GUEST COMMENTARY
TANVEER RAB, MD; MICHAEL C. MCDANIEL, MD
An Algorithm for Cardiac Arrest
A Review of the Recent Publication in JACC
A
state-of-the-art review on the management
of out-of-hospital cardiac arrest (OHCA)
in the resuscitated comatose patient was
published in the July 7th, 2015 issue of the Journal
of the American College of Cardiology by Rab et al.1
This important topic was undertaken on behalf of
the Interventional Council of the American College of
Cardiology (ACC) as currently there are no universal
guidelines or consensus documents for the optimal
management of these patients who have high mortality, heterogeneous presentations, and few randomized
trials to guide management. Furthermore, this topic
is timely due to increasing focus on quality initiatives
such as pay-for-performance and public reporting of
percutaneous coronary intervention (PCI) mortality,
which have the potential to create conflicting incentives if clinicians have to select between their patient’s
best interest and their own quality metrics.
The highlight of the manuscript is a simplified
management algorithm (FIGURE).
First, most comatose patients with OHCA without
unfavorable resuscitation features should undergo
urgent targeted temperature management (TTM),
invasive angiography, and culprit lesion revascularization despite the findings on the initial ECG or
neurologic status. Second, given the heterogeneity of
comatose patients with OHCA without ST-elevations,
emergent consultation with an interventional cardiologist should be undertaken prior to activation of
the cardiac catheterization lab to discuss the patient,
evaluate for unfavorable resuscitation features, and
exclude other causes for the cardiac arrest that are
unlikely to benefit from angiography. While there are
no absolute predictors of futility, the algorithm lists
multiple unfavorable resuscitation features which
would predict lower likelihood of meaningful survival
and where care should be individualized.
There are several reasons to consider targeted
t V