Skip to main content
SpringerLink
Log in

Routinemäßige sofortige Koronarographie/PCI

Ist sie bei möglicher kardialer Ursache eines Kreislaufstillstandes sinnvoll?

Routine immediate coronary angiography/percutaneous coronary intervention (PCI)

Is it for potential coronary causes of cardiac arrest justified?

  • Leitthema
  • Published:
Notfall + Rettungsmedizin Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Die ERC-Leitlinien empfehlen im Rahmen der Nachbehandlung nach Wiederbelebung eine routinemäßige Koronarographie und eventuelle perkutane Koronarintervention (PCI) bei Patienten mit vermuteter koronarer Ursache des Kreislaufstillstands. Neben dem Analogschluss zum unkomplizierten Infarkt ist die Grundlage hierfür eine angebliche diagnostische Unsicherheit bezüglich Koronarverschlüssen, die eine Abklärung notwendig machen würde. Daneben werden zahlreiche Berichte und Fallserien zur Überlebensrate mit gutem neurologischem Outcome für die Empfehlungen herangezogen. Die ungewöhnlich guten Ergebnisse sind möglicherweise Folge einer im Einzelfall nicht sicher nachvollziehbaren Patientenselektion und eines Publikationsbias. Hierfür spricht v. a., dass der Einfluss der PCI bei ST-Streckenhebungsinfarkt (STEMI) bzw. Non-STEMI-ACS mit Kreislaufstillstand auf das Outcome höher zu sein scheint als bei routinemäßiger Anwendung im Rahmen eines unkomplizierten STEMI oder eines Non-STEM-ACS.

Empfehlung

Aus den offenen Fragen ergeben sich die Forderung und Notwendigkeit, künftige Leitlinien auf den Boden einer ausreichend großen kontrollierten randomisierten Studie zu stellen, aus der der tatsächliche Nutzen eines interventionellen Vorgehens nach erfolgreicher CPR hervorgeht. Die Tatsache, dass das Risiko einer Intervention zumindest bei erfolgreicher PCI relativ begrenzt zu sein scheint und einige Publikationen aus nichtrandomisierten Studien reichen als Begründung der Empfehlungen für diese kritisch kranken Patienten nicht aus.

Abstract

Background

The European Resuscitation Council (ERC) guidelines on post-resuscitation care recommend coronary angiography and if suitable a subsequent percutaneous coronary intervention (PCI) for survivors of cardiac arrest potentially caused by coronary heart disease. These recommendations originate from analogy conclusions with respect to procedures for uncomplicated STEMI and non-STEMI-ACS by an assumed uncertainty regarding the diagnostic reliability of a 12-lead electrocardiograph (ECG) after cardiopulmonary resuscitation (CPR) and finally based on larger case series reporting exceptionally high survival rates and good neurological outcome in patients where PCI was performed soon after hospital admission. Patient selection as well as a publication bias may at least in part explain the astonishing results reported. The latter assumption seems to be supported by the observation that the positive influence of PCI on outcome of patients with ACS and cardiac arrest reported in these series is several fold higher compared to the outcome of patients with uncomplicated ACS.

Recommendations

Good clinical practice requires that recommendations are based on results of controlled randomized trials. Consequently and with regard to the potential risks, controlled randomized trials in sufficiently large populations are necessary and should be urgently performed to come to reliable future guideline recommendations on the role of invasive procedures after successfully resuscitated cardiac arrest of suspected coronary origin.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1

Literatur

  1. Arntz HR, Wenzel V, Dissmann R et al (2008) Out-of-hospital thrombolysis during cardiopulmonary resuscitation in patients with high likelihood of ST-elevation myocardial infarction. Resuscitation 76:180–184

    Article  PubMed  Google Scholar 

  2. Batista LM, Lima FO, Januzzi JL Jr et al (2010) Feasibility and safety of combined percutaneous coronary intervention and therapeutic hypothermia following cardiac arrest. Resuscitation 81:398–403

    Article  PubMed  Google Scholar 

  3. Bendz B, Eritsland J, Nakstad AR et al (2004) Long-term prognosis after out-of-hospital cardiac arrest and primary percutaneous coronary intervention. Resuscitation 63(1):49–53

    Article  PubMed  CAS  Google Scholar 

  4. Body R, Carley S, Wibberley C et al (2010) The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation 2010:281-

    Article  Google Scholar 

  5. Böttiger BW, Arntz HR, Chamberlain DA et al (2008) Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med 359:265

    Article  Google Scholar 

  6. Cronier P, Vignon P, Bouferrache K et al (2011) Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to ventricular fibrillation. Crit Care 15:R122

    Article  PubMed  Google Scholar 

  7. Davies MJ, Thomas A (1984) Thrombosis and acute coronary-artery lesions in sudden cardiac ischemic death. N Engl J Med 310:1137–1140

    Article  PubMed  CAS  Google Scholar 

  8. Dumas F, Cariou A, Manzo-Silberman S et al (2010) Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Circ Cardiovasc Interv 3:200–207

    Article  PubMed  Google Scholar 

  9. Deakin CD, Nolan JP, Soar J et al (2010) ERC Leitlinien 2010: Kardiopulmonale Reanimation Section 5. Notfall Rettungsmed 13:559–620

    Article  Google Scholar 

  10. Wijns W, Kolh P, Danchin N et al (2010) ESC Guidelines on myocardial revascularization. Eur Heart J 31:2501–2555

    Article  PubMed  Google Scholar 

  11. Garot P, Lefevre T, Eltchaninoff H et al (2007) Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after cardiac arrest complicating ST-elevation myocardial infarction. Circulation 115:1354–1362

