1. Dallas 2015 TFQO: Darren Walters #422 EVREVs: EVREV 1: Darren Walters COI #422 EVREV 2: Chris Ghaemmaghami COI #89 Taskforce: Acute Coronary Syndrome PCI after ROSC with ST- elevation ACS 340

2. Dallas 2015 COI Disclosure Chris Ghaemmaghami COI #89 Commercial/industry none Potential intellectual conflicts none Darren Walters COI #317 Commercial/industry none Potential intellectual conflicts Editor IJC, HLC Meta analysis author, Resuscitation 2014: 85:1533–1540

3. Dallas 2015 2010 CoSTR In Out of Hospital Cardiac Arrest patients with ST elevation myocardial infarction or new LBBB on ECG following return of spontaneous circulation, early angiography and Primary Percutaneous Coronary Interevntion should be considered.

4. Dallas 2015 C2015 PICO Population:Among adult patients who are experiencing ROSC after cardiac arrest with evidence of ST-elevation on ECG Intervention:emergent cath lab evaluation Comparison: cardiac catheterization later in the hospital stay or no catheterization Outcomes:Outcome Importance :survival to hospital discharge with good neurological outcome 9-Critical survival to hospital discharge 9-Critical

5. Dallas 2015 Inclusion/Exclusion & Articles Found PubMed Search StringsDate PubMed Search Completed("Angioplasty"[MeSH] OR "Angioplasty, Balloon"[MeSH] OR angioplasty[TIAB] OR PTCA[TIAB] OR “Balloon Dilatation” [TIAB] OR "Cardiac Catheterization"[MeSH] OR “heart catheterization”[TIAB] OR PCI[TIAB] OR PPCI[TIAB] OR "Percutaneous Coronary Intervention"[MeSH] OR “percutaneous coronary intervention”[TIAB] OR “percutaneous transluminal coronary angioplasty”[TIAB] OR catheterisation[TIAB] OR catheterization[TIAB] OR "coronary angiography"[MeSH] OR angiography[TIAB] OR "Atherectomy"[MeSH]) AND ("heart arrest"[MeSH] OR "cardiac arrest"[TIAB] OR "cardiac arrests"[TIAB] OR "cardiovascular arrest"[TIAB] OR "cardiovascular arrests"[TIAB] OR "heart arrest"[TIAB] OR "heart arrests"[TIAB] OR "asystole"[TIAB] OR "pulseless electrical activity"[TIAB] OR "cardiopulmonary arrest"[TIAB] OR "cardiopulmonary arrests"[TIAB] OR "cardio-pulmonary arrest"[TIAB] OR "cardio-pulmonary arrests"[TIAB] OR "cardiopulmonary resuscitation"[MeSH] OR "cardiopulmonary resuscitation"[TIAB] OR "cardiopulmonary resuscitations"[TIAB] OR "Heart Massage"[MeSH] OR "Advanced Cardiac Life Support"[TIAB] OR "return of spontaneous circulation"[TIAB] OR ROSC[TIAB] OR “spontaneous circulation”[TIAB] OR ("Blood Circulation"[MeSH] AND "Recovery of Function"[MeSH])) NOT (animal[MeSH] NOT humans[MeSH]) NOT ((adolescent[MeSH] OR child[MeSH] or infant[MeSH] OR child*[TIAB] OR infant*[TIAB] OR adolescent*[TIAB] OR "Pediatrics"[MeSH] OR pediatric*[TIAB] OR paediatric*[TIAB]) NOT adult[Mesh]) NOT ("letter"[Publication Type] OR "comment"[Publication Type] OR "editorial"[Publication Type] or Case Reports[Publication Type]) Embase Search StringsDate Embase Search Completed('angioplasty'/exp OR angioplasty:ti,ab OR PTCA:ti,ab OR “Balloon Dilatation”:ti,ab OR 'heart catheterization'/exp OR "cardiac catheterization":ti,ab OR “heart catheterization”:ti,ab OR PCI:ti,ab OR PPCI:ti,ab OR 'percutaneous coronary intervention'/exp OR “percutaneous coronary intervention”:ti,ab OR “percutaneous transluminal coronary angioplasty”:ti,ab OR catheterisation:ti,ab OR catheterization:ti,ab OR 'angiocardiography'/exp OR