791308 ACC European Heart Journal: Acute Cardiovascular CareVrints et al.
Issue @ a Glance
Management of out-of-hospital
cardiac arrest and electric storm
Christiaan JM Vrints FESC FACC
Sudden out-of-hospital circulatory arrest (OHCA) fre-
quently resulting in sudden cardiac death is a major public
health problem.1,2 The survival rate of OHCA is low
(<10%) and increases only by immediately alerting the
emergency medical system (EMS) and early initiation of
basic life support and defibrillation.3 In order to improve
the quality of first responder resuscitation before arrival of
the mobile EMS team systems have been developed that
allow rapid dispatching of trained lay rescuers activated by
text messaging4,5 or via a mobile phone app.6 A study per-
formed in the Dutch province Limburg shows that the con-
tribution of a text message based alert system to improved
survival after OHCA is most substantial in cases of wit-
nessed arrest, in the home situation, at slightly delayed
arrival of the first ambulance and during the evening/night.7
Coronary artery disease accounts for the great majority
(66 to 75%) of the OHCA cases8 and therefore emergent
coronary angiography should always be performed in
OHCA patients with return of spontaneous circulation
(ROSC) with ST-segment elevation (STE) or new left bun-
dle branch block.9 In a series of Japanese OHCA patients
who showed ST segment changes after ROSC a culprit
lesion was detected by coronary angiography in 81% of the
patients with STE and in and in 33% of patients with non-
STE changes.10 ST-segment analysis showed good positive
predictive value (81%) but low negative predictive value
(68%) in diagnosing the presence of acute coronary lesions.
This study shows therefore that the presence of ST-segment
changes cannot be considered as a strict selection criterion
for performing emergent coronary angiography in patients
resuscitated from OHCA. Furthermore, it is important to
note that a vasospastic angina was diagnosed in 9.6% in the
STE group and in 11.7% in the non-STE group. Appropriate
coronary spasm provocation testing11 should be therefore
performed in OHCA survivors with normal coronary angio-
grams in order to detect vasospastic angina as a cause of the
arrest.
Women frequently suffer from underutilization of inva-
sive diagnostics and interventions. In a retrospective study
of successfully resuscitated OHCA patients in Copenhagen
women showed a higher 30 day mortality after adjustment
European Heart Journal: Acute Cardiovascular Care
2018, Vol. 7(5) 395­–396
© The European Society of Cardiology 2018
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DOI: 10.1177/2048872618791308
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for age and comorbidities but this increase could be
explained by less favorable prehospital conditions with an
increased prevalence of non-shockable rhythms.12 Women
underwent less often coronary angiography and revascu-
larization procedures, but it remained unclear if this repre-
sented underutilization or could be explained by different
patient characteristics.
Airway management is very important both during and
after resuscitation for OHCA. In a large OHCA registry in
Vienna use of a laryngeal tube was associated with an almost
two times increased 30 day mortality and a more unfavorable
neurological outcome than observed in the patients venti-
lated through endotracheal intubation.13 Immediate endotra-
cheal intubation appears therefore the best airway strategy
both during the prehospital and in hospital phase.
The scientific evidence for targeted temperature man-
agement (TTM) following resuscitation from OHCA is
addressed in this issue by a systematic review of the litera-
ture and by meta-analyses focusing on its usefulness, opti-
mal timing of initiation and duration.14 The review provides
low quality evidence supporting the in-hospital initiation of
TTM at 32–36°C amongst adult survivors of OHCA with
an initial shockable rhythm for 18–24 h.
Extracorporeal cardiopulmonary resuscitation (ECPR)
as a rescue therapy for refractory cardiac arrest is assessed
by a retrospective analysis of the clinical results obtained
with this therapy at a regional ECPR referral center in
Lombardy, Italy.15 The study demonstrates the feasibility of
ECPR in selected patients with a recovery of neurological
and cardiac function similar to patients with early ROSC.
However, survival after ECPR was much lower and criti-
cally depends on total cardiac arrest time. More research is
needed to better identify the patients who may benefit from
ECPR.
Cardiovascular diseases, University of Antwerp, Belgium
Corresponding author:
Christiaan JM Vrints FESC FACC, Department of Cardiology, University
Hospital and AZ Monica Antwerp, Belgium.
Email: christiaan.vrints@uantwerpen.be
396 European Heart Journal: Acute Cardiovascular Care 7(5)
The survival and neurological outcome in relation to the
mean blood glucose levels during the first 96 hours of hos-
pital admission was studied in a retrospective cohort study
of comatose survivors of OHCA with an initial shockable
rhythm.16 Hyperglycemia was associated with increased
rates of death and severe neurological dysfunction.
Non-occlusive mesenteric ischaemia is a rare (0.68%)
but life-threatening (50% in hospital mortality) complica-
tion in OHCA survivors.17 Elevated lactate and leukocytes
at admission in the absence of a clear infectious focus
should raise suspicion for this complication in patients with
congenital heart disease a worse outcome after cardiopul-
monary resuscitation is mainly related to the complexity of
the underlying heart defect and the presence of pulmonary
hypertension.18
In patients with cardiogenic shock due to an electrical
storm percutaneous extracorporeal membrane oxygenation
may result in hemodynamic stabilization with restoration of
sufficient vital organ perfusion allowing invasive electo-
physiologic studies and therapies.19
The management of electric storm is further discussed in
an educational review.20
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