Thread by @tscquizzato

WHAT ARE THE FINDINGS OF CAG AFTER OHCA?🫀

We performed a SRMA of 128 studies (>62k pts) to describe angiographic features in resuscitated and refractory OHCAs

We found that
🔸 significant CAD is present in 75%
🔸 CAD is more severe in refractory OHCA
🔸 CAD is common also in… twitter.com/i/web/status/1…

@giovannilandoni @NickJohnsonMD @expensivecare @Pipes_n_pumps @EduardArgudo @CritCareReviews @jas_soar @krychtiukmd @PabloJ @proftomquinn 2/

Although the high frequency of CAD in OHCAs is well known and numerous studies were published, use and findings of CAG are variable and often described only in some subgroups of patients

Type/frequency of coronary lesions in OHCA pts were not summarized before

#ResusTwitter

@giovannilandoni @NickJohnsonMD @expensivecare @Pipes_n_pumps @EduardArgudo @CritCareReviews @jas_soar @krychtiukmd @PabloJ @proftomquinn 3/

We conducted a systematic review with meta-analysis of proportions combining CAG findings from 128 studies (62k patients), including refractory OHCA

Nine subgroups were analyzed for a more accurate description of CAG use and findings

📄 resuscitationjournal.com/article/S0300-… #ResusTwitter

4/

Before mechCPR/ECPR, CAD was predominantly described in patients with prehospital ROSC who underwent CAG.

Prolonged or refractory cardiac arrests usually resulted in on-scene death and thus did not receive CAG, which biased the description of CAD burden.

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5/

Thanks to the possibility to transport patients with ongoing CPR for ECPR and CAG/PCI, we now have CAD data also for patients with prolonged OHCAs.

Combining for the first time also refractory OHCA patients allowed to have a more complete description of CAD

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6/

We found that CAG was performed in 69%, PCI in 46%

Patients with ST↑ and ST↑ + shockable rhythm were those receiving CAG/PCI more frequently

Patients with nonshockable rhythm and no ST↑ were those receiving CAG/PCI less frequently

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7/

We found that in patients undergoing CAG after OHCA 75% had at least one significant stenosis

In 30% was a 1-vessel disease and in 46% a multivessel disease

24% had normal coronaries or non-significant CAD

LAD was the most frequently involved coronary artery

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8/

We found that in 63% of OHCA patients undergoing CAG a culprit lesion was identified (LAD in 34%)

Culprit lesions were more frequent in shockable and ST-elevation cases

~9% of patients with nonshockable initial rhythm and no ST-elevation had a culprit lesion

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9/

We found that 43% of OHCA patients had ≥1 acute coronary occlusion, more frequently in pts with ST↑ after ROSC

LAD was the most frequent acute coronary occlusion (21%)

18% of patients had at least 1 chronic total occlusion, most frequently in the RCA (16%)

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10/

We found that patients with refractory OHCA, compared with early ROSC, had:

higher rate of pre-arrest chest pain

higher use of CAG/PCI

higher rate of LM involvement: >50% stenosis in 17% and LM as the culprit in 12%

higher rate of LAD acute occlusion (27%)

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11/

Our data suggest that the underlying disease of refractory OHCA is frequently a more severe and complex myocardial ischemia

This could also be a substrate for a shock-refractory VFib

AMSA values in the future could help to rapidly identify these patients

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12/

Our data also show that many pts had CS and required MCS even when ROSC was rapidly achieved or in the absence of ST↑

This reminds the importance of transporting OHCAs to Cardiac Arrest Centres capable of offering all the diagnostic and treatment options

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It is important to note that only few studies performed CAG in all admitted patients → selection biases ⚠️ → limit the generalizability and certainty of estimates

Repeating analyses including only these studies did not showed clinically relevant differences

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In clinical practice, the value of immediate CAG is established in patients with ST↑ after OHCA

In patients without ST↑ on post-ROSC ECG, guidelines recommend emergency CAG in case of high probability of ACS (hemodynamic or electrical instability)

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15/

In addition to clinical history, presentation and echo, our data could help selecting pts for immediate CAG by estimating the likelihood of CAD

CAG could also be considered in low risk pts for neuro injury and the #MIRACLE2 score could help select these pts

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16/

To facilitate the access to the results, we developed an interactive web-based tool to search and visualize type, location and frequency of coronary lesions in OHCA patients among the overall population and 9 different subgroups

➡️ resuslab.com/CAGfindingsOHC…

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17/

Lastly, I recommend reading the full-text: we have results for >180 variables!

This 1y long work would not have been possible without my coauthors 🙏🏻

@ResusJournal Editors/Reviewers should also be thanked for rapidly assessing such a long/complex manuscript

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