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Review
. 2023 Nov 24;12(23):7275.
doi: 10.3390/jcm12237275.

Percutaneous Coronary Intervention in Out-of-Hospital Cardiac Arrest Related to Acute Coronary Syndrome: A Literature Review

Emmanuel Gall  1   2 , Donia Mafi  1 , Tahar Ghannam  1 , Pierre Brami  1 , Vincent Pham  1 , Olivier Varenne  1 , Fabien Picard  1
Affiliations
Review

Percutaneous Coronary Intervention in Out-of-Hospital Cardiac Arrest Related to Acute Coronary Syndrome: A Literature Review

Emmanuel Gall et al. J Clin Med. .

Abstract

Out-of-hospital cardiac arrest (OHCA) continues to be a major global cause of death, affecting approximately 67 to 170 per 100,000 inhabitants annually in Europe, with a persisting high rate of mortality of up to 90% in most countries. Acute coronary syndrome (ACS) represents one of the most significant cause of cardiac arrest, and therefore invasive coronary angiography (CAG) with subsequent percutaneous coronary intervention (PCI) has emerged as a fundamental component in the management of OHCA patients. Recent evidence from large randomized controlled trials (RCTs) challenges the routine use of early CAG in the larger subgroup of patients with non-ST segment elevation myocardial infarction (NSTEMI). Additionally, emerging data suggest that individuals resuscitated from OHCA related to ACS face an elevated risk of thrombotic and bleeding events. Thus, specific invasive coronary strategies and anti-thrombotic therapies tailored to this unique setting of OHCA need to be considered for optimal in-hospital management. We sought to provide an overview of the prevalence and complexity of coronary artery disease observed in this specific population, discuss the rationale and timing for CAG after return of spontaneous circulation (ROSC), summarize invasive coronary strategies, and examine recent findings on antithrombotic therapies in the setting of ACS complicated by OHCA. By synthesizing the existing knowledge, this review aims to contribute to the understanding and optimization of care for OHCA patients to improve outcomes in this challenging clinical scenario.

Keywords: NSTEMI; PCI; STEMI; bleeding; invasive coronary angiogram; ischemic; out-of-hospital cardiac arrest.

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Conflict of interest statement

F.P. reports research, consulting, and speaking fees from Astra-Zeneca, Bayer, BBraun, Boehringer-Ingelheim, Biotronik, BMS-Pfizer Alliance, Boston Scientific, Servier, and Sanofi outside the submitted work. O.V. reports personal fees from Boston Scientific, Biotronik, and Abbott Vascular. The authors declare that they have no competing interests.

Figures

Figure 4
Figure 4
Balance between ischemic and bleeding risk in OHCA patients and further implication for anti-thrombotic regimen. Abbreviations: ACS: acute coronary syndrome; ACT: activated clotting time; I.V.: intravenous; NGT: nasogastric tube; OHCA: out-of-hospital cardiac arrest; PCI: percutaneous coronary intervention; TTM: targeted temperature management; UFH: unfractionated heparin.
Figure 1
Figure 1
Impactful randomized clinical trials on early vs. delayed CAG in OHCA patients without ST elevation on electrocardiogram and current international guidelines. Abbreviations: COACT: coronary angiography after cardiac arrest without ST-segment elevation; DISCO: direct or subacute coronary angiography in out-of-hospital cardiac arrest; EMERGE: emergency vs. delayed coronary angiogram in survivors of out-of-hospital cardiac arrest; ERC: European Resuscitation Council; ESC: European Society of Cardiology; NSTEMI: non ST-segment elevation myocardial infarction; PEARL: randomized pilot clinical trial of early coronary angiography versus non-early coronary angiography after cardiac arrest without ST-segment elevation; TOMAHAWK: angiography after out-of-hospital cardiac arrest without ST-segment elevation.
Figure 2
Figure 2
Proposed algorithm for management of patients based on angiographic findings on CAG. Abbreviations: CABG: coronary artery bypass graft; CAD: coronary artery disease; CAG: coronary angiography; CS: cardiogenic shock; FFR: fractional flow reserve; OCT: optical coherence tomography; PCI: percutaneous coronary intervention; VA-ECMO: venoarterial extracorporeal membrane oxygenation.
Figure 3
Figure 3
Role of intracoronary imaging in OHCA patients. Abbreviations: PCI: percutaneous coronary intervention.
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