Columbia University Medical CenterColumbia University Medical CenterThe Cardiovascular Research FoundationThe Cardiovascular Research Foundation

The Role of the Cardiac The Role of the Cardiac CathCath Lab FollowingLab Following

Cardiac ArrestCardiac Arrest

Ajay J. Ajay J. KirtaneKirtane, MD, SM, MD, SM

Conflict of Interest DisclosureConflict of Interest Disclosure

•• Ajay J. Ajay J. KirtaneKirtane

Consultant/Honoraria/Lecture Fees from Consultant/Honoraria/Lecture Fees from Medtronic Medtronic CardioVascularCardioVascular, Abbott , Abbott Vascular, Boston Scientific, St. Jude Vascular, Boston Scientific, St. Jude Medical, Medicines CompanyMedical, Medicines CompanyAdvisor to Medtronic Advisor to Medtronic CardioVascularCardioVascular

Level of Evidence for Primary PCI Level of Evidence for Primary PCI Following Resuscitated Cardiac ArrestFollowing Resuscitated Cardiac Arrest•• Virtually all randomized trials of primary Virtually all randomized trials of primary

PCI have excluded patients with cardiac PCI have excluded patients with cardiac arrestarrest

•• The majority of data is therefore The majority of data is therefore observationalobservational

•• Observational studies of cardiac arrest Observational studies of cardiac arrest are typically small, and patient selection are typically small, and patient selection (especially for invasive procedures) (especially for invasive procedures) plays a large role in outcomesplays a large role in outcomes

StableStable11--2VD2VD

The Spectrum of CADThe Spectrum of CAD

DeathDeathMIMIRiskRisk

3VD3VD LMLM STEMISTEMIACSACS

StableStable11--2VD2VD

The Spectrum of CADThe Spectrum of CAD

DeathDeathMIMIRiskRisk

3VD3VD LMLM STEMISTEMIACSACS

The The PathophysiologyPathophysiology of AMIof AMI

Ruptured plaque with luminal and Ruptured plaque with luminal and intraplaqueintraplaqueocclusive thrombusocclusive thrombus

9.3%

7.4%7.0%5.3%

0%

2%

4%

6%

8%

10%

12%

Death Death (excl shock)

Even

t rat

e

Lysis PCI

23 Randomized Trials of PCI vs. Lysis23 Randomized Trials of PCI vs. 23 Randomized Trials of PCI vs. LysisLysis

p=0.0002p=0.0002 p=0.0003p=0.0003

N = 7,739N = 7,739

KeeleyKeeley, , GrinesGrines. Lancet 2003;361:13. Lancet 2003;361:13--2020

6.8%

1.0%2.0%2.5%

0.1%1.0%

0%

2%

4%

6%

8%

Reinfarction Hemorrhagic stroke Total stroke

Even

t rat

e

Lysis PCI

P<0.0001

N = 7,739N = 7,739

P<0.0001

p=0.0002

KeeleyKeeley, , GrinesGrines. . LancetLancet 2003;361:132003;361:13--2020

23 Randomized Trials of PCI vs. 23 Randomized Trials of PCI vs. LysisLysis

The RIKSThe RIKS--HIA HIA RegistryRegistry

Consecutive pts admitted in 75 of Consecutive pts admitted in 75 of 78 hospitals with 78 hospitals with CCUsCCUs in Sweden in Sweden (N=26,206 (N=26,206 STEMIsSTEMIs))

StenestrandStenestrand U et al. U et al. JAMAJAMA 2006;296:17492006;296:1749--5656

Unadjusted Cumulative MortalityUnadjusted Cumulative Mortality

0

5

10

15

20

0 100 200 300 4000

5

10

15

20

0 100 200 300 400DaysDays

Cum

ulat

ive

Mor

talit

y, %

Cum

ulat

ive

Mor

talit

y, %

InIn--Hospital Hospital ThrombolysisThrombolysisPrePre--hospital hospital ThrombolysisThrombolysisPrimary PCIPrimary PCI

