Risk-adjusted outcome prediction with initial post-cardiac arrest illness severity: implications for cardiac arrest survivors being considered for early invasive strategy

Abstract

Background: Early CATH is recommended for cardiac arrest survivors with STEMI or suspicion for coronary ischemia. Comatose patients are at risk of death from neurologic injury irrespective of CATH, but post-procedural mortality data do not distinguish between causes of death. Pittsburgh Post Cardiac Arrest Category (PCAC) is a validated, early post-cardiac arrest illness severity score based on initial cardiopulmonary dysfunction and neurologic examination. We evaluated the association between early coronary angiography (CATH) and patient outcome after adjusting for initial post-cardiac arrest illness severity.

Methods: Retrospective study of a prospective cardiac arrest database at a single site. We included 1011 adult survivors of non-traumatic in-hospital or out-of-hospital cardiac arrest from 2005 to 2012, then stratified by PCAC and immediate CATH. Logistic regression tested the association between immediate CATH and patient outcomes, adjusting for PCAC.

Results: Overall, 273 (27%) received immediate CATH. Patients with immediate CATH had higher proportions of good outcome in all but the most severe stratum of illness severity (11% vs. 6%; p=0.11). The primary mode of death was neurologic for all but the least severe stratum. Adjusting for PCAC, immediate CATH was associated with favorable discharge disposition (OR 1.92; 95%CI 1.20, 3.07; p=0.006) and modified Rankin scale (OR 1.95; 95%CI 1.12, 3.38; p=0.02).

Conclusions: The benefit of CATH is less clear in the most severe stratum of illness, in which the high risk of mortality is primarily from neurologic causes. PCAC is a risk-stratification tool that provides pre-procedural risk-adjusted outcome prediction for post-cardiac arrest patients being evaluated for immediate CATH.

Keywords: Cardiac arrest; Cardiac catheterization; Illness severity.