Author + information
- Karl B. Kern, MD⁎ ()
- ↵⁎Section of Cardiology, University of Arizona, Sarver Heart Center, 1501 North Campbell Avenue, Tucson, Arizona 85724
I appreciate the comments by Dr. Hosmane and colleagues on my paper (1), particularly their support that now is the time to provide “operators and medical centers the opportunity to do what is best for the individual ST-segment elevation myocardial infarction (STEMI) patient, without fear of unfair inflation of their overall reported mortality figures.” This change in public reporting of outcomes data will require the main body of interventional cardiologists and their societal leaders to join together in championing this cause for the benefit of patients who suffer cardiac arrest. Reporting outcomes among the cardiac arrest population itself is warranted and needed, but such data should be separated from the general population undergoing percutaneous coronary intervention (PCI) to realistically compare apples to apples, not apples to oranges.
These clinical investigators, who recently published their experience supporting the performance of emergent coronary intervention post-cardiac arrest, now acknowledge their fear “that with aggressive door-to-balloon time initiatives and our prior report on STEMI and out-of-hospital cardiac arrest, that operators are performing emergent percutaneous coronary intervention too often in comatose patients when STEMI doesn't in fact truly exist.” They express concern that not all ST-segment elevation indicate an acute myocardial infarction, and that coronary angiography might delay the true diagnosis and appropriate treatment. Theoretically this is possible, but the alternative diagnosis they note (sepsis, hyperkalemia, intracranial hemorrhage, aortic dissection, left ventricular aneurysm and pulmonary emboli), when severe enough to cause cardiac arrest are associated with very poor outcomes, with the possible exception of timely treatment for hyperkalemia. I believe the real issue is who post-resuscitation can truly benefit from emergent catheterization, can we prospectively identify them, and do our efforts help or harm them? Finding the cardiac arrest victim with an acutely occluded or unstable culprit lesion is the goal. We know that post-resuscitation ST-segment elevation is not definitive (2), with a 20% to 30% ‘false negative’ rate (3), and as noted by Dr. Hosmane and colleagues some degree of ‘false positives’ as well. That is why I argue to extend emergency coronary angiography to all successfully resuscitated with a likely cardiac etiology, regardless of their post-arrest electrocardiographic findings. I prefer to include some who ultimately do not have a culprit lesion found, in order not to miss those whose acute coronary lesion is only detected at emergent angiography. The literature suggests that approximately 50% of the successfully resuscitated without an obvious noncardiac cause of their arrest will have an acute culprit coronary lesion (3,4). One out of two is enough to convince me to perform emergent coronary angiography whenever someone is lucky enough to arrive at the hospital after being successfully resuscitated from out-of-hospital cardiac arrest.
- American College of Cardiology Foundation