Identifying Candidates for Advanced Hemodynamic Support After Cardiac Arrest
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Article, see p 273
Out-of-hospital cardiac arrest has a high incidence with ≈400 000 cases in the United States each year.1 Between 20% and 40% of these patients achieve return of spontaneous circulation resulting in hospital admission.2,3 Although return of spontaneous circulation is strongly associated with survival, only 25% to 40% of admitted patients survive to hospital discharge. The most common cause of death for patients admitted after cardiac arrest is neurological injury. However, shock accounts for most deaths within the first 3 days.4 Given these competing risks, the selection of candidates for advanced hemodynamic therapies should consider both neurological and hemodynamic prognosis.
Although the timing of coronary angiography following cardiac arrest without signs of ST-segment–elevation myocardial infarction remains controversial, there has been a dramatic rise in the use of mechanical circulatory support that can be deployed quickly and safely in the cardiac catheterization laboratory to support patients experiencing cardiac arrest. These devices include extracorporeal membrane oxygenation, Impella, and Tandem Heart. Multiple small observational studies have demonstrated that post–cardiac arrest shock can be effectively treated with these devices.5,6 However, the logistical and financial burdens of these advanced therapies, the risk of complications to the patient, and the absence of definitive randomized trials have led some clinicians to a nihilistic resistance to the use of these support technologies in patients after cardiac arrest. Wider adoption of hemodynamic support technologies will require accurate identification of neurologically viable patients likely to develop shock such that they would benefit from advanced hemodynamic support. To date, no such identification system exists.
In this issue of Circulation, Bascom et al7 describe the development and validation of a simple scoring system for the prediction of refractory hemodynamic compromise …