angiography:ti,ab OR 'atherectomy'/exp OR atherectomy:ti,ab) AND ('heart arrest'/exp OR “Out of Hospital Cardiac Arrest”:ti,ab OR “Out-of-Hospital Cardiac Arrest”:ti,ab OR “Out of Hospital Cardiac Arrests”:ti,ab OR “Out-of-Hospital Cardiac Arrests”:ti,ab OR (("out-of-hospital":ti,ab OR “out of hospital”:ti,ab OR “outside of hospital”:ti,ab) AND cardiac:ti,ab AND arrest*:ti,ab) OR "cardiac arrest":ti,ab OR "cardiac arrests":ti,ab OR "cardiovascular arrest":ti,ab OR "cardiovascular arrests":ti,ab OR "heart arrest":ti,ab OR "heart arrests":ti,ab OR "asystole":ti,ab OR "pulseless electrical activity":ti,ab OR "cardiopulmonary arrest":ti,ab OR "cardiopulmonary arrests":ti,ab OR "cardio+pulmonary arrest":ti,ab OR "cardio+pulmonary arrests":ti,ab OR 'resuscitation'/exp OR "cardiopulmonary resuscitation":ti,ab OR CPR:ti,ab OR 'heart massage'/exp OR "Advanced Cardiac Life Support":ti,ab OR "ACLS":ti,ab OR 'return of spontaneous circulation'/exp OR "return of spontaneous circulation":ti,ab OR ROSC:ti,ab OR “spontaneous circulation”:ti,ab OR “post resuscitation”:ti,ab OR “post-resuscitation”:ti,ab OR “post cardiac arrest”:ti,ab OR “post-cardiac arrest”:ti,ab) NOT (('adolescent'/exp OR 'child'/exp OR 'infant'/exp OR child*:ab,ti OR infant*:ab,ti OR adolescent*:ab,ti OR 'pediatrics'/exp OR pediatric*:ab,ti OR paediatric*:ab,ti) NOT 'adult'/exp) NOT ('animal'/exp NOT 'human'/exp) NOT ([editorial]/lim OR [letter]/lim OR 'case report'/de) AND [embase]/lim Cochrane Search StringsDate Cochrane Search Completed([mh "Angioplasty"] OR [mh "Angioplasty, Balloon"] OR angioplasty:ti,ab OR PTCA:ti,ab OR “Balloon Dilatation” :ti,ab OR [mh "Cardiac Catheterization"] OR “heart catheterization”:ti,ab OR PCI:ti,ab OR PPCI:ti,ab OR [mh "Percutaneous Coronary Intervention"] OR “percutaneous coronary intervention”:ti,ab OR “percutaneous transluminal coronary angioplasty”:ti,ab OR catheterisation:ti,ab OR catheterization:ti,ab OR [mh "coronary angiography"] OR angiography:ti,ab OR [mh "Atherectomy"]) AND ([mh "heart arrest"] OR “Out of Hospital Cardiac Arrest” :ti,ab OR “Out-of-Hospital Cardiac Arrest” :ti,ab OR “Out of Hospital Cardiac Arrests”:ti,ab OR “Out-of- Hospital Cardiac Arrests”:ti,ab OR (("out-of-hospital":ti,ab OR “out of hospital”:ti,ab OR “outside of hospital”:ti,ab) AND cardiac:ti,ab AND arrest*:ti,ab) OR "cardiac arrest":ti,ab OR "cardiac arrests":ti,ab OR "cardiovascular arrest":ti,ab OR "cardiovascular arrests":ti,ab OR "heart arrest":ti,ab OR "heart arrests":ti,ab OR "asystole":ti,ab OR "pulseless electrical activity":ti,ab OR "cardiopulmonary arrest":ti,ab OR "cardiopulmonary arrests":ti,ab OR "cardio-pulmonary arrest":ti,ab OR "cardio-pulmonary arrests":ti,ab OR [mh "cardiopulmonary resuscitation"] OR "cardiopulmonary resuscitation":ti,ab OR CPR:ti,ab OR [mh "Heart Massage"] OR "Advanced Cardiac Life Support":ti,ab OR "ACLS":ti,ab OR "return of spontaneous circulation":ti,ab OR ROSC:ti,ab OR “spontaneous circulation”:ti,ab OR “post resuscitation”:ti,ab OR “post-resuscitation”:ti,ab OR “post cardiac arrest”:ti,ab OR “post-cardiac arrest”:ti,ab OR ([mh "Blood Circulation"] AND [mh "Recovery of Function"])) NOT (([mh adolescent] OR [mh child] or [mh infant] OR child*:ab,ti OR infant*:ab,ti OR adolescent*:ab,ti OR [mh "Pediatrics"] OR pediatric*:ab,ti OR paediatric*:ab,ti) NOT [mh adult])

