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A new study has identified factors that predict poor long-term survival in patients who have survived a cardiac arrest and are being considered for coronary angiography.
Patients who were older than 85 years, had nonshockable rhythm, and who required more than 30 minutes to return to spontaneous circulation (ROSC), had a poor long-term prognosis, as did patients who had at least six of several unfavorable features, such as no bystander cardiopulmonary resuscitation, lactate levels above 7 mmol/L, unwitnessed arrest, pH below 7.2, and chronic kidney disease.
For both groups, the chance of survival to hospital discharge was 10% or less.
The results, from an analysis of more than 2500 resuscitated cardiac arrest patients, were published in the February 2 issue of the Journal of the American College of Cardiology.
“Delaying or even forgoing invasive procedures in such patients is reasonable,” write lead author, Ahmed A. Harhash, MD, University of Arizona Sarver Heart Center, Tucson, and colleagues.
“Obviously, if you only have one or two risk factors, you should go,” senior author Karl B. Kern, MD, Gordon A. Ewy MD Distinguished Endowed Chair of Cardiovascular Medicine, and professor at the University of Arizona at the Sarver Heart Center, told theheart.org | Medscape Cardiology. “But if you have six or seven, then you don’t go. It’s not worth it, it’s not going to help, and frankly, it’s just using resources that probably should not be used.”
This information will help clinicians make better decisions about who to send on to the cath lab, Kern said. “I’ve always been a big fan of going to cath post cardiac arrest because I think there’s real value, but I understand that it’s not for everybody,” he added.
The researchers used the International Cardiac Arrest Registry (INTCAR) to individually analyze the impact of the proposed “unfavorable features” on survival to hospital discharge in 2508 patients successfully resuscitated after cardiac arrest.
In total, 39% of patients survived to hospital discharge. The presence of any three or more unfavorable features predicted less than 40% survival.
The presence of the “big three” or strongest risk factors — age older than 85 years, nonshockable rhythm, and time to ROSC greater than 30 minutes — predicted a chance of survival of 10% or less, as did the presence of six or more unfavorable features.
| Odds Ratio (OR) of Survival to Hospital Discharge for Each Unfavorable Factor | ||
| Unfavorable factor | OR | 95% CI |
|---|---|---|
| Age >85 years | 0.30 | 0.15–0.61 |
| Time to ROSC >30 min | 0.30 | 0.23–0.39 |
| Nonshockable rhythm | 0.39 | 0.29–0.54 |
| No bystander cardiopulmonary resuscitation | 0.49 | 0.38–0.64 |
| Lactate >7 mmol/L | 0.50 | 0.40–0.63 |
| Unwitnessed arrest | 0.58 | 0.44–0.78 |
| pH <7.2 | 0.78 | 0.63–0.98 |
| Chronic kidney disease | 0.96 | 0.70–1.33 |
Age alone is not a contraindication to going to the cath lab, Kern noted.
“You could be old, but if everything else is okay, you should go,” he said. “I had a colleague whose father came in at 87. We took him, we fixed him, and he died 3 years later of cancer, but he had 3 great years. So just being old, alone, with no other risk factors, would not dissuade me. But if you’ve been told it had taken 40 minutes to get your pulse back, so they worked on you a long time, and it was nonshockable to start with, I’d have to say that your chances are not good. You’re not going to do well.”
Kern hopes that this new risk stratification will result in more trips to the cath lab, not fewer.
“I think a lot more people should be going to the cath lab than are going now,” he said. “There are a lot of reasons for this. For one thing, often times these cases occur in the middle of the night, and you get called, the patient is comatose, you don’t know how they are going to do and people are really afraid that they’re going to fix this patient’s heart for no reason because they’re going to be brain dead and die. But what we found out is that this is a self-fulfilling prophecy. If you don’t treat them aggressively, they won’t do well.”
Most of these patients should be given the option, he added. “This paper should help us understand the true subgroup that frankly shouldn’t go versus the vast majority who deserve a chance. My opinion has always been if you’re lucky enough to be resuscitated from out-of-hospital cardiac arrest, then you deserve a chance.”
Insightful Analysis
This analysis “is insightful and clinically relevant. It enables us to quantitatively weigh prognostic factors when considering emergent catheterization in victims of SCA, and is a strong platform from which to generate novel hypotheses for future studies,” write James P. Daubert, MD, Duke University School of Medicine, Durham, North Carolina; Joshua S. Lee, DO, Duke University School of Medicine, and Sanjiv M. Narayan, MD, PhD, Stanford University School of Medicine, California, in an accompanying Editorial Comment
The study is important for several reasons, Daubert told theheart.org | Medscape Cardiology.
“First, SCA is not declining as fast as other modes of cardiac death, and even seems to be increasing at present, related to patients not presenting in a timely manner due to the COVID-19 pandemic,” he said. “Second, the paper highlights that some patients have a very poor prognosis and are unlikely to benefit from aggressive measures.”
Third, he added, “although the overall survival is low, in patients presenting with VT/VF, some SCA is due to acute coronary events. Revascularization has been shown to be beneficial in such patients, so the risk factor stratification system put forward by Harhash et al can help with timely evaluation and intervention of those likely to benefit from emergent catheterization and where amenable, revascularization.”
Daubert reports that he has received honoraria for consultation from Abbott, Biosense, Biotronik, Boston Scientific, Microport, Farapulse, Phillips, Medtronic, and Vytronus; and has received research grants from Abbott and Medtronic. Kern discloses that he has served as a science advisory board member for Zoll Medical and Physio-Control, Inc., now part of Stryker, Inc.
J Am Coll Cardiol. 2021;77:360-371, 372-374. Full text, Editorial
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