Editor’s 2024 Top 10: Acute Coronary Occlusion and Percutaneous Coronary Intervention After Out-of-Hospital Cardiac Arrest

JIC catches up with Dr Dhruv Sarma about his Editor’s 2024 Top 10 article, “Acute Coronary Occlusion and Percutaneous Coronary Intervention After Out-of-Hospital Cardiac Arrest”.

Transcript:

Thank you so much for the opportunity to speak today. My name is Dr Dhruv Sarma. I am currently a 1st year cardiology fellow at Vanderbilt University Medical Center, and I completed my Internal Medicine Residency at Mayo Clinic, in Rochester, Minnesota, which is where I worked on this on this study as a medicine resident.

00:30: Could you please describe what inspired your group to conduct this study?

Absolutely. Outcomes for patients with out-of-hospital cardiac arrest and cardiogenic shock are very poor, and this is a notoriously difficult area of medicine to study in terms of randomized evidence and also retrospective evidence. And so, really, our study was motivated by the need, the clinical need in these patients to have more informed clinical decision making and research, and also some of my experiences as a resident and fellow in the CCU trying to take care of these patients.

1:14: What were the main findings of this study?

So, we studied 155 patients with out-of-hospital cardiac arrest who underwent early coronary angiography. We essentially aimed to correlate ECG findings and troponin values with findings on coronary angiography. And the first important finding is that ST-elevation is neither specific nor sensitive for acute coronary occlusion in patients with cardiac arrest who actually were selected to go for early coronary angiography. And also, the troponin elevation was equally a very nonspecific finding in this population, which raises the question and really motivates us to think about more accurate tests to identify patients who would benefit from coronary angiography to identify an acutely occluded coronary artery.

We also found that successful PCI in patients in our study was associated with improved outcomes. Now this is perhaps in contradistinction to randomized control trials which have failed to show the benefit of routine coronary angiography in patients with out-of-hospital cardiac arrest who are hemodynamically stable. But those studies have really been affected by a number of issues, including the high prevalence of neurological death in those populations, and also the low prevalence of acute coronary occlusion. Again, bringing us back to this idea of how do we find the right patient to undergo coronary angiography? And if we can, then maybe early coronary angiography would be beneficial in that subset of patients.

2:57: What do you see as the most important clinical implications of your study?

So as a CCU fellow, or a cardiology fellow, or an attending who is taking a call and looking at an ECG in a patient with out-of-hospital cardiac arrest, what we really look for is ST-elevation as the first decision point to take someone to the lab. I think our study reinforces the fact that ST-elevation can be nonspecific and also not sensitive for acute coronary occlusion in these patients. We don't really have a better method of triaging at the moment, but I think that that message should be disseminated, and people should be aware of that when they're looking at these ECGs and taking care of these patients.

And also, I think, you know, really coming back to the fact that there are trials out there, and there's guidelines out there, but really focusing on the patient in front of you and making a clinical decision about whether an early trip to the cath lab is worth it or not remains important because our tests right now don't have the ability to really accurately identify the patients who have an acutely occluded coronary artery, particularly in those patients with shockable rhythms, you know, a high index of suspicion should be maintained. And the question is that in those appropriately selected patients, there still may be a benefit to early angiography, even without the presence of ST-elevation.

4:28: Is your group working on any more research in this area? And what do you see as the next steps for this space?

Our group and my focus has shifted somewhat to cardiogenic shock and the prevalence of out-of-hospital cardiac arrest in patients with cardiogenic shock is also incredibly high. So really, my focus is trying to identify the best way to take care of that overlapping subset of patients, cardiac arrest and cardiogenic shock, whether that's to do with mechanical circulatory support, or how to identify the risk of brain injury and severe brain injury as a competing etiology for death in these patients.

Really, with the big aim of how do we allocate resources efficiently? How do we discuss the prognosis with family and loved ones? And how do we make the best decisions at time-critical points in the first 24 to 48 hours of their journey with us in the hospital. And I think the next big space or big frontier in this journey is identifying acute coronary occlusion in a more sensitive way, and I would be very interested to see what comes through in that space in the next few months and years.