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Out-of-hospital Cardiac Arrest
Contemporary Issues
Kwan S Lee MD FSCAI FACC
Associate Professor of Medicine
Sarver Heart Center
University of Arizona


Relevant Disclosures
None


Improving Bystander Chest
Compression CPR


An Alternative Form of CPR:
CardioCerebral Resuscitation
Three Pillars
1.

2.

3.

Chest Compression-Only BLS for witnessed
unexpected collapse in adults
New Cardiocerebral Resuscitation ACLS
algorithm for dispatchers and EMS
personnel
Post Resuscitation Care to include the use

of mild hypothermia and aggressive
reperfusion


Thank You

Thank You


“OK, Doc…but what are you going to do
differently when we bring more post cardiac
arrest patients to the hospital
with a pulse and BP?”


Current Outcomes From OOH CA

Number of Patients

100

100 pts

80

Δ= 60%

60
40

40 pts

20

Largest drop off occurs
In hospital, where 75%
Of those initially
resuscitated die

Δ=75%

Δ= 50%
10 pts

5 pts

0
Pre-arrest

ROSC

Hosp DC

Surv at 1 yr


15 (26%)

Resuscitation 2007;73:29-39

What Makes the Difference?


Aggressive Post Resuscitation Care
Two major factors:
• Mild Therapeutic Hypothermia
• Early Coronary Angiography & PCI



Hypothermia for Coma After Cardiac Arrest

Hypothermia

Normothermia

Dr. Fritz Sterz, Vienna, Austria and The Hypothermia After Cardiac Arrest
Study Group, N Engl J Med 2002; 346:549-556


Hypothermia and Post Resuscitation Care


First promising post resuscitation
therapyEVER!

Improved survival
Improved neurological function of survivors

Hypothermia
in the
guidelines
AHA
guidelines:
2005,
2010 & 2015
Comatose out-of-hospital VF:
2005: Class IIa recommendation
2010: Changed to Class I recommendation
2015: Remains Class I recommendation, LOE B-R

In-hospital arrest, other rhythms:
2005: Class IIb recommendation

2010: Still Class IIb recommendation
2015: Changed to Class I, LOE C-EO


The TTM Trial – Nielsen et al



The TTM Trial – Nielsen et al

p=0.51

Making sense of the post-arrest trials
no cooling

HACA

36%

100% VF

33oC

no cooling

53%

0

10

20

30
40
% 26%
survival

50

60
Bernard

100% VF

33oC

49%

36oC

52%

33oC

50%

Both arms are active Rx !

TTM
80% VF/VT

How can
this be?


CAD and OOH Cardiac Arrest





70% of Adult victims of OOH CA

have CAD
Culprit Vessel Concept


The worst presentation of ACS is not STEMI …
but rather Cardiac Arrest !


Potential Value of
Coronary Angiography Post Arrest








Identify ‘culprit’ coronary lesion
Restore coronary flow
Salvage myocardium
? Reduce risk of Re-arrest
? Improve hemodynamics of CNS perfusion
? Improve Survival


Who Should Go to the Cath Lab
Post Resuscitation?
Patients resuscitated from OHCA
Associated with a STEMI

Patients resuscitated from OHCA
Without ST Elevation


ILCOR 2015 Resuscitation Science Review


Hospital Reperfusion Decisions After ROSC
We recommend emergency cardiac catheterization
laboratory evaluation in comparison with cardiac
catheterization later in the hospital stay or no
catheterization in select adult patients with ROSC
after out-of-hospital cardiac arrest (OHCA) of
suspected cardiac origin with ST elevation on ECG.

Welsford M, et al; on behalf of the Acute Coronary Syndrome Chapter Collaborators. Part
5: acute coronary syndromes: 2015 International Consensus on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science With Treatment
Recommendations. Circulation. 2015;132(suppl 1):S146–S176.


2015 AHA CPR Guidelines
2015 Recommendations—Updated


Coronary angiography should be performed
emergently (rather than later in the hospital stay or
not at all) for OHCA patients with suspected cardiac
etiology of arrest and ST elevation on ECG
(Class I, LOE B-NR).

O’Connor RE, et al. Part 9: acute coronary syndromes: 2015 American Heart
Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2015;132(suppl 2):S483–S500.


2015 AHA CPR Guidelines
2015 Recommendations—Updated


Coronary angiography is reasonable in post–cardiac
arrest patients where coronary angiography is
indicated regardless of whether the patient is
comatose or awake
(Class IIa, LOE C-LD).

O’Connor RE, et al. Part 9: acute coronary syndromes: 2015 American Heart
Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2015;132(suppl 2):S483–S500.