACC 2004;44:1268-75 Cobb SS. JAMA 2002;288:3009-13

4. SUDDEN CARDIAC ARREST-WHY AN ISSUE FOR INTERVENTIONAL CARDIOLOGIST? Urgent CAG (84) Normal 17 (20%) Nonobstructive CAD 7 (8%) Obstructive CAD60 (71%) Single vessel22 Multivessel37 Isolated LM1 Coronary occlusion 40 (48%) Spaulding CM. N Engl J Med 1997;336:1629-33. Sudden cardiac arrest is usually a coronary event

5. OUR STRATEGY- IMMEDIATELY DEFINE A CORONARY SUBSTRATE Urgent coronary angiography regardless of ECG and level of consciousness after ROSC unless: Nonishemic etiology of cardiac arrest is obvious Severe pre-arrest comorbidities Comatose survivor with no realstic hope for neurological recovery

6. SCIENTIFIC SUPPORT FOR URGENT INVASIVE STARTEGY ? Spaulding CM. N Engl J Med 1997;336:1629-33 Anyfantakis ZA. Am Heart J 2009;157:312-8. Reynolds JC. J Intensive Care Med 2009;March 25, doi;1177 Author n Multivariante predictor of survival Spaulding85 Successful PCI (OR 5.2; p=0.004) Anafantakis72 Not PCI attempt Reynolds241 CAG/PCI strategy (OR 2.16; p=0.02) Nielsen 986 CAG/PCI strategy (OR 1.56; p=0.008) Dumas 714 Successful PCI (OR 2.06; p=0.013) No randomized trials Multivariante analysis of registries Nielsen N, et al. Acta Anaesthesiol Scand 2009;53:926-934 Dumas. Circ Cardiovasc Interv 2010;3:200-7

7. Consecutive patients with resuscitated cardiac arrest of pressumed cardiac origin (2003-2008) n=462 STEMI 242 (52%) No STEMI 220 (48%) Urgent CAG 224 (93%)Urgent CAG 84 (38%) Excluded (18) -1 Nonischemic cause -14 CNS recovery not likely - 2 Decision of attending - 1 Death before cath lab Excluded (136) -65 Nonischemic cause -12 prearrest comorbidities -26 CNS recovery unlikely -26 Decision of an attending -7 Death before cath lab ROSC to CAG: 128+/-67 min Radsel P, et al. Submitted 2011

8. URGENT CORONARY ANGIOGRAPHY IN PATIENTS WITH RESUSCITATED SUDDEN CARDIAC ARREST STEMI No STEMI p (n=224)(n=84) Normal angiogram1% 33%<.001 Nonobstuctive disease1%1%0.679 >1 obstructive stenosis97%66%<.001 >1 Stable 8%40%<.001 > 1 Pressumed acute 89% 26%<.001 Unprotected LM7%13%0.115 Multivessel CAD51%57%0.395 >1 Occlusion80%44%<.001 >1 CTO 20%34%0.011 > 1 Pressumed acute 69%13%<.001 Radsel P, et al. Submitted 2011

9. ABSENCE OF “STEMI” IN POSTRESUSCITION ECG DOES NOT EXCLUDE PRESENCE OF ACUTE OCLUSION Positive Negative Chest discomfort and ST-elevation 87% 61% Spaulding CM. N Engl J Med 1997;336:1629-33. Predictive value

10. ANGIOGRAPHIC CHARACTERISTICS OF PRESUMED ACUTE CULPRIT LESION STEMI No STEMIp (n=204)(n=23) Proximal location46%48%0.824 Mean stenosis, % 98+698+30.839 Thrombus score 2.7+2.11.2+1.80.004 TIMI 0-1 77%48%<0.001 Rentrop (0-3)0.25+0.600.37+0.900.464 Radsel P, et al. Submitted 2011

11. Urgent coronary angigraphy Presumed acute culprit lesion PCI of culprit Additional non- culprit PCI only if patient unstable* Stable obstructive CAD with normal flow Comatose after ROSC None or PCI of obvious lesion** Nonobstructive CAD/no CAD Search for aletrnative cause of cardiac arrest * If ischemia/hemodynamic instability after successful IRA PCI and IABP **If considered responsible for cardiac arrest (?) or beneficial for hemodyanmic stability OUR REVASCULARIZATION STRATEGY Conscious after ROSC Urgent PCI/CABG

12. URGENT PCI STEMINo STEMIp (n=224)(n=84) PCI/Urgent CAG94% 38%<0.001 PCI-acute lesion94%69%<0.001 Stenting85%78%0.329 TIMI 383%84%0.896 IABP22%17%0.497 Radsel P, et al. Submitted 2011

