REVASCULARIZATION FOR STEMI

Revascularization Benefits Resuscitated Patients With STEMI Regardless of Neurologic Status

January 27, 2009 (Newark, Delware) — Patients with ST-segment-elevation MI (STEMI) who are resuscitated from cardiac arrest should undergo emergent angiography and revascularization regardless of neurologic status, a new study suggests [1].

In-hospital mortality was significantly lower in resuscitated patients with STEMI who are revascularized compared with patients who did not undergo revascularization, and this benefit extended to patients neurologically unresponsive after resuscitation, report investigators.

Although the study does not provide conclusive evidence for the benefits of revascularization in cardiac-arrest patients with MI, "these patients should be treated with the same urgency as patients with acute STEMI without cardiac arrest," write lead investigator Dr Vinay Hosmane (Christiana Care Health System, Newark, DE) and colleagues in the February 3, 2009 issue of the Journal of American College of Cardiology.

Revascularization for the Unresponsive

Although emergent PCI is the preferred treatment for patients who have an out-of-hospital cardiac arrest owing to MI, a number of patients show signs of neurologic impairment before revascularization. The prognosis of these patients and benefits of PCI compared with patients without neurologic damage are not well-known, and this has caused a dilemma about whether or not to proceed directly to angiography and possible revascularization, according to Hosmane and colleagues.

Over a five-year period, the researchers retrospectively identified consecutive patients resuscitated from cardiac arrest, regardless of the time to return of spontaneous circulation and neurologic status, and reviewed the outcomes of 98 patients who had STEMI.

Overall, 64% of these patients survived to hospital discharge, and 92% had full neurologic recovery. Survival to discharge was 96% among alert patients, 93% among patients minimally responsive to pain and stimuli, and 44% among those who were unresponsive. In multivariate analysis, unresponsive patients were 47 times more likely to die than alert patients. In addition, delays in the time to return of spontaneous circulation and older age increased the risk of dying. Women were also six times more likely to die than men.

Revascularization was performed in 77 of the 98 patients, with a majority of these undergoing PCI. In-hospital mortality was 25% among revascularized patients compared with 76% for those who were not revascularized. Among those classified as unresponsive following resuscitation, 40 of 59 patients underwent revascularization. In line with the entire cohort, in-hospital mortality was significantly higher in those who did not undergo emergent PCI or coronary artery bypass graft surgery compared with those who were revascularized (84% vs 42%, respectively).

Researchers point out that the study was not randomized, nor was it designed to assess the benefits of revascularization in this patient population. The difference in survival rates among unresponsive patients receiving and not receiving revascularization is likely attributable to selection bias, but the researchers add that the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) study showed cardiogenic shock patients also derive benefit from revascularization.