6. Dallas 2015 Inclusion/Exclusion & Articles Found Inclusions/Exclusions Included studies with outcomes delineated for patients without ST elevation 4529 articles initially identified 15 Articles included Profile tables RCTs – 0 Meta analysis 2 (Camuglia 2014 1533, Larsen 2012 1427) non-RCTs – 15 outcomes death non-RCTs – 9 outcomes neurologic Excluded - 4514

7. Dallas 2015 Inclusion/Exclusion & Articles Found List Inclusions/Exclusions Criteria Inclusion:("Angioplasty"[MeSH] OR "Angioplasty, Balloon"[MeSH] OR angioplasty[TIAB] OR PTCA[TIAB] OR “Balloon Dilatation” [TIAB] OR "Cardiac Catheterization"[MeSH] OR “heart catheterization”[TIAB] OR PCI[TIAB] OR PPCI[TIAB] OR "Percutaneous Coronary Intervention"[MeSH] OR “percutaneous coronary intervention”[TIAB] OR “percutaneous transluminal coronary angioplasty”[TIAB] OR catheterisation[TIAB] OR catheterization[TIAB] OR "coronary angiography"[MeSH] OR angiography[TIAB] OR "Atherectomy"[MeSH]) AND ("heart arrest"[MeSH] OR "cardiac arrest"[TIAB] OR "cardiac arrests"[TIAB] OR "cardiovascular arrest"[TIAB] OR "cardiovascular arrests"[TIAB] OR "heart arrest"[TIAB] OR "heart arrests"[TIAB] OR "asystole"[TIAB] OR "pulseless electrical activity"[TIAB] OR "cardiopulmonary arrest"[TIAB] OR "cardiopulmonary arrests"[TIAB] OR "cardio-pulmonary arrest"[TIAB] OR "cardio-pulmonary arrests"[TIAB] OR "cardiopulmonary resuscitation"[MeSH] OR "cardiopulmonary resuscitation"[TIAB] OR "cardiopulmonary resuscitations"[TIAB] OR "Heart Massage"[MeSH] OR "Advanced Cardiac Life Support"[TIAB] OR "return of spontaneous circulation"[TIAB] OR ROSC[TIAB] OR “spontaneous circulation”[TIAB] OR ("Blood Circulation"[MeSH] AND "Recovery of Function"[MeSH])) Exclusion: (animal[MeSH] NOT humans[MeSH]) NOT ((adolescent[MeSH] OR child[MeSH] or infant[MeSH] OR child*[TIAB] OR infant*[TIAB] OR adolescent*[TIAB] OR "Pediatrics"[MeSH] OR pediatric*[TIAB] OR paediatric*[TIAB]) NOT adult[Mesh]) NOT ("letter"[Publication Type] OR "comment"[Publication Type] OR "editorial"[Publication Type] or Case Reports[Publication Type]) 2361 articles filtering 1317,105 full articles,50relevant papers, 27reporting survival data for STEMI PCI ROSC RCTs, nil non-RCTs 27 Meta analysis 2 (Camuglia 2014 1533, Larsen 2012 1427) Included 15 studies reporting survival data Included 9 studies reporting neurological outcome.

8. Dallas 2015 2015 Proposed Treatment Recommendations We suggest emergent cardiac catheterization lab evaluation in comparison to cardiac catheterization later in the hospital stay or no catheterization may be considered in selected adult patients who are comatose and are experiencing ROSC after OHCA of suspected cardiac origin with evidence of ST-elevation on ECG (weak recommendation, low quality of evidence).