# at Risk# at RiskIn Hospital TLIn Hospital TL 1426014260 1232212322 1210012100 1193111931PrehospitalPrehospital TLTL 27362736 24912491 24602460 24422442Primary PCIPrimary PCI 60306030 56615661 56075607 55555555

15.9%

10.3%7.6%

SHOCK TrialSHOCK Trial

7063

5647 50 55

0

20

40

60

80

30 days 6 months 12 months

Mor

talit

y (%

)

Medical stabilization Emergency revascularization

302 pts with cardiogenic shock within 36302 pts with cardiogenic shock within 36°° of AMI of AMI & ST& ST↑↑/new LBBB randomized to emergency/new LBBB randomized to emergency

revasc. (n=152) or initial medical care (n=150)revasc. (n=152) or initial medical care (n=150)

p=NS P<0.05 P<0.05

HochmanHochman J et al. J et al. NEJMNEJM

0

2

4

6

8

10

0 60 120 180 240 300 360

Primary PCI: Primary PCI: Impact of Total Ischemic TimeImpact of Total Ischemic Time

Time from symptom onset to balloonTime from symptom onset to balloon

1 ye

ar m

orta

lity

1 ye

ar m

orta

lity

De Luca G et al. De Luca G et al. CircCirc 2004;109:12232004;109:1223--55

N=1791 STEMI ptsN=1791 STEMI pts5.8% 1 year mortality5.8% 1 year mortalityQuadratic regressionQuadratic regression

RR for 1RR for 1--year mortality for each 30 minute year mortality for each 30 minute delay of 1.08 [1.01 to 1.15], delay of 1.08 [1.01 to 1.15], p=0.041p=0.041

Y=2.86 (+1.46) + 0.0045XY=2.86 (+1.46) + 0.0045X11 + 0.000043X+ 0.000043X22

p<0.001p<0.001

Impact of Patient Risk on the Relationship Impact of Patient Risk on the Relationship Between DBT and MortalityBetween DBT and Mortality

2300 pts undergoing primary PCI (Moses Cone)2300 pts undergoing primary PCI (Moses Cone)

BrodieBrodie BR et al. BR et al. JACCJACC 2006;47:2892006;47:289––9595

High risk = High risk = KillipKillip class 3/4, age >70 years, or anterior infarctionclass 3/4, age >70 years, or anterior infarction

Car

diac

Sur

viva

l %C

ardi

ac S

urvi

val %

YearsYears

p<0.0001p<0.0001

00--1.41.41.51.5--1.91.92.02.0--2.92.9>>3.03.0

High Risk PatientsHigh Risk Patients

DoorDoor--toto--Balloon Time (hrs)Balloon Time (hrs)

(n=1,307)(n=1,307)

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11

Car

diac

Sur

viva

l %C

ardi

ac S

urvi

val %

YearsYears

p=0.54p=0.5400--1.41.41.51.5--1.91.92.02.0--2.92.9>>3.03.0

Low Risk PatientsLow Risk Patients

DoorDoor--toto--Balloon Time (hrs)Balloon Time (hrs)

(n=993)(n=993)

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11

NRMI: Multivariate Adjusted Impact of Incremental NRMI: Multivariate Adjusted Impact of Incremental PCI Delay Stratified by Age, MI Location PCI Delay Stratified by Age, MI Location

and Presentation Delayand Presentation Delay

Pinto DS et al. Circulation 2006;114:2019-2025

PCI R

elat

ed D

elay

(DB

-DN

) Whe

rePC

I and

Fib

rono

lytic

Mor

talit

y A

re E

qual

(Min

)

Non Ant MI65+ YRS

Ant MI65+ YRS

Non Ant MI

<65 YRS

Ant MI<65 YRS

0-120 PrehospitalDelay (min)

121+

0

60

120

180

168 20,424

1079,812

5841,774 40

19,517

435,296

10316,119

1483,739

17910,614

192,509 ptsat 645 hospitals

Distal Protection and Distal Protection and ThrombectomyThrombectomyin AMIin AMI

Macroscopic embolic debris can be Macroscopic embolic debris can be retrieved from >75% of casesretrieved from >75% of cases

