Question 10#
A 58-year-old with active tobacco use, hyperlipidemia, and hypertension presents with substernal chest pain that developed following snow shoveling.
Shortly following his presentation, he is observed to have a witnessed cardiac arrest with multiple episodes of ventricular fibrillation. He required 10 minutes of cardiopulmonary resuscitation with advanced cardiac life support and four defibrillator therapies. Following return of spontaneous circulation (ROSC), the patient was noted to have the following laboratory data. His mental status is not determinable.
His post-ROSC ECG is shown:
What is the MOST appropriate timing for coronary angiography?
A. Urgently post-ROSC
B. Within 24 to 48 hours of presentation
C. Following correction of metabolic derangement
D. Following establishment of a favorable neurologic prognosis
Correct Answer is A
Comment:
Correct Answer: A
The timing of coronary angiography in patients with cardiac arrest and unknown mental status is controversial. Coronary angiography should be performed emergently for cardiac arrest patients with suspected cardiac etiology of arrest and ST segment elevation on ECG. Patients with ventricular fibrillation or pulseless ventricular tachycardia should be considered at high risk for coronary event, for which urgent angiography should be considered. Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after out-of-hospital cardiac arrest of suspected cardiac origin even without ST elevation on ECG.
There are no guideline consensus statements on the timing of angiography in the absence of ST elevations. There is additional evidence that in those patients with out-of-hospital cardiac arrest and a nonshockable rhythm, early coronary angiography (within 24 hours) was associated with improved mortality. Thus, many argue in favor of early coronary angiography.
Neurologic prognosis is difficult to reliably determine immediately following resuscitation. Thus, the decision with regard to cardiovascular intervention should be made independent of perception of neurologic prognosis.
References:
- Callaway CW, Donnino MW, Fink EL, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132 (18 suppl 2):S465-S482.
- Yannopoulos D, Bartos JA, Aufderheide TP, et al. The evolving role of the cardiac catheterization laboratory in the management of patients with out-of-hospital cardiac arrest: a scientific statement from the American Heart Association. Circulation. 2019;139(12):e530-e552. doi:10.1161/CIR0000000000000630.