13. IF THE “CHAIN OF SURVIVAL” WORKED, THE PATIENT WOKE UP IMMEDIATELY AFTER ROSC (28%) Survival STEMI 97% No STEMI 100% Take home message: “Conscious” survivor of cardiac arrest – treat him as a “very high” risk ACS

14. IF PATIENT REMAINED COMATOSE DESPITE ROSC (72%), POSTRESUSCITATION BRAIN INJURY WILL OCCUR -Severity of postresuscitation brain injury can not be securely predicted on hospital admission SurvivalCPC 1-2 STEMI 65%44% No STEMI 69%47%

15. IMMEDIATE EMS CONTACT VERSUS SELF- PRESENTATION IN ACS In case of prehospital sudden cardiac arrest......emergency medical team is present and “converts” comatose into conscious survivor of sudden cardiac arrest

16. MILD INDUCED HYPOTHERMIA (32-34 C) IS „EVIDENCE BASED“ TREATMENT OF POSTRESUSCITATION BRAIN INJURY N Engl J Med 2002; 346:557-63 346:549-56. Independent randomized clinical trials Number needed to treat 7 !!!

17. Knafelj R, et al. Resuscitation 2007; 74;227-34. WE COMBINED PPCI AND MILD INDUCED HYPOTHERMIA IN COMATOSE SURVIVORS OF CARDIAC ARREST WITH STEMI 40 patients undergoing PPCI+MIH (2003-2005) were compared 40 patients undergoing PPCI+MIH (2003-2005) were compared to 32 historical controls undergoing only PPCI and no MIH (2000-2003) to 32 historical controls undergoing only PPCI and no MIH (2000-2003) Combination of PPCI+MIH was feasable and safe without increase in Combination of PPCI+MIH was feasable and safe without increase in arrhythmias, hemodynamic instability, oxygen reqirements for mechanical ventilation, renaly dysfunction…. Addition of MIH to PPCI significantly improved survival with good Addition of MIH to PPCI significantly improved survival with good neurological recovery compared to historical controls neurological recovery compared to historical controls

18. MIH (40)No MIH (32)p Post PCI TIMI 2/3,%9088.41 >70% ST resolution,%6859.64 Stent thrombosis2.501.0 Sustained VT,%1319.69 Repeat VF,%2019.87 P- AF,%1816.92 DC/cardioversion,%3034.89 Antiarrhytmics,%3353.13 Need for IAPB,%2022.92 Vasopressors,%6553.44 Inotropes,%4859.44 Knafelj R, et al. Resuscitation 2007;74:227-34. ADDITION OF “MIH” IN COMATOSE SURVIVORS OF CARDIAC ARREST DOES NOT COMPROMISE RESULTS OF PCI Knafelj R, et al. Resuscitation 2007; 74;227-34.

19. PPCI AND “MIH” IN COMATOSE SURVIVORS OF CARDIAC ARREST WITH STEMI- FEASALBLE AND SAFE AuthorPPCI llb///a Stent Open IRA IABP Knafelj 36 18 32 36 8 Hovdenes 36 NA NA NA 23 Koutouzis 1 NA 1 1 0 Wolfrum 16 15 16 16 5 Schefold 25 16 16 NA NA Together114 64% 93% 93% 34% Noc M. Interventional Cardiology 2008; (Volume 9, Number 4);123-5.

20. CATH LAB FOR COMATOSE SURVIVORS OF CARDIAC ARREST ?

21. GET A CICU INTENSIVIST TO THE CATH LAB ! -Control of respiration, hemodynamics, rhythm, hypothermia, IABP… -ACLS due to reccurent cardiac arrest -Portable echo to identify cause of hemodynamic instability if present

22. COMPETENT CARDIAC INTENSIVE CARE UNIT- ESSENTIAL FOR SURVIVAL OF COMATOSE PATIENTS AFTER RESUSCITATED CARDIAC ARREST

23. Start effective hypotermia already on the field Urgent transport to „24-7“ PCI center without unneccesary stops Urgent CAG+PCI during ongoing hypothermia 1.2. 3.4. Hypotermia and intensive care support “FAST TRACK” FOR COMATOSE SURVIVORS OF OUT-OF-HOSPITAL CARDIAC ARREST

24. Tadel KS, et al. Acute Cardiac Care, 2010 1995-7 (78)2006-8 (149) p Urgent CAG/PCI 0% 70% <.001 Hypotermia 0% 90% <.001 p<.0001 24% 15% 62% 40% CONSECUTIVE COMATOSE SURVIVORS OF OUT-OF-HOSPITAL CARDIAC ARREST ADMITTED TO LJUBLJANA UNIVESITY MEDICAL CENTER

25. NSTE-ACS with high risk features Resuscitated sudden cardiac arrest COMPLEMENT „STEMI NETWORK“ TO BECOME “ACUTE CARDIAC NETWORK” STEMI + +