9. Dallas 2015 Risk of Bias in studies Non-RCT bias asssesment StudyYearDesignTotal PatientsPopulationIndustry Funding Eligibility Criteria Exposure/Outcome Confounding Follow up Aurore2011non RCCT452OHCA ROSCnohigh unclearlow Bro-Jeppesen2012non RCCT360OHCA ROSCnohigh unclearlow Bulut1999non RCCT37OHCA ROSCnohigh unclearlow Cronier2011non RCCT111OHCA ROSCnohigh unclearlow Grasner2011non RCCT584OHCA ROSCnohigh unclearlow Hollenbeck2013non RCCT269OHCA ROSCnohigh unclearlow Mooney2011non RCCT140OHCA ROSCnohigh unclearlow Nanjayya2012non RCCT70OHCA ROSCnohigh unclearlow Nielsen2009non RCCT986OHCA ROSCnohigh unclearlow Reynolds2009non RCCT96OHCA ROSCnohigh unclearlow Strote2012non RCCT240OHCA ROSCnohigh unclearlow Tomte2011non RCCT174OHCA ROSCnohigh unclearlow Waldo2013non RCCT110OHCA ROSCnohigh unclearlow Werling2007non RCCT85OHCA ROSCnohigh unclearlow Zanuttini2012non RCCT93OHCA ROSCnohigh unclearlow

10. Dallas 2015 Key data from key studies Optional slide(s). May use up to 3 slides (with <30 seconds each) to cover key data (given restrictions imposed by total time available to present topic). May refer to more than one citation per slide if necessary. Data could be pasted from SEERs. Reference P: I: C: O:

11. Dallas 2015 Evidence profile table(s)

12. Dallas 2015 Risk of Bias in studies survival

13. Dallas 2015 Risk of Bias in studies neurologic Outcome

14. Dallas 2015 Proposed Consensus on Science statements For the Critical outcome of “survival to hospital discharge” we have identified very low quality evidence (downgraded for risk of bias) from 15 observational studies (Hollenbeck 2014 88, Mooney 2011 206, Gräsner 2011 1649, Cronier 2011 R122, Bulut 2000 155, Bro-Jeppesen 2012 291, Aurore 2011 73, Nanjayya 2012 699, Reynolds 2009 179, Strote 2012 451, Tømte 2011 1186, Waldo 2013 1253, Nielsen 2009 926, Werling 2007 40, Zanuttini 2012 1723) enrolling 3800 patients showing benefit (OR 2.83 95% CI 2.44 – 3.27).

15. Dallas 2015 Proposed Consensus on Science statements For the Critical outcome of “survival to hospital discharge with neurological good outcome” we have identified very low quality evidence (downgraded for risk of bias) from 9 observational studies (Hollenbeck 2014 88, Mooney 2011 206, Gräsner 2011 1649, Bro-Jeppesen 2012 291, Nanjayya 2012 699, Reynolds 2009 179, Strote 2012 451, Tømte 2011 1186, Nielsen 2009 926), enrolling 2919 patients showing benefit (OR 2.54 95% CI 2.17 – 2.99).

16. Dallas 2015 Draft Treatment Recommendations We suggest emergent cardiac catheterization lab evaluation in comparison to cardiac catheterization later in the hospital stay or no catheterization may be considered in selected adult patients who are comatose and are experiencing ROSC after OHCA of suspected cardiac origin with evidence of ST-elevation on ECG (weak recommendation, low quality of evidence). Values and preferences statement: In making this recommendation, we place a higher value on survival and good neurologic outcome over resource utilization

17. Dallas 2015 Knowledge Gaps Specific research required A randomized control trial Among adult patients who are experiencing ROSC after cardiac arrest with evidence of ST-elevation on ECG to compare whether emergent cath lab evaluation and intervention (where appropriate) versus cardiac catheterization later in the hospital stay or no catheterization survival to hospital discharge with good neurological outcome or survival to hospital discharge.

18. Dallas 2015 Next Steps This slide will be completed during Task Force Discussion (not EvRev) and should include: Consideration of interim statement Person responsible Due date Essential slide (one slide only). Estimated time <30 sec