    Article  PubMed  Google Scholar 

  12. Gorjup V, Radsel P, Kocjancic ST et al (2006) Acute ST-elevation myocardial infarction after successful cardiopulmonary resuscitation. Resuscitation 72:379–385

    Article  PubMed  Google Scholar 

  13. Gräsner JT, Meybohm P, Caliebe A et al (2011) Postresuscitation care with mild therapeutic hypothermia and coronary intervention after out-of-hospital cardiopulmonary resuscitation: a prospective registry analysis. Crit Care 15:R61

    Article  PubMed  Google Scholar 

  14. Hosmane VR, Doorey AJ, Abraham N et al (2011) Out-of-hospital cardiac arrest patients with ST-segment elevation on electrocardiogram: don’t rush patients for emergent percutaneous coronary intervention in the era of aggressive door-to-balloon time. Catheter Cardiovasc Interv 4:1052

    Google Scholar 

  15. Knafelj R, Radsel P, Ploj T, Noc M (2007) Primary percutaneous coronary intervention and mild induced hypothermia in comatose survivors of ventricular fibrillation with ST-elevation acute myocardial infarction. Resuscitation 74:227–234

    Article  PubMed  Google Scholar 

  16. Kern KB, Rahman O (2010) Emergent percutaneous coronary intervention for resuscitated victims of out-of-hospital cardiac arrest. Catheter Cardiovasc Interv 75:616–624

    PubMed  Google Scholar 

  17. Lettieri C, Savonitto S, De Servi S et al (2009) Emergency percutaneous coronary intervention in patients with ST-elevation myocardial infarction complicated by out-of-hospital cardiac arrest: early and medium-term outcome. Am Heart J 157:569–575

    Article  PubMed  Google Scholar 

  18. Marcusohn E, Roguin A, Sebbag A et al (2007) Primary percutaneous coronary intervention after out-of-hospital cardiac arrest: patients and outcomes. Isr Med Assoc J 9:257–259

    PubMed  Google Scholar 

  19. Müller D, Schnitzer L, Brandt J, Arntz HR (2008) The accuracy of an out-of-hospital 12-lead ECG for the detection of ST-elevation myocardial infarction immediately after resuscitation. Ann Emerg Med 52:658–664

    Article  PubMed  Google Scholar 

  20. Müller D, Agrawal R, Arntz HR (2006) How sudden is sudden cardiac death? Circulation 114:1146–1150

    Article  PubMed  Google Scholar 

  21. Nanjayya VB, Nayyar V (2011) Immediate coronary angiogram in comatose survivors of out-of-hospital cardiac arrest-An Australian study. Resuscitation [Epub ahead of print]

  22. Peels HO, Jessurun GA, Horst IC van der et al (2008) Outcome in transferred and nontransferred patients after primary percutaneous coronary intervention for ischaemic out-of-hospital cardiac arrest. Catheter Cardiovasc Interv 71:147–151

    Article  PubMed  Google Scholar 

  23. Renard A, Verret C, Jost D et al (2011) Impact of fibrinolysis on immediate prognosis of patients with out-of-hospital cardiac arrest. J Thromb Thrombolysis 32:405–409

    Article  PubMed  CAS  Google Scholar 

  24. Richling N, Herkner H, Holzer M et al (2007) Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac arrest due to acute ST-segment elevation myocardial infarction and its effect on outcome. Am J Emerg Med 25:545–550

    Article  PubMed  Google Scholar 

  25. Schefold JC, Storm C, Joerres A, Hasper D (2009) Mild therapeutic hypothermia after cardiac arrest and the risk of bleeding in patients with acute myocardial infarction. Int J Cardiol 132:387–391

    Article  PubMed  Google Scholar 

  26. Sideris G, Voicu S, Dillinger JG et al (2011) Value of post-resuscitation electrocardiogram in the diagnosis of acute myocardial infarction in out-of-hospital cardiac arrest patients. Resuscitation 82:1148–1153

    Article  PubMed  Google Scholar 

  27. Sunde K, Pytte M, Jacobsen D et al (2007) Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation 73:29–39

    Article  PubMed  Google Scholar 

  28. Spaulding CM, Joly LM, Rosenberg A et al (1997) Immediate coronary angiography in survivors of out-of-hospital cardiac arrest. N Engl J Med 336:1629–1633

    Article  PubMed  CAS  Google Scholar 

  29. Voipio V, Kuisma M, Alaspää A et al (2001) Thrombolytic treatment of acute myocardial infarction after out-of-hospital cardiac arrest. Resuscitation 49:251–258

    Article  PubMed  CAS  Google Scholar 

  30. Wolfrum S, Pierau C, Radke PW et al (2008) Mild therapeutic hypothermia in patients after out-of-hospital cardiac arrest due to acute ST-segment elevation myocardial infarction undergoing immediate percutaneous coronary intervention. Crit Care Med 36:1780–1786

    Article  PubMed  Google Scholar 

  31. Zimmermann S, Flachskampf FA, Alff A et al (2011) Out-of-hospital cardiac arrest and percutaneous coronary intervention for ST-elevation myocardial infarction: long-term survival and neurological outcome. Int J Cardiol [Epub ahead of print]

Download references

Interessenkonflikt:

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Medizinische Klinik II; Kardiologie und Pulmonologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Deutschland

    H.-R. Arntz

Authors
  1. H.-R. Arntz
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to H.-R. Arntz.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Arntz, HR. Routinemäßige sofortige Koronarographie/PCI. Notfall Rettungsmed 15, 505–509 (2012). https://doi.org/10.1007/s10049-011-1570-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10049-011-1570-5

Schlüsselwörter

Keywords

Search

Navigation