Paul W. McMullan

Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI

AIM To determine if early cardiac catheterization (CC) is associated with improved survival in comatose patients who are resuscitated after cardiac arrest when electrocardiographic evidence of ST-elevation myocardial infarction (STEMI) is absent. METHODS We conducted a retrospective observational study of a prospective cohort of 754 consecutive comatose patients treated with therapeutic hypothermia (TH) following cardiac arrest. RESULTS A total of 269 (35.7%) patients had cardiac arrest due to a ventricular arrhythmia without STEMI and were treated with TH. Of these, 122 (45.4%) received CC while comatose (early CC). Acute coronary occlusion was discovered in 26.6% of patients treated with early CC compared to 29.3% of patients treated with late CC (p=0.381). Patients treated with early CC were more likely to survive to hospital discharge compared to those not treated with CC (65.6% vs. 48.6%; p=0.017). In a multivariate regression model that included study site, age, bystander CPR, shock on admission, comorbid medical conditions, witnessed arrest, and time to return of spontaneous circulation, early CC was independently associated with a significant reduction in the risk of death (OR 0.35, 95% CI 0.18-0.70, p=0.003). CONCLUSIONS In comatose survivors of cardiac arrest without STEMI who are treated with TH, early CC is associated with significantly decreased mortality. The incidence of acute coronary occlusion is high, even when STEMI is not present on the postresuscitation electrocardiogram.

Endovascular stenting for vertebral artery stenosis.

OBJECTIVES The aim of this study was to demonstrate the safety and long-term durability of catheter-based therapy for symptomatic vertebral artery stenosis (VAS). BACKGROUND Symptomatic VAS carries with it a 5-year 30% to 35% risk of stroke. The 2-year mortality approaches 30% for medically managed strokes involving the posterior circulation. Surgical bypass is rarely performed, due to high morbidity and mortality. Endovascular revascularization with primary stenting offers an attractive treatment option for these patients. METHODS One-hundred five consecutive symptomatic patients (112 arteries, 71% male) underwent stent placement for extracranial (91%) and intracranial (9%) VAS from 1995 to 2006. Fifty-seven patients (54%) had bilateral VAS, 71 patients (68%) had concomitant carotid disease, and 43 patients (41%) had a prior stroke. RESULTS Procedural and clinical success was achieved in 105 (100%) and 95 (90.5%) patients, respectively. One-year follow-up was obtained in 87 (82.9%) patients, of which 69 patients (79.3%) remained symptom-free. At 1 year, 6 patients (5.7%) had died and 5 patients (5%) had a posterior circulation stroke. Target vessel revascularization occurred in 7.4% at 1 year. At a median follow-up of 29.1 months (interquartile range 12.8 to 50.9 months), 13.1% underwent target vessel revascularization, 71.4% were alive, and 70.5% remained symptom-free. CONCLUSIONS In experienced hands, stenting for symptomatic VAS can be accomplished with a very high success rate (100%), with few periprocedural complications, and is associated with durable symptom resolution in the majority (approximately 80%) of patients. We conclude that endovascular stenting of vertebral artery atherosclerotic disease is safe and effective compared with surgical controls and should be considered first-line therapy for this disease.

Outcomes of Comatose Cardiac Arrest Survivors With and Without ST-Segment Elevation Myocardial Infarction: Importance of Coronary Angiography

