Early Access to the Cardiac Catheterization Laboratory for Patients Resuscitated From Cardiac Arrest Due to a Shockable Rhythm: The Minnesota Resuscitation Consortium Twin Cities Unified Protocol

Abstract

BackgroundIn 2013 the Minnesota Resuscitation Consortium developed an organized approach for the management of patients resuscitated from shockable rhythms to gain early access to the cardiac catheterization laboratory (CCL) in the metro area of Minneapolis‐St. Paul.Methods and ResultsEleven hospitals with 24/7 percutaneous coronary intervention capabilities agreed to provide early (within 6 hours of arrival at the Emergency Department) access to the CCL with the intention to perform coronary revascularization for outpatients who were successfully resuscitated from ventricular fibrillation/ventricular tachycardia arrest. Other inclusion criteria were age >18 and <76 and presumed cardiac etiology. Patients with other rhythms, known do not resuscitate/do not intubate, noncardiac etiology, significant bleeding, and terminal disease were excluded. The primary outcome was survival to hospital discharge with favorable neurological outcome. Patients (315 out of 331) who were resuscitated from VT/VF and transferred alive to the Emergency Department had complete medical records. Of those, 231 (73.3%) were taken to the CCL per the Minnesota Resuscitation Consortium protocol while 84 (26.6%) were not taken to the CCL (protocol deviations). Overall, 197 (63%) patients survived to hospital discharge with good neurological outcome (cerebral performance category of 1 or 2). Of the patients who followed the Minnesota Resuscitation Consortium protocol, 121 (52%) underwent percutaneous coronary intervention, and 15 (7%) underwent coronary artery bypass graft. In this group, 151 (65%) survived with good neurological outcome, whereas in the group that did not follow the Minnesota Resuscitation Consortium protocol, 46 (55%) survived with good neurological outcome (adjusted odds ratio: 1.99; [1.07–3.72], P=0.03).ConclusionsEarly access to the CCL after cardiac arrest due to a shockable rhythm in a selected group of patients is feasible in a large metropolitan area in the United States and is associated with a 65% survival rate to hospital discharge with a good neurological outcome.

Minnesota Resuscitation Consortium's Advanced Perfusion and Reperfusion Cardiac Life Support Strategy for Out‐of‐Hospital Refractory Ventricular Fibrillation

“…Four years ago, the MRC established a protocol to provide early cardiac catheterization laboratory (CCL) activation and intervention (within 4 hours) to all OHCA VF/VT patients that achieved ROSC. Fifty‐two percent underwent PCI and 7% underwent CABG regardless of the presence or absence of ST elevation on 12‐lead ECG . Given the high prevalence of significant CAD in this population, the MRC hypothesized that the burden of CAD in patients with refractory VF/VT would be higher.…”

“…Patients resuscitated from VF/VT cardiac arrest have a high prevalence of coronary artery disease (CAD) and are likely to have an underlying reversible cause for their cardiac arrest . When taken to the cardiac catheterization laboratory, more than half receive revascularization with primary coronary intervention (PCI) or coronary artery bypass grafting (CABG) regardless of the presence or absence of ST elevation in the postresuscitation electrocardiogram (ECG) . We hypothesized that patients with VF/VT cardiac arrest, refractory to initial resuscitation efforts, would have an even higher prevalence of significant CAD and that their disease would be more complicated.…”

Impact of early coronary angiography on the survival to discharge after out-of-hospital cardiac arrest

“…Performing CAG, which enables immediate confirmation of coronary artery disease followed by revascularization if necessary, has been reported to improve clinical outcomes of OHCA patients [7,9,12-14], and was confirmed in this propensity score-matched analysis of a nationwide registry. Among patients who underwent early CAG, revascularization was performed in half of the patients, which might be a critical component in the acute care of these patients, potentially leading to better outcomes.…”

“…The definition of early CAG was not consistent in prior studies and ranged from 6 to 24 hours [7,9,12-14]. In this study, we assessed the relationship between the timing of early CAG and the resulting clinical benefits.…”

Sodium nitroprusside enhanced cardiopulmonary resuscitation improves short term survival in a porcine model of ischemic refractory ventricular fibrillation

“…1,7,8,10,11 In Minnesota, the first community-wide refractory VF/VT protocol that focuses on early EMS mobilization to the CCL of patients with refractory OHCA has shown significant promise for improving survival. 7 Preliminary experience indicates that the majority of the patients arriving at the hospital have already received 45–60 minutes of CPR with automated CPR devices.…”