An article entitled ìImmediate coronary angioplasty in survivors of out of hospital cardiacî recently published in the New England Journal of Medicine (N Engl J Med 1997;336:1629-33), suggests that immediate coronary angiography followed by angioplasty improves survival in patients with out-of-hospital cardiac arrest.  Is this conclusion justified?  Should the evaluation and treatment of patients with out-of-hospital cardiac arrest change to incorporate this new strategy?  A critical review of the article and its conclusions presented here in the Arrhythmia News suggests that this is not the case.   In this study, 1762 subjects with out-of-hospital cardiac arrest in a single hospital district of Paris, France, were screened for entry in the study.  Only 186 arrived at the hospital alive.  From this population, the 84 patients who underwent immediate coronary angiography were included in the study.  Forty patients had complete coronary artery occlusion;  PTCA restored blood flow in 28 of these patients, categorizing them as the ìsuccessfulî treatment group.  The remaining 56 patients, including those with unsuccessful PTCAs, non-critical cornary artery disease, and normal coronary arteries, comprised the comparison group. 
  
 A total of 32 of these 84 patients were eventually discharged from the hospital alive; 14/32 had undergone successful angioplasty.  Based on this data, the authors reported successful PTCA as having the strongest association with survival to hospital discharge by multivariate logistic regression analysis (14/28 with successful PTCA surviving to hospital discharge as compared to 18/56 surviving without successful PTCA). 

 In reviewing this data, the Arrhythmia News strongly disagrees with the conclusions reached by the authors.  First, the population being evaluated in this study is a highly select one.  Only 40 patients underwent PTCA our of 1,762 out-of-hospital cardiac arrests screened.  Even when only  the 186 patients reaching the hospital following cardiac arrest are viewed as the sample population, the percentage is a relatively small. 
  
 Second, the definition of cardiac arrest needs to be examined in this study.  The term ìcardiac arrestî was not defined in the text.  Greater than 40% of patients arriving in the emergency room following out-of-hospital cardiac arrest were excluded because of anîobvious causeî, presumably noncardiac, for the cardiac arrest.  This seems to suggest that many patients may not have actually suffered from the unstable ventricular rhythms traditionally defined as cardiac arrest. 

 Clearly a high prevalence of coronary artery disease exists in the population of patients with traditionally defined cardiac arrest.  The only population previously demonstrated to benefit from revascularization alone following cardiac arrest are those patients with extensive, severe coronary disease and normal left ventricular function.  Thus, the authorís recommendations represent a major departure from the current standard of care. 
  
 A common cause of cardiac arrest is acute myocardial infarction complicated by ventricular fibrillation.  These events are caused by acute coronary occlusion manifesting the characteristic ECG and enzyme changes.  Most of the ìsuccessful PTCAî group may in fact be among these patients, who are known to have a low incidence of recurrent ventricular fibrillation and do not require antiarrhythmic treatment.  These patients differ from patients with late arrhythmias, including ventricular fibrillation, following prior myocardial infarction; the prognosis is far more ominous for this group. The authors make no effort to distinguish between these two distinct groups of patients. 
  
 This controversial and provocative French study emphasizes the need to consider the role of acute coronary occlusion in cardiac arrest patients.  However, the data it presents fail to support the conclusions reached by its authors. In particular, treatment of high risk patient surviving cardiac arrest with revascularization alone oversimplifies the treatment of a complex condition. 
 
 

Arrhythmia Service Adds New Attending 
  
 The Arrhythmia Service is pleased to announce the addition of Dr. Nidal Isber to its staff effective July 1, 1997.  Dr. Isber, who compleated his cardiology fellowship training at SUNY Downstate Medical Center in Brooklyn, completed electrophysiology and ablation training at Good Samaritan Medical Center, the busiest electrophysiology service in Los Angeles, California.  Before returning to the New York area, Dr. Isber worked for one year as an attending electrophysiologist at Good Samaritan. 
  
Dr. Isber will be based at the Staten Island office, performing the full range of clinical and procedural electrophysiologic services. 

Reproduced with permission. Published by the Arrhythmia Service of St. Luke's-Roosevelt Hospital Center, New York, New York.

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