OBJECTIVES The aim of this study was to compare outcomes and coronary angiographic findings in post-cardiac arrest patients with and without ST-segment elevation myocardial infarction (STEMI). BACKGROUND The 2013 STEMI guidelines recommend performing immediate angiography in resuscitated patients whose initial electrocardiogram shows STEMI. The optimal approach for those without STEMI post-cardiac arrest is less clear. METHODS A retrospective evaluation of a post-cardiac arrest registry was performed. RESULTS The database consisted of 746 comatose post-cardiac arrest patients including 198 with STEMI (26.5%) and 548 without STEMI (73.5%). Overall survival was greater in those with STEMI compared with those without (55.1% vs. 41.3%; p = 0.001), whereas in all patients who underwent immediate coronary angiography, survival was similar between those with and without STEMI (54.7% vs. 57.9%; p = 0.60). A culprit vessel was more frequently identified in those with STEMI, but also in one-third of patients without STEMI (80.2% vs. 33.2%; p = 0.001). The majority of culprit vessels were occluded (STEMI, 92.7%; no STEMI, 69.2%; p < 0.0001). An occluded culprit vessel was found in 74.3% of STEMI patients and in 22.9% of no STEMI patients. Among cardiac arrest survivors discharged from the hospital who had presented without STEMI, coronary angiography was associated with better functional outcome (93.3% vs. 78.7%; p < 0.003). CONCLUSIONS Early coronary angiography is associated with improved functional outcome among resuscitated patients with and without STEMI. Resuscitated patients with a presumed cardiac etiology appear to benefit from immediate coronary angiography.

Geriatric experience following cardiac arrest at six interventional cardiology centers in the United States 2006-2011: interplay of age, do-not-resuscitate order, and outcomes.

Objectives:It is not known if aggressive postresuscitation care, including therapeutic hypothermia and percutaneous coronary intervention, benefits cardiac arrest survivors more than 75 years old. We compared treatments and outcomes of patients at six regional percutaneous coronary intervention centers in the United States to determine if aggressive care of elderly patients was warranted. Design:Retrospective evaluation of registry data. Setting:Six interventional cardiology centers in the United States. Patients:Six hundred and twenty-five unresponsive cardiac arrest survivors aged 18–75 were compared with 129 similar patients aged more than 75. Interventions:None. Measurements and Main Results:Cardiac arrest survivors aged more than 75 had more comorbidities (3.0 ± 1.6 vs 2.0 ± 1.6, p < 0.001), but were matched to younger patients in initial heart rhythm, witnessed arrests, bystander cardiopulmonary resuscitation, and total ischemic time. Patients aged more than 75 frequently underwent therapeutic hypothermia (97.7%), urgent coronary angiography (44.2%), and urgent percutaneous coronary intervention (24%). They had more sustained hyperglycemia (70.5% vs 59%, p = 0.015), less postcooling fever (25.2% vs 35.2%, p = 0.03), were more likely to have do-not-resuscitate orders (65.9% vs 48.2%, p < 0.001), and undergo withdrawal of life support (61.2% vs 47.5%, p = 0.005). Good functional outcome at 6 months (Cerebral Performance Category 1–2) was seen in 27.9% elderly versus 40.4% younger patients overall (p = 0.01) and in 44% versus 55% (p = 0.13) of patients with an initial shockable rhythm. Of 35 survivors more than 75 years old, 33 (94.8%) were classified as Cerebral Performance Category 1 or 2 at (mean) 6.5-month follow-up. In multivariable logistic regression modeling, age more than 75 was significantly associated with outcome only when the presence of a do-not-resuscitate order was excluded from the model. Conclusions:Elderly patients were more likely to have do-not-resuscitate orders and to undergo withdrawal of life support. Age was independently associated with outcome only when correction for do-not-resuscitate status was excluded, and functional outcomes of elderly survivors were similar to younger patients. Exclusion of patients more than 75 years old from aggressive care is not warranted on the basis of age alone.

