Angeletti Chiara, Ielasi Alfonso, Personeni Davide, Mamprin Filippo, Silvestro Antonio, Saino Antonio, Bertocchi Ester, Costalunga Alessandra, Keim Roberto, Tespili Maurizio
G Ital Cardiol (Rome). 2014 May;15(5):323-9. doi: 10.1714/1563.17035.
Therapeutic hypothermia (TH) is associated with improved neurologic outcomes in comatose survivors of out-of-hospital cardiac arrest (OHCA). There are currently limited data on the outcomes of patients presenting with resuscitated OHCA in the setting of acute myocardial infarction. The aim of this study was to assess the outcomes of comatose survivors of OHCA complicating acute myocardial infarction treated with primary percutaneous coronary intervention (PCI) and TH.
A retrospective cohort analysis was performed on all consecutive patients referred for primary PCI and TH between August 2008 and December 2013 in a single center. The primary endpoint was survival to hospital discharge with sufficient neurologic recovery (defined as Cerebral Performance Category score <2).
Among 886 consecutive patients referred for primary PCI, 24 were comatose survivors of OHCA complicating acute myocardial infarction. All these patients underwent primary PCI followed by TH. Median patient age was 59 (IQR 35-87) years and 11 (45.8%) patients had anterior ST-elevation myocardial infarction. Median OHCA-to-balloon time was 120 min (IQR 75-340) while median OHCA-to-TH initiation time was 250 min (IQR 180-310). Survival with sufficient neurologic recovery to enable discharge home was reached in 16 (66.7%) patients. Time between initiation of cardiopulmonary resuscitation (CPR) to return of spontaneous circulation (ROSC) <20 min was associated with a lower occurrence of death and poor neurologic outcome compared to CPR-to-ROSC time ≥20 min (15.4 vs 54.5%, p=0.05). The occurrence of major bleeding was 8.3%, while no stent thrombosis was reported.
TH in conjunction with primary PCI is feasible and associated with acceptable outcome in the majority of comatose survivors of OHCA complicating acute myocardial infarction, especially if CPR-to-ROSC time was <20 min. Randomized studies are needed to better assess the superiority of TH and primary PCI vs primary PCI alone in this complex subset of OHCA patients.
治疗性低温（TH）与院外心脏骤停（OHCA）昏迷幸存者神经功能改善相关。目前，关于急性心肌梗死情况下复苏成功的OHCA患者结局的数据有限。本研究旨在评估接受直接经皮冠状动脉介入治疗（PCI）和TH的急性心肌梗死合并OHCA昏迷幸存者的结局。
对2008年8月至2013年12月在单一中心接受直接PCI和TH的所有连续患者进行回顾性队列分析。主要终点是存活至出院且神经功能充分恢复（定义为脑功能分类评分<2）。
在886例接受直接PCI的连续患者中，24例为急性心肌梗死合并OHCA的昏迷幸存者。所有这些患者均接受了直接PCI，随后进行TH。患者中位年龄为59岁（四分位间距35 - 87岁），11例（45.8%）患者为前壁ST段抬高型心肌梗死。OHCA至球囊扩张的中位时间为120分钟（四分位间距75 - 340分钟），而OHCA至开始TH的中位时间为250分钟（四分位间距180 - 310分钟）。存活且神经功能充分恢复得以出院的患者有16例（66.7%）。与心肺复苏（CPR）至自主循环恢复（ROSC）时间≥20分钟相比，CPR至ROSC时间<20分钟与较低的死亡率和不良神经功能结局相关（15.4%对54.5%，p = 0.05）。大出血发生率为8.3%，未报告支架血栓形成。
TH联合直接PCI是可行的，并且在大多数急性心肌梗死合并OHCA的昏迷幸存者中具有可接受的结局，尤其是CPR至ROSC时间<20分钟时。需要进行随机研究以更好地评估在这一复杂的OHCA患者亚组中，TH联合直接PCI与单纯直接PCI相比的优势。
