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Editorial| Volume 169, P185-186, December 2021

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Post cardiac arrest care in 2021: Back to the drawing board

      One of the basic tenets of post-cardiac arrest care is identifying and addressing reversible causes for the cardiac arrest.
      • Lott C.
      • Truhlář A.
      • Alfonzo A.
      • et al.
      European Resuscitation Council Guidelines 2021: cardiac arrest in special circumstances.
      Unfortunately, the primary cause of an out-of-hospital cardiac arrest (OHCA) is often unclear during the early resuscitation period. Ischemic heart disease is a common suspect as it is highly prevalent in comatose survivors of OHCA.
      • Kern K.B.
      • Lotun K.
      • Patel N.
      • et al.
      Outcomes of comatose cardiac arrest survivors with and without ST-segment elevation myocardial infarction: importance of coronary angiography.
      However, cardiovascular risk stratification is reliant on clinical history and the physical exam, which are often unavailable or difficult to interpret in the early post-cardiac arrest period. Without this important information, the cardiovascular assessment in comatose survivors of OHCA can be prone to cognitive biases.

      Tversky A, Kahneman D. Judgment under Uncertainty: Heuristics and Biases. Science. 1974;185(4157):1124-31.

      Clinicians often resort to the initial rhythm (ventricular fibrillation or pulseless ventricular tachycardia versus pulseless electrical activity or asystole) and electrocardiograms (ECG) recorded post-return of spontaneous circulation (ROSC) to risk stratify ischemic heart disease as the primary cause of the cardiac arrest.
      • McFadden P.
      • Reynolds J.C.
      • Madder R.D.
      • Brown M.
      Diagnostic test accuracy of the initial electrocardiogram after resuscitation from cardiac arrest to indicate invasive coronary angiographic findings and attempted revascularization: a systematic review and meta-analysis.
      Cardiac arrests in patients presenting with initial non-shockable rhythms (pulseless electrical activity or asystole) and no ST-segment elevation are deemed less likely to be the result of an acute coronary culprit and therefore undergo coronary angiography less frequently.
      • Yannopoulos D.
      • Bartos J.A.
      • Aufderheide T.P.
      • et al.
      The evolving role of the cardiac catheterization laboratory in the management of patients with out-of-hospital cardiac arrest: a scientific statement from the American Heart Association.
      • Hanuschak T.A.
      • Peng Y.
      • Day A.
      • Morrison L.J.
      • Zhan C.C.
      • Brooks S.C.
      Patient and hospital factors predict use of coronary angiography in out-of-hospital cardiac arrest patients.
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      References

        • Lott C.
        • Truhlář A.
        • Alfonzo A.
        • et al.
        European Resuscitation Council Guidelines 2021: cardiac arrest in special circumstances.
        Resuscitation. 2021; 161: 152-219
        • Kern K.B.
        • Lotun K.
        • Patel N.
        • et al.
        Outcomes of comatose cardiac arrest survivors with and without ST-segment elevation myocardial infarction: importance of coronary angiography.
        JACC Cardiovasc Interv. 2015; 8: 1031-1040
      1. Tversky A, Kahneman D. Judgment under Uncertainty: Heuristics and Biases. Science. 1974;185(4157):1124-31.

        • McFadden P.
        • Reynolds J.C.
        • Madder R.D.
        • Brown M.
        Diagnostic test accuracy of the initial electrocardiogram after resuscitation from cardiac arrest to indicate invasive coronary angiographic findings and attempted revascularization: a systematic review and meta-analysis.
        Resuscitation. 2021; 160: 20-36
        • Yannopoulos D.
        • Bartos J.A.
        • Aufderheide T.P.
        • et al.
        The evolving role of the cardiac catheterization laboratory in the management of patients with out-of-hospital cardiac arrest: a scientific statement from the American Heart Association.
        Circulation. 2019; 139: e530-e552
        • Hanuschak T.A.
        • Peng Y.
        • Day A.
        • Morrison L.J.
        • Zhan C.C.
        • Brooks S.C.
        Patient and hospital factors predict use of coronary angiography in out-of-hospital cardiac arrest patients.
        Resuscitation. 2019; 138: 182-189
        • Harhash A.A.
        • May T.
        • Hsu C.-H.
        • et al.
        Incidence of cardiac interventions and associated cardiac arrest outcomes in patients with nonshockable initial rhythms and no ST elevation post resuscitation.
        Resuscitation. 2021; 167: 188-197
        • Desch S.
        • Freund A.
        • Akin I.
        • et al.
        Angiography after out-of-hospital cardiac arrest without ST-segment elevation.
        N Engl J Med. 2021;
        • Lemkes J.S.
        • Janssens G.N.
        • van der Hoeven N.W.
        • et al.
        Coronary angiography after cardiac arrest without ST-segment elevation.
        N Engl J Med. 2019; 380: 1397-1407
        • Ibanez B.
        • James S.
        • Agewall S.
        • et al.
        2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).
        Eur Heart J. 2018; 39: 119-177
        • Witten L.
        • Gardner R.
        • Holmberg M.J.
        • et al.
        Reasons for death in patients successfully resuscitated from out-of-hospital and in-hospital cardiac arrest.
        Resuscitation. 2019; 136: 93-99
        • Ostenfeld S.
        • Lindholm M.G.
        • Kjaergaard J.
        • et al.
        Prognostic implication of out-of-hospital cardiac arrest in patients with cardiogenic shock and acute myocardial infarction.
        Resuscitation. 2015; 87: 57-62
        • Kelly E.M.
        • Pinto D.S.
        Invasive management of out of hospital cardiac arrest.
        Circ: Cardiovasc Interv. 2019; 12: e006071
        • Jentzer J.C.
        • van Diepen S.
        • Henry T.D.
        Understanding how cardiac arrest complicates the analysis of clinical trials of cardiogenic shock.
        Circ: Cardiovasc Qual Outcomes. 2020; 13: e006692
        • Lagedal R.
        • Elfwén L.
        • Jonsson M.
        • et al.
        Coronary angiographic findings after cardiac arrest in relation to ECG and comorbidity.
        Resuscitation. 2020; 146: 213-219
      2. Branch KR, Hira R, Brusen R, et al. Diagnostic accuracy of early computed tomographic coronary angiography to detect coronary artery disease after out-of-hospital circulatory arrest. Resuscitation 2020;153:243-250.

        • Nolan J.P.
        • Berg R.A.
        • Andersen L.W.
        • et al.
        Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the utstein resuscitation registry template for in-hospital cardiac arrest: a consensus report from a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia).
        Resuscitation. 2019; 144: 166-177
        • Kleinman M.E.
        • Perkins G.D.
        • Bhanji F.
        • et al.
        ILCOR scientific knowledge gaps and clinical research priorities for cardiopulmonary resuscitation and emergency cardiovascular care: a consensus statement.
        Circulation. 2018; 137: e802-e819

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