A randomized trial of intravenous N-acetylcysteine to prevent contrast induced nephropathy in acute coronary syndromes

Background: Pharmacokinetic data suggests that the intravenous form of n‐acetylcysteine (NAC) may be more effective than the oral formulation in preventing contrast induced nephropathy (CIN). NAC owing to its anti‐oxidant properties might be beneficial for patients with acute coronary syndromes (ACS) who are at increased risk for CIN. The aim of this prospective randomized, single‐center, double‐blind, placebo controlled trial (NCT00939913) was to assess the effect of high‐dose intravenous NAC on CIN in ACS patients undergoing coronary angiography and/or percutaneous coronary intervention (PCI). Methods: We randomized 398 ACS patients scheduled for diagnostic angiography ± PCI to an intravenous regimen of high‐dose NAC (1,200 mg bolus followed by 200 mg/hr for 24 hr; n = 206) or placebo (n = 192). The primary end‐point was incidence of CIN defined as an increase in serum creatinine concentration ≥25% above the baseline level within 72 hr of the administration of intravenous contrast. Results: There was no difference found for the primary end point with CIN in 16% of the NAC group and in 13% of the placebo group (p = 0.40). Change in serum cystatin‐C, a sensitive marker for renal function, was 0.046 ± 0.204 in the NAC group and 0.002 ± 0.260 in the control group (p = 0.07). Conclusion: In ACS patients undergoing angiography ± PCI, high‐dose intravenous NAC failed to reduce the incidence of CIN.

Carotid artery stent placement is safe in the very elderly (>= 80 years)

Background: Carotid artery stent (CAS) placement is an alternative to carotid endarterectomy (CEA) for stroke prevention. Clinical adoption of CAS depends on its safety and efficacy compared to CEA. There are conflicting reports in the literature regarding the safety of CAS in the elderly. To address these safety concerns, we report our single‐center 13‐year CAS experience in very elderly (≥80 years of age) patients. Methods: Between 1994 and 2007, 816 CAS procedures were performed at the Ochsner Clinic Foundation. Very elderly patients, those ≥80 years of age, accounted for 126 (15%) of all CAS procedures. Independent neurologic examination was performed before and after the CAS procedure. Results: The average patient age was 82.9 ± 2.9 years. Almost one‐half (44%) were women and 40% were symptomatic from their carotid stenoses. One‐third of the elderly patients met anatomic criteria for high surgical risk as their indication for CAS. The procedural success rate was 100% with embolic protection devices used in 50%. The 30‐day major adverse coronary or cerebral events (MACCE) rate was 2.7% (n = 3) with all events occurring in the symptomatic patient group [death = 0.9% (n = 1), myocardial infarction = 0%, major (disabling) stroke = 0.9% (n = 1), and minor stroke = 0.9% (n = 1)]. Conclusion: Elderly patients, ≥80 years of age, may undergo successful CAS with a very low adverse event rate as determined by an independent neurological examination. We believe that careful case selection and experienced operators were keys to our success.

Catheter-based therapy of common femoral artery atherosclerotic disease

The objective of this paper is to describe outcomes of endovascular therapy in patients with symptomatic common femoral artery (CFA) lesions. Symptomatic atherosclerotic disease of the common femoral artery is an uncommon clinical entity, and there is no consensus regarding the suitability of catheter-based therapy. We reviewed the records of 26 consecutive patients treated with catheter-based therapy for symptomatic CFA lesions between 1994 and 2009. Angiographic success and procedure success were obtained in all vessels and in all patients. At 1 year, 100% (16/16) of the claudication patients and 70% (7/10) of the critical limb ischemia (CLI) patients maintained clinical success. The ankle— brachial index (ABI) significantly improved from a baseline of 0.47 ± 0.18 to 0.77 ± 0.18 (p < 0.001) after the procedure. At their most recent clinic visit (31 months ± 14 months), clinical success was maintained in 100% of the claudication patients and in 70% (7/10) of the CLI patients. During the follow-up period, femoral vascular access for an unrelated procedure was obtained through the CFA stent. In conclusion, patients with symptomatic CFA atherosclerotic disease obtained excellent clinical outcomes with angioplasty with stenting. We found that angioplasty with stenting of the CFA did not preclude future CFA vascular access. Our data suggest that catheter-based therapies should be considered as an option to open surgery in selected patients with symptomatic CFA disease.