16.2

9.87.5

18.3

12.515

0

5

10

15

20

25

Emerald  (n=501) AIMI (n=480) K altoft et al (n=225)

Infa

rct size

 (%

 LV)

C ontrol (N=208)Dis tal protec tion  or thrombectomy

AMI:AMI: Attempts to Decrease Infarct SizeAttempts to Decrease Infarct SizeHave been mostly met with frustrationHave been mostly met with frustration

The concept of reducing embolic loadThe concept of reducing embolic load

Stone GW et al. Stone GW et al. JAMAJAMA 20052005

Distal protectionDistal protection(GuardWire Plus)(GuardWire Plus)

Passive thrombus Passive thrombus aspiration (Rescue)aspiration (Rescue)

Active thrombectomy Active thrombectomy (AngioJet)(AngioJet)

Ali A et al. Ali A et al. JACCJACC 20062006 Kaltoft A et al. Kaltoft A et al. JAMAJAMA 20052005

P=0.26P=0.018 P=0.004

RCA Occlusion (Inferior STEMI)RCA Occlusion (Inferior STEMI)

Direct Stent ImplantationDirect Stent Implantation

Final AngiogramFinal Angiogram

StableStable11--2VD2VD

The Spectrum of CADThe Spectrum of CAD

DeathDeathMIMIRiskRisk

3VD3VD LMLM STEMISTEMIACSACS

Mehta SR et al. Mehta SR et al. JAMAJAMA 2005;293:29082005;293:2908--29172917

SourceSourceRoutine Routine invasiveinvasive

Selective Selective invasiveinvasive

TIMI IIIBTIMI IIIB 86/740 (11.6)86/740 (11.6) 101/733 (13.8)101/733 (13.8)VANQWISHVANQWISH 152/462 (32.9)152/462 (32.9) 139/458 (30.3)139/458 (30.3)MATEMATE 16/111 (14.4)16/111 (14.4) 11/90 (12.2)11/90 (12.2)FRISC IIFRISC II 127/1222 (10.4)127/1222 (10.4) 174/1235 (14.1)174/1235 (14.1)TACTICSTACTICS 81/1114 (7.3)81/1114 (7.3) 105/1106 (9.5)105/1106 (9.5)VINOVINO 4/64 (6.3)4/64 (6.3) 15/67 (22.4)15/67 (22.4)RITARITA 95/895 (10.6)95/895 (10.6) 118/915 (12.9)118/915 (12.9)TotalTotal 561/4608 (12.2)561/4608 (12.2) 663/4604 (14.4)663/4604 (14.4)

Favors RoutineInvasive

Favors SelectiveInvasive

OR, 0.82[0.72-0.93]

P<0.001

0.1 1.0 10

MetaMeta--analysis of Conservative vs. analysis of Conservative vs. Invasive Strategies in ACSInvasive Strategies in ACS

9,212 randomized pts in 7 trials9,212 randomized pts in 7 trials

Composite death or MI from rand to latest FUComposite death or MI from rand to latest FU

18%18%⇓⇓

TIMI IIIBTIMI IIIBTIMI IIIB

9 Randomized Trials9 Randomized TrialsN=10,412N=10,412

ConservativeConservative(N=920)(N=920)

InvasiveInvasive(N=6618)(N=6618)

VANQWISHVANQWISHVANQWISHMATEMATEMATE

FRISC IIFRISC IIFRISC II

TACTICS-TIMI 18

TACTICSTACTICS--TIMI 18TIMI 18

VINOVINOVINO

RITA-3RITARITA--33

TRUCS TRUCS TRUCS

Optimal Strategy for ACSOptimal Strategy for ACS

N=2874N=2874

ICTUSICTUSICTUS

c/o Chris Cannon

When to Take a Patient to the LabWhen to Take a Patient to the Lab

Mehta et al, NEJM 2009

Mehta et al, NEJM 2009

Mehta et al, NEJM 2009

Mehta et al, NEJM 2009

StableStable11--2VD2VD

The Spectrum of CADThe Spectrum of CAD

DeathDeathMIMIRiskRisk

3VD3VD LMLM STEMISTEMIACSACS

There is a Wide-Range of Morbidity/Mortality among “Stable Angina” Patients

Hachamovitch et al, Circulation 2003;107:2900-07

% Total Ischemic Myocardium

0% 1- 5% 5-10% 11-20% >20%

Car

diac

Dea

th R

ate

(%)

