If an AVR (augmented voltage right) lead shows ST elevation post cardiac arrest, should the patient undergo Percutaneous Coronary Intervention (PCI)?

ST Elevation in AVR Lead Post-Cardiac Arrest: Indications for PCI

Coronary angiography should be performed emergently for all cardiac arrest patients with ST-segment elevation in AVR lead, as this finding suggests a cardiac cause of arrest that may benefit from immediate revascularization.

Understanding ST Elevation in AVR Lead

ST elevation in AVR lead post-cardiac arrest has significant clinical implications:

• It often indicates proximal left main coronary artery or severe three-vessel disease
• This finding represents a high-risk pattern associated with increased mortality
• The presence of ST elevation in AVR should trigger immediate consideration for coronary angiography

Evidence-Based Approach to Management

The 2024 American Heart Association guidelines provide clear direction for this scenario:

• Class I recommendation (Level of Evidence: B-NR): "Coronary angiography should be performed emergently for all cardiac arrest patients with suspected cardiac cause of arrest and ST-segment elevation on electrocardiogram" 1
• This recommendation is consistent with global recommendations for all patients with ST-segment elevation myocardial infarction 1

Similarly, the European Society of Cardiology guidelines specifically state:

• "Patients with ST-elevation on post-resuscitation ECG should undergo a primary PCI strategy" 1
• This recommendation is based on very-low-quality evidence but shows a large treatment effect with an odds ratio of 0.35 (95% CI, 0.31-0.41) for hospital mortality 1

Implementation Algorithm

1. Immediate Recognition:

   • Identify ST elevation in AVR lead on post-resuscitation ECG
   • Consider this finding as a STEMI equivalent requiring urgent intervention

2. Transfer Protocol:

   • Transfer directly to a PCI-capable center, bypassing the emergency department 1, 2
   • Alert the catheterization laboratory immediately 1

3. Procedural Considerations:

   • Perform primary PCI of the culprit vessel 2
   • Consider the timing: aim for PCI within 90 minutes if at a PCI-capable hospital or within 120 minutes if transfer is required 2

4. Concurrent Management:

   • Administer antiplatelet therapy (aspirin 162-325 mg and a P2Y12 inhibitor) 2
   • Consider therapeutic hypothermia for comatose patients 2, 3

Special Considerations

• Neurological Status: Coronary angiography is reasonable in post-cardiac arrest patients regardless of neurological status if coronary angiography is otherwise indicated 1

• Combined Approach: Multiple studies demonstrate that primary PCI can be safely combined with mild induced hypothermia in comatose survivors, with one study showing improved survival with good neurological outcome (55% versus 16%; p=0.001) 3

• Timing Considerations: Do not delay PCI while waiting for neurological recovery, as immediate intervention may actually improve such recovery 4

Potential Pitfalls

• Avoid Delays: Waiting for evidence of neurological recovery before acting can result in missed opportunity to improve outcomes 4

• Medication Cautions: Be aware that hypothermia conditions may be associated with slow uptake and delayed onset of action of oral antiplatelet agents 1

• Contraindications: Recognize absolute contraindications to fibrinolytic therapy if PCI is not immediately available, including active internal bleeding, history of cerebrovascular accident, or severe uncontrolled hypertension 5

In conclusion, ST elevation in AVR lead post-cardiac arrest should prompt immediate coronary angiography and PCI if indicated, as this approach has been shown to significantly improve survival and neurological outcomes in this high-risk population.