Stroke intervention: Catheter-based therapy for acute ischemic stroke

The majority (>80%) of the three-quarters of a million strokes that will occur in the United States this year are ischemic in nature. The treatment of acute ischemic stroke is very similar to acute myocardial infarction, which requires timely reperfusion therapy for optimal results. The majority of patients with acute ischemic stroke do not receive any form of reperfusion therapy, unlike patients with acute myocardial infarction. Improving outcomes for acute stroke will require patient education to encourage early presentation, an aggressive expansion of qualified hospitals, and willing providers and early imaging strategies to match patients with their best options for reperfusion therapy to minimize complications.

Doing what's right for the resuscitated†

In the current issue of Catheterization and Cardiovascular Interventions, Kern and Rahman review the available data supporting percutaneous coronary intervention (PCI) in patients resuscitated from out-of-hospital cardiac arrest (OHCA). They tabulate the results of 17 reports with a total of 930 post-cardiac arrest (PCA) patients, who underwent early cardiac catheterization along with appropriate revascularization and another four case series in which a total of 150 PCA patients were treated with therapeutic hypothermia in addition to early coronary intervention. Survival-to-discharge rates were 60% in the first group and 70% in the second with very high rates (87% and 81%, respectively) of intact neurologic function among survivors. These are remarkably high figures when applied to a population whose expected survival has been only 25%, half of whom have significant neurologic impairment. The authors further point out the unreliability of chest pain and electrocardiographic abnormalities in predicting acute coronary occlusion as the inciting event in these patients. They conclude that the induction of mild therapeutic hypothermia and early coronary angiography/PCI should be strongly considered for all comatose PCA patients regardless of their postresuscitation electrocardiographic findings, a recommendation already made by the International Liaison Committee on Resuscitation in its 2008 Post-Cardiac Arrest Syndrome Consensus Statement [1]. Mounting evidence suggests that therapeutic hypothermia combined with early cardiac catheterization should be adopted as a systematic strategy for PCA patients. Two sentinel randomized-controlled trials published in 2002 [2,3] demonstrated benefits in mortality and neurologic outcome in survivors of OHCA who were treated with therapeutic hypothermia. The publication of these studies brought renewed vigor to the field of resuscitation science, which for decades had struggled for a method to better outcomes. In recent years, the concept of the ‘‘post-cardiac arrest syndrome’’ and how we might further improve this very high-risk subgroup’s odds of survival have received great attention [1]. Many national and international medical societies, including the American Heart Association (AHA), have updated their guidelines recommendations to incorporate therapeutic hypothermia in the treatment of OHCA [4], and a Policy Statement on Regional Systems of Care for OHCA issued by the AHA in January, 2010 specifically addresses the need for early PCI in this population [5]. So what are the obstacles? One is the persistent perception by institutions and physicians that the cardiac arrest survivor has a nearhopeless prognosis [6,7] and that decisions regarding further aggressive care such as coronary intervention should be delayed until the patient has demonstrated adequate promise of neurologic recovery. In fact, available data suggest that currently employed methods of neurologic prognostication are unreliable in the early stages of post-arrest care [6,8]. This is particularly true in patients treated with therapeutic hypothermia [9]. Kern and Rahman’s review of almost 1,100 patients, 150 of whom were treated with hypothermia, suggests significantly better-than-expected outcomes are achievable if these patients are managed aggressively. The solution to this obstacle is education of healthcare providers and hospitals on a national level to change the perception of OHCA from a diagnosis with uniformly negative outcomes to one of hope, which can be positively influenced by improvements in care. Another obstacle is the current enthusiasm for ‘‘score carding’’ for quality outcomes. Hospitals and

Acute stroke intervention by interventional cardiologists

To report the technical success and clinical outcomes of catheter‐based therapy (CBT) for acute ischemic stroke in patients ineligible for intravenous thrombolysis.