(1.9

yr F

U)

N=7110 N=1331 N=718 N=545 N=252

N=9,956 pts

5.4% cardiac mortality in 1.9 years -

Is this “stable” angina?

6.7%

3.7%3.3%

1.0%

2.9%

4.8%

1.8% 2.0%

0%

2%

4%

6%

8%

10% Medical RxRevasc

Mitigated Gradient with Revascularization

% Total Ischemic Myocardium1- 5% 5-10% 11-20% >20%

Car

diac

Dea

th R

ate

1331 56 718 109 545 243 252 267

P <.0001

Hachamovitch et al Circulation. 2003; 107:2900-2907.

0.0%

15.6%

22.3%

39.3%

0%

10%

20%

30%

40%

Dea

th o

r MI R

ate

(%)

Rates of Death or MI by ResidualRates of Death or MI by ResidualIschemia on 6Ischemia on 6--18m MPS18m MPS

p=0.002p=0.002

0%(n=23)

p=0.023p=0.023

p=0.063p=0.063

1%-4.9%(n=141)

5%-9.9%(n=88)

>10%(n=62)

Shaw, et al, AHA 2007 and Circulation 2008

Revascularization: The Bottom LineRevascularization: The Bottom Line•• Revascularization improves prognosis Revascularization improves prognosis

(hard clinical endpoints) in:(hard clinical endpoints) in:STEMI (timeSTEMI (time--dependent)dependent)NSTACS (moderately timeNSTACS (moderately time--dependent)dependent)Stable CAD with high ischemic burden (less Stable CAD with high ischemic burden (less timetime--dependent)dependent)

•• Prompt revascularization therefore Prompt revascularization therefore has the potential to improve has the potential to improve outcomes in appropriately selected outcomes in appropriately selected patients with cardiac arrest!!patients with cardiac arrest!!

Etiologies of Cardiac ArrestEtiologies of Cardiac Arrest•• Coronary Heart Disease (>65%)Coronary Heart Disease (>65%)

Coronary Occlusion (Coronary Occlusion (↑↑frequent on autopsy)frequent on autopsy)ArrhythmiaArrhythmiaPump DysfunctionPump Dysfunction

•• Structural Heart Disease (10%)Structural Heart Disease (10%)Valvular DiseaseValvular DiseaseHOCMHOCMCoronary AnomaliesCoronary Anomalies

•• Other: Takotsubo, Primary Arrhythmias, etcOther: Takotsubo, Primary Arrhythmias, etc•• NonNon--cardiac / metabolic abnormalities (30%?)cardiac / metabolic abnormalities (30%?)

Diagnoses in 72 Pts with Cardiac Arrest Diagnoses in 72 Pts with Cardiac Arrest Undergoing Routine CatheterizationUndergoing Routine Catheterization

Anyfantakis et al, Am Heart J 2009

PCI performed in one-third of patients

Use and Utility of Angiography afterUse and Utility of Angiography afterInIn--Hospital VF ArrestHospital VF Arrest

•• Of 110 patients with confirmed VFOf 110 patients with confirmed VF--arrest at a major US academic hospital, arrest at a major US academic hospital, only 30 (27%) received angiography only 30 (27%) received angiography within 1 day of the arrestwithin 1 day of the arrest•• Less than half had STEMI or new LBBBLess than half had STEMI or new LBBB•• More than half underwent PCIMore than half underwent PCI

•• Performance of angiography has been Performance of angiography has been associated with increased survival (but associated with increased survival (but this association is quite confounded)this association is quite confounded)

