Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Department of Emergency Medicine, Reading Hospital, Reading, Pennsylvania, USA.
Acad Emerg Med. 2022 Apr;29(4):456-464. doi: 10.1111/acem.14416. Epub 2021 Dec 1.
Out-of-hospital cardiac arrest (OHCA) afflicts >350,000 people annually in the United States. While postarrest coronary angiography (CAG) with percutaneous coronary intervention (PCI) has been associated with improved survival in observational cohorts, substantial uncertainty exists regarding patient selection for postarrest CAG. We tested the hypothesis that symptoms consistent with acute coronary syndrome (ACS), including chest discomfort, prior to OHCAs are associated with significant coronary lesions identified on postarrest CAG.
We conducted a multicenter retrospective cohort study among eight regional hospitals. Adult patients who experienced atraumatic OHCA with successful initial resuscitation and subsequent CAG between January 2015 and December 2019 were included. We collected data on prehospital documentation of potential ACS symptoms prior to OHCA as well as clinical factors readily available during postarrest care. The primary outcome in multivariable regression modeling was the presence of significant coronary lesions (defined as >50% stenosis of left main or >75% stenosis of other coronary arteries).
Four-hundred patients were included. Median (interquartile range) age was 59 (51-69) years; 31% were female. At least one significant stenosis was found in 62%, of whom 71% received PCI. Clinical factors independently associated with a significant lesion included a history of myocardial infarction (adjusted odds ratio [aOR] = 6.5, [95% confidence interval {CI} = 1.3 to 32.4], p = 0.02), prearrest chest discomfort (aOR = 4.8 [95% CI = 2.1 to 11.8], p ≤ 0.001), ST-segment elevations (aOR = 3.2 [95% CI = 1.7 to 6.3], p < 0.001), and an initial shockable rhythm (aOR = 1.9 [95% CI = 1.0 to 3.4], p = 0.05).
Among survivors of OHCA receiving CAG, history of prearrest chest discomfort was significantly and independently associated with significant coronary artery lesions on postarrest CAG. This suggests that we may be able to use prearrest symptoms to better risk stratify patients following OHCA to decide who will benefit from invasive angiography.
在美国，每年有超过 35 万人发生院外心脏骤停（OHCA）。虽然事后冠状动脉造影（CAG）联合经皮冠状动脉介入治疗（PCI）已被观察性队列研究证实与生存率提高相关，但对于事后 CAG 的患者选择仍存在较大的不确定性。我们检验了一个假设，即在 OHCA 发生前存在符合急性冠状动脉综合征（ACS）的症状（包括胸痛）的患者，其在事后 CAG 中发现的冠状动脉病变显著。
我们进行了一项在 8 家地区医院开展的多中心回顾性队列研究。纳入 2015 年 1 月至 2019 年 12 月期间经历无创伤性 OHCA 且初始复苏成功并随后接受 CAG 的成年患者。我们收集了 OHCA 前院前记录的潜在 ACS 症状以及事后复苏期间可获得的临床因素的数据。多变量回归模型中的主要结局是存在显著的冠状动脉病变（定义为左主干>50%狭窄或其他冠状动脉>75%狭窄）。
共纳入 400 例患者。中位（四分位间距）年龄为 59（51-69）岁；31%为女性。62%的患者至少存在一处狭窄，其中 71%接受了 PCI。与显著病变独立相关的临床因素包括心肌梗死史（校正优势比[OR]为 6.5，95%置信区间[CI]为 1.3 至 32.4]，p=0.02）、事后复苏前胸痛（OR 为 4.8[95%CI 为 2.1 至 11.8]，p≤0.001）、ST 段抬高（OR 为 3.2[95%CI 为 1.7 至 6.3]，p<0.001）和初始可除颤节律（OR 为 1.9[95%CI 为 1.0 至 3.4]，p=0.05）。
在接受 CAG 的 OHCA 幸存者中，事后复苏前胸痛的病史与事后 CAG 中的显著冠状动脉病变显著且独立相关。这表明我们可能能够使用事后前的症状更好地对 OHCA 后患者进行风险分层，以确定谁将从血管造影术获益。
