Quinn, Tom

Tom Quinn

Crossref

Resuscitation

Where do I take my patient post ROSC in the absence of ST elevation on the ECG?

Kingston University Research Repository

Accepted ManuscriptTitle: Where do I take my patient post ROSC in the absence ofST elevation on the ECG?Author: Tom QuinnPII: S0300-9572(17)30128-4DOI: http://dx.doi.org/doi:10.1016/j.resuscitation.2017.03.027Reference: RESUS 7119To appear in: ResuscitationPlease cite this article as: Quinn Tom.Where do I take my patientpost ROSC in the absence of ST elevation on the ECG?.Resuscitationhttp://dx.doi.org/10.1016/j.resuscitation.2017.03.027This is a PDF file of an unedited manuscript that has been accepted for publication.As a service to our customers we are providing this early version of the manuscript.The manuscript will undergo copyediting, typesetting, and review of the resulting proofbefore it is published in its final form. Please note that during the production processerrors may be discovered which could affect the content, and all legal disclaimers thatapply to the journal pertain.Where do I take my patient post ROSC in the absence of ST elevation on the ECG?   Professor Tom Quinn FRCN FESC FAHA FACC Centre for Health and Social Care Research, Faculty of Health, Social Care and Education,Kingston University and St George’s, University of London, London, UK   Email t.quinn@sgul.kingston.ac.uk  Twitter: proftomquinn   Two decades ago Spaulding and colleagues from Paris reported angiographic findings from a small observational series of 84 initial survivors of cardiac arrest who were taken directly to the cardiac catheter laboratory.[1]  A significant proportion (48%) had ‘clinically significant’ coronary disease at angiography, which is perhaps unsurprising given longstanding assumptions that the aetiology of the majority of OHCAS is coronary disease. Since that time, efforts have been made to identify treatments used routinely  in management of the acute coronary patient without OHCA, which could be administered to the advantage of those who have sustained cardiac arrest. The TROICA investigators, for example, hypothesised that prompt administration of the fibrinolytic agent tenecteplase by prehospital clinicians might improve survival from refractory OHCA where massive pulmonary embolism was excluded as the provoking insult. [2] Unfortunately, this trial was terminated early because of funding difficulties, and the research question remains unanswered.  Where an OHCA patient has regained spontaneous circulation and presents with ST elevation (STEMI) on the 12 lead electrocardiogram (ECG), decisions in contemporary practice appear straightforward: guidelines recommend that such patients should be taken immediately to the catheter laboratory even if comatose.[3,4]  This of course depends on the availability of a health system with capability for rapid decision making and transportation to a hospital with facilities and personnel to effect rapid angiography and intervention if required. In many Western countries regional ‘heart attack centres’ act as the hub of such systems. The American Heart Association has also recommended regionalisation of care for OHCA in ‘cardiac arrest centres’.[5] This seems sensible, certainly for those with STEMI (and accepting that addressing the coronary anatomy is but one component of high quality post-resuscitation care).   But what to do for those who present without ST elevation? While there is a growing volume of observational data, mostly suggesting an association with improved outcome and transport to a cardiac arrest centre, there are to date no high quality randomised trials. Millin et al undertook a systematic review of 11 observational studies (all but one of which were retrospective in design) and concluded that patients with STEMI post-ROSC were thirteen times more likely to be taken directly to the catheter laboratory than those without. In those without ST elevation who did undergo emergency angiography, a third had an acute culprit lesion warranting angioplasty (compared to almost 80% for those with STEMI). [6] Conducting trials in the prehospital care setting is challenging, and conducting a trial spanning both prehospital and (largely) tertiary cardiological communities even more so, particularly when exposure of individual paramedics to the condition of interest is infrequent. [7] It is therefore crucial, to avoid waste of resources and unnecessary burden on trial participants, that any proposed trial is designed and conducted based on the lessons learnt from conducting a pilot study of the feasibility of such a trial succeeding (i.e. recruiting sufficient patients to answer the research question with a high degree of certainty; protocol compliance to preserve integrity and trust in study findings, etc). [8] In this issue, Patterson and colleagues from London, UK, report a pilot randomised trial of expedited transfer to the catheter laboratory of initial survivors of witnessed OHCA where the presenting rhythm was ventricular fibrillation.[9]  The purpose of this study was to assess the feasibility of conducting a larger trial, powered for outcomes that will be important to patients; thus, it is not possible to draw any conclusions from the clinical outcomes presented in the report. Of 118 patients screened by emergency medical service (EMS) personnel, 63 met study eligibility criteria and 40 (63%) of these were randomised. Follow up for the primary and secondary outcomes was acceptable at 83%, suggesting completion of the full trial is feasible with modification e.g. using national administrative datasets (NHS Digital) to increase follow up rates. The full trial has now been registered [ISRCTN 96585404] and within the next two or three years we will, for the first time, have high level evidence on this important question for patients, clinicians, and those who plan and fund our health systems.   Conflict of interest statement No conflicts of interest to declare.  References  1. Spaulding C, Jolly L, Rosenberg A et al. Immediate coronary angiography in survivors of out of hospital cardiac arrest. N Engl J Med 1997;336:1629-33 2. Bottiger B, Arnts H, Chamberlain D et al. Thrombolysis during resuscitation for out of hospital cardiac arrest. N Engl J Med 2008;359:2651-62 3. O’Gara P, Kushner F, Ascheim D et al. 2013 guideline for the management of ST elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013;127:e362-425 4. National Institute for Health and Care Excellence. The acute management of myocardial infarction with ST segment elevation. National Institute for Health and Care Excellence; London. 2013 5. Nichol G, Aufterheide T, Eigel B et al. Regional systems of care for out of hospital cardiac arrest: a policy statement from the American Heart Association. Circulation 2010;121:709-29 6. Millin M, Comer A, Nable J et al. Patients without ST elevation after return of spontaneous circulation may benefit from emergency percutaneous intervention: a systematic review and meta-analysis. Resuscitation 2016;108:54-60 7. Perkins G, Lall R, Quinn T et al. Mechanical versus manual chest compression for out of hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Lancet 2015;385:947-55 8. Eldridge S, Chan C, Campbell M et al. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. BMJ 2016:355:i5239 9. Patterson T, Perkins G, Joseph J et al. A randomised trial of expedited transfer to a cardiac arrest centre for non ST elevation ventricular fibrillation out of hospital cardiac arrest: the ARREST pilot randomised trial. Resuscitation [in press] 

http://eprints.kingston.ac.uk/37862/1/Quinn-T-37862-AAM.pdf

Where do I take my patient post ROSC in the absence of ST elevation on the ECG?

Abstract

Similar works

Full text

Available Versions

Crossref

Kingston University Research Repository