Coronary Angiography and Out-of-Hospital Cardiac Arrest

Roughly 395,000 people suffer out-of-hospital cardiac arrest (OHCA) each year in the United States, with a survival rate of 6% to 10%. In this heterogenous group of patients, those who present with a cardiac cause of arrest have favorable outcomes. Factors that suggest a cardiac cause include the presence of a shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia) at the time of arrest and the presence of ST elevation on ECG after return of spontaneous circulation (ROSC). Current guidelines recommend urgent coronary angiography in OHCA patients with ST elevation and state that coronary angiography is reasonable in patients without ST elevation, if a cardiac cause is suspected. Recent randomized trials (COACT, TOMAHAWK) have compared strategies of immediate versus delayed angiography in OHCA patients without ST elevation and suggest there may be no difference in outcomes with these two strategies.

In the study we presented at #AHA21, we examined practice patterns of coronary angiography use in OHCA patients from a large, nationally representative cohort from multiple clinical sites. We also described the variation in coronary angiography use between clinical sites. Patients were stratified by their presenting rhythm (shockable versus non-shockable) and whether they had ST elevation on post-ROSC ECG. We found that coronary angiography use was significantly higher in patients with ST elevation compared to no ST elevation and in patients with a shockable rhythm compared to a non-shockable rhythm. However, when comparing different sites, there was more variation in coronary angiography use among patients with – rather than without – a presumed cardiac cause of arrest than in those with, versus without, ST elevation. These data suggest ongoing challenges in interpreting current guidelines, leading to inconsistency in decision-making for OHCA patients, especially among patients with a presumed cardiac cause of arrest. Future studies identifying specific cohorts of patients who could benefit the most from urgent coronary angiography should help in optimizing post-resuscitation care.