Coronary angiography findings in patients with shock-resistant ventricular fibrillation cardiac arrest

Abstract

Introduction: Shock-resistant ventricular fibrillation (VF) poses a therapeutic challenge during out-of-hospital cardiac arrest (OHCA). For these patients, new treatment strategies are under active investigation, yet underlying trigger(s) and substrate(s) have been poorly characterised, and evidence on coronary angiography (CAG) data is often limited to studies without a control group.Methods: In our OHCA-registry, we studied CAG-findings in OHCA-patients with VF who underwent CAG after hospital arrival. We compared baseline demographics, arrest characteristics, CAG-findings and outcomes between patients with VF that was shock-resistant (defined as >3 shocks) or not shock-resistant ( 3 shocks).Results: Baseline demographics, arrest location, bystander resuscitation and AED-use did not differ between 105 patients with and 196 patients without shock-resistant VF. Shock-resistant VF-patients required more shocks, with higher proportions endotracheal intubation, mechanical CPR, amiodaron and epinephrine. In both groups, significant coronary artery disease (!1 stenosis >70%) was highly prevalent (78% vs. 77%, p = 0.76). Acute coronary occlusions (ACOs) were more prevalent in shock-resistant VF-patients (41% vs. 26%, p = 0.006). Chronic total occlusions did not differ between groups (29% vs. 33%, p = 0.47). There was an association between increasing numbers of shocks and a higher likelihood of ACO. Shockresistant VF-patients had lower proportions 24-h survival (75% vs. 93%, p < 0.001) and survival to discharge (61% vs. 78%, p = 0.002). Conclusion:In this cohort of OHCA-patients with VF and CAG after transport, acute coronary occlusions were more prevalent in patients with shockresistant VF compared to VF that was not shock-resistant, and their clinical outcome was worse. Confirmative studies are warranted for this potentially reversible therapeutic target.

Clinical Features and Outcomes Among Patients With Refractory Out-of-Hospital Cardiac Arrest and an Initial Shockable Rhythm

“…12,19 Notably, other studies with similar inclusion criteria have reported comparable rates of survival to discharge of ≈70% for all patients with OHCA and shockable rhythm, and 60% for those with refractory VF/pVT. 3,20…”

“…3 Patients in this cohort have prolonged low-flow duration, may never attain return of spontaneous circulation (ROSC), and have a heightened risk of short-term mortality in excess of 80% with equally adverse neurological outcomes. 2–4…”

“…2 Yet, more than half of the patients with a shockable rhythm remain in or have recurrent VF/pVT that is refractory to standard treatment with advanced cardiac life support. 3 Patients in this cohort have prolonged low-flow duration, may never attain return of spontaneous circulation (ROSC), and have a heightened risk of short-term mortality in excess of 80% with equally adverse neurological outcomes. [2][3][4] Multiple treatment modalities have been trialed for patients with refractory OHCA.…”

“…3 Patients in this cohort have prolonged low-flow duration, may never attain return of spontaneous circulation (ROSC), and have a heightened risk of short-term mortality in excess of 80% with equally adverse neurological outcomes. [2][3][4] Multiple treatment modalities have been trialed for patients with refractory OHCA. Randomized controlled trials (RCTs) of antiarrhythmic and vasopressor agents have not demonstrated improved functionally favorable survival.…”

Pilot study on VF-waveform based algorithms for early detection of acute myocardial infarction during out-of-hospital cardiac arrest

“…Importantly, ACO constitutes a major cause of difficult-to-defibrillate VF. 23,24 Especially this group with a treatable underlying cause may constitute a target population for early hospital transportation in case of refractory VF, with support of a mechanical resuscitation devices or ECMO. In case of confirmative data, additional optimisation of the diagnostic algorithms is needed, which requires multiple datasets on larger populations.…”