The first speaker was Dr. Kjetil Sunde from Norway who discussed mechanical devices in cardiac arrest. Real life CPR is often suboptimal because of poor performance and operator fatigue. Therefore, mechanical CPR devices have been investigated for their ability to improve outcomes. Some of these devices were shown to be useful even during patient transport. The ongoing LINC study is evaluating in 2500 patients the ability of one such device to improve patient outcomes. Another device was tested in a randomized trial and found to be associated with worse neurological outcomes. Wik et al reported on another randomized trial of a mechanical device vs. manual CPR and showed no overall benefit. Nevertheless, these devices can be useful in special situations such as during catheterization or as a bridge to allow PCI. Other patients may gain benefit from such devices during transport or as a bridge to cardio-pulmonary bypass. Studies are ongoing for these indications. Other options are LV assist devices which have been used, mostly in animal experiments, during cardiac arrest with evidence of maintenance of cerebral and coronary circulation. Current guidelines state that the evidence is insufficient to support or refute the use of mechanical devices during CPR but ongoing studies should provide more definitive evidence.
The second talk was given by Dr. Uwe Zeimer of Germany about pharmacological management post cardiac arrest in STEMI. The PREMIER registry included patients with STEMI diagnosed in the pre hospital setting. Of about 2400 patients included in the registry, 190 had cardiac arrest in the ambulance. In patients presenting with asystole or PEA, mortality was about 60% and among patients presenting with VF it was about half. Patients given reperfusion therapy did better than others. The diagnosis of STEMI among survivors of cardiac arrest can be challanging. History and biomarkers are often not helpful and the ECG is the main diagnostic aid. In terms of medical management, amiodarone has shown benefit in patients with refractory VF, not necessarliy with STEMI. Epinephrine has been used widely during cardiac arrest but its value has been recently challenged. A recent paper in the JAMA compared epinephrine to no epinephrine in cardiac arrest and found short term, but not longer term benefit for epinephrine. Further studies are needed. The role of fibrinolysis has been examined in small studies in patients after cardiac arrest. However, the TROICA study of patients with cardiac arrest of presumed cardiac origin did not find a beneficial effect of tenecteplase in these patients. However, if STEMI is documented and the patient has had VF, primary PCI should be considered. Dr. Susanna Price from the UK discussed the issue of cardiac rupture, including free wall and septal rupture. The typical symptom of cardiac rupture is syncope followed by shock in about 60% of cases. About 40% of cases may be subacute. The incidence of cardiac rupture has been declining with the widespread introduction of reperfusion therapy. The rates of death from EMD have been declining. Patients with cardiac rupture more commonly present with STEMI, are more often elderly and females and have less prior infarctions. The delay to reperfusion is associated with the risk of rupture. Primary PCI does not prevent the risk of free wall rupture, although it occurs less than with thrombolysis. After intervention, ruptures more often occur in the first 24 hours. Surgery offers the only chance of survival. VSR is a rarer complication. Prognosis is more influenced by RV dilatation and failure than LV function. Location of the rupture is also important prognostically. The challenge for the future is to find ways to stabilize patients until later percutaneous or surgical correction can be performed. Dr. JP Henriques from the Netherlands discussed cardiogenic shock. Inotropic agents have not been shown to improve outcome in cardiogenic shock. The SHOCK trial, while initially a negative trial, did show a benefit for revascularization, although a smaller one than originally anticipated. The use of IABP has been generally recommended by guidelines until recently, although a meta analysis of controlled studies showed no sign of benefit. This recommendation has been downgraded by the 2012 STEMI guidelines. The CRISP AMI. Study showed no effect of IABP on the reduction of infarct size in patients with a large anterior MI. The IABP SHOCK II trial published in this meeting failed to show any benefit for the IABP in cardiogenic shock. There is some experience with Tandem heart and ECMO in this situation. Impella improves hemodynamic parameters but mortality has not been shown to be favourably affected. There are ongoing studies of this device in STEMI.
Acute complications of ST-elevation myocardial infarction
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