Merchant et al, Resuscitation 2008Werling et al, Resuscitation 2007

A Case for Immediate Angiography forA Case for Immediate Angiography forSurvivors of OutSurvivors of Out--ofof--Hospital ArrestHospital Arrest•• 85 (selected) patients with no obvious 85 (selected) patients with no obvious

nonnon--cardiac cause of arrestcardiac cause of arrest•• Coronary occlusions seen in 48% of ptsCoronary occlusions seen in 48% of pts•• Clinically significant CAD in 71% of ptsClinically significant CAD in 71% of pts•• Mean LVEF 34%Mean LVEF 34%•• 38% Survival; predictors were:38% Survival; predictors were:

No need for inotropes on transportNo need for inotropes on transportSuccessful angioplastySuccessful angioplastyShorter time from arrest to presentationShorter time from arrest to presentation

Spaulding et al, NEJM 2007

History

MarkersEKG

Problems with the Diagnosis of Problems with the Diagnosis of Ischemic CAD in Arrest PatientsIschemic CAD in Arrest Patients

Often Difficult to Obtain

Too LongTo Wait!

Often abnormalin post-arrest setting

Diagnostic Dilemmas in Cardiac ArrestDiagnostic Dilemmas in Cardiac ArrestImmediate post-arrest EKG

Diagnostic Dilemmas in Cardiac ArrestDiagnostic Dilemmas in Cardiac ArrestAfter ventilation/sodium bicarbonate (3 min later)

Diagnostic Dilemmas in Cardiac ArrestDiagnostic Dilemmas in Cardiac Arrest35 minutes after initial EKG

Diagnostic Dilemmas in Cardiac ArrestDiagnostic Dilemmas in Cardiac Arrest4 hours post-arrest

Diagnostic Dilemmas in Cardiac ArrestDiagnostic Dilemmas in Cardiac ArrestThe next morning (12 hours post-arrest)

Müller et al, Ann Emerg Med 2008

MI at MI at DischargeDischarge

No MI at No MI at DischargeDischarge

ST Elevation on ST Elevation on Admission EKGAdmission EKG 37 3 40

No ST Elevation on No ST Elevation on EKGEKG 11 24 35

48 27 77

Ability of 12Ability of 12--lead EKG to Diagnose lead EKG to Diagnose STEMI after Resuscitated ArrestSTEMI after Resuscitated Arrest

Out of hospital EKG: PPV 88% and NPV 69%Sensitivity 77% and Specificity 83%

Summary of PCI Outcomes DataSummary of PCI Outcomes Data•• Studies of primary PCI for STEMI after Studies of primary PCI for STEMI after

resuscitated cardiac arrest:resuscitated cardiac arrest:•• 7 studies, 458 patients; successful 7 studies, 458 patients; successful

PCI in 89%PCI in 89%•• 66% survival, 58% neuro recovery66% survival, 58% neuro recovery•• Lower survival / recovery in Lower survival / recovery in

comatose patientscomatose patients•• PCI also performed in 34 patients PCI also performed in 34 patients

undergoing active resuscitationundergoing active resuscitation•• 88% success, 41% survival88% success, 41% survival

Noc and Radsel, Curr Op Crit Care 2008

PCI for STEMI after ResuscitationPCI for STEMI after Resuscitation

Gorjup et al, Resuscitation 2007

OROR 95% CI95% CI

Time from Arrest to 1Time from Arrest to 1stst

Responder (per min)Responder (per min) 0.67 0.54-0.84

ROSC time (per 10 min)ROSC time (per 10 min) 0.43 0.25-0.66

Absence of ShockAbsence of Shock 12.66 3.39-47.62

Absence of DiabetesAbsence of Diabetes 7.30 1.80-29.41

Absence of prior PCIAbsence of prior PCI 10.99 1.65-71.43

Correlates of 6Correlates of 6--Month Survival in STEMI Month Survival in STEMI Patients With Cardiac ArrestPatients With Cardiac Arrest

Garot et al, Circulation 2007

186 PCI patients; overall survival 54%

Outcomes in STEMI Patients with Outcomes in STEMI Patients with Cardiac Arrest (n=98)Cardiac Arrest (n=98)

96% 96%93%

71%

44% 39%

0

25

50

75

100

Alert (n=25)Minimally Responsive (n=14)Unresponsive (n=59)

Survival Full Neurologic Recovery

Hosmane et al, JACC 2009

OROR 95% CI95% CI pp

Neurologic StatusNeurologic Status

AlertAlert - - -

Min ResponsiveMin Responsive 2.1 0.1-68.1 0.69

UnresponsiveUnresponsive 47.8 3.3-549.1 0.004ROSC time (per 10 min)ROSC time (per 10 min) 2.8 1.5-5.7 0.002Age (per 5Age (per 5--yr)yr) 1.3 1.1-1.7 0.009Female GenderFemale Gender 5.9 1.2-30.1 0.034

Correlates of Death in STEMI Patients Correlates of Death in STEMI Patients Following Cardiac Arrest (n=98)Following Cardiac Arrest (n=98)

Hosmane et al, JACC 2009

Patients arresting in ED had better survival and neurologic recovery than out-of-hospital arrest patients

Combining Hypothermia and PCI for Combining Hypothermia and PCI for Cardiac Arrest Patients with STEMICardiac Arrest Patients with STEMI•• Can be accomplished with minimal Can be accomplished with minimal

increases in doorincreases in door--balloon timesballoon times•• Requires regimented protocols and buyRequires regimented protocols and buy--

in / cooperation between ED, Cath Lab, in / cooperation between ED, Cath Lab, ICU units / staffICU units / staff

•• No differences in inNo differences in in--hospital hospital complications with a trend toward complications with a trend toward improved outcomes (vs. historical improved outcomes (vs. historical controls in 3 published studies)controls in 3 published studies)

Wolfrum et al, Crit Care Med 2008Knafelj et al, Resuscitation 2007Sunde et al, Resuscitation 2007

“COOL-IT” Outcomes

Abbott Northwestern Hospital 53/96 55.2%

• Survival by initial rhythm– VF/VT: 47/75 62.6%– PEA/Asystole: 5/19 26.3%

• Survival by diagnosis

– Other: 20/46 43.5%– STEMI: 33/50 66.0%

Alive at hospital discharge with favourable neurological recovery

Mooney, TCT 2008

CPC Comparison

42.1%

2.6%

13.2%

42.1%

50.0%

10.0%

2.5%

37.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

CPC 1 CPC 2 CPC 3 Death

% o

f pat

ient

s

Pre n=38Post n=40

Pre and Post Cool-It program

Mooney, TCT 2008

COOLCOOL--MI MI –– A Negative TrialA Negative Trial•• Preliminary data has suggested that Preliminary data has suggested that

systemic cooling has the potential to systemic cooling has the potential to reduce infarct size (animal models of reduce infarct size (animal models of ischemia/reperfusion)ischemia/reperfusion)

•• Endovascular cooling to 33Endovascular cooling to 33ºº for 3 hrs was for 3 hrs was tested in a 357 patient randomized trialtested in a 357 patient randomized trial

•• 94% of patients tolerated the cooling94% of patients tolerated the cooling•• No difference in SPECTNo difference in SPECT--measured infarct measured infarct

size, ?possible trends in anterior size, ?possible trends in anterior infarctioninfarction

O’Neill et al, TCT 2003

What About What About FibrinolyticFibrinolytic TherapyTherapy(post(post--TROICA)?TROICA)?

