AHA Details Cath Lab’s Role in Out of Hospital Cardiac Arrest

The American Heart Association (AHA) has released a new scientific statement that clarifies the role of the cath lab in managing patients who’ve experienced out-of-hospital cardiac arrest (OHCA), both those who are resuscitated and those with ongoing arrest.

“The cardiac catheterization laboratory is an important link in the coordinated Chain of Survival for individuals with OHCA,” Jacqueline E. Tamis-Holland, MD (Cleveland Clinic, OH), and colleagues write. The cath lab “can provide a useful setting to resuscitate and stabilize patients with sudden cardiac arrest from many different cardiac causes, but it has a unique importance in the treatment of OHCA resulting from underlying coronary artery disease.”

OHCA is often fatal, with fewer than 10% of patients surviving to hospital discharge, and accounts for around half of all cardiovascular deaths. The best strategies for treating the condition are still evolving.

Tamis-Holland, who chaired the new statement, told TCTMD the document is timely. Although it’s not the first devoted to what the cath lab brings to OHCA care, “there’s been a lot of data, particularly on the patients with no ST elevation on their ECG and [those] with ongoing arrest,” she commented. “We felt it was important to make a statement on when the cath lab should be utilized, what the advantages of the cath lab are in helping these patients, and when we don’t necessarily have to take these patients to the cath lab immediately because the outcome won’t change.”

Published last month in Circulation, the paper incorporates data from numerous trials that have emerged in recent years as well as the current AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.

What we really want people to do is think before they take somebody to the lab, and to individualize care. Jacqueline E. Tamis-Holland

Perhaps most interesting to the interventional-cardiology audience are two sections: one devoted to best practices for lab management and the other to the role of emergency cardiac catheterization, coronary angiography, and intervention.

Here, Tamis-Holland et al cover six recent trials of coronary angiography in patients without ST elevation on ECG: COACT, DISCO, PEARL, TOMAHAWK, EMERGE, and COUPE. “Every single one of them did not show a clear benefit in terms of improvement in outcome,” she said. Based on the evidence, “what we really want people to do is think before they take somebody to the lab, and to individualize care.”

The authors also explore the impact of three trials that provided clarity on extracorporeal cardiopulmonary resuscitation: INCEPTION, ARREST, and Prague OHCA. “One was clearly positive, one was clearly negative, and one was kind of on the border, with a trend toward significance in a secondary outcome,” 6-month survival with a favorable neurologic outcome, Tamis-Holland noted. “There’s a lot of information, so what we do is spend a lot of time describing the ideal system to allow for effective collaboration between the EMS [emergency medical services] system and the hospitals to ensure extracorporeal CPR can be done and done well. This can be associated with better survival for a select group of patients who are young and would really benefit from that.”

In addition, the AHA statement details everything from the initial assessment of patients with OHCA to clinical risk prediction, public reporting, systems of care, and future directions for research. The new document does not, however, comprehensively address temperature management, which is covered in a separate advisory released by the AHA last fall after lackluster results from the TTM2 trial.

When envisioning best practices, said Tamis-Holland, the cath lab team is “one part of the picture. Coordination between EMS, the emergency department, and us will improve care.” In an ideal world, EMS will give the cath lab a head’s up when an OHCA patient is headed their way. Especially with ongoing cardiac arrest, “every minute counts,” she stressed.