Circulation. 2019 Mar 19;139(12):e530-e552. doi: 10.1161/CIR.0000000000000630.
Coronary artery disease is prevalent in different causes of out-of-hospital cardiac arrest (OHCA), especially in individuals presenting with shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). The purpose of this report is to review the known prevalence and potential importance of coronary artery disease in patients with OHCA and to describe the emerging paradigm of treatment with advanced perfusion/reperfusion techniques and their potential benefits on the basis of available evidence. Although randomized clinical trials are planned or ongoing, current scientific evidence rests principally on observational case series with their potential confounding selection bias. Among patients resuscitated from VF/pVT OHCA with ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 70% to 85%. More than 90% of these patients have had successful percutaneous coronary intervention. Conversely, among patients resuscitated from VF/pVT OHCA without ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 25% to 50%. For these patients, early access to the cardiac catheterization laboratory is associated with a 10% to 15% absolute higher functionally favorable survival rate compared with more conservative approaches of late or no access to the cardiac catheterization laboratory. In patients with VF/pVT OHCA refractory to standard treatment, a new treatment paradigm is also emerging that uses venoarterial extracorporeal membrane oxygenation to facilitate return of normal perfusion and to support further resuscitation efforts, including coronary angiography and percutaneous coronary intervention. The burden of coronary artery disease is high in this patient population, presumably causative in most patients. The strategy of venoarterial extracorporeal membrane oxygenation, coronary angiography, and percutaneous coronary intervention has resulted in functionally favorable survival rates ranging from 9% to 45% in observational studies in this patient population. Patients with VF/pVT should be considered at the highest severity in the continuum of acute coronary syndromes. These patients have a significant burden of coronary artery disease and acute coronary thrombotic events. Evidence from randomized trials will further define optimal clinical practice.
冠心病在院外心脏骤停 (OHCA) 的不同病因中较为常见，尤其是在出现室颤/无脉性室性心动过速 (VF/pVT) 可电击性节律的患者中。本报告的目的是回顾 OHCA 患者中已知的冠心病患病率和潜在重要性，并描述基于现有证据，使用先进的灌注/再灌注技术的新兴治疗模式及其潜在益处。尽管正在计划或进行随机临床试验，但目前的科学证据主要基于具有潜在混杂选择偏倚的观察性病例系列。在复苏后心电图上出现 ST 段抬高的 VF/pVT OHCA 患者中，冠心病的患病率已显示为 70%至 85%。这些患者中超过 90%接受了成功的经皮冠状动脉介入治疗。相反，在复苏后心电图上无 ST 段抬高的 VF/pVT OHCA 患者中，冠心病的患病率已显示为 25%至 50%。对于这些患者，与更保守的晚期或无心脏导管插入术实验室的方法相比，早期进入心脏导管插入术实验室与 10%至 15%的绝对更高的功能良好生存率相关。对于对标准治疗有反应的 VF/pVT OHCA 患者，也出现了一种新的治疗模式，即使用静脉动脉体外膜肺氧合来促进正常灌注的恢复，并支持进一步的复苏努力，包括冠状动脉造影和经皮冠状动脉介入治疗。在这种患者人群中，冠心病的负担很高，在大多数患者中可能是病因。在该患者人群的观察性研究中，静脉动脉体外膜肺氧合、冠状动脉造影和经皮冠状动脉介入治疗的策略导致功能良好的生存率从 9%到 45%不等。VF/pVT 患者应被视为急性冠状动脉综合征连续体中最严重的患者。这些患者有冠心病和急性冠状动脉血栓事件的高负担。随机试验的证据将进一步确定最佳临床实践。