•• Riskier to implement many successful Riskier to implement many successful hemodynamichemodynamic diagnostic / therapeutic diagnostic / therapeutic maneuvers after maneuvers after lyticslytics are givenare given

•• Worries about use in cardiac arrest Worries about use in cardiac arrest patients (particularly prolonged CPR)patients (particularly prolonged CPR)

•• In a nonIn a non--randomized study of 147 STEMI randomized study of 147 STEMI patients with VF arrest (101 treated with patients with VF arrest (101 treated with fibrinolysisfibrinolysis and 47 treated wit primary and 47 treated wit primary PCI), there were similar outcomes with PCI), there were similar outcomes with both strategies, which is reassuringboth strategies, which is reassuring

Richling et al, Am J Emerg Med 2007

PCI During Cardiac Arrest

• Gas-driven sternalcompression device with suction cup (LUCAS)• PCI feasible in 13 pts with arrest or severe hypotension / bradycardia; mean BP 81/34 mmHg

Larsen et al, Resuscitation 2007

PCI Using PCI Using HemodynamicHemodynamic Support Support

Ao Tracing

Impella 2.5 Device duringLMCA Dissection

Cardiac Cardiac CathCath Lab Lab ≠≠ Always a Always a StentStent!!!!!!•• Distinction between diagnostic and Distinction between diagnostic and

interventional interventional cathcath proceduresprocedures•• Diagnostic:Diagnostic:

HemodynamicHemodynamic evaluationevaluation•• Right heart catheterization / shunt evaluationRight heart catheterization / shunt evaluation•• Left heart catheterizationLeft heart catheterization•• Simultaneous LV/PCWP, LV/RVSimultaneous LV/PCWP, LV/RV

Left Left ventriculographyventriculography (ability to identify (ability to identify structural defects)structural defects)Coronary angiographyCoronary angiographyAortographyAortography

Cardiac Cardiac CathCath Lab Lab ≠≠ Always a Always a StentStent!!!!!!•• Interventional Procedures:Interventional Procedures:

PercutaneousPercutaneous coronary interventioncoronary interventionIABP, IABP, hemodynamichemodynamic supportsupport•• TandemHeartTandemHeart•• ImpellaImpella

PressorPressor/Vasodilator titration/Vasodilator titrationTemporary pacemaker (Ventricular, Temporary pacemaker (Ventricular, CS/Ventricular)CS/Ventricular)PericardiocentesisPericardiocentesisPulmonary Pulmonary EmbolectomyEmbolectomyRapid access to other subspecialtiesRapid access to other subspecialties•• EP, CHF Team, CT SurgeryEP, CHF Team, CT Surgery

SummarySummary•• A significant proportion of patients with A significant proportion of patients with

cardiac arrest (especially VT/VF) have cardiac arrest (especially VT/VF) have coronary occlusion or significant coronary occlusion or significant coronary artery diseasecoronary artery disease

•• There are clear data supporting primary There are clear data supporting primary PCI for STEMI (acute coronary PCI for STEMI (acute coronary occlusion), a major cause of VT/VFocclusion), a major cause of VT/VF

•• Cardiac catheterization has other Cardiac catheterization has other benefits, including making a diagnosis / benefits, including making a diagnosis / further triage / further triage / hemodynamichemodynamic supportsupport

Summary (2)Summary (2)•• An early invasive strategy is preferred for An early invasive strategy is preferred for

patients with nonpatients with non--STST--elevation acute elevation acute coronary syndromes, but the timing may coronary syndromes, but the timing may be less urgentbe less urgent

•• Patients with significant Patients with significant ““stable ischemic stable ischemic CADCAD”” can benefit from revascularization, can benefit from revascularization, typically on an urgent / elective basistypically on an urgent / elective basis

•• The key question is whether all (or The key question is whether all (or selected) cardiac arrest patients should selected) cardiac arrest patients should undergo emergent angiography and/or undergo emergent angiography and/or PCI if indicatedPCI if indicated

ConclusionsConclusions•• Integrated systems of care are being Integrated systems of care are being

implemented with success for patients implemented with success for patients with STEMI (primary PCI) as well as for with STEMI (primary PCI) as well as for cardiac arrest patients (hypothermia cardiac arrest patients (hypothermia protocols)protocols)

•• The overlap between these two areas is The overlap between these two areas is significant, and it makes sense to significant, and it makes sense to coordinate effortscoordinate efforts

•• Angiography / catheterization is likely Angiography / catheterization is likely underutilized in arrest patients and ought underutilized in arrest patients and ought to be considered 1to be considered 1stst line care for VT/VFline care for VT/VF