Pechmajou Louis, Marijon Eloi, Varenne Olivier, Dumas Florence, Beganton Frankie, Jost Daniel, Lamhaut Lionel, Lecarpentier Eric, Loeb Thomas, Agostinucci Jean-Marc, Sideris Georgios, Riant Elisabeth, Baudinaud Pierre, Hagege Albert, Bougouin Wulfran, Spaulding Christian, Cariou Alain, Jouven Xavier, Karam Nicole
Université de Paris, PARCC, INSERM, F-75015 Paris, France (L.P., E.M., O.V., F.D., F.B., L.L., P.B., W.B., A.C., X.J., N.K.).
Cardiology Department, European Hospital Georges Pompidou, Paris, France (L.P., E.M., E.R., P.B., A.H., C.S., X.J., N.K.).
Circ Cardiovasc Interv. 2020 Sep;13(9):e009181. doi: 10.1161/CIRCINTERVENTIONS.119.009181. Epub 2020 Sep 8.
Conflicting data exist regarding the benefit of urgent coronary angiogram and percutaneous coronary intervention (PCI) after sudden cardiac arrest, particularly in the absence of ST-segment elevation. We hypothesized that the type of lesions treated (stable versus unstable) influences the benefit derived from PCI.
Data were taken between May 2011 and 2014 from a prospective registry enrolling all sudden cardiac arrest in Paris and suburbs (6.7 million inhabitants). Patients undergoing emergent coronary angiogram were included. Decision to perform PCI was left to the discretion of local teams. We assessed the impact of emergent PCI on survival at discharge according to whether the treated lesion was angiographically unstable or stable, and we investigated the predictive factors for unstable coronary lesions.
Among 9265 sudden cardiac arrests occurring during the study period, 1078 underwent emergent coronary angiogram (median age: 59.6 years, 78.3% males): 463 (42.9%) had an unstable lesion, 253 (23.5%) only stable lesions, and 362 (33.6%) no significant lesions. Emergent PCI was performed in 478 patients (91.4% of unstable and 21.7% of stable lesions). At discharge, PCI of unstable lesions was associated with twice-higher survival rate compared with untreated unstable lesions (47.9% versus 25.6%, =0.013), while stable lesions PCI did not improve survival (25.5% versus 26.3%, =1.00). After adjustment, PCI of unstable coronary lesions was independently associated with improved survival (odds ratio, 2.09 [95% CI, 1.42-3.09], <0.001), contrary to PCI of stable lesions (odds ratio, 0.92 [95% CI. 0.44-1.87], =0.824). Angina, initial shockable rhythm, ST-segment elevation, and absence of known coronary artery disease were independent predictors of unstable lesions.
Emergent PCI of unstable lesions is associated with improved survival after sudden cardiac arrest, contrary to PCI of stable lesions. Accordingly, early PCI should only be performed in patients with unstable lesions. Four factors (chest pain, ST-elevation, absence of coronary artery disease history, and shockable initial rhythm) could help identify patients with unstable lesions who would, therefore, benefit from emergent coronary angiogram.
关于心脏骤停后紧急冠状动脉造影和经皮冠状动脉介入治疗（PCI）的益处，存在相互矛盾的数据，尤其是在无ST段抬高的情况下。我们假设所治疗病变的类型（稳定型与不稳定型）会影响PCI带来的益处。
数据取自2011年5月至2014年期间一项前瞻性登记研究，该研究纳入了巴黎及其郊区（670万居民）所有心脏骤停患者。纳入接受紧急冠状动脉造影的患者。是否进行PCI由当地团队自行决定。我们根据所治疗病变在血管造影上是否不稳定或稳定，评估了紧急PCI对出院生存率的影响，并研究了不稳定冠状动脉病变的预测因素。
在研究期间发生的9265例心脏骤停患者中，1078例接受了紧急冠状动脉造影（中位年龄：59.6岁，男性占78.3%）：463例（42.9%）有不稳定病变，253例（23.5%）仅有稳定病变，362例（33.6%）无明显病变。478例患者接受了紧急PCI（不稳定病变患者中的91.4%，稳定病变患者中的21.7%）。出院时，与未治疗的不稳定病变相比，不稳定病变的PCI与两倍高的生存率相关（47.9%对25.6%，P=0.013），而稳定病变的PCI并未提高生存率（25.5%对26.3%，P=1.00）。调整后，不稳定冠状动脉病变的PCI与生存率提高独立相关（比值比，2.09[95%CI，1.42 - 3.09]，P<0.001），与稳定病变的PCI相反（比值比，0.92[95%CI，0.44 - 1.87]，P=0.824）。心绞痛、初始可电击心律、ST段抬高以及无已知冠状动脉疾病是不稳定病变的独立预测因素。
与稳定病变的PCI相反，不稳定病变的紧急PCI与心脏骤停后生存率提高相关。因此，早期PCI应仅在有不稳定病变的患者中进行。四个因素（胸痛、ST段抬高、无冠状动脉疾病史以及可电击的初始心律）有助于识别有不稳定病变的患者，这些患者将因此从紧急冠状动脉造影中获益。
