What is the recommended management for an out-of-hospital cardiac arrest survivor resuscitated in a non-PerCutaneous Coronary Intervention (PCI)-capable hospital with signs of acute coronary syndrome?

Transfer to PCI Center for Out-of-Hospital Cardiac Arrest Survivors

Out-of-hospital cardiac arrest survivors resuscitated in a non-PCI-capable hospital with STEMI on ECG should be immediately transferred to a PCI-capable center, regardless of neurologic status, as this is associated with improved survival. 1

Decision Algorithm Based on ECG and Neurologic Status

If STEMI is Present on ECG:

Transfer immediately to PCI-capable center (Class I recommendation) 1

• Awake/Non-comatose patients: Proceed directly to primary PCI upon arrival—these patients have survival rates comparable to STEMI patients who never arrested 1

• Comatose patients with favorable prognostic features: Proceed to primary PCI to improve survival (Class I recommendation) 1

  • Favorable features include: witnessed arrest, bystander CPR, shockable rhythm (VF/VT), CPR duration <30 minutes, time to ROSC <30 minutes, arterial pH >7.2, lactate <7 mmol/L, age <85 years 1

• Comatose patients with unfavorable prognostic features: Transfer for individualized assessment, as PCI may still be reasonable (Class IIb recommendation) 1

  • Unfavorable features include: unwitnessed arrest, no bystander CPR, non-shockable rhythm, CPR >30 minutes, time to ROSC >30 minutes, pH <7.2, lactate >7 mmol/L, age >85 years, end-stage renal disease on dialysis 1

If NO STEMI on ECG:

Do NOT transfer for immediate angiography if patient is electrically and hemodynamically stable (Class III: No Benefit recommendation) 1

• Defer coronary angiography pending further risk stratification 1
• The COACT trial demonstrated no survival benefit from immediate angiography in stable post-arrest patients without STEMI (64.5% vs 67.2% survival at 90 days, p=0.51) 2

Evidence Supporting Transfer to PCI Centers

The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guidelines provide the strongest and most recent evidence for this approach 1:

• Direct transport to PCI centers is associated with improved survival even when bypassing closer non-PCI hospitals, with adjusted odds ratio of 2.47 for discharge survival 3
• This survival benefit persists across all transport times (1-5 minutes, 6-10 minutes, 11-20 minutes, 21-30 minutes, and >30 minutes) 3
• Data from the CARES registry showed that approximately 10% of STEMI patients transferred by EMS have out-of-hospital cardiac arrest, and early recognition with direct transfer to PCI centers improves outcomes 1

Critical Pitfalls to Avoid

Do not delay transfer while waiting to assess neurologic recovery 1

• Waiting for neurologic improvement before acting results in missed opportunities to improve both cardiac and neurologic outcomes 4
• Nearly one-third of cardiac arrest patients with STEMI have normal neurologic status on ED presentation, and being alert is an independent predictor of survival 1

Do not keep patients at the non-PCI facility for observation after resuscitation 1

• Even patients who appear stable can deteriorate or have recurrent arrest
• Transfer arrangements should begin immediately upon achieving ROSC with STEMI on ECG 1

Do not assume comatose patients cannot benefit from PCI 1

• While survival-to-discharge in comatose post-arrest patients is <10% overall, those with witnessed arrest and shockable rhythm have significantly improved survival 1
• Immediate PCI combined with therapeutic hypothermia has resulted in long-term survival rates up to 70% with >80% neurologically functional 4

Nuances in the Evidence

The guidelines distinguish clearly between patients with and without STEMI 1:

• With STEMI: Strong evidence (Class I, Level C-LD) supports immediate transfer and PCI 1
• Without STEMI: Strong evidence against immediate angiography (Class III: No Benefit, Level A) in stable patients 1

This distinction is critical because the ARREST trial, which showed no benefit from triaging to cardiac arrest centers, specifically evaluated patients without STEMI on ECG 1

Observational studies consistently demonstrate that immediate PCI after cardiac arrest with STEMI is associated with reduced short-term mortality (adjOR 0.71) and long-term mortality (adjHR 0.44) 5, with 5-year post-discharge survival of 81.7% in patients managed with on-admission coronary angiography 6