CardioSource WorldNews October 2015 | Page 58

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