This well done review and meta-analysis examined the current
evidence in support of cardiac catheterization for survivors of out of hospital
cardiac arrest.
Let’s cut right to the chase.
For the primary outcome,
the acute catheterization group was
clearly superior with almost 60%
vs. 30% in hospital survival (Odds
ratio 2.77 95% CI 2.06-3.72). Survival with good neurological outcome was
nearly the same.
Of course the authors conclude that early coronary
angiography in patients following OHCA is associated with improved outcomes...
which is true of course.
But is all of the
evidence on shaky ground?
Perhaps.
All of the studies included in this meta-analysis were
observational in nature. From a pure evidence based standpoint, it is possible
that all of the difference in survival could
be due to selection bias and confounding
rather than the real efficacy of the intervention.
All observational studies are challenged by these issues.
The best way around this is to conduct a properly blinded and randomized
clinical trial. Of course this is not always ethical or feasible.
But there are those who believe there is enough clinical equipoise to warrant a proper experimental
trial. A quick look at www.clinicaltrials.gov
demonstrates several centres (USA, Spain, Sweden, & Canada) are currently on
to it. Let’s hope we get some better data.
Despite lack of definitive efficacy I’m not about to jump out of an airplane without a parachute. Currently,
I think it is very reasonable to be aggressive with early angiography in suitable
patients. This is especially for those with STEMI’s and/or presumed primary
cardiac cause of arrest.
In the future, let’s hope the ground doesn’t start shaking.
Covering:
Camuglia AC, Randhawa VK, Lavi S, et al. Cardiac catheterization in associated with superior outcomes for survivors of out of hospital cardiac arrest: Review and meta-analysis. Resuscitation 2014;